SADTJ Vol 6 Issue 3 by SADTJ

June 2017 • Vol 6 Issue 3

SADTJ

ISSN 2077-2793

• Communication methods and production techniques in ﬁxed prosthesis fabrication: a UK based survey. Part 2 • Utilizing a New Full-arch Treatment Solution • Soft versus hard occlusal splint therapy in the management of temporomandibular disorders (TMDs) • Effect of palatal form on movement of teeth during processing of complete denture prostehesis: An in-vitro study.

The Southern African Dental Technology Journal

dentasa

summit & agm 21 & 22 JULY 2017 THE BOARDWALK HOTEL PORT ELIZABETH

CEU 8.6

Invitation to write articles and case presentations The Southern African Dental Technology Journal invites all dental technicians/technologists and dentists, who have original articles or case presentations to submit their work. The SADTJ is a peer review publication, and all original articles will be reviewed by our Associate Editors. Do not let this scare you off, you will receive constructive criticism and suggestions on how to improve your writing, should your article not be published the first time round.

Length of Manuscripts: •

•

• • •

Technical Article: 1500-2000 words and 15-20 photos or diagrams. These articles should be up-to-date accounts of interesting and noteworthy developments in techniques. They should be case specific and engage the intermediate and advanced-level technologies as well as new techniques. Articles should give step by step information on how to do something, but also provide insight on the why and how of a particular technique or product. Please include a 10 question, multiple choice quiz, about the contents of the article, when submitting a technical article. All technical articles submitted to the journal must be written or co-written by a Certified Dental Technician, a foreign technician with a SADTC approval to work in South Africa, or a dentist. Photo Technical Article (Case presentation): 1000 words maximum and 10-26 photos. These articles should be up-to-date accounts of interesting and noteworthy developments in techniques. This kind of article is usually a case presentation sharing tips or a quick technique with others. The photos should be accompanied by a written explanation (maximum 1000 words) of how the final results were accomplished. Research Article: 6000 words. Here the criteria of intelligibility and wider interest are strictly applied. Review Articles: up to 6000 words long. These articles should be up-to-date surveys of important current developments in dentistry. News Articles: 250-700 words, photos optional. We are interested in all news-worthy events that involved or impact dental technicians, or their laboratories. Please keep us up to date so we can share the news.

Manuscripts and Photo Requirements: • • • •

• • • • •

Articles submitted should be in the proper format for scientific papers. All submissions should be the original work of the author/s as noted. Articles should be submitted in Microsoft Word. Images should be in JPEG format. It should have a resolution of no less than, 300dpi, should be uncompressed, be of high quality and clarity and should have no copyright. You are not allowed to reproduce any images without the proper copyright releases. If the images are not your own, please make sure that you obtain the copyright release on the images before submitting it to the SADTJ, as this remains your responsibility. The journal reserves the right to edit your article, for the sake of clarity. Articles that have been submitted to the Journal of Dental Technology in Southern Africa, may not be submitted to another publication for a period of four months. Include a photograph of the authors as well as a short biography. Include copies of the completed authors release form, conflict of interest and photo release forms with the submission, of your article. Include the cover page for your article.

Presentation of Content: • • • • • •

Use Arial or Times Roman as font. Number each page clearly. No footnotes will be allowed. Keep your presentation clear and simple. Tables, figures and images (including photographs), should be presented on a separate page at the end of the document, separate from other documents. All tables, figures and images must be clearly marked using Arabic numerals.

All manuscripts must be submitted in English. Remember to include all your contact details when submitting your work. Make use of this invitation, and submit your work today, we look forward to hear from you. 2

SADTJ Vol 6 Issue 3

In This Issue SADTJ Vol 6 Issue 3 June 2017

Editor

Axel Grabowski

Managing Editor Mariaan Roets

Communication Methods and Production Techniques in Fixed Prosthesis Fabrication: a UK Based Survey. Part 2

PUBLISHED BY

The Dental Technicians Association of South Africa

LAYOUT AND DESIGN Nicola van Rensburg

Soft versus Hard Occlusal Splint Therapy in the Management of Temporomandibular Disorders (TMDs)

ADVERTISING ENQUIRIES m.roets@dentiworks.com

ADDRESS CHANGES

Elize Morris: dentasa@absamail.co.za

Utilizing a New Full-arch Treatment Solution

ACCOUNTS

Elize Morris: dentasa@absamail.co.za Tell: 012 460 1155 Fax: 086 233 7122

Effect of Palatal Form on Movement of Teeth During Processing of Complete Denture Prostehesis: An in-vitro Study.

DENTASA

PO Box 95340, Waterkloof, 0145 Tel: 012 460 1155 Fax: 086 233 7122 dentasa@absamail.co.za www.dentasa.org.za

STATEMENT OF INTENT The Southern African Dental Technology Journal is published quarterly. The main objective of the Journal is to provide the professional with the opportunity to earn CDP credits through completing the questionnaires, or writing articles. All papers in English, on any aspect of dental laboratory science or related disciplines, will be considered on merit and subject to the review of the editorial board and the CPD accreditation committee.

EDITORIAL, ADVERTISING AND COPYRIGHT POLICY Copyright of individual articles appearing in this publication reside with the individual authors. No article appearing in this publication may be reproduced in any manner, or in any format without the express written permission of its author and a release from this publication. All rights are reserved. Opinions and statements, of whatever nature, are published under the authority of the submitting author and should not be taken as the ofďŹ cial policy of the Dental Technology Association of South Africa.

SADTJ Vol 6 Issue 3

Editorâ&#x20AC;&#x2122;s Page Here we are, the first SADTJ for 2017, and it promises to be well worth reading and completing the questionnaires for the required CEUs for this cycle. Thank you once again for the Traderâ&#x20AC;&#x2122;s contribution of advertising, as this journal depends greatly on you. I am happy announce that after a long void, the Southern Gauteng branch of DENTASA is proud to introduce Johan van der Vyver as its new branch chair. From my side, welcome Johan and I know that you will make a difference, and get the branch up and running as it should in no time. It seems that all branch chairs of Northern Gauteng are defecting to Namibia. Not to long after Wicus Kruger left, our new chair, Gerhard Combrink got himself married and left for (a better life?) in Namibia. Gerhard, thank you for your time in the DENTASA Exco and wishing you and your new wife all the very best for the future. We have however been lucky to welcome Luan Moolman to the Exco and new branch chair for north Gauteng. Welcome, and no, there are no more vacancies in Namibia. I will inform you of all the many changes and challenges that lie ahead of this wonderful profession of ours, at the DENTASA Summit and AGM 2017 . Hope to see you all in Port Elizabeth on the 21st and 22nd July. Happy reading Editorially yours Axel

SADTJ Vol 6 Issue 3

IMPORTANT INFORMATION REGARDING CPD How are the CEUs calculated for the Journal? The Journal falls under Category B: (Measurable) Training and Publications: Dental Technology and related fields, sub-category B8. A maximum of 20 of the required CEUs may be obtained/claimed from this category but not more than 10 from any sub-category, with the exception of B4 which may not exceed 20 CEUâ&#x20AC;&#x2122;s Answer/complete multiple-choice questionnaires (MCQ) in journals, including electronic journals and or professional association News Letters with required pass mark. 70% is needed to pass and 0.2 CEU per standard page of prescribed reading and 0.2 CEU per question is awarded.

CPD via the SADTJ â&#x20AC;&#x201C; Request to Council The DENTASA office has been inundated with phone calls and request from all dental technicians to be allowed to do older SADTJ issues to be able to acquire the additional CPD credits as stipulated by letters received by Council. We have sent a formal request to Council regarding the abovementioned and our correspondence was tabled at the CPD Committee meeting of the SADTC. We in addition tabled a request for Council to remove the maximum CEUs per category limitation to ensure that CPD becomes achievable and accessible to all in the profession. We are now awaiting a response from Council. We will inform you as soon as we receive an answer. Regards,

Elize Morris DENTASA Secretary The Dental Technology Association of South Africa Tel: 012-460 1155 www.dentasa.org.za SADTJ Vol 6 Issue 3

CPD: The waiting game It is generally accepted that CPD requirements must be: • • • • • •

reasonable, achievable, fair, accessible to all (cost-effective), transparent, flexible, and

•

inclusive.

Measured against these categories the SADTC’s CPD requirements falls far short as the rules are draconian and very user-unfriendly towards the profession. The maximum threshold for CEUs in certain categories is a case in point. When bench marking against other councils like the Pharmacy Council, The South African Council for Social Service Professions, The South African Institute for Professional Accountants , The Actuarial Society and most importantly the HPCSA with its TWELVE professional boards, none of them have a maximum threshold for CEUs in a category. By removing the maximum CEUs per category and making it possible to obtain all the CEUs from the Journal the SADTC will go a long way in making CPD achievable and accessible to all in the profession. DENTASA also requested the SADTC to allow the technicians to complete the SADTJ questionnaires of the 2014/2015 period to make up their CEU short fall, this will also be discussed at the planned workshop. In light of the above DENTASA requested that Mariaan Roets be allowed to attend and give her valued input at their proposed workshop which was supposed to have been held in March. It is now the middle May and we are still waiting for any feedback from Council, seven months after our initial letters. Our request to publish the SADTC newsletters and annual report in order for technicians to gain Ethic and Business points by completing the questionnaires was prohibited. We regret this decision as it would have made it possible for technicians in the rural areas to earn their Ethics and Business CEUs much easier and cheaper. Half of this year is almost gone, we need clarity on the above issues, the CPD compliance rate is abysmal, let’s make it reasonable, achievable, fair, accessible, transparent, flexible and inclusive. It is possible. Ms. Roets attended the CPD workshop representing DENTASA. We suggested the following to make it easier for technicians to comply, for service providers to apply and for the Council to administer: 1. Abolish maximum threshold per category 2. Make Ethics and Business CEUs available in accredited publications and other media 3. Simplify accreditation process 4. That technicians be given a chance to get the required CEU’s for 2014/2015 by completing the 2014/2015 questionnaires in the SADTJ. The CPD Committee discussed the requests after the workshop in their meeting and will make recommendations to the Council. The next SADTC meeting is 15 July.

SADTJ Vol 6 Issue 3

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OPEN

This is an open access article

Communication methods and production techniques in fixed prosthesis fabrication: a UK based survey. Part 2: Production techniques

•

Highlights that even though clear guidelines are available, there still seems to be a lack of agreement between dentists and laboratories regarding the disinfection and quality of dental impressions. Despite the promotion of all-ceramic crowns, this survey indicated that metal-ceramic crowns are still the most frequently prescribed for both anterior and posterior restorations.

