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Smile Dental Journal Volume 4, Issue 2 - 2009


Ulternative Therapy

Dental Pulp Stem Cells,

a New Era in Tissue Engineering


Stem cells are primitive cells that can differentiate and regenerate deteriorating cells in different parts of the body such as heart, bones, muscles and nervous system. For years scientists all over the world have been working on possibilities of using these stem cells to regenerate human cells which are damaged due to illness, developmental defects and accidents. This article is to give an overall idea about stem cells in general, history and future, and where does dentistry stand in that field.

Key words: Stem cell, Embryonic stem cells, Adult stem cells, SHED, Chondrocytes, Osteoblasts, Adipocytes, Mesenchymal stem cells. Introduction

Dr. Ghada A. Karien BDS, JDB (Paed) • Paediatric dentist Jordanian Dental Board in paediatric dentistry • MOH/Al-Basheer hospital

The term stem cell was proposed for scientific use by Russian histologist Alexander Maksimov in 1908. While research on stem cells grew out of findings by Canadian scientists in the 1960s.1, 2 In general there are two broad types of stem cells which are: Embryonic stem cells, and Adult stem cells. Embryonic stem cells were harvested from embryos, they are cells derived from the inner cell mass of the blastocyst (early stage embryo, 4-5 days old, consist of 50-150 cells) of earlier morula stage embryo.3 In other words these are the cells that form the three germ layers, and are capable of developing more than 200 cell types. In 1998 the first human embryonic stem cell line was derived at university of Wisconsin-Madison.4 Embryonic stem cells have both moral and technical problems, because these cells will later develop into a human being, taking these cells will require destruction of an embryo. Technically these cells are difficult to control and grow and they might as well form tumors after their injection. Differentiating embryonic stem cells into usable cells while avoiding transplant rejection are just a few of the hurdles that embryonic stem cell researchers still face.5 And after ten years of research6, there are no approved treatments or human trials using embryonic stem cells; but because of the combined abilities of unlimited expansion and pluripotency, embryonic stem cells remain a theoretically potential source of regenerative medicine and tissue replacement after injury or disease.


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That opened the window wide for the so called adult stem cells, which are cells found in a developed organism and they have two properties: first the ability to divide and create another cell like itself. Second they divide to create a more differentiated cell than itself. They can be found in both children and adult.7 Adult stem cells can in general be found in umbilical cord blood, blood and bone marrow. Pluripotent stem cells can be found in cord blood but are small in Number.8 These adult stem cells have been successfully used for many years to treat leukemia and related bone/blood cancers through bone marrow transplants. The first one marrow transplant between two siblings was done successfully in 1968.

Osteoblasts: They are stem cells that have the ability to regenerate bone. Adipocytes: Another type of stem cells that have the ability to repair damaged cardiac tissues following a heart attack. Mesenchymal Stem Cells: Those are the most potent among all tissue stem cells and have the ability to differentiate into various types of reparative cells. In general Mesenchymal Stem Cells MSC are non-haematopoietic stromal cells capable of differentiating into a range of cells, those cells were first discovered in bone marrow and they were noticed to have the ability to double into many populations without loss of function, they also have the so called homing property which means that when they are delivered systemically they migrate to the site of injury. So it is to say that MSC are more promising for therapeutic applications than other types of stem cells.12

Most adult stem cells are lineage restricted and are generally referred by their tissue of origin e.g. mesenchymal stem cells, adipose derived stem cells, endothelial stem cells...etc.9,10

Stem Cells in Dentistry

In the year 2003 Dr. Songtao Shi who is a paediatric dentist discovered baby tooth stem cells by using the deciduous teeth of his six year old daughter, he was luckily able to isolate, grow and preserve these stem cells’ regenerative ability, and he named them as SHED (Stem cells from Human Exfoliated Deciduous teeth).11 After the scientists studied the dental pulp looking for stem cells they found that the dental pulp was rich in different stem cell types such as: Chondrocytes: which are stem cells that have the ability to regenerate cartilage and these cells play an important role in the treatment of arthritis and joint diseases.

Mesenchymal stem cells

Recently stem cell banks are present, and even some of these banks do not only freeze cord stem cells but also dental stem cells of baby teeth. This can be done easily when a child’s anterior milk tooth is shedding, the tooth is extracted by the dentist and preserved in a special kit provided from the stem cell bank company who then in their turn transfer the tooth to their special labs to harvest the dental stem cells and store them in their bank for each child confidentially until they are needed later for the child himself or a member of his family. Smile Dental Journal Volume 4, Issue 2 - 2009


Ulternative Therapy Tissue engineering and regenerative medicine seek to replace lost or damaged tissues due to any reason, and this needs three major ingredients which are: 1- Morphogenic signals such as growth factors and differentiation factors, these factors play an important role in the multiplication and differentiation of stem cells into the specifically needed type of cells. BMPs (bone morphogenic proteins) and cytokines play a major role in organogenesis, and in the dental aspect specifically GDf-11 (growth/differentiation factor 11) which is a novel member of BMP/TGF B family is expressed in differentiating odontoblasts and plays a major role in differentiation of dental pulp stem cells into odontoblasts which is the corner stone in teeth tissue engineering.13 2- Responding stem cells which are originally harvested from the patient and preserved under good conditions to maintain their special ability to differentiate into a wide range of cells. 3- Scaffold of extra cellular matrix, which provide these cells with the environment and mold to grow into what we want them to become and function. One of the major advantages one gets from harvesting stem cells from his own body and then using them later in his tissue regeneration if he has an illness is that there will be no refusal of these cells as they are already body parts, in other words the patient will not need to go through the process of immunosuppressant and that will spare him lots of suffering and time. In the future, medical researchers anticipate being able to use technologies derived from stem cell research to treat a wider variety of diseases including cancer, Parkinson’s, Alzhimer, spinal cord injuries, diabetes, heart diseases, liver disease,

blindness, multiple sclerosis, muscle damage and many other diseases.14,15,16,17 Specifically talking about the dental field, years from now dental stem cells will hopefully be able to correct cleft palate sparing children from multiple surgeries, stem cells will also have the potential to save injured teeth and jaw bones, correct periodontal defects, and most strikingly regenerating entire teeth structures is the horizon. Many people will ask themselves, how can the scientists be able to use dental stem cells in regenerating dental tissues? Well, there are three approaches which were investigated by different labs to implant stem cells from teeth in humans and these are: 1- Placing the stem cell into a mold of tooth crown which is made of Enamel-like substance with a scaffold material, and then they will start to loop blood vessels through this scaffold, after that this will be implanted elsewhere in the body and wait until it is mature, then these teeth will be extracted and implanted in the oral cavity. 2- Harvesting a wisdom tooth of a person and releasing stem cells from their pulp tissue, the stem cells are then implanted in a severely injured tooth, for example in cases of car accidents or falling down, and these implanted stem cells will help to regenerate the pulp of the injured teeth sparing them root canal treatments. 3- If there are no teeth present in the oral cavity from which stem cells can be harvested, we can take stem cell from unerupted wisdom tooth, organize them into three dimensional structures and give proper cues to them before putting them back into the socket; this is like planting a seed and waiting for it to grow.18 Discovery that human mature pulp tissue contains a population of multi-potent mesenchymal dental pulp stem cells with high proliferative potential for self renewal and the ability to differentiate into functional odontoblast has revolutionized dental research and opened new avenues in particular for reparative and reconstructive dentistry and tissue engineering in general. Stem cell therapy which was once a science fiction is now becoming more towards reality, and it might make the dream of many people come true. So parents taking the decision to bank their children’s milk teeth might be the best gift they could ever give to their child. Milk teeth which were kept by children under their pillows to be collected by the tooth fairy might have a greater meaning; the tooth fairy might be able one day to save their life.