RESEARCH

J. Berry,1 M. Nesbit,2 S. Saberi,2 and H. Petridis*3

IN BRIEF

2.8

Aim The aim of this study was to identify the communication methods and production techniques used by dentists and dental technicians for the fabrication of fixed prostheses within the UK from the dental technicians’ perspective. This second paper reports on the production techniques utilised. Materials and methods Seven hundred and eightytwo online questionnaires were distributed to the Dental Laboratories Association membership and included a broad range of topics, such as demographics, impression disinfection and suitability, and various production techniques. Settings were managed in order to ensure anonymity of respondents. Statistical analysis was undertaken to test the influence of various demographic variables such as the source of information, the location, and the size of the dental laboratory. Results The number of completed responses totalled 248 (32% response rate). Ninety percent of the respondents were based in England and the majority of dental laboratories were categorised as small sized (working with up to 25 dentists). Concerns were raised regarding inadequate disinfection protocols between dentists and dental laboratories and the poor quality of master impressions. Full arch plastic trays were the most popular impression tray used by dentists in the fabrication of crowns (61%) and bridgework (68%). The majority (89%) of jaw registration records were considered inaccurate. Forty-four percent of dental laboratories preferred using semi-adjustable articulators. Axial and occlusal under-preparation of abutment teeth was reported as an issue in about 25% of cases. Base metal alloy was the most (52%) commonly used alloy material. Metalceramic crowns were the most popular choice for anterior (69%) and posterior (70%) cases. The various factors considered did not have any statistically significant effect on the answers provided. The only notable exception was the fact that more methods of communicating the size and shape of crowns were utilised for large laboratories. Conclusion This study suggests that there are continuing issues in the production techniques utilised between dentists and dental laboratories. INTRODUCTION Prosthodontics is a discipline that requires a synergy between the dentist and dental technician, in order to fabricate intraoral prostheses with acceptable fit, function and aesthetics.1–3 The General Dental Council’s (GDC) policy document Principles of dental team working 4 states that ‘members of the dental team should work effectively together in patients’ best interest’. In 1 Clinical Lecturer, Department of Adult Oral Health, Institute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London; 2Senior Technical Instructor, Prosthodontic Unit, UCL Eastman Dental Institute, London; 3Senior Lecturer, Department of Restorative Dentistry, Prosthodontics Unit, UCL Eastman Dental Institute, London. *Correspondence to: Dr Haralampos (Lambis) Petridis Email: c.petridis@ucl.ac.uk

Online article number E13 Refereed Paper - accepted 14 July 2014 DOI: 10.1038/sj.bdj.2014.644 © British Dental Journal 2014; 217: E13

SADTJ Vol 6 BRITISH DENTAL JOURNAL

addition, legislation such as the updated European Medical Devices Directive5 must be complied with so that all laboratory made products are constructed of materials considered to be safe and to a standard that will not harm the patient in any way. In order for these recommendations to be implemented, both dentists and dental technicians need to be aware of the processes and protocols used in the fabrication of fixed prostheses. However, a number of studies6–13 from around the world have highlighted the need for improved communication methods and production techniques between dentists and dental technicians during fabrication of fixed restorations. Problems have been identified in various parts of production processes and communication ranging from quality of impressions, to adequate tooth preparation, articulation, and adequate instructions regarding the use of materials.6–13

Und erg rad u at e t raining shoul d theoretically prepare dentists with the required knowledge to provide fixed prostheses in a safe and predictable manner. However, a number of studies12,14 have raised concerns regarding the competency of newly qualified dentists on their understanding of production techniques, possibly due to the reduction in dental technology teaching within the undergraduate curriculum,1,15 as well as the lack of interaction between dental technicians and students during these important formative years. This apparent disparity has led to the conclusion12 that the General Dental Council has failed in its aims published in The first five years: a framework for undergraduate dental education.16 Indeed in Australia this is now being addressed with the introduction of inter-professional teaching schemes.17 The purpose of this cross-sectional study was to identify the communication methods

Issue 3

RESEARCH and production techniques used by dentists and dental technicians for the fabrication of fixed prostheses within the UK from the dental technicians’ perspective. Part one of this cross-sectional survey reported on the communication issues between dentists and dental laboratories.13 The current publication concentrates on the production techniques used for fixed prosthesis fabrication.

MATERIALS AND METHODS The details regarding materials and methods have been published in the first paper.13 A questionnaire was constructed to investigate communication methods and production techniques used between dentists and dental laboratories from the laboratories perspective. The final questionnaire consisted of 30 questions within the following subcategories: general information, communication methods, impression disinfection and suitability, production techniques, shade matching, and time and team management issues. The Dental Laboratories Association (DLA, Nottingham, UK) was approached and approved the use of their database of e-mail contacts (782 addresses). A web-based survey tool, Opinio (ObjectPlanet Inc. Oslo, Norway), was utilised for the administration of the survey and assimilation of data. Settings were managed in order to ensure anonymity of respondents. The data collected was presented as descriptive statistics and analysed using Fisher’s exact test, the Mann-Whitney test or the Spearman’s rank correlation (SPSS 12.0; SPSS Inc, Chicago). P-values of less than 0.025 were regarded as statistically significant. A significance level of 2.5% was chosen rather than the conventional 5% to avoid spuriously significant results arising from multiple testing. The null hypothesis was that factors such as the source of information used to answer the questionnaire, the location, and size of the dental laboratory, did not influence the communication methods and production techniques.

RESULTS The number of responses totalled 248, which yielded a 32% response rate. Sixtyeight respondents answered only some of the questions. The results presented in this paper pertain to the subchapters of general information, disinfection and suitability of impressions and production techniques. The subchapters and questions along with the results in parentheses are depicted in Table 1. The results of the general information subchapter have been published in part one,13 but the main points are presented

Table 1 Relevant subchapters of the questionnaire with answers in parentheses GENERAL INFORMATION 1. Please indicate the source of the information that you will be giving: From memory (81%) From records (19%) 2. This survey is anonymous so please indicate the country that you are based in: England (90%) Scotland (4%) Northern Ireland (1%) Wales (5%) 3. Approximately, what number of dentists do you currently work with? 1 – 25 (43%) 26 – 50 (30%) 51 – 75 (8%) 76 – 100 (6%) 100+ (13%) IMPRESSION DISINFECTION AND SUITABILITY 4. When the impressions arrive at the dental laboratory, what percentages are clearly labelled indicating that they have been disinfected? 0-25% (30%) 26-50% (22%) 51-75% (22%) 76-100% (26%) 5. Do you always disinfect the impressions from the dentists before pouring them up? Yes (65%) No (35%) PRODUCTION TECHNIQUES 6. What is the most popular impression tray used for the fabrication of crowns? Dual arch impression -triple tray technique (14%) Quadrant plastic trays (9%) Quadrant metal trays (1%) Full arch plastic trays (61%) Full arch metal trays (6%) Custom tray (9%) 7. What is the most popular impression tray used for the fabrication of bridgework that you see in your laboratory? Dual arch impression - triple tray technique (7%) Quadrant plastic trays (4%) Quadrant metal trays (0%) Full arch plastic trays (69%) Full arch metal trays (9%) Custom tray (11%) 8. What is the approximate percentage of final master impressions that you consider to be inadequate? 0-25% (57%) 26-50% (26%) 51-75% (12%) 76-100% (5%) 9. What is the main reason for the poor quality of the final master impression? Presence of bubbles/voids (8%) Deformation of impression material (11%) Defects at the preparation margins (7%) Combination of above (72%) Other reasons (2%) 10. How often do you feel that there has been insufficient bucco-lingual tooth removal to achieve satisfactory crown fabrication? 0-25% (48%) 26-50% (34%) 51-75% (16%) 76-100% (2%) 11. How often do you feel that there has been insufficient occlusal tooth removal to achieve satisfactory crown fabrication? 0-25% (43%) 26-50% (31%) 51-75% (20%) 76-100% (6%) 12. What type of articulator do you usually use for fabrication of fixed crown and bridgework? Static - only up & down motion (9%) Simple hinge (28%) Mean value (19%) Semi adjustable (44%) 13. What percentage of dentists send you the appropriate occlusal records? 0-25% (33%) 26-50% (29%) 51-75% (27%) 76-100% (11%) 14. What percentage of dentists provide you with a guide to aid you in the fabrication of the definitive prosthesis (diagnostic wax up, tooth preparation guides, impression of provisional restorations)? 0-25% (68%) 26-50% (23%) 51-75% (4%) 76-100% (5%) 15. How do dentists communicate with you the shape and size of the crown? (Tick all that apply) Diagnostic wax-up (16%) Written instructions (30%) Drawing (19%) Contour guides (putty index) (13%) Photographs (22%) 16. What percentage of the time, as the dental technician, do you have to decide on the type of material to be used as it is not specified by the dentist on the laboratory prescription? 0-25% (56%) 26-50% (20%) 51-75% (16%) 76-100% (8%) 17. During the fabrication of a fixed dental prosthesis, what is the most commonly used metal alloy? High gold content (8%) Low gold content (14%) Palladium alloy (26%) Base metal (52%) 18. What is the most commonly requested material for the construction of an anterior crown? Metal-ceramic (69%) All-ceramic (29%) Metal-composite (2%) Metal-acrylic (0%) 19. What is the most commonly requested material for the construction of a posterior crown? Metal only (19%) Metal-ceramic (71%) All-ceramic (8%) Metal-composite (2%) 20. What percentage of the time therefore do you have to decide on the surface needed to be covered with metal or aesthetic veneering material because it has not been prescribed by the dentist? 0-25% (57%) 26-50% (20%) 51-75% (11%) 76-100% (12%)

here as they were factors for the statistical analysis that followed. The majority of the information (81%) used to answer the survey questions were sourced from memory. Ninety percent of the respondents were based in England. This unequal distribution among

England, Scotland, Wales and Northern Ireland did not permit any further analysis of this particular factor. The majority of dental laboratories were categorised as small sized (43% working with up to 25 dentists), 38% as medium (working with 26-75 dentists) and SADTJBRITISH Vol 6DENTAL IssueJOURNAL 3 9

RESEARCH

Photographs

Contour guides/putty indices

Drawing

Written instructions

Diagnostic wax-up 0

100

120

140

160

Number of replies Fig. 1 Communication of the size and shape of the crown

High gold content

Low gold content

Palladium alloy

Base metal 0

Percentage response Fig. 2 Most commonly used metal alloys

19% as large (working with 76+ dentists). The results of this study showed that a significant number of respondents (52%) considered that less than half of the impressions received from the dentist were clearly labelled as having been disinfected. Sixty-five percent of dental laboratories indicated that they routinely disinfected the impressions received from the dentist before pouring them up. The most popular impression tray used in the fabrication of crowns and bridgework was the full arch plastic tray, which was used in 61% and 69% of cases respectively. Custom made trays were only used in 10% of cases and quadrant plastic trays were the least popular. A significant number of respondents (17%) considered that the majority of final master impressions received were of poor quality and inadequate to use for a varied number of reasons including

air voids, defects at the preparation margin and deformation of the impression material. The aforementioned results, pertaining to the disinfection and suitability of impressions, were not influenced by the size of the laboratory or the source of information with the exception of the responses about the inadequacy of the master impressions (p = 0.03), which suggested that the proportion of inadequate impressions was greater in the records group than the memory group. Regarding the adequacy of tooth preparations, the results of this study showed that, on average, 18% of respondents considered that they routinely received tooth preparations where there had been inadequate bucco-lingual tooth reduction. The analysis showed that the percentage was statistically (p = 0.01) higher (28%) in the records group compared to the

memory group. With respect to occlusal tooth reduction, 26% indicated that they frequently encountered tooth preparations with insufficient reduction. The semi-adjustable articulator was the most frequently used (44%) in the fabrication of fixed prostheses followed by the simple hinge type (28%). This survey indicated that only 11% of the dental laboratories perceived that the majority of inter-occlusal records were accurate. The majority of respondents (68%) reported that they rarely received any particular guide, such as a diagnostic wax-up, or impressions from provisional restorations, in order to communicate the shape and size of the definitive restoration. Written instructions were the most widely used means of communicating the size and shape of crowns, and were often supplemented with photographs, drawings, or the use of diagnostic wax-ups (Fig. 1). The statistical analysis revealed that the size of the laboratory affected these communication methods as they all varied significantly between groups; the diagnostic wax-up (p = 0.002), contour guides (p = 0.02) and photographs (p = 0.01). These three methods of communication were least common within the small-sized laboratory group. The use of written instructions and drawings was not found to be significantly associated with the size of the laboratory. The study also showed that dental technicians often had to decide on the type of material and the surface on which to use the material, as it had not been accurately prescribed by the dentist. Almost a quarter (24%) of dental technicians had to routinely choose both for the materials to be used for the fixed prostheses as well as the particular surfaces that needed to be covered with an aesthetic veneering material. For the fabrication of fixed prostheses, base metal alloys (52%) were the most commonly used, with high gold content alloys only used in 8% of cases (Fig. 2). The most commonly requested combination of materials for the construction of both anterior and posterior crowns was metal-ceramic (69% and 71% respectively). All-ceramic crowns accounted for 29% of anterior cases and only 8% of posterior crowns. Metal-only posterior crowns were only used in 19% of situations. No significant statistical observations were noticed for the aforementioned results.

DISCUSSION This cross-sectional survey was undertaken to identify the communication and production techniques used by dentists and dental technicians for the fabrication

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RESEARCH of fixed prostheses within the UK from the dental technicians’ perspective. The current publication reports on the production techniques used. The response rate of 32% was similar to previously published surveys10–12,18 of dental laboratories. This current survey was unique in that it was administered online in the anticipation of making it more appealing and easier to participate.13 However, the response rate was similar to previous postal ones. This survey was limited by the fact that no distinction was made between possible differences in production techniques in laboratories, which provided a fully private service, a fully NHS service or a mixed arrangement.6,13 Personal bias may have affected the accuracy of the results as the majority of the information used to answer the survey questions was sourced from memory. Dental technicians could have exaggerated the extent of poor impression disinfection and suitability of the impressions, as well as potential issues in production techniques. Nevertheless, the statistical analysis showed that the source of the information did not play a significant role. The results of this study showed that a significant number of dental laboratories were receiving impressions from dentists that were not clearly labelled as having been disinfected. It was also shown that 65% of laboratories would routinely disinfect the impressions on their arrival. It seems that there is a lack of agreement between dentists and laboratories regarding decontamination and disinfection of dental impressions, even though clear guidelines have been made available via the British Dental Association.19 These results are in agreement with previous studies in the UK,20 Greece,11 and the USA.21 Robust disinfection protocols are essential to prevent the risk of cross infection between team members.22–24 Full-arch plastic trays were the most frequently used impression trays for the fabrication of crowns and bridgework, and this confirms previous findings.6,11,25 Dual arch impression trays were the second most popular (14%) for the fabrication of single crowns, and were also used in 7% of bridgework cases. This technique has become more popular with dentists as a time and material efficient way of recording an impression.26–28 However, the available literature29,30 shows that dualarch impressions only compare favourably with full-arch impressions with respect to the fabrication of single units. Dental laboratories considered this technique as being difficult to work with, leading to the possibility of further inaccuracies. Custom made trays were only prescribed in 9-11%

of cases, which is low considering that the master impression technique recommended by the British Society for Restorative Dentistry31 is the utilisation of a custom tray with a medium body silicone within the tray, and a low viscosity silicone syringed around the tooth preparation. A concerning finding of this survey was that a high proportion of final master impressions were considered as inadequate for use by the dental technician. Most troublesome was the fact that the majority of the inadequate impressions presented with a combination of problems. Similar results regarding the frequency and aetiology of inadequate definitive impressions have been reported in previous studies7,11,21,32–34 and the lack of improvement is a troublesome issue. It is essential that the dentist carefully scrutinises the impression, preferably under good lighting and magnification, to ensure its suitability before sending it to the laboratory. The lack of sufficient tooth preparation presents the dental technician with the difficult task of fabricating a crown or bridge with adequate form and aesthetics.35 This study confirmed the results of previous ones11,36–38 in that under preparation of teeth frequently happens, and this is the first time that it has been reported in the UK. The routine clinical use of preparation guides, such as putty or plastic indices derived from diagnostic wax-ups would help ensure the correct occlusal and bucco-lingual tooth reduction. To date there has been no research data on the use of articulators and occlusal records within commercial dental laboratories the UK. This particular survey showed that the semi-adjustable articulator was favoured in the fabrication of fixed crown and bridgework, being used 44% of the time. This type of articulator is also preferred in dental schools in the UK39 and is the preferred choice of the British Society of Restorative Dentistry.31 A troublesome finding was the use of static articulators in 9% of cases. These types of articulators are not indicated for any quality restorative work. Interestingly, the results of this study showed that only 11% of occlusal records received were routinely considered adequate. The majority of records sent to the technicians were probably not used and discarded. An accurate and usable occlusal record is very important and any inaccuracies may lead to the need for extensive intraoral adjustments, which may compromise aesthetics or mechanical strength of restorations.40,41 A previous study in Greece11 reported that dental laboratories had confidence in the jaw registration records provided and may be a reflection

on possible different jaw registration techniques taught and used by dentists in the UK and Greece. The results of this study also showed that, in the majority of cases (68%), no guides were provided by the dentists for the fabrication of definitive prostheses. In cases that it happened, it was usually in the form of written instructions or photographs. Guides, such as the diagnostic wax-up, a copy of the provisional crowns, and occlusal aids, such as a custom incisal guide table should be provided by dentists.41 The statistical analysis showed that diagnostic wax-ups, contour guides, and photographs were used more often with large labs and this may reflect the need for improved communication in such settings. This survey concurs with previous ones6,25,42 that dentists commonly do not prescribe the materials to be used or the surfaces to be covered by the veneering material in the construction of crowns or bridgework, leaving the decision to the technician. The dentist is now obliged by law to prescribe the materials to be used,4,5 and it is the responsibility of the dentist to assess each patient individually to decide on the surfaces to be covered with a particular material. The increasing cost of gold was reflected in the popular use (52%) of base metal alloys for crown and bridgework. This has also been a trend in other countries,7,11 but based on the previous answer, it would be interesting to explore whether the dentists are aware, as they should be, of the types of metal alloys that are used for the fabrication of the prescribed fixed prostheses. The increased use of base metal alloys may have implications regarding the corrosion resistance of crown and bridgework.43 Finally the survey investigated the combination of materials used in certain situations. Metalceramic crowns were still the most popular choice for anterior and posterior crowns. Many previous studies44,45 have reported their good survival rates. All-ceramic crowns, despite having potentially high survival rates,46,47 were still not frequently prescribed by dentists, even for anterior cases. Surprisingly, full metal coverage posterior crowns were not a popular choice nowadays, probably a reflection of the increased cosmetic awareness of the population in general.

CONCLUSIONS Within the limitations of this UK based study, the following conclusions could be drawn: 1. There is still an apparent lack of protocol in the disinfection of impressions between the dentists and SADTJ Vol 6 Issue 3

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RESEARCH

laboratories, thus creating a potential health risk Plastic full arch trays were the dentists’ preferred choice of impression tray for recording master impressions Dentists frequently sent master impressions to the laboratory, which are not appropriate for the fabrication of fixed prostheses More use of diagnostic wax-ups and reduction guides to ensure adequate tooth removal should be used by dentists The dental technicians in the main did not trust the authenticity of the occlusal relationship records provided Dentists frequently failed to prescribe the material to be used or the design of the prosthesis, incorrectly leaving the decision to the dental technician Metal-ceramic crowns were still the most popular choice for both anterior and posterior units.

The authors acknowledge the Dental Laboratories Association for their valuable assistance in carrying out this survey. The authors declare that they have no conflict of interest with respect to the submitted work. 1. 2.

8. 9.

Christensen G J. A needed remarriage: dentistry and dental technology. J Am Dent Assoc 1995; 126: 116–117. Davenport J C, Basker R M, Heath J R, Ralph J P, Glantz P O, Hammond P. Communication between the dentist and the dental technician. Br Dent J 2000; 189: 471–474. Malament K A, Pietrobon N, Nesser S. The interdisciplinary relationship between prosthodontics and dental technology. Int J Prosthodont 1996; 9: 341–354. General Dental Council. Principles of dental team working. London: GDC, 2013. Online information available at www.gdc-uk.org/Dentalprofessionals/ Standards/Documents/DentalTeamWorking.pdf (accessed July 2014). Council of the European Communities. The medical devices directive. Council of the European Communities, 2010. Online information available at www.ec.europa.eu/enterprise/policies/europeanstandards/harmonised-standards/medical-devices/ index_en.htm (accessed July 2014). Jenkins S J, Lynch C D, Sloan A J, Gilmour A S. Quality of prescription and fabrication of single-unit crowns by general dental practitioners in Wales. J Oral Rehabil 2009; 36: 150–156. Aquilino S A, Taylor T D. Prosthodontic laboratory and curriculum survey. Part III: fixed prosthodontic laboratory survey. J Prosthet Dent 1984; 52: 879–885. Leith R, Lowry L, O’Sullivan M. Communication between dentists and laboratory technicians. J Irish Dent Assoc 2000; 46: 5–10. Lynch C D, Allen P F. Quality of communication between dental practitioners and dental technicians for fixed prosthodontics in Ireland. J Oral Rehabil