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Refrences 1. BECKER AJ, McCULLOCH EA, TILL JE. Cytological demonstration of the clonal nature of spleen colonies derived from transplanted mouse marrow cells. Nature. 1963 Feb 2;197:452-4. 2. SIMINOVITCH L, MCCULLOCH EA, TILL JE. The distribution of colony-Forming cells among spleen colonies. J Cell Physiol. 1963 Dec;62:327-36. 3. Shapiro SS, Waknitz MA, Swiergiel JJ, Marshall VS, Jones JM. Embryonic stem cell lines derived from human blastocysts. Science. 1998 Nov 6;282(5391):1145-7. 4. “New Stem-Cell Procedure Doesn’t Harm Embryos, Company Claims”. Fox News.,2933,210078,00.html. 5. Wu DC, Boyd AS, Wood KJ. Embryonic stem cell transplantation: potential applicability in cell replacement therapy and regenerative medicine. Front Biosci. 2007 May 1;12:4525-35. 6. Thomson JA, Itskovitz-Eldor J, Shapiro SS, Waknitz MA, Swiergiel JJ, Marshall VS, Jones JM. Embryonic stem cell lines derived from human blastocysts. Science. 1998 Nov 6;282(5391):1145-7. 7. JJiang Y, Jahagirdar BN, Reinhardt RL, et al. (2002). Pluripotency of mesenchymal stem cells derived from adult marrow. Nature. 2002 Jul 4;418(6893):41-9. Epub 2002 Jun 20. 8. Ratajczak MZ, Machalinski B, Wojakowski W, Ratajczak J, Kucia M. A hypothesis for an embryonic origin of pluripotent Oct-4(+) stem cells in adult bone marrow and other tissues. Leukemia. 2007 May;21(5):860-7. Epub 2007 Mar 8. 9. Barrilleaux B, Phinney DG, Prockop DJ, O’Connor KC. Review: ex vivo engineering of living tissues with adult stem cells. Tissue Eng. 2006 Nov;12(11):3007-19. 10. Gimble JM, Katz AJ, Bunnell BA. Adipose-derived stem cells for regenerative medicine. Circ Res. 2007 May 11;100(9):1249-60. 11. Miura M, Gronthos S, Zhao M, Lu B, Fisher LW, Robey PG, Shi S. SHED: stem cells from human exfoliated deciduous teeth. Proc Natl Acad Sci U S A. 2003 May 13;100(10):5807-12. Epub 2003 Apr 25. 12. Chamberlain G, Fox J, Ashton B, Middleton J. Concise review: mesenchymal stem cells: their phenotype, differentiation capacity, immunological features, and potential for homing. Stem Cells. 2007 Nov;25(11):2739-49. Epub 2007 Jul 26. 13. Nakashima M, Mizunuma K, Murakami T, Akamine A. Induction of dental pulp stem cell differentiation into odontoblasts by electroporation-mediated gene delivery of growth/differentiation factor 11 (Gdf11). Gene Ther. 2002 Jun;9(12):814-8. 14. Fiegel HC, Lange C, Kneser U, Lambrecht W, Zander AR, Rogiers X, Kluth D. Fetal and adult liver stem cells for liver regeneration and tissue engineering. J Cell Mol Med. 2006 Jul-Sep;10(3):577-87. 15. Timper K, Seboek D, Eberhardt M, Linscheid P, Christ-Crain M, Keller U, Müller B, Zulewski H. Human adipose tissue-derived mesenchymal stem cells differentiate into insulin, somatostatin, and glucagon expressing cells. Biochem Biophys Res Commun. 2006 Mar 24;341(4):1135-40. Epub 2006 Jan 26. 16. Lindvall O. Stem cells for cell therapy in Parkinson’s disease. Pharmacol Res. 2003 Apr;47(4):279-87. 17. Goldman SA, Windrem MS. Cell replacement therapy in neurological disease. Philos Trans R Soc Lond B Biol Sci. 2006 Sep 29;361(1473):1463-75. 18. Zhang W, Walboomers XF, van Kuppevelt TH, Daamen WF, Bian Z, Jansen JA. The performance of human dental pulp stem cells on different three-dimensional scaffold materials. Biomaterials. 2006 Nov;27(33):5658-68. Epub 2006 Aug 17.

Oral Medicine

Bad Breath:

What’s The Story?


Bad breath or “Oral halitosis” is a frequent or persistent unpleasant odor of breath. It is a common and multi-factorial condition. In around 85 percent of cases, halitosis is the result of microbial activity in the mouth. In patients with healthy periodontal tissue, causative bacteria deposit on the dorsal tongue. The basic psychopathological process is manifested by the release of substances caused by degradation due to bacterial activity, such as volatile sulfur compounds (VSC), organic acids, and products of metabolic activity. Factors contributing to the overgrowth of causative bacteria include decreased salivary flow and stress. This presentation reviews the current knowledge of etiology and measurement methods of halitosis, as well as the different aspects of its diagnosis and treatment.

Key words: Halitosis, Volatile sulfur compounds, tongue coating. Introduction Dr. Rafif Tayara DCD Department of Pediatric Dentistry (resident), St-Joseph University, School of Dentistry, Beirut, Lebanon

Have you ever tried to smell your own breath? It’s a common myth people use, but deprived of any truth. It is impossible to smell your own breath by cupping your hand up to your nose and smelling. Because our nose and mouth are not separate organs, and because our nose tends to filter out our own smells, smelling our own breath is practically impossible... Every day, while many develop faulty perceptions about having bad breath that affect their entire lives, others who have halitosis are unaware of their condition: this is called the “Bad breath Paradox”. Mouth malodor, an extremely common disease affects one out of four adults. 25 to 85 million American suffer from chronic bad breath, depending on who supplies the data.1,2,3 Mouth odor has negative connotations; it does not only affect the patient’s self image, but it also affects others attitudes towards the patient. That’s why “bad breath therapy” has become an increasing business, especially with commercials reinforcing existing attitudes: Over ten billion dollars are made every year out of mouthwashes, drops, mints, gums and toothpastes; dentists, being the authors of active marketing of breath treatment clinic franchises, are being more and more seeked for advice and treatment. What is bad breath? What is the etiology of bad breath? What kinds of treatments are available to patients suffering from bad breath, and how effective are all those halitosis kits which claim to treat bad breath? All these questions will be answered in our short review about halitosis.