2005; 32: 901–905. 10. Afsharzand Z, Rashedi B, Petropoulos V C. Communication between the dental laboratory technician and dentist: work authorization for fixed partial dentures. J Prosthodont 2006; 15: 123–128. 11. Hatzikyriakos A, Petridis H P, Tsiggos N, Sakelariou S. Considerations for services from dental technicians in fabrication of fixed prostheses: A survey of commercial dental laboratories in Thessaloniki, Greece. J Prosthet Dent 2006; 96: 362–366. 12. Juszczyk A S, Clark R K, Radford D R. UK dental laboratory technicians’ views on the efficacy and teaching of clinical-laboratory communication. Br Dent J 2009; 206: E21. 13. Berry J, Nesbit M, Saberi S, Petridis H. Communication methods and production techniques used by dentists and commercial dental laboratories regarding fixed prosthesis fabrication: a UK based survey. Part 1: Communication methods. Br Dent J 2014; 217. 14. Clark R K. The future of teaching of complete denture construction to undergraduates. Br Dent J 2002; 193: 13–14. 15. Barret P A, Murphy W M. Dental technician education and training - a survey. Br Dent J 1999; 18: 85–88. 16. General Dental Council. The first five years: a framework for undergraduate dental education. London: GDC, 2002. 17. Evans J, Henderson A, Johnson N. The future of education and training in dental technology: designing a dental curriculum that facilitates teamwork across the oral health professions. Br Dent J 2010; 208: 227–230. 18. Stewart C A. An audit of dental prescriptions between clinics and dental laboratories. Br Dent J 2011; 211: E5. 19. British Dental Association. Advice sheet A12: Infection control in dentistry. London: BDA, 2009. 20. Almortadi N, Chadwick R G. Disinfection of dental impressions- compliance to accepted standards. Br Dent J 2010; 209: 607–611. 21. Kugel G, Perry R D, Ferrari M, Lalicata P. Disinfection and communication practices: A survey of U S. dental laboratories. J Am Dent Assoc 2000; 131: 786–792. 22. Powell, G L, Runnells R D, Saxon B A, Whisenant B K. The presence and identification of organisms transmitted to dental laboratories. J Prosthet Dent 1990; 64: 235–237. 23. Owen C P, Goolam R. Disinfection of impression materials to prevent viral cross contamination: a review and a protocol. Int J Prosthodont 1993; 6: 480–494. 24. Matalon S, Eini A, Gorfil C, Ben-Amar A, Slutzky H. Do dental impressions play a role in cross contamination? Quintessence Int 2011; 42: 124–130. 25. Lynch C D, Allen P F. Quality of written prescriptions and master impressions for fixed and removable prosthodontics: a comparative study. Br Dent J 2005; 198: 17–20. 26. Davis R D, Schwartz R S. Dual-arch and custom impression accuracy. Am J Dent 1991; 4: 89–92. 27. Lane D A, Randall R C, Lane N. A clinical trial to compare double-arch and complete-arch impression techniques in the provision of indirect restorations. J Prosthet Dent 2003; 89: 141–145. 28. Mitchell S T, Ramp M H, Ramp L C, Liu P R. A preliminary survey of impression trays used in the fabrication of fixed indirect restorations. J Prosthodont 2009; 18: 582–588. 29. Lane D A, Randall R C, Lane N S, Wilson N H. A clinical trial to compare double-arch impression

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BRITISH DENTAL JOURNAL

COMMUNICATION METHODS AND PRODUCTION TECHNIQUES IN FIXED PROSTHESIS FABRICATION: A UK BASED SURVEY. PART 2 QUESTION 1 THE RESPONDENTS SOURCED THEIR INFORMATION FOR THE SURVEY QUESTIONS FROM: A DENTAL AND DENTAL TECHNOLOGY JOURNALS B THEIR RECORDS C MEMORY D THE INTERNET QUESTION 2

ACCORDING TO THE RESPONDENTS, ____ OF THE IMPRESSIONS WERE CLEARLY LABELLED AS HAVING BEEN DISINFECTED.

A NONE B LESS THAN HALF C THREE QUARTERS D ALL QUESTION 3 A B C D

COMMUNICATION REGARDING THE SIZE AND SHAPE OF THE CROWN ARE MOSTLY DONE BY:

PHOTOGRAPHS CONTOUR GUIDES/PUTTY INDICES WRITTEN INSTRUCTIONS DIAGNOSTIC WAX-UP

QUESTION 4 A OFTEN B NEVER C ALWAYS

TECHNICIANS ____ HAD TO DECIDE THE TYPE OF MATERIAL AND THE SURFACE ON WHICH TO USE THE MATERIAL FOR A RESTORATION.

QUESTION 5

AVAILABLE LITERATURE SHOWS THAT DUAL-ARCH IMPRESSIONS ONLY COMPARE FAVOURABLY WITH FULL-ARCH IMPRESSIONS WITH RESPECT TO THE FABRICATION OF ______ PROSTHESES.

A B C D

SINGLE UNIT PROSTHESIS SIX UNIT ANTERIOR FIXED PROSTHESIS PARTIAL DENTURES FULL UPPER AND LOWER DENTURES

QUESTION 6 A B C D

BECAUSE OF A HIGH PROPORTION OF INADEQUATE FINAL MASTER IMPRESSIONS, IT IS SUGGESTED THAT

THE HYGIENIST TAKE THE IMPRESSION AN INTRA-ORAL SCAN IS USED THE DENTISTS SCRUTINIZES THE IMPRESSION BEFORE SENDING TO THE LABORATORY THE DENTISTS CAST THE MODELS SADTJ Vol 6 Issue 3

The Saudi Dental Journal (2015) 27, 208–214

King Saud University

SOFT VERSUS HARD OCCLUSAL The Saudi DentalSPLINT Journal THERAPY IN THE MANAGEMENT OF TEMPOROMANDIBULAR DISORDERS www.ksu.edu.sa www.sciencedirect.com (TMDS) ORIGINAL ARTICLE

Soft versus hard occlusal splint therapy in the management of temporomandibular disorders (TMDs) Sameh A Seifeldin a b

a,b,*

, Khaled A. Elhayes

2.2 Maxillofacial Department, College of Dentistry, King Saud University, Saudi Arabia Maxillofacial Department, Faculty of Oral And Dental Medicine, Cairo University, Egypt

Received 19 October 2014; revised 12 November 2014; accepted 21 December 2014 Available online 25 June 2015

KEYWORDS Soft occlusal splint; Hard occlusal splint; MPD; Internal derangement; TMJ

Abstract Aim: To compare between soft and hard occlusal splint therapy for the management of myofacial pain dysfunction (MPD) or internal derangement (ID) of the temporomandibular joint (TMJ) with reciprocal clicking. Patients and methods: This study included 50 patients (age range: 24–47 years) who had been diagnosed with MPD or ID of the TMJ in the form of reciprocal clicking. Patients were divided into two groups. They were treated for 4 months with either a vacuum-formed soft occlusal splint constructed from 2-mm-thick elastic rubber sheets (soft splint group) or a hard flat occlusal splint fabricated from transparent acrylic resin (hard splint group). Monthly follow-up visits were performed during the treatment period. Before treatment and 1, 2, 3 and 4 months after treatment, the dentist measured all parameters of TMJ function (pain visual analog scores, tenderness of masticatory muscles, clicking and tenderness of the TMJ, and range of mouth opening). Results: All parameters of TMJ function showed significant improvement in both groups during the follow-up period, with a statistically significant difference between the two groups at the 4-month follow-up visit. Conclusions: Both forms of occlusal splints (soft and hard) improved TMJ symptoms in patients with MPD or ID of the TMJ. However, the soft occlusal splints exhibited superior results after 4 months of use. ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

* Corresponding author at: 11545, Riyadh-B.O. 60169, Riyadh, Saudi Arabia. Mobile: +966 506944359; fax: +966 14678548. E-mail address: samehseif@doctor.com (S.A Seifeldin). Peer review under responsibility of King Saud University.

Production and hosting by Elsevier

1. Introduction The temporomandibular joint (TMJ) is interrelated with other neuromuscular components. Defects of any of these components or factors preventing them from working in harmony could lead to temporomandibular disorders (TMDs). The American Academy of Orofacial Pain classiﬁes TMD broadly

http://dx.doi.org/10.1016/j.sdentj.2014.12.004 1013-9052 ª 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

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Soft versus hard occlusal splint TMD therapy into myogenous and arthrogenous types, both of which can be present at the same time, making diagnosis and treatment more difficult (Kafas and Leeson, 2006). TMDs have a multifactorial etiology, with bruxism, psychological illness, and traumatic injuries from mastication, extreme mouth opening, and dental treatments being considered as the main causes (Fearon and Serwatka, 1983; Seligman et al., 1988; Pullinger and Seligman, 1991; Lavigne et al., 2008). TMDs are characterized by clicking and pain, either confined to the TMJ region or radiating to the eyes, shoulder, and neck. Headaches, tinnitus, jaw deviation, locking, and limited mouth opening are common symptoms (Pollmann, 1993; Kafas et al., 2007a). Pain is the most crucial symptom for which patients seek medical care (Dworkin et al., 1990). TMJ locking could progress to complete jaw motion inability. Symptoms range from minor to disabling (Dworkin, 1997). Management of TMD includes conservative and surgical interventions. Examples of conservative treatments are physical therapy, localized steam application, external muscle massage (Reisine and Weber, 1989), occlusal adjustment (Lundh et al., 1988), analgesia, psychotropic medication (Greene, 1992), splint therapy (Kafas et al., 2007b), alternative therapies such as acupuncture (List et al., 1993), as well as treatment modalities such as ultrasound, soft laser, diathermy, and infrared radiation (Mohl et al., 1990). Surgical treatments include meniscoplasty, meniscectomy, and meisectomy with disk replacement using the Proplast-Teflon interpositional implant (Tolvanen et al., 1988; Peltola et al., 2000). Occlusal adjustment involves repositioning the mandible to a centric position by using prosthodontic or orthodontic appliances. Intraoral occlusal splints are designed to provide even and balanced occlusal contact without forcefully altering the mandibular rest position or permanently altering the dental occlusion. Usually made of processed hard acrylic, a splint is worn on the teeth like retainer or a removable denture. Types of occlusal splints include the stabilization splint, modified Hawley splint, and repositioning splint (Wright et al., 1995). Nevertheless, the use of occlusal splints to alleviate TMD signs and symptoms is controversial (Mona et al., 2004). Most comparative studies of different splint designs have relied only on medical history and clinical examination to diagnose disk displacement (Lundh et al., 1985). Soft splints, which are more convenient for patients than hard splints, can be used immediately after provisional diagnosis with TMD (Wright et al., 1995). The rationale for using soft splints is that the soft resilient material may help in distributing the heavy load associated with parafunctional habits (Okeson, 2003). Hard splints are thought to reduce TMD symptoms by altering the occlusal equilibrium, changing the afferent impulses to the central nervous system, improving the vertical dimension, correcting the condylar position, and aiding cognitive awareness (Dylina, 2001). Littner et al. (2004) reported that hard splints offer more successful outcomes than soft splints for patients with functional disorders of the masticatory system. However, other studies have shown that both soft and hard appliances are equally beneficial in improving masticatory muscle pain in the short term (Pettengill et al., 1998). Given these contradictions, this study aimed to evaluate soft and hard occlusal splint therapies for the management of myofacial pain dysfunction (MPD) or internal derangement (ID) of the TMJ in patients with reciprocal clicking.

209 2. Patients and methods 2.1. Patient selection The study sample included 50 patients (21 males and 29 females) who were referred to the Oral and Maxillofacial Surgery outpatient clinic of the Faculty of Oral and Dental Medicine of the Cairo University between January 2010 and November 2012. Inclusion criteria for patient selection were a diagnosis of MPD or ID of the TMJ reciprocal clicking. Patients with a history of previous treatment for TMD were excluded. Diagnostic criteria of MPD included tenderness of the masticatory muscles, restricted or deviated mandibular movement due to muscular restriction, and a myofacial pain duration of at least 3 months. Diagnostic criteria of ID included a history of TMJ noise, anterior disk displacement with reduction, and negative locked jaw. Selected patients were divided into two groups and treated for 4 months with either vacuum-formed soft occlusal splints constructed from 2-mmthick elastic rubber sheets (soft splint group), or hard flat occlusal splints fabricated from transparent acrylic resin (hard splint group). 2.2. Preoperative examination At the first visit after study selection, each patient provided a thorough medical history that included a description of the pain (type, frequency, and intensity) and reaction to jaw movements during chewing, speaking, and swallowing. To record pain intensities, patients used the Visual Analog Scale (VAS, 10-cm line), which ranged from 0 (no pain) to 10 (worst possible pain). A clinical evaluation was performed, which included measurement of the maximum comfortable jaw opening using a Boley gauge, as well as assessments of clicking, tenderness at rest and during various jaw movements, and deviation during opening and closing movements. Tenderness of the extraoral masticatory and neck muscles was evaluated by digital palpation. Resistance testing and functional manipulation were used to evaluate the medial and lateral pterygoid muscles. Symptom severity of clicking and tenderness of the TMJ and muscles were graded as 1 (negative), 2 (moderate), or 3 (severe). 2.3. Splint construction Splints were constructed for the upper arch of each patient. For both splint types, a master cast of the maxilla was fabricated by taking an alginate impression of the maxillary arch. For the soft splint, a vacuum pressure molding device was used for fabrication with 2-mm-thick rubber sheets measuring 13 · 13 cm. The rubber sheet was completely and properly adapted to the cast in the vacuum former. The sheet was removed, and sharp scissors were used to trim the splint edges. The palatal portion of the splint was removed to obtain the final shape (Figs. 1 and 2). For the hard splint, self-curing transparent acrylic resin was used to fabricate the splint in the form of a flat anterior bite plane with a thickness of 2–3 mm, which separated the posterior teeth while allowing contact between the anterior teeth. The hard splint was retained by Adam’s clasps on the upper first molars (Figs. 3 and 4).

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All splints were disinfected with 2% glutaraldehyde and then tried in the patient’s mouth to check retention. Patients were advised to wear the splint for 4 months. Instructions were given to the patients for progressively increasing the duration of splint use, starting from 2 h on the ﬁrst day. The time that the splint was used was increased by 2 h each day to reach 14 h per day by the end of the ﬁrst week. This splinting time was maintained during the second week. At the beginning of the third week, the splinting time was increased by 2 h per day to reach 24 h per day by the end of the week. Subsequently, patients were advised to wear the splint at all times except during meal times and while performing oral hygiene procedures.

Figure 3 mouth.

Flat anterior bite plane hard splint inside patient

2.4. Data and statistical analyses Patients were recalled weekly during the ﬁrst month and then monthly after 1, 2, 3, and 4 months of treatment. Monthly follow-up intervals between start of treatment and 1 month, 1–2 months, 2–3 months, and 3–4 months are designated as 1 M, 2 M, 3 M, and 4 M, respectively. TMJ functional parameters, including pain visual analog scale (VAS) scores, tenderness of the masticatory muscles, clicking and tenderness of the TMJ, and range of mouth opening, were recorded before treatment and at each follow-up visit. TMJ functional parameters were measured and compared between groups and across the follow-up period. Adequate treatment was deﬁned as pain VAS scores less than 2, negative clicking, and a maximum mouth opening of greater than 38 mm. For statistical analysis, the Microsta7 for Windows software package (Microstat Inc.) was used. A one-way ANOVA was used to evaluate the effect of time on parameters in each group, whereas the independent Student t-test was used

Figure 1

The ﬁnal trimmed night guard & patient cast.

to compare the two groups at each follow-up interval. The significance level for this study was set at p 6 .05. 3. Results The study comprised of 50 patients (age range: 24–47 years) who had been diagnosed with MPD or ID of the TMJ with reciprocal clicking. Patients in both groups responded well to splint therapy. Pain, maximum jaw opening, TMJ clicking, and muscle tenderness improved in all patients during all follow-up intervals. The maximum mouth opening significantly increased over the follow-up period in both groups, with increases starting from 1 M in the soft splint group and 2 M in the hard splint group. At 4 M, but not at any other follow-up interval, the soft splint group showed significantly higher values of mouth opening (Table 1, Fig. 5). VAS scores for pain significantly decreased in both groups throughout the entire follow-up period, with no significant differences between the two groups at any interval (Table 2, Fig. 6). Clicking scores significantly decreased in both groups throughout the follow-up period, starting from 2 M with the hard splint and 3 M with the soft splint. However, there were no statistically significant differences between the two groups at any follow-up interval (Table 3, Fig. 7). Statistically significant improvements in the tenderness of the TMJ, masticatory muscles, and neck muscles were found in both groups throughout the follow-up period. TMJ tenderness did not differ between the groups at any follow-up interval (Table 4, Fig. 8). However, tenderness of the masticatory muscles showed a significantly greater percentage of improvement in the soft compared to the hard splint group, with complete disappearance of tenderness at 3 M versus 4 M (Table 5, Fig. 9). Similarly, the tenderness of the neck muscles showed a greater percentage of improvement in the soft compared to the hard splint group. Neck tenderness disappeared by 3 M in the soft splint group, but remained at 4 M in the hard splint group (Table 6, Fig. 10).

4. Discussion

Figure 2

Night guard inside patient mouth.

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As most TMD symptoms have a high incidence of remission over time, usually within 2–4 weeks (Dworkin, 1997), conservative treatment is considered more appropriate than surgery for these disorders. As a conservative treatment of TMDs, soft splints have some advantages, such as their relative simplicity, reversibility, noninvasiveness, and cost. These splints could be made to ﬁt either the maxillary or mandibular arch and often are inserted immediately (Wright et al., 1995). Owing to their soft and resilient material features, soft splints easily distribute the heavy loads encountered during parafunctional activities, and they have been associated with a high degree of patient tolerance (Okeson, 2003). In contrast, Littner et al. (2004) found that hard splints had successful outcomes in patients

Soft versus hard occlusal splint TMD therapy

Figure 4

211

Occlusion with hard splint inside patient mouth.

Table 1 Means of mouth opening during whole follow up intervals. Mean ± standard deviation

Preoperative 1M 2M 3M 4M F value Probability LSD

Hard

Soft

26.94 ± 20.60 28.39 ± 2.95 29.89 ± 3.38 32.67 ± 2.67 34.22 ± 1.77 21.779 2.14E-12 1.818

26.03 ± 3.84 27.88 ± 3.93 29.34 ± 4.15 33.28 ± 3.05 35.22 ± 2.01 38.239 3.09E-22 1.726

‘‘t’’

Probability

0.898 0.482 0.475 0.713 1.754

0.187 0.316 0.318 0.240 0.043

complaining of masticatory system disorders. Offering a third opinion, Pettengill et al. (1998) claimed that both soft and hard occlusal appliances are equally useful in improving masticatory muscle pain in the short term. Given these conflicts of opinions, the present study was conducted to compare the efficiency of soft versus hard occlusal splint therapies for the management of TMDs. In the current study, gradual rehabilitation using occlusal splints was applied to allow patient accommodation to the intraoral bulk and avoid splint rejection. VAS scores for pain showed significant improvement throughout all study intervals. Similarly, Raphael et al. (2003) reported a decrease in VAS scores and the number of painful muscles in patients with myofacial pain after 6 weeks of occlusal splint therapy. A significant improvement in mouth opening was attained in both groups across the study period. This improvement was significant after 1 or 2 months of treatment in the soft or hard splint group, respectively. These results are comparable to those of Suvinen and Reade (1989), who reported a 7.4-mm increase in jaw opening after splint therapy. The early improvement in mouth opening observed with the soft splint therapy might be due to the material resiliency, which helped to distribute the heavy functional occlusal forces and hastened relief from muscle spasms. This resiliency could also underlie the early relief from masticatory muscle tenderness compared to the hard splint group. Nevertheless, both splint therapies alleviated the pain and tenderness of the TMJ and muscles, leading to an increase in maximal jaw opening. This result is in accordance with Block et al. (1978), who concluded that almost 74% of patients with TMDs had complete remission of symptoms after 6 weeks of occlusal splint therapy. The early improvement in TMJ clicking observed with hard splint therapy might be due to the wider TMJ space created by the hard occlusal splint. The increased TMJ space allows the

37 35 33 31 29 27 25

Hard

Soft

Figure 5 Effect of time on mean values of mouth opening in both groups throughout study intervals.

Table 2 Mean values of pain scores in both groups throughout the study intervals. Mean ± standard deviation

Preoperative 1M 2M 3M 4M F value Probability LSD

Hard

Soft

8.06 ± 1.39 6.72 ± 1.99 5.39 ± 2.45 3.06 ± 1.95 0.61 ± 0.78 48.456 3.62E-21 1.21

8.19 ± 1.60 7.03 ± 1.99 5.84 ± 2.26 2.91 ± 1.78 0.47 ± 0.76 103.650 8.9765E-43 0.868

‘‘t’’

Probability

0.293 0.526 0.663 0.274 0.630

0.385 0.301 0.255 0.392 0.266

meniscus to return to its original position with ease, thus reducing the chance for clicking. The improvement in TMJ clicking and alleviation of tenderness in the TMJ and masticatory muscles observed in this study are in agreement with Kovaleski (1975), who reported improvements in TMJ clicking and tenderness after 2 months of occlusal splint therapy. Another study reported that 87% of patients showed a reduction in pain, 50% showed a reduction in VAS scores, and 70% had no clicking after splint therapy (Tsuga et al., 1989). In another study, soft splint therapy reduced facial myalgia and TMJ clicking by 74% (Harkins et al., 1988). These improvements can be attributed to the even intensity of contacts among all teeth, with disocclusion of the posterior teeth and condylar guidance in all movements. These conditions lead to a relaxation of the elevator and positioning muscles and contribute to reduce the abnormal muscle hyperactivity (Boero, 1989). Occlusal splint insertion alters the resting position, and adapting to this new position increases the occlusal vertical dimension beyond the free space. The new resting position

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9 8 7 6 5 4 3 2 1 0

Table 4 Mean values of joint tenderness in both groups throughout the study intervals. Mean ± standard deviation

PreOperative

Hard

Soft

Figure 6 Effect of time on mean values of pain scores in both groups throughout the study intervals.