Also called “fetor oris”, “mauvaise haleine”, the universal medical term “halitosis” used since 1930 comes from “Halitus” meaning “breath”, and “-osis” meaning “chronic disorder”.

Dr. Riad Bacho DCD, DSO, FICD Associate professor, Department of Pediatric Dentistry, Lebanese University School of Dentistry, Beirut, Lebanon


Now if the term “halitosis” is relatively recent, its negative effects go way back to the most ancient times of humanity. In Talmudic Law (2000 years old), mouth malodor of the partner may constitute a founded motive for divorce. Chinese emperors in Old China used to ask their visitors to chew clove before personal meetings.4 Since the beginning of times, wizards, wise men, and doctors had tried to find recipes and cocktails to treat halitosis: Ebert’s Papyrus (around 1700 before J-C) mentions a medication used in Old Egypt to alleviate bad breath: the tablets are made out of a cocktail based on incense, cinnamon, myrrh, and honey. Hippocrates (460-377 before J-C) had an exotic recipe based on marble powder for women suffering from bad breath.5 Old traditional treatments used Guava leafs in Thailand, eggshells in China, parsley in Italy, and urine-based mouth rinse in some European cultures. In the era of “Renaissance”, Laurent Joubert (1529-1582), the medical doctor

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consequently halitosis but also consists as a cariogenic risk factor. Moreover, an oxygen-depleted environment will allow growth of anaerobic microorganisms which do not need oxygen to degrade proteins into VSCs. A recent study3 suggests that there’s greater bacterial diversity in subjects with halitosis. More importantly, those halitosis subjects are infected with specific species such as Solobacterium moorei that are not found in subjects without halitosis. S.moorei is a Gram-positive bacteria originally isolated from human feces associated with bacteremia, septicemia, and refractory cases of endodontic infections.3 of King Henri III states that bad breath is caused by dangerous miasma that fall into the lungs and through the heart, causing severe damages. Miswak (a traditional chewing stick), particularly used in Saudi Arabia, is a natural toothbrush made from twigs of the Salvadora Persica tree. In 1993, in Tel Aviv, the first international workshop on halitosis6 led to the creation, in 1996, of the ISBOR (International Society for Breath Odor Research).


Oral halitosis usually affects about one of four adults and is mostly caused by bacteria infecting the dorsal surface of the tongue and producing volatile sulfur compounds (VSC). 60% of bacteria are present on the dorsum of the tongue, in which fissures create a low oxygen micro-environment protected from the flushing action of saliva, and especially worsen with dry mouth while sleeping.7-9 Among the species capable of VSC production are Peptostreptococcus, Eubacterium, Selenomonas, Centipeda, Bacteroides, and Fusobacterium.10 Oral breath contains VSCs (Volatile Sulfur Compounds), namely methyl mercaptan (CH3SH) and hydrogen sulfide (H2S), dimethylsulfur, diamines (putrescine, cadaverine), volatile aromatic compounds (indole, skatole), and organic acids (acetic and proprionic). VSCs are normally present in very low concentrations, but in case of halitosis, a considerable increase of their concentrations is noted. The main putative bacteria producing VSCs are the Gram-negative anaerobic bacteria, mostly affected by pH, saliva, and oxygen pressure; their main nutrient sources are proteins, peptides, or amino acids. Physic-chemical conditions, such as a neutral or alkaline pH allow anaerobic bacterial growth, degradation of proteins, and therefore the synthesis of VSCs and other odoriferous substances.9 In contrary, fermentation of carbon hydrates lowers the oral ph; an acidic ph inhibits VSCs formation and

Periodontal disease also proved to be an enhancing factor of putrefaction of saliva and production of malodor.11 Another important factor is salivary flow: “morning breath” is due to minimal salivary flow, favoring stagnation and the initiation of putrefaction processes.12 “What you eat also affects the air you exhale: Types of food known to encourage halitosis are dairy products, protein-rich diets, garlic and onion, coffee, alcohol and tobacco. Fasting, lack of sugar and stress are also responsible for halitosis”. Less frequently (20-25% of cases), halitosis is related to extra-oral causes, such as: Gastrointestinal tract disturbances, some metabolic disorders such as diabetes mellitus and renal failure.13 It may also manifest among heavy smokers, and as a side- effect of some medications that reduce salivary flow, such as antihistamines, diuretics, narcotics, antidepressants, decongestants, antihypertensives, and antipsychotics.8 Therefore, halitosis should not be treated simply as a cosmetic problem, but it may be amenable to specific and nonspecific antimicrobial therapies.

Diagnosing Smells

When diagnosing halitosis, a dentist should focus on his investigation when examining the patient: History of halitosis, its onset and duration are key factors for a good diagnosis; is the bad breath constant or intermittent? Is it only in the morning? How long does it take place after meals? Is it self reported or reported by others? The dentist should also consider non-oral factors such as tobacco, alcohol use, as well as dietary factors, neurological problems, upper respiratory tract problems, gastrointestinal tract disturbances and some metabolic disorders such as diabetes mellitus. Therefore, a comprehensive oral examination is necessary for a proper diagnosis of oral halitosis. There are three main methods of

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Oral Medicine quantifying oral malodor: organoleptic measurement, gas chromatography (GC), and sulfide monitoring: Organoleptic Measurement A subjective test dependant on the examiner’s perception of patient’s oral malodor. Different scales have been used. However, at the International Workshop on Oral Halitosis of 1999, there was a consensus on using a scale ranging from 0 to 5. Before the assessment, patients are instructed to abstain from eating strong foods and drinks (ex. garlic, onion, coffee, alcohol, etc…) at least 48 hours before the assessment and to avoid using scented cosmetics for 24 hours before the assessment. Patients must also abstain from ingesting any food or drink, or smoking, omit their usual oral hygiene practices, and abstain from using oral rinse and breath fresheners for 12 hours before the assessment.14,15

In physiological halitosis, treatment should focus on patient’s self-care and oral hygiene: explanation of halitosis and oral hygiene instructions including appropriate instructions for tongue and interdental cleaning. For oral pathological malodor, dental treatment should additionally include periodontal health assessment, Oral prophylaxis, professional cleaning, and treatment of oral diseases especially periodontal diseases, caries and faulty restorations. In cases of extra-oral pathologic halitosis where patients exhibit breath malodor with no oral origin, referral to an appropriate medical specialist should take place. Some patients are convinced of not having halitosis after they can see the lack of objective signs of malodor for themselves (pseudo-halitosis): these patients need

Gas Chromatography (GC) GC is considered the gold standard for measuring oral malodor since it is specific for VSCs, the main cause of oral malodor. The GC equipment is expensive, bulky, and the procedure requires a skillful operator. Therefore, this technology has been confined to research and not to clinical use.14,16 Sulfide Monitoring Sulfide monitors measure the concentration of Sulfide molecules in one’s breath and/or saliva. The borderline for fresh breath vs. bad breath is about 75 ppb (parts per billion). Although compact sulfide monitors are inexpensive, portable, and easy to use, most of them are not able to distinguish among the VSCs. For example, the Halimeter® (Interscan Co., Chatsworth, CA) has high sensitivity for hydrogen sulfide but low sensitivity for methyl mercaptan which is a significant contributor to halitosis caused by periodontal disease.1,15,17 Therefore, the use of sulfide monitoring device in conjunction with the organoleptic method proved to be an effective and accurate strategy for diagnosing bad breath.14 A dental clinician may also evaluate tongue coating in order to assess the level of malodor and the treatment need for halitosis. Since different tongue coating indexes have been reported in the literature, it is recommended to use one method to quantify changes in the amount of coating; One of the most reliable methods is the tongue coating index reported by Delanghe and coll.18, ranging from 0 to 3 (0: no tongue coating, 1: thin coating over 1/3 of the tongue dorsum, 2: thin coating over 2/3 of the tongue dorsum or thick coating of 1/3, 3: thick coating over 2/3 of the tongue dorsum).


Recent studies implicate the dorsum of the tongue as the primary source of VSC production both in periodontally healthy and diseased populations.11 These studies demonstrate4 that removal of the tongue coating reduces VSC production and5 when comparisons are performed among samples of mouth air collected following tongue scraping, tooth brushing, and rinsing with water in subjects with malodor, the longer lasting reductions in VSC levels are followed after tongue scraping. Therefore, hygiene improvement is the main key to treat oral halitosis.1,19 12

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to be counseled by educating them that their problem is psychological through an explanation of their results of diagnostic assessment. Others will remain completely obsessed about their perceived problem in spite of any counseling (halitophobia). Those patients should be referred to a psychological specialist.1,2,13,20 Halitosis kits and “bad breath” treatment products are available in the middle-eastern Over-the-counter pharmacies. Masking fragrances (drops, mints, gums and mouth rinses) are the least effective because of their short-term effect. More useful products include those which contain chemicals interacting with VSCs, such as oxidizing agents and zinc (Therabreath, California). Other effective products would be the antimicrobial ones; chlorhexidine and/or cetylpyridinium chloride (BreathRX/ Discus Dental, USA and Halita/ Dentaid, Spain).


Despite promoting new cures for one of society’s oldest and most troublesome social maladies, “bad breath” is still a prevalent affliction and therefore a major oral health concern. On the other hand, bad breath also merits concern since all individuals may occasionally experience episodes of malodour at some point in their lives. Halitosis is not only an esthetic issue, but has also negative implications on psychological, social and systemic health.3 There is now evidence to suggest that even low concentrations of VSCs may be toxic. Increased VSC levels also may play a role in the link between oral infection and systemic diseases such as heart disease and preterm low

birth weight.3 With few exceptions, dental schools don’t emphasize on the treatment of bad breath. It’s time to put more time and focus on this rising affliction, and incorporate bad breath treatment into oral health care providers’ agenda.

References 1. Van Steenberghe D. Breath malodor: a step-by-step approach. Coppenhagen, Quintessence books, 2004. 2. Scully C, Rosenberg M. Halitosis. Dent Update. 2003 May;30(4):205-10. 3. Haraszthy VI, Zambon JJ, Sreenivasan PK, Zambon MM, Gerber D, Rego R, Parker C. Identification of oral bacterial species associated with halitosis. J Am Dent Assoc. 2007 Aug;138(8):1113-20. 4. Talmud de Babylone. Traité Ketubot, p.72-77a, New York, Mesorah Publications, 1998 5. Anthologie Grecque., 11 241; 11 247; 11415, Paris, Editions Les Belles Lettres, 2003. 6. Rosenberg M. Bad breath: research perspectives. Tel Aviv, Rosenberg M. ed., Ramot Publishing- Tel Aviv University, 1995. 7. Tonzetich J. Production and origin of oral malodor: a review of mechanisms and methods of analysis. J Periodontol. 1977 Jan;48(1):13-20. 8. Messadi DV. Oral and nonoral sources of halitosis. J Calif Dent Assoc. 1997 Feb;25(2):127-31. 9. Washio J, Sato T, Koseki T, Takahashi N. Hydrogen sulfide-producing bacteria in tongue biofilm and their relationship with oral malodour. J Med Microbiol. 2005 Sep;54(Pt 9):889-95. 10. Szpirglas H., Ben Slama L. Pathologie de la muqueuse buccale. Paris. EMC 1999. 11. Ratcliff PA, Johnson PW. The relationship between oral malodor, gingivitis, and periodontitis. A review. J Periodontol. 1999 May;70(5):485-9. 12. Koshimune S, Awano S, Gohara K, Kurihara E, Ansai T, Takehara T. Low salivary flow and volatile sulfur compounds in mouth air. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Jul;96(1):38-41.

13. Sanz M, Roldán S, Herrera D. Fundamentals of Breath Malodour. J Contemp Dent Pract. 2001 Nov 15;2(4):1-17. 14. Baharvand M, Maleki Z, Mohammadi S, Alavi K, Moghaddam EJ. Assessment of oral malodor: a comparison of the organoleptic method with sulfide monitoring. J Contemp Dent Pract. 2008 Jul 1;9(5):76-83. 15. Ilana Eli, Roni Baht, Hilit Koriat, Mel Rosenberg. Sel-perception of breath odor. J Am Dent Assoc. 2001;132: 621-626. 16. Murata T, Rahardjo A, Fujiyama Y, Yamaga T, Hanada M, Yaegaki K, Miyazaki H. Development of a compact and simple gas chromatography for oral malodor measurement. J Periodontol. 2006 Jul;77(7):1142-7. 17. De Boever EH, Loesche WJ. Assessing the contribution of anaerobic microflora of the tongue to oral malodor. J Am Dent Assoc. 1995 Oct;126(10):1384-93. 18. Delanghe G, Ghyselen J, Bollen C, et. al. An inventory of patients’ response to treatment at a multidisciplinary breath odor clinic. Quintessence Int. 1999 May;30(5):307-10. 19. Tonzetich J. Production and origin of oral malodor: A review of mechanisms and methods of analysis. J Periodontol. 1977 Jan;48(1):13-20. 20. Yaegaki K, Coil JM. Examination, classification, and treatment of halitosis; clinical perspectives. J Can Dent Assoc. 2000 May;66(5):257-61.


Osteotomy Timing of the Implant Surgical Site: A Comparative Study in Immediately Loaded Implant Denture Cases Using Split-Mouth Design Abstract

This study is designed to compare tissue response to immediately loaded endosseous implants supporting mandibular dentures. One insertion timing stage combined with early and immediate osteotomy preparation was used in each case; thanks to split-mouth design. The comparison included soft tissue healing and bone response to the osteotomy procedure from the time of surgery to the stage of punch approach and implants’ insertion and loading with the overdenture. The criteria of comparison included soft tissue healing around the implants, implants mobility, and bone level changes around the implants.