Table 3 Mean values OF CLICKING SCORES IN both groups throughout the study intervals. Mean ± standard deviation

Preoperative 1M 2M 3M 4M F value Probability LSD

‘‘t’’

Probability

Preoperative 1M 2M 3M 4M F value Probability LSD

Hard

Soft

2.39 ± 0.61 2.00 ± 0.43 1.72 ± 0.46 1.44 ± 0.51 1.06 ± 0.24 23.095 6.11E-13 0.301

2.47 ± 0.57 2.03 ± 0.54 1.63 ± 0.66 1.28 ± 0.46 1.00 ± 0.00 43.661 1.68E-24 0.251

‘‘t’’

Probability

0.466 0.222 0.553 1.162 1.344

0.322 0.413 0.292 0.126 0.093

3 2.5 2 1.5

Hard

Soft

2.72 ± 0.46 2.67 ± 0.49 2.39 ± 0.61 1.83 ± 0.38 1.06 ± 0.24 42.990 1.12E-19 0.301

2.66 ± 0.48 2.56 ± 0.50 2.44 ± 0.62 1.63 ± 0.49 100. ± 0.00 74.226 5.01E-35 0.236

0.471 0.711 0.268 1.549 1.344

0.320 0.240 0.395 0.064 0.093

1 0.5 0

PreOperative

2M Hard

Soft

Figure 8 Effect of time on mean values of joint tenderness in both groups throughout the study intervals. Severe = 3, Moderate = 2, Absent = 1.

3 2.5

Table 5 Percent of negative sings of tenderness of masticatory muscles in both groups throughout the study intervals.

2 1.5

Percent of negative tenderness

1 0.5 0

PreOperative

2M Hard

Soft

Preoperative 1M 2M 3M 4M

Hard

Soft

16.67 27.78 44.4 83.33 100

18.75 40.625 75 100 100

Figure 7 Effect of time on mean values of clicking in both groups throughout the study intervals. Severe = 3, Moderate = 2, Absent = 1. 120

allows muscles to function more efficiently during contact and reduces muscle activities during postural functions. Meanwhile, the increase in the vertical dimension decreases the muscular effort required, resulting in relaxation of the muscles and TMJ (Mona et al., 2004). The findings of the present study are in agreement with those of Naikmasur et al. (2008). These authors compared the use of a soft occlusal splint with muscle relaxants and analgesics in the management of MPD, and concluded that occlusal splint therapy was superior to pharmacological treatment in terms of improving pain, muscle tenderness, and TMJ clicking. From findings obtained by electromyography of the masticatory muscles, Daif Emad (2012) concluded that occlusal splint therapy for MPD improves the signs and symptoms of TMD. Our findings support their results, revealing that occlusal splint therapy is a conservative

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100 80 60 40 20 0

PreOperative

Hard

Soft

Figure 9 Effect of time on percent of negative signs of tenderness in masticatory muscles in both groups throughout the study intervals.

treatment modality that is beneﬁcial for reducing pain and muscle tenderness and for improving jaw opening.

Soft versus hard occlusal splint TMD therapy

213

Table 6 Percent of negative sings of tenderness of neck muscles in both groups throughout the study intervals. Percent of negative tenderness

Preoperative 1M 2M 3M 4M

Hard

Soft

33.33 44.44 66.67 94.44 94.44

56.25 75 96.88 100 100

120 100 80 60 40 20

PreOperative

Hard

Soft

Figure 10 Effect of time on percent of negative signs of tenderness in neck muscles in both groups throughout the study intervals.

5. Conclusions Both hard and soft occlusal splint therapies are beneficial in the treatment of TMD; however, soft splint therapy results in earlier improvement of some TMD symptoms. Three months is considered to be the minimum period for splint therapy to improve TMD symptoms. Therefore, this study supports the use of splint therapy for managing MPD and TMDs in patients with anterior disk displacement and reduction. Ethics statement Patients participated in the current study were consented prior participation after detailed explanation of the treatment steps. Approval for the study proposal was obtained from the dental research center, faculty of oral and dental medicine, Cairo University. Conflict of interest The authors reported no conflicts of interest related to this study. Disclosure of funding We would like to declare that we did not receive any funding regarding this clinical research. All the work was done at our own expenses. References Block, S.L., Apfel, M., Laskin, D.M., 1978. The use of a resilient rubber bite appliance in the treatment of MPD syndrome. J. Dent. Res. 57, 92.

Boero, R.P., 1989. The physiology of splint therapy: a literature review. Angle Orthod. 59, 165–180. Daif Emad, T., 2012. Correlation of splint therapy outcome with electromyography of masticatory muscles in temporomandibular disorders with myofascial pain. Acta Odontol. Scand. 70 (1), 72–77 (6). Dworkin, S.F., Truelove, E., 1997. In: Rakel, R. (Ed.), Conn’s Current Therapy. WB Saunders, Philadelphia, pp. 1006–1011. Dworkin, S.F., Huggins, K.H., LeResche, L., Von Korff, M., Howard, J., Truelove, E., Sommers, E., 1990. Epidemiology of signs and symptoms in temporomandibular disorders: clinical signs in cases and controls. J. Am. Dent. Assoc. 120, 273–281. Dylina, T.J., 2001. A common-sense approach to splint therapy. J. Prosthet. Dent. 86, 539–545. Fearon, C.G., Serwatka, W.J., 1983. A common denominator for nonorganic TMJ pain-dysfunction. J. Prosthet. Dent. 49, 805–808. Greene, C.S., 1992. Managing TMD patients: initial therapy is the key. J. Am. Dent. Assoc. 123, 43–45. Harkins, S., Marteney, J.L., Cueva, O., Cueva, L., 1988. Application of soft occlusal splints in patients suffering from clicking temperomandibular joints. J. Cranio. Pract. 6, 71–75. Kafas, P., Leeson, R., 2006. Assessment of pain in temporomandibular disorders: the bio-psychosocial complexity. Int. J. Oral Maxillofac. Surg. 35, 145–149. Kafas, P., Chiotaki, N., StavrianosCh, Stavrianou I., 2007a. Temporomandibular joint pain: diagnostic characteristics of chronicity. J. Med. Sci. 7, 1088–1092. Kafas, P., Kalfas, S., Leeson, R., 2007b. Chronic temporomandibular joint dysfunction: a condition for a multidisciplinary approach. J. Med. Sci. 7, 492–502. Kovaleski, W.C., Beaver De, J., 1975. Influence of occlusal splints on jaw position and musculature in patients with temporomandibular joint dysfunction. J. Prosthet. Dent. 33, 321–327. Lavigne, G.J., Khoury, S., Abe, S., Yamaguchi, T., Raphael, K., 2008. Bruxism physiology and pathology: an overview for clinicians. J. Oral Rehabil. 35 (7), 476–494. List, T., Helkimo, M., Karlsson, R., 1993. Pressure pain thresholds in patients with craniomandibular disorders before and after treatment with acupuncture and occlusal splint therapy: a controlled clinical study. J. Orofac. Pain 7, 275–282. Littner, D., Perlman-Emodi, A., Vinocuor, E., 2004. Efficacy of treatment with hard and soft occlusal appliance in TMD. Refuat Hapeh Vehashinayim 21 (3), 52–58, 94. Lundh, H., Westesson, P.-L., Koop, S., Tillstrom, B., 1985. Anterior repositioning splint in the treatment of temporomandibular joints with reciprocal clicking: comparison with flat occlusal splint and an untreated controlled group. Oral Surg. Oral Med. Oral Pathol. 60, 131–136. Lundh, H., Westesson, P.L., Jisander, S., Eriksson, L., 1988. Discrepositioning onlays in the treatment of temporomandibular joint disc displacement: comparison with a flat occlusal splint and with no treatment. Oral Surg. Oral Med. Oral Pathol. 66, 155–162. Mohl, N.D., Ohrbach, R.K., Crow, H.C., Gross, A.J., 1990. Devices for the diagnosis and treatment of temporomandibular disorders. Part III: Thermography, ultrasound, electrical stimulation, and electromyographic biofeedback. J. Prosthet. Dent. 63 (4), 472–477. Mona, F., Nagwa, E., Dalia, E., Adel, B., 2004. Occlusal splint therapy and magnetic resonance imaging. World J. Orthod. 5, 133–140. Naikmasur, V., Bhargava, P., Guttal, K., Burde, K., 2008. Soft occlusal splint therapy in the management of myofascial pain dysfunction syndrome: follow-up study. Indian J. Dent. Res. 19, 196–203. Okeson, J.P., 2003. Management of Temporomandibular Disorders and Occlusion. 5th ed. Mosby, St. Louis. p. 260. Oral Surg. Oral Med. Oral Pathol. 1991, 71:529-534. Peltola, M.K., Pernu, H., Oikarinen, K.S., Raustia, A.M., 2000. The effect of surgical treatment of the temporomandibular joint: a survey of 70 patients. Cranio 18, 120–126.

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S.A Seifeldin, K.A. Elhayes

Pettengill, Craig A., Growney Jr., Maurice R., Schoff, Robert, Kenworthy, Christian R., 1998. A pilot study comparing the efﬁcacy of hard and soft stabilizing appliances in treating patients with temporomandibular disorders. J. Prosthet. Dent. 79, 165–168. Pollmann, L., 1993. Sounds produced by the mandibular joint in a sample of healthy workers. J. Orofac. Pain 7 (359), 361. Pullinger, A.G., Seligman, D.A., 1991. Trauma History in Diagnostic Groups of Temporomandibular Disorders. Oral Surg. Oral Med. Oral Pathol. 71 (5), 529–534. Raphael, K.G., Marbach, J.J., Klausner, J.J., Teaford, M.F., Fischoff, D.K., 2003. Is bruxism severity a predictor of oral splint efﬁcacy in patients with myofascial face pain? J. Oral Rehabil. 30, 17–29. Reisine, S.T., Weber, J., 1989. The effects of temporomandibular joint disorders on patients’ quality of life. Community Dent. Health 6, 257–270.

Seligman, D.A., Pullinger, A.G., Solberg, W.K., 1988. The prevalence of dental attrition and its association with factors of age, gender, occlusion, and TMJ symptomatology. J. Dent. Res. 67, 1323–1333. Suvinen, T., Reade, P., 1989. Prognostic features of value in the management of temporomandibular joint pain-dysfunction syndrome by occlusal splint therapy. J. Prosthet. Dent. 61, 355–361. Tolvanen, M., Oikarinen, V.J., Wolf, J., 1988. A 30-year follow-up study of temporomandibular joint meniscectomies: a report on ﬁve patients. Br. J. Oral Maxillofac. Surg. 26 (4), 311–316. Tsuga, K., Akagawa, Y., Sakaguchi, R., Tsuru, H., 1989. A short-term evaluation of the effectiveness of stabilization-type occlusal splint therapy for speciﬁc symptoms of temporomandibular joint dysfunction syndrome. J. Prosthet. Dent. 61, 610–613. Wright, E., Anderson, G., Schulte, J., 1995. A randomized clinical trial of intraoral soft splints and palliative treatment for masticatory muscle pain. J. Orofac. Pain 9, 192–199.