Key words: osteotomy timing, punch technique, immediate loading, split-mouth design, atraumatic implant placement. Dr. Hazem Mourad Aly Hassan BDS, MS, FICOI • Lecturer of Prosthodontics College of Dentistry Qassim University, KSA • Prosthodontist Alexandria University Hospital, Egypt Prof. Aly Mahmoud BDS, MS, PhD, DCD, DSO, FICD Professor of Prosthodontics Faculty of Dentistry Alexandria University, Egypt Prof. Muhey El-Din El-Rashedy BDS, MS, PhD Professor of Periodontology Faculty of Dentistry Alexandria University, Egypt Prof. Mohammed Fata MD, DDS, PhD Professor of Oral and Maxillofacial/Plastic Surgery Alexandria University, Egypt Dr. Osama Gaber BDS, MS, PhD • Assistant Professor of Prosthodontics, Riyadh College of Pharmacy & Dentistry, KSA • Lecturer of Prosthodontics MUST University, Egypt



Many edentulous patients suffer from reduced stability, retention, and load-bearing areas especially in mandibular dentures.1-4 With the introduction of osseointegration concept by Branemark, osseointegrated implant supported overdentures have been used in the rehabilitation of the edentulous lower jaw with excellent results.1 An overdenture supported by two implants is the simplest and least expensive alternative that also presents fewer complications and maintenance requirements than fixed prosthesis in the mandible.1, 2 The survival rate of dental implants has been correlated with the formation of a bone-implant interface.5 A two-stage approach with a 3-to-6 month healing period is recommended for the conventional osseointegration technique with oral implants. However, this may induce inconvenience and discomfort for patients, and immediate loading protocols are preferable.6 The success rate for immediately loaded mandibular implants is similar to that obtained in cases of delayed loading and there is no significant difference between results.7 Accordingly, immediate loading of the edentulous mandible with an implant-borne restoration is an acceptable and predictable method to deliver efficient return of function for the edentulous patient.8 With appropriate patient selection, single-stage surgery, and immediate loading, significant benefits to implant patients can be achieved.9 However, two main problems seemed to face protocols of immediate loading, namely bone and soft tissue healing. Several types of research designs are available including, split-mouth design, whole-mouth design, and cross-over clinical trials….etc. Split-mouth designs are trials in which each subject receives greater than or equal to 2 treatments, each to a separate section of the mouth.10 Split-mouth design seems to be an effective type of clinical trial giving the advantages of reducing bias, obtaining definitive results, and decreasing cost.11,12

Review Of Literature

1. Concerning soft tissue healing and response to surgery: Second stage surgery in single or multiple implant cases is currently a simple procedure. Nevertheless, complications arising from inappropriate handling of the soft tissues, particularly during exposure of several implants, can lead to poor cosmetic and/or functional results.13

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A very simple technique of cutting the gingiva and soft tissues covering the implants’ coronal aspect with a circular blade is called “punch technique�.13 Punch technique provides a mean for implant placement that greatly reduces associated surgical morbidity and increases patient acceptance. The benefits of avoiding a mucoperiosteal flap increases final esthetic outcome and may result in reduction of crestal bone loss.14 The accuracy of the punching site can be determined by using the surgical stent again. The previously performed holes for placing the implant will be a very accurate guide to perform the punch. A probe was used, after anaesthetizing the patient, to produce a bleeding point, exactly above the implant site, which will be the center of the punch. 2. Concerning bone healing: Lamellar and woven bones are the primary bone tissues types found around a dental implant. The Lamellar bone is organized and highly mineralized. It is the strongest bone type and has the highest modulus of elasticity. Thus it is described as load-bearing bone.15 On the other hand, woven bone is unorganized, less mineralized, of less strength, and more flexible (lower modulus of elasticity). Woven bone may form at a rate of up to 10 microns per day.15 The two-stage surgical approach of dental implants permits the bone repair around the implant avoiding the early loading response by 3 to 6 months. The surgical process of the implant osteotomy preparation and implant insertion cause a regional accelerated phenomenon of bone repair around the implant interface.16 As a consequence of the surgical placement, organized, mineralized lamellar bone in the preparation site becomes unorganized, less mineralized woven bone of repair next to the implant.15 At 4 months, the bone is still 60% mineralized, organized lamellar bone.17 However, this has proven to be sufficient in most bone types and clinical situations for implant loading. Therefore, a rationale for immediate loading is not only to reduce the risk of fibrous tissue formation (which results in clinical failure) but also to promote lamellar bone maturation to sustain a continued occlusal load.18 The risks of the immediate implant loading procedure are often perceived during the first week after the implant insertion surgery.19 As a matter of fact, the bone in the macroscopic thread design of implant is stronger on the day of the implant placement compared with 3 months later, since there is more mature bone in the threads of the implant.19 However, the cellular connection of the implant surface condition does not yet exist.18 On the day of surgery, there is residual cortical and trabecular bone around the implant. When the implant is inserted, it has some contact with this prepared bone. Early cellular repair is triggered by the surgical trauma and begins to form an

increased vascularization and repair process to the injured bone.18 Woven bone formation by appositional bone growth may begin to form as early as the second week after insertion at a rate of 30 to 50 microns per day. The implant-bone interface is weakest and at highest risk of overload at approximately 3 to 5 weeks after surgical insertion, since the implant-bone interface is least mineralized and unorganized during this time frame.18 Causes of surgical trauma include thermal injury and mechanical trauma that may cause microfracture of bone during implant placement, which may lead to osteonecrosis and possible fibrous and granulation tissue encapsulation around the implant.20 Roberts reported a devitalized zone of bone of 1 mm or more around the implants as a result of the surgery.17 Eriksson and Albrektsson reported bone cell death at temperatures as low as 40oC.21 Sharawy et al reported that the amount of heat generated in the bone next to the implant drills was dependent on their design and revolutions of the drill. The temperature next to the drill ranged from 38oC to more than 41oC from a 37oC baseline and requires 34 to 58 seconds to return to base line. The two implant drill systems tested with internal cooled drills cut at a higher temperature than the two implant drill systems with external irrigation.22, 23 Other factors related to heat generation within bone during drilling include the amount of bone prepared, drill sharpness, depth of the osteotomy, variation in cortical thickness, and the temperature and solution chemistry of the irrigant.24 One method for decreasing the risk of immediate occlusal load is to have more vital bone in contact with the implant interface by decreasing the surgical trauma at implant placement.18 Misch et al suggested a method to decrease microstrain and the associated remodeling rate in bone by providing conditions to increase functional surface area to the implant-bone interface. The surface area of load may be increased in a number of ways, i.e., implant number, size, design and body surface conditions.25 A new clinical approach offers a solution to this dilemma. The approach is based on an atraumatic surgical technique through which gradual drilling (by following the regular protocol for cutting using the pilot drill, 2mm drill, and 3.5 mm drill in my case) and increasing the cutting speed will decrease the cutting force and specific energy which is defined as the energy per unit mass. Accordingly, the heat generation will decrease avoiding thermal bone necrosis that may influence bone healing and implant fixation,26 as increasing the cutting speed will decrease the time needed for cutting so less friction with bone will occur, and as a result, less heat will be produced. Also, increasing the cutting speed will need less energy to perform the drilling and thus less heat will be produced, and as a result, less osteonecrosis. Smile Dental Journal Volume 4, Issue 2 - 2009


Implantology (Figure 1) Completely edentulous patient

Rationale for New Approach

Perrone reported that bone healing after osteotomy passes through three stages:27 1. Inflammation (granulation tissue). 2. Fibrous tissue phase. 3. Maturation phase.

(Figure 2) Reflection of lingualized mucoperiosteal flap

The fibrous tissue phase was chosen to be definitely an acceptable implant bed configuration since it shows irregular collagen formation and revascularization. Moreover, at the second week, maximum resorption is complete at the margins of the bony defect and by the third week, rapid formation of new trabecular bone to repair the defect begins.27 Atraumatic heat-free insertion of implants at the fibrous tissue stage and before maturation stage provides primary stability that enables the immediate loading of implants.26

(Figure 3) Preparation of the implant site

Accordingly, it seems logical to try avoiding most of the factors resisting ideal osseointegration combined with immediate loading, namely, heat generation, edema and soft tissue problems.

Materials and Methods

Six healthy edentulous male patients were selected for the present study from the out-patient clinic, Faculty of Dentistry; Alexandria University, Egypt, with their ages ranging from 53 to 62 years. (Fig.1)

(Figure 4) Suturing the prepared site without placing the implant

For all patients, screening test for hemostasis, fasting blood sugar, measuring the blood pressure, and preoperative panoramic radiographs were done. According to split-mouth design, each patient was a member of the control group and the study group, simultaneously as follows: For all patients, the left mandibular canine area was considered as group I and the right side was considered as group II.

(Figure 5) Application of punch technique

Pre-Surgical Procedures

Upper and lower complete dentures were constructed. All lower dentures were then duplicated and clear surgical stents were fabricated using a plastic vacuum forming machine. Two small metallic balls were attached bilaterally to the cuspid area of each stent. Patients were asked to wear their stents and panoramic x-rays were taken to check the bone height and the relation of the balls to the mental foramina. The stents were perforated in the pre-determined implant areas.

(Figure 6) The exposed implant site


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Surgical Procedures

Step 1: Group I (Study Group) A lingualized full thickness mucoperiosteal flap was reflected for the osteotomy procedure of the implant. The flap was sutured after osteotomy without inserting the implant. (Figs.2, 3, 4) Patients were instructed to follow a soft diet and a drug therapy (antibiotics, anti-inflammatories, and mouth wash) was prescribed. One week later, the sutures were removed.

Implantology (Figure 7) The 2 implants in place with the ball abutments and the metal keepers


1. Results of Clinical Evaluation: A. Results of soft tissue healing: Soft tissue healing around the implants was assessed for group I, immediately after implant placement, after 7 days, and after 14 days from implant placement and loading with the prosthesis. For group II, evaluation was made immediately after surgery for implant placement, after 7 days, and after 14 days from implant placement and loading with the prosthesis.

(Figure 8) Seating of denture in close-mouth position until complete setting of acrylic resin

Step 2: (2 Weeks Later) Group I (Study Group) Punch technique was applied to expose the previously prepared osteotomy site, fibrous tissue curettage and copious irrigation of the site were performed, and then, an endosseous screw type implant (ENDURE, IMTEC Co., 11 mm length, and 3.5 mm diameter) was placed. (Figs.5, 6) Group II (Control Group) At the same time, similar implant was placed in the mandibular right canine area immediately after osteotomy preparation using conventional technique and the flap was sutured around the implant. Two mm collar O-ball abutments were placed and secured in position and the implants were immediately loaded with the overdenture. O-rings and keepers were secured over the O-ball abutments. Pick-up technique was applied to attach the O-ring system in place using cold-cured, self-cured acrylic resin SECURE (Hard Pick-Up Kit, IMTEC Co.) The patient was recalled during the week following the denture insertion to relief the denture at certain areas that may cause pain and ulceration in the mucosa. (Figs.7, 8)


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The evaluation was carried out visually by inter-examiner observation according to the following criteria:28 1. Incision line dehiscence. 2. Sloughing of the flap area. 3. Inflammation. 4. Infection. The criteria for assessment were graded as follows: 0 = Excellent healing. 1 = Slight redness at maximum 1 suture area. 2 = Moderate redness, swelling and oedema at 2-4 suture areas. 3 = Severe redness, swelling and oedema at more than 4 suture areas. B. Results of implant mobility: Mobility of the implants was assessed at 1, 3, 6 and 9 months intervals. For all patients of both groups, none of the implants showed signs of mobility. The success rate was 100%. 2. Results of Radiographic Evaluation: Both groups were examined radiographically using indirect standardized digital periapical radiographs immediately after osteotomy, implant insertion, 1 month, 3 months, 6 months and 9 months postoperatively, to measure the amount of marginal bone remodeling around each implant. Rinn technique was employed using the XCP instrument for extension cone paralleling technique. 3. Assessment of Alveolar Bone Change: Mesial and distal bone heights of the implants were evaluated using the linear assessment system supplied by the specially designed Image J software.

The approach included preparation of the implant site two weeks before implant placement. This timing allowed tissues to be relieved from the trauma induced by the preparation and ensured the placement of the implants at the fibrous tissue phase of bone healing which showed revascularization, and irregular collagen formation. Moreover, maximum alveolar bone resorption was completed at the margins and new trabecular bone was rapidly formed which is essential for repair.26, 27 Consequently, implants were placed in an excellent implant bed formed of vital bone obtained by this atraumatic surgical technique. This was in agreement with Misch who reported that decreasing the surgical trauma at the time of implant placement will decrease the risk of immediate occlusal overload. He added that this can be achieved by obtaining more vital bone in contact with the implant interface.18

The data collected from the measurements of the bone level at the mesial and distal aspects of all implants of both groups were tabulated. Wilcoxin signed rank test revealed statistically significant difference of bone level changes around the implants from LT-3 months, from LT-6 months, and from LT-9 months at P<0.05. Results showed more bone loss around the implants of group II at the mentioned periods of evaluation.

Since soft tissue health is one of the factors involved in the osseointegration process, another benefit from this approach was gained by applying a lingualized full thickness mucoperiosteal flap during preparation of the implant site.36 Reflecting the flap and repositioning it in the same place allowed uncomplicated healing of the soft tissue by primary intention, leaving the area of gingiva covering the implant bed intact.36, 37 Thereby decreasing the possibility of any peri-implant soft tissue problems affecting osseointegration.38 Consequently, application of punch technique at the time of implant placement over the prepared site giving excellent soft tissue healing besides the advantages of punch technique including simplicity, excellent esthetics, minimal bleeding, pain, discomfort, and tenderness. Also, no sutures were needed and attachment gingiva was rapidly and completely achieved.13


The new brand of cold-cured acrylic resin prevented the harmful effects of heat produced by conventional self-cured types of acrylic resin on underlying tissues.39 In this study, clinical evaluation of soft tissue healing around the implants showed that the study group had less inflammation than the control group especially 7 days after surgery.