SOFT VERSUS HARD OCCLUSAL SPLINT THERAPY IN THE MANAGEMENT OF TEMPOROMANDIBULAR DISORDERS (TMDS) QUESTION 7 WHAT IS THE MOST CRUCIAL SYMPTOM FOR WHICH PATIENTS SEEK MEDICAL CARE? A TINNITUS B JAW DEVIATION C JAW LOCKING D PAIN QUESTION 8 WHICH OF THE FOLLOWING DOES NOT REDUCE TMJ SYMPTOMS USING HARD SPLINTS. A B C D

ALTERING THE OCCLUSAL EQUILIBRIUM, CHANGING THE AFFERENT IMPULSES TO THE CENTRAL NERVOUS SYSTEM, DISTRIBUTING THE HEAVY LOAD ASSOCIATED WITH PARAFUNCTIONAL HABITS IMPROVING THE VERTICAL DIMENSION

QUESTION 9 SPLINTS WERE CONSTRUCTED FOR THE ______ ARCH/ARCHES FOR EACH PATIENT. A UPPER B LOWER C UPPER AND LOWER QUESTION 10 A B C D 20

PATIENTS WERE INSTRUCTED TO INCREASE DURATION OF SPLINT USE BY ___ HOURS PER DAY.

1 HOURS 2 HOURS 6 HOURS 8 HOURS SADTJ Vol 6 Issue 3

QUESTION 11 A B C D

THE SOFT SPLINT GROUP SHOWED SIGNIFICANT HIGHER VALUES OF MOUTH OPENING AFTER ___ MONTHS.

1 MONTH 2 MONTHS 3 MONTHS 4 MONTHS

QUESTION 12 TENDERNESS OF THE MASTICATORY MUSCLES AND NECK MUSCLES SHOWED A GREATER PERCENTAGE OF IMPROVEMENT AT THE THREE MONTH PERIOD WITH THE SOFT SPLINT/HARD SPLINT GROUP. A B

SOFT SPLINT HARD SPLINT

QUESTION 13 A B C D

____ MONTHS IS CONSIDERED TO BE THE MINIMUM PERIOD FOR SPLINT THERAPY TO IMPROVE TMD SYMPTOMS.

2 MONTHS 3 MONTHS 4 MONTHS 6 MONTHS

SADTJ Vol 6 Issue 3

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SADTJ Vol 6 Issue 3

1.6

Printed with permission from the March 2017 issue of JDT SADTJ Vol 6 Issue 3

The alveoloplasty was completed, dental implants were placed and the team began the restorative phase of the procedure. The appropriate LOCATOR F-Tx Abutment heights were selected based on the tissue depth. The goal was to ensure the height of contour of the spherical portion of the abutment and be equal to the gingival height or slightly sub gingival (Fig. 4 LOCATOR F-Tx Abutment engaged with Abutment Driver). The LOCATOR F-Tx System features all-in-one packaging that is sterile, each package includes an Abutment (with cap to deliver the abutment to the implant site), denture attachment housing with preinserted processing ball, an extra processing ball, as well as one Blue (Low), Tan (Medium) and Green (High) Retention Ball (Fig. 5 LOCATOR F-Tx all-in-one packaging). The LOCATOR F-TX Abutments were placed onto the dental implants and each abutment was then torqued according to the implant manufacturerâ&#x20AC;&#x2122;s recommendations (Fig. 6a placement of the LOCATOR F-Tx Abutment and Fig. 6b LOCATOR F-Tx Abutments torqued into place). Once all four abutments were torqued, LOCATOR F-Tx Healing Caps were placed and the clinician proceeded to suturing (Fig. 7 LOCATOR F-Tx Healing Caps).

4 2 3

March 2017 Journal of Dental Technology 29

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Upon suturing completion, a direct technique was used for processing the LOCATOR F-Tx Denture Attachment Housings into the prosthesis. A wash impression was taken using the denture to mark the location of each abutment (Fig. 8 wash impression). The bite was then stabilized using a silicone putty bite fork that was made at the time of the denture fabrication (Fig. 9 bite stabilization). Once the impression was complete, the denture was prepared to accommodate the Denture Attachment Housings. At each abutment location, the intaglio of the denture was

marked with the CHAIRSIDE Vent Bur, drilling through the impression (Fig. 10 marking the abutment location in the denture). Next, a CHAIRSIDE Recess Bur was used to create the desired depth recesses for the LOCATOR F-TX Denture Attachment Housings (Fig. 11 recesses are made in the denture to accommodate the Denture Attachment Housing). A vent hole was also placed in the lingual of the denture to visualize full seating and for all excess CHAIRSIDE material to vent (Fig. 12 vent holes are created for visualization and excess materials to vent).

Pick up of the Denture Attachment Housings into the provisional prosthesis LOCATOR F-Tx Denture Attachment Housings with pre-inserted black Processing Ball (included in the allin-one packaging) were placed onto each of the LOCATOR F-Tx Abutments (Fig. 13 LOCATOR F-Tx Denture Attachment Housings placed on the LOCATOR F-Tx Abutment). A rubber dam was then placed over the Denture Attachment Housings to protect the surgical site and sutures during the pickup of the provisional prosthesis (Fig. 14 rubber dam placed over the Housings to

30 Journal of Dental Technology March 2017

SADTJ Vol 6 Issue 3

protect the sutures). During this stage, each Denture Attachment Housing was oriented to be parallel to each other and to maximize esthetics of the prosthesis. This process was simple and quick due to the unique spherical design of the coronal aspect of the LOCATOR F-Tx Abutment as it allows the Denture Attachment Housing to rotate in any direction (Fig. 15 LOCATOR F-Tx Denture Attachment Hosing rotating on the Abutment). CHAIRSIDE Attachment Processing Material was injected onto each Denture Attachment Housing and undercut, also into the recesses of the denture (Fig. 16ab CHAIRSIDE Attachment Processing Material injected on top of the Housings and inside the recesses of the denture). The patient was then asked to close into occlusion using the silicone bite index to stabilize the bite (Fig. 17 patient closed into occlusion allowing the CHAIRSIDE material to set)

Delivery of the completed provisional prosthesis The denture was then removed from the mouth (Fig. 18 denture removed from the mouth), the denture flanges were removed and the prosthesis was polished. The black Processing Balls were replaced with the least retentive (Blue) LOCATOR F-Tx Retention Balls included in the packaging (Fig. 19 replacement of the LOCATOR F-Tx black Processing Balls with the final Retention Balls and Fig. 20 final LOCATOR F-Tx blue Retention Balls placed using the dedicated Hex Driver

16a

16B

19 and finger tightened only). The LOCATOR F-Tx Attachment System includes PEEK Retention Balls that are available in varying levels of retention based on the specific needs of the case (Fig. 21 LOCATOR F-Tx Retention Balls). Because the LOCATOR F-Tx Fixed Attachment System did not require screws or sub-gingival cement to secure the prosthesis to the Abutments, the Completed Provisional Prosthesis had no screw access channels which maximized

March 2017 Journal of Dental Technology 31

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esthetics and increased strength (Fig. 22ab LOCATOR F-Tx provisional prosthesis with no screw access channels). The prosthesis, with the Blue Retention Balls was delivered to the patient by aligning the balls within the cavities of the F-Tx Abutments and firmly snapping it into place (Fig. 23a-b final provisional prosthesis delivered to the patient).

Conclusion

About the Author

•

With this system, the process of converting the denture to the fixed provisional took less chair time than a conventional full-arch immediate load protocol.

•

Because the definitive restoration for LOCATOR F-Tx does not require a milled titanium framework, the cost of the definitive restoration is significantly less making a fixed solution available to more patients.

•

Tooth fractures are common on a conventional hybrid, and it can take 20-30 minutes to remove and to replace back into the mouth after the repair is completed. The time to remove a LOCATOR F-Tx hybrid is minimal making managing a tooth fracture much more efficient.

Tom Wiand, CDT, has been the owner and general manager of Wiand Dental Laboratory for nearly 25 years specializing exclusively in removable prosthetics, implant assisted/supported dentures and now the All-on-4. Tom serves as an adjunct instructor at the Arizona School of Dentistry and Oral Health. Tom is also a dental technician alliance member of the American College of Prosthodontics (ACP) and an active NADL member. He also consistently donates his time, talents and resources to the AzDA DDS program, A.T. Stills C.A.R.E program, the Arizona Mission of Mercy and the Smiles Beyond the Bars.

22a

22B

23a

JDt Quiz

23B

Receive .5 point documented scientific credit for passing a quiz about this article. To get the quiz go to www.nadl.org/jdt. You can enter your answers to this quiz (course code #34916) at www. nadl.org/members/JDT/quizzes/index.cfm or fax the completed quiz to (850) 222-0053. This quiz is provided to test the technician’s comprehension of the article’s content and does not necessarily serve as an endorsement of the content by NADL or NBC.

32 Journal of Dental Technology March 2017

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UTILIZING A NEW FULL-ARCH TREATMENT SOLUTION QUESTION 14 A 62-YEAR-OLD FEMALE PATIENT PRESENTED WITH A CHIEF COMPLAINT OF NOT BEING ABLE TO WEAR HER LOWER DENTURE BECAUSE A B C

IT WAS MORE THAN 10 YEARS OLD AND NOT FITTING PROPERLY IT WAS AN IMMEDIATE DENTURE AND NEEDED A RELINE OF DISCOMFORT THROUGHOUT THE ALVEOLAR RIDGE

QUESTION 15 A B C D

A FIXED SOLUTION WAS CHOSEN AS THE BEST RESTORATIVE OPTION BUT A FIXED HYBRID WITH A MILLED TITANIUM FRAME WAS NOT AN OPTION BECAUSE

IT WAS TOO EXPENSIVE THERE WAS NOT ENOUGH INTER-OCCLUSAL SPACE IT WAS TOO COMPLICATED IT WAS ESTHETICALLY CHALLENGING

QUESTION 16

AFTER THE MEASUREMENT EVALUATION, IT WAS DETERMINED THAT A __ BONE REDUCTION WOULD BE NECESSARY PRIOR TO PLACING THE DENTAL IMPLANTS.