Recent researches reported that root form implants may osseointegrate during early bone remodeling, even when loaded immediately. Immediate loading has the merit of significantly decreasing patient discomfort and eliminating the need for a second stage surgery.18, 32, 33

This may be attributed to the difference in the soft tissue condition around the implants at the time they were loaded with the prosthesis. As for the study group, the soft tissue had enough time to heal properly (2 weeks) before the prepared osteotomy site was re-entered with the soft tissue punch to place the implant which was then loaded by the prosthesis.

Although predictable long-term osseointegration had been reported after the two-stage surgical protocol established by Branemark for placement of implants in both completely and partially edentulous patients, studies of immediate loading have shown encouraging results.18, 29, 30, 31

Two implants were used to support the mandibular overdenture in all patients of this study. The screw implant design helps to increase the surface contact area between the bone and the implant, and thus minimizing the shear forces.34 Implantsâ&#x20AC;&#x2122; length and diameter were the same for all patients of this study (11 mm and 3.5 mm respectively), since any difference may influence pressure per unit area in the supporting bone.35 All surgical procedures for implant placement are considered to be traumatic to the host tissues.9 Furthermore, atraumatic surgical technique is one of the most important factors that may influence the success of immediate loading, an approach aiming to reduce the trauma to the host tissues was used in this study (group I).18

The presence of paired or multiple organs (arches, quadrants, teeth) and the chronic nature of many dental diseases suggest the use of split-mouth design. In the present study each patient was a member of both groups; considering the left mandibular canine area as group I, and the right mandibular canine area as group II. The left side was prepared first, two weeks later, the right side was prepared and both implants were placed and immediately loaded with the prostheses. By applying appropriate methods of sequencing and assignment, this design offers potential savings in resources, reduction of variables, and accurate results.40- 42

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Implantology Conclusion

From the results of this study, it could be concluded that: 1. Soft tissue healing around the implants showed marked progression by the use of punch technique in patients of group I. 2. None of the implants showed any degree of mobility in all patients of both groups. 3. Significant difference in bone level was reported around the implants starting form the 3rd month till the 9th month after implants placement and loading with the prosthesis. Group II showed more bone resorption.


The authors claim to have no financial interest in any company or any of the products mentioned in this article.

References 1. Naert I, Quirynen M, Theuniers G, van Steenberghe D. Prosthetic aspects of osseointegrated fixtures supporting overdentures. A 4-year report. J Prosthet Dent. 1991 May;65(5):671-80. 2. Christensen GJ. Treatment of the edentulous mandible. J Am Dent Assoc. 2001 Feb;132(2):231-3. 3. Feine JS, de Grandmont P, Boudrias P, Brien N, LaMarche C, Taché R, Lund JP. Withinsubject comparisons of implant-supported mandibular prostheses: choice of prosthesis. J Dent Res. 1994 May;73(5):1105-11. 4. Quirynen M, Naert I, van Steenberghe D, Teerlinck J, Dekeyser C, Theuniers G. Periodontal aspects of osseointegrated fixtures supporting an overdenture. A 4-year retrospective study. J Clin Periodontol. 1991 Nov;18(10):719-28. 5. Lum LB, Beirne OR. Viability of the retained bone care in core-vent dental implant. J Oral Maxillofac Surg. 1986 May;44(5):341-5. 6. Huré G, Aguado E, Grizon F, Baslé MF, Chappard D. Some biomechanical and histologic characteristics of early-loaded locking pin and expandable implants: a pilot histologic canine study. Clin Implant Dent Relat Res. 2004;6(1):33-9. 7. Gatti C, Chiapasco M: Immediate loading of Branemark implants: A 24-month followup of a comparative prospective pilot study between mandibular overdentures supported by conical transmucosal and standard MK II implants. Clin Implant Dent Relat Res. 2002;4(4):190-9. 8. Castellon P, Block MS, Smith MB, Finger IM. Immediate loading of the edentulous mandible: delivery of the nal restoration or a provisional restoration—which method to use? J Oral Maxillofac Surg. 2004 Sep; 62(9 Suppl 2): 30-40. 9. Hahn J. Single-stage, immediate loading, and flapless surgery. J Oral Implantology. J Oral Implantol. 2000;26(3):193-8. 10. Antezak-Bouckoms AA, Tulloch JF, Berkey CS. Split-mouth and cross-over designs in dental research. J Clin Periodontol. 1990 Aug;17(7 Pt 1):446-53. 11. Hujoel PP, Loesche WJ. Efficiency of split-mouth designs. J Clin Periodontol. 1990 Nov;17(10):722-8. 12. Hujoel PP, Derouen TA. Determination and selection of the optimum number of sites and patients for clinical studies. J Dent Res. 1992 Aug;71(8):1516-21. 13. Zunino JH, Zunino D. Implant surgery: Our experience in performing second-stage surgery by a punch approach. J Oral Implantol. 1995;21(2):148-9. 14. Auty C, Siddiqui A. Punch technique for preservation of interdental papilla at nonsubmerged implant placement. Implant Dent. 1999;8(2):160-6. 15. Roberts WE, Turley PK, Brezniak N, Fielder PJ. Implants: bone physiology and metabolism. CDA J. 1987 Oct;15(10):54-61. 16. Frost HM. The regional acceleratory phenomenon: a review. Henry Ford Hosp Med J. 1983;31(1):3-9. 17. Roberts WE, Smith RK, Zilberman Y et al. Osseous adaptation to continuous loading of rigid endosseous implants. Am J Orthod. 1984 Aug;86(2):95-111. 18. Misch CE, Wang HL, Misch CM et al. Rationale for the application of immediate load in implant dentistry: Part I. Implant Dent. 2004 Sep;13(3):207-17. 19. Strid KG. Radiographic results. In: Branemark PI, Zarb GA, Albrektsson T, eds. Tissue integrated prostheses: Osseointegration in clinical dentistry. Chicago: Quintessence; 1985: 187-191.