A 0.5-2MM B 2-3MM C 3-4MM D 4-5MM QUESTION 17 THE LOCATION OF EACH ABUTMENT WAS MARKED IN THE DENTURE BY A B C D

USING A FIT CHECKER A WASH IMPRESSION AN INDELIBLE MARKING PENCIL USING GNATHOLOGICAL TEST PAPER

QUESTION 18 EACH DENTURE ATTACHMENT HOUSING WAS ORIENTED TO BE PARALLEL TO EACH OTHER AND TO MAXIMIZE ESTHETICS OF THE PROSTHESIS A TRUE B FALSE

SADTJ Vol 6 Issue 3

NobelProcera® fixed and fixed-removable bars It’s time to raise the bar Discover outstanding individualized solutions only state-of-the-art design technology can offer. – – – –

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SADTJ Vol 6 Issue 3

EFFECT OF PALATAL FORM ON MOVEMENT OF TEETH DURING PROCESSING OF COMPLETE DENTURE PROSTHESIS: AN INâ&#x20AC;&#x2018;VITRO STUDY 2

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SADTJ Vol 6 Issue 2

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[Downloaded free from http://www.contempclindent.org on Sunday, July 03, 2016, IP: 105.229.224.168]

Babu, et al.: Effect of palatal form on movement of teeth 11. Hegde V, Patil N. Comparative evaluation of the effect of palatal vault configuration on dimensional changes in complete denture during processing as well as after water immersion. Indian J Dent Res 2004;15:62-5. 12. Harman IM. Effects of time and temperature on polymerization of a methacrylate resin denture base. J Am Dent Assoc 1949;38:188-203. 13. Anthony DH, Peyton FA. Evaluating dimensional accuracy of denture bases with a modified comparator. J Prosthet Dent 1959;9:683-92. 14. Mainieri ET, Boone ME, Potter RH. Tooth movement and dimensional change of denture base materials using two investment methods. J Prosthet Dent 1980;44:368-73. 15. Sykora O, Sutow EJ. Comparison of the dimensional stability of two waxes and two acrylic resin processing techniques in the production of complete dentures. J Oral Rehabil 1990;17:219-27. 16. Nogueira SS, Ogle RE, Davis EL. Comparison of accuracy

17. 18. 19.

20. 21.

between compression- and injection-molded complete dentures. J Prosthet Dent 1999;82:291-300. Pasam N, Hallikerimath RB, Arora A, Gilra S. Effect of different curing temperatures on the distortion at the posterior peripheral seal: An in vitro study. Indian J Dent Res 2012;23:301-4. Glazier S, Firtell DN, Harman LL. Posterior peripheral seal distortion related to height of the maxillary ridge. J Prosthet Dent 1980;43:508-10. McCartney JW. Flange adaptation discrepancy, palatal base distortion, and induced malocclusion caused by processing acrylic resin maxillary complete dentures. J Prosthet Dent 1984;52:545-53. Jagger RG. Dimensional accuracy of thermoformed polymethyl methacrylate. J Prosthet Dent 1996;76:573-5. Komiyama O, Kawara M. Stress relaxation of heat-activated acrylic denture base resin in the mold after processing. J Prosthet Dent 1998;79:175-81.

EFFECT OF PALATAL FORM ON MOVEMENT OF TEETH DURING PROCESSING OF COMPLETE DENTURE PROSTEHESIS: AN IN-VITRO STUDY. QUESTION 19 WHICH OF THE FOLLOWING IS NOT A CAUSE OF TOOTH MOVEMENT DURING THE PROCESSING OF COMPLETE DENTURES. A B C D

DIFFERENT INVESTING PROCEDURES THICKNESS OF THE DENTURE BASE AMBIENT TEMPERATURE CARELESS PACKING OF ACRYLIC RESINS

QUESTION 20

OVERALL MOVEMENT OF TEETH BETWEEN STAGES 1 AND 3, IN THE SHALLOW PALATAL FORM DENTURES WAS IN _______ DIRECTION

A BUCCAL B ANTERIOR C PALATAL D POSTERIOR QUESTION 21

OVERALL MOVEMENT OF TEETH BETWEEN STAGES 1 AND 3, IN THE DEEP PALATAL FORM DENTURES WAS IN _______ DIRECTION

A BUCCAL Contemporary Clinical Dentistry | Jan-Mar 2016 | Vol 7 | Issue 1 B ANTERIOR C PALATAL D POSTERIOR 34

SADTJ Vol 6 Issue 3

QUESTION 22 INACCURACIES IN THE OCCLUSAL HARMONY OF COMPLETED PROSTHESES CAN BE CAUSED BY: A TECHNICAL OR CLINICAL JUDGMENT ERRORS MADE BY THE DENTIST B TECHNICAL ERRORS MADE IN THE DENTAL LABORATORY C PATIENT NON-COMPLIANCE D DEFICIENCIES OF THE TECHNIQUES AND MATERIALS USED IN THE CONSTRUCTION OF THE DENTURE A ALL OF THE ABOVE B NONE OF THE ABOVE C A, B, D D C QUESTION 23

THE TECHNIQUES USED IN FINISHING AND POLISHING PRODUCE HEAT THAT MAY CAUSE DISTORTION OF THE DENTURE BASE.

A TRUE B FALSE QUESTION 24 THE AMOUNT OF TOOTH MOVEMENT COULD BE ______ DURING THE PROCESSING OF COMPLETE DENTURES BY PROPER HANDLING OF WAX, POWDER/LIQUID RATIO FOR INVESTING, TECHNIQUE OF DEFLASKING, AND USING MANUFACTURERS RECOMMENDED CURING CYCLES. A INCREASED B REDUCED

SADTJ Vol 6 Issue 3

#dentasa2017

Dr Dittmar Eichhoff Snoring - Is Snoring a Problem or just an Irritation? This presentation will explore and summarize the need to recognize snoring as a medical condition, the evaluation, diagnosis and appropriate treatment

#dentasa2017

David Bullock 3D Printing and associated tech, what is required to enable the use of the technology? Why does it make sense to use 3D Tech in various applications? What skills are required, whatâ&#x20AC;&#x2122;s the learning curve like?

SADTJ Vol 6 Issue 3

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Bill Marais Demystifying Full Arch Implant Retained Cases With full arch implant cases, technicians must rely on past experience, intuition, and logic to achieve the sought after outcome for a case. Yet a successful outcome is also largely dependent on the preparation in the dental practice, as well as the vital communication between the dentist and the technician (included in that communication is the relaying of pertinent information via photography). In the dental practice, stabilizing jigs, stone jigs, duplication techniques, bite management, and understanding the cleansability of the full arch implant retained cases are crucial to the successful outcome of such cases.

#dentasa2017

Bill Marais One Step Back, Ten Steps Forward (Reverting to the Basics of Dental Technology) The market for systems manufacturing dental restorations and prostheses today is tremendously overwhelming - for dental technicians and dentists alike. Extreme pressure from marketing propaganda dictates that in order to prevent â&#x20AC;&#x153;falling behindâ&#x20AC;? in an advancing health field, one must follow a particular course, a path to advance you in the dental field. Purchase a particular system and you will advance your practice, your skills and your artistry. Circumstances dictated my professional choices several years ago. Because of my situation, I was forced to resort to using the fundamentals of dental technology. Reverting to the basics of dental technology not only supported the survival of my business, it took my restorative skills to a level I never imagined possible.

#dentasa2017 Back by popular demand:

AndrĂŠ Buys

PERFECT SHOT From start to finish, either lab-side or chair-side, capturing cases photographically is an integral part of Dental Technology.

SADTJ Vol 6 Issue 3

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Dr. Niel Grundling Rehabilitation of a midface injury in a young patient. A multidisciplinary approach over a 10-year period In 2003, a 9 year old girl sustained soft tissue and facial bone injuries when a brick was thrown through the window of the vehicle in which she was travelling. The injuries included laceration and abrasion of the upper lip, nose and glabella, degloving of the midface, fracture of the frontal bone, nasal septum, nasal bones, nasal cartilage, dentoalveolar fracture and avulsion of teeth 12 and 11 and fracture of the incisal edges of the lower insicors. The multidisciplinary approach to the management and rehabilitation of this young girl will be presented which includes the initial, intermediate and final phases of treatment. The challenges of managing such an injury will be highlighted and will include the effect that trauma has on the growth of the midface in young patients.

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Dr Albertyn Potgieter TMJ Anatomy & Practical TMD Therapy During this presentation I will be reviewing TMJ anatomy, normal TMJ function, TMJ pathology with its associated signs & symptoms and share a classification of TMJ disorders that enables us to treat any TMJ disorder practically and for the most part non-surgically. Dental treatment options include: Splint therapy, TMJ Orthopedics & Orthodontics and Bite rehabilitation (Dentures, Implants, Crown & Bridge work).

SADTJ Vol 6 Issue 3

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SADTJ Vol 6 Issue 3

International

4 May 2017

| Evening Edition

NO ONE SAW IT COMING So, 2016. That was the year that was. And what it was, was exactly what everyone thought it wouldn’t be. Seldom in history has a year confounded every prediction and bafﬂed every so-called “expert”. Accepted wisdom was that the US would see its ﬁ rst female president. Instead, she got trumped by a man we’d written off. The general consensus of the British (and world) media was that Britain would “bremain” part of the European Union. By contrast, the general consensus of the British public was the complete opposite

– and a world woke up to be shocked by Brexit over breakfast.

2016 was a watershed year in a multitude of ways – but it will mostly be remembered as the year when we, quite simply, got it wrong. The global zeitgeist was misinterpreted in ways that will have profound repercussions. Talk is of the “echo chamber effect” – the self-fulﬁ lling prophecy of a minority of elitist voices echoing each other’s presumptions, but ultimately being completely out of touch with the masses. Except this time, it didn’t fulﬁ ll itself.

And what that means is that the “smart” media, the “thinking man’s” papers, the intellectuals and the “experts” are wildly out of touch with what the common man is thinking and feeling.

Whether what the common man is thinking and feeling, and consequently doing, is right or wrong, is a moot point. Those of us who thought we had our ﬁ nger on the pulse of public sentiment, were miles off. So as reporters, conveyors and ultimately shapers of thought, we have some very serious soul-searching to do.

HERE’S SOMETHING TRULY R ARE – A BUSINESS THAT FLOURISHED FINANCIALLY IN 2016 2016. The US Elections. Brexit. To name but two. It will go down in history as a year of unpredictability, where the economic climate was, well, stormy to say the least. Yet PPS flourished – allocating over R2.7 billion in profits to members’ PPS Profit-Share Accounts as well as accumulating a record R31.4 billion in PPS Group assets.** A rare achievement indeed. And a rewarding one for all our members. Because while for many, 2016 is a year they’d rather forget, PPS has made it a year to remember. So if you’re a graduate professional who wants to join this community and share all our profits, visit pps.co.za or speak to a PPS-accredited financial adviser today.

#R AREISREWARDING Life Insurance

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PPS offers unique financial solutions to select graduate professionals. PPS is an authorised Financial Services Provider. Members with qualifying products share all the profits of PPS. **Excluding assets in unit trusts for third parties. Past performance is not necessarily indicative of future performance.

SADTJ Vol 6 Issue 3

havas 15501/E

THE FINANCIAL JOURNAL