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20. Eriksson A, Albrektsson T, Grane B et al. Thermal injury to bone: A vital microscopic description of heat effects. Int J Oral Surg. 1982 Apr;11(2):115-21. 21. Eriksson AR, Albrektsson T. Temperature threshold levels for heat-induced bone tissue injury: a vital-microscopic study in the rabbit. J Prosthet Dent. 1983 Jul;50(1):101-7. 22. Sharawy M, Misch CE, Weller N, Tehemar S. Heat generation during implant drilling: the significance of motor speed. J Oral Maxillofac Surg. 2002 Oct;60(10):1160-9. 23. Matthews LS, Hirsch C. Temperatures measured in human cortical bone when drilling. J Bone Joint Surg Am. 1972 Mar;54(2):297-308. 24. Haider R, Watzek G, Plenk H. Effects of drill cooling and bone structure on IMZ implant fixation. Int J Oral Maxillofac Implants. 1993;8(1):83-91. 25. Misch CE, Bidez MW, Sharawy M. A biointegrated implant for an ideal bone cellular response to loading forces: a literature review and case report. J Periodontol. 2001 Sep;72(9):1276-86. 26. Lorenzoni M, Pertl C, Zhang K, Wimmer G, Wegscheider WA. Immediate loading of single tooth implants in the anterior maxilla. Preliminary results after one year. Clin Oral Implants Res. 2003 Apr;14(2):180-7. 27. Perrone MA. Physiologic and histologic response to bone cutting with rotary instruments. J Am Podiatry Assoc. 1972 Nov;62(11):413-24. 28. Hassan El-Sharkawy. Augmentation of resorbed mandibular ridge with resorbable Tricalcium phosphate and non resorbable hydroxyapatite. thesis Ph.D. 1988. 29. Branemark PI, Hansson BO, Adell R et al. Osseointegrated implants in the treatment of the edentulous jaw: Experience from a 10 year period. Scand J Plast Reconstr Surg Suppl. 1977;16:1-132. 30. Babbush CA, Kent JN, Misiek DJ. Titanium plasma-sprayed (TPS) screw implants for the reconstruction of the edentulous mandible. J Oral Maxillofac Surg. 1986 Apr;44(4):274-82. 31. Henry P, Rosenberg I. Single stage surgery for rehabilitation of the edentulous mandible: preliminary results. Pract Periodontics Aesthet Dent. 1994 NovDec;6(9):15-22; quiz 24. 32. Gotfredsen K, Hjorting-Hansen E. Histologic and histomorphometric evaluation of submerged and nonsubmerged titanium implants. In: Laney WR, Tolman DE, eds. Tissue integration in oral, orthopedic and maxillofacial reconstruction. Chicago: Quintessence; 1990: 31-40. 33. Buser D, Weber HP, Bragger U, Balsiger C. Tissue integration of one stage ITI implants: 3-year results of longitudinal study with hollow cylinder and hollow screw implants. Int J Oral Maxillofac Implants. 1991 Winter;6(4):405-12. 34. Lew I. The endosseous implant: Evaluations and modications. Dent Clin North Am. 1970 Jan;14(1):201-13. 35. Meijer HJ, Kuiper JH, Starmans FJ, Bosman F. Stress distribution around dental implants: influence of superstructure, length of implants, and height of mandible. J Prosthet Dent. 1992 Jul;68(1):96-102. 36. Eckert SE, Laney WR. Patient education and prosthodontic treatment planning for osseointegrated implants. Dent Clin North Am. 1989 Oct;33(4):599-618. 37. Strub JR, Gaberthüel TW, Grunder U. The role of attached gingiva in the health of peri-implant tissue in dogs. 1. Clinical findings. Int J Periodontics Restorative Dent. 1991;11(4):317-33. 38. Rapley JW, Mills MP, Wylam J. Soft tissue management during implant maintenance. Int J Periodontics Restorative Dent. 1992;12(5):373-81. 39. Misch CE. Contemporary implant dentistry. Chapter 15; Mandibular implant overdenture design. St Louis: Mosby Co., 2005; 228-251. 40. Hujoel PP, Derouen TA. Determination and selection of the optimum number of sites and patients for clinical studies. J Dent Res. 1992 Aug;71(8):1516-21. Erratum in: J Dent Res 1992 Oct;71(10):1760. 41. Antezak-Bouckoms AA, Tulloch JF, Berkey CS. Split-mouth and cross-over designs in dental research. J Clin Periodontol. 1990 Aug;17(7 Pt 1):446-53. 42. Hujoel PP, Loesche WJ. Efficiency of split-mouth designs. J Clin Periodontol. 1990 Nov;17(10):722-8.


Progressive Attachment Loss Resulting in Tooth Mobility Due to Failure of Endodontic Treatment: A Case Report Abstract

Because of the relative frequency of both periodontal disease and periapical pathology, it is not surprising that both may occur together, which can result in diagnostic confusion. However there is no doubt that pulp pathology can exacerbate present periodontal problems resulting in gingival recession and eventually tooth mobility. The aim of this report is to show the effect and complications of failure of Endodontic treatment on periodontal tissue.

Key words: Case report; chronic periodontitis; gingival recession. Methods

Elimination of the pathogenic factor, the use of lateral displaced flap, autogenous bone graft and dental implant placement were performed to restore the lost tissues and tooth.

Results Dr. Moutaz Al-Khen DDS, MSc Head of Oral & Maxillo-Facial Surgery Department Damascus General Hospital Syria

A clinically significant amount of keratinized gingival tissue and alveolar bone were restored. Dental implant and abutment restored the extracted tooth as part of the treatment plan.


Chronic Periodontitis has been defined as an infectious disease resulting in inflammation within the supporting tissues of the teeth, progressive attachment loss and bone loss.1 Teeth with chronic periodontal lesions are typically free of acute symptoms. The patient may be unaware of the condition, except for bleeding on brushing and flossing or bad breath, until sufficient attachment is lost, resulting in increased tooth mobility. Gingival recession (GR) is a common and undesirable condition. It is defined as the displacement of the marginal gingival tissue apical to the cement-enamel junction with exposure of the root surface to the oral environment.2 The simultaneous existence of pulpal pathology and inflammatory periodontal disease can complicate diagnosis and treatment planning and affect the sequence of care to be performed. Pulpal tissue maybe significantly inflamed and yet exerts little or no effect on the periodontium. As long as the pulp remains vital, it is unlikely that significant changes will occur in the periodontium. Necrosis of the pulp, however, can result in bone resorption and the presence of radiolucency on x-ray radiographs at the apex of the tooth, in the furcation, or at points along the root. The resulting lesion may be an acute apical lesion or abscess, a more chronic periradicular lesion (cyst or granuloma), or a lesion associated with a lateral or accessory canal. The lesion may remain small, or it can expand sufficiently to destroy a substantial amount of the attachment of the tooth and communicate with a periodontal lesion.

Dr. Bader E. Abdeen DDS Maxillo-Facial Surgery Department, Damascus General Hospital, Syria


Case report

In 2007, a 30-year-old healthy white female presented to the Maxillofacial Department of Damascus General Hospital for the treatment of severe GR and advanced tooth mobility of the upper left central incisor. The patient had a Miller class IV GR with the absence of nearly all of the keratinized gingiva of the offended tooth. Also, there were premature contacts related to the same tooth as a result of bone loss and drifting of the tooth. The tooth mobility was grade 3.3,4 The patient was initially treated with a conventional R.C.T in 2004. Due to the failed treatments, she underwent four separate apicoectomy surgeries and a full porcelain crown restoration over three years duration all done per her general dentist. The result was progressive GR and exposure of nearly all the buccal surface of the root and severe mobility of the offended tooth (Figs. 1,2).

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The patient was placed on phase I therapy for 3 weeks, including fastidious oral hygiene program, scaling and root planning. During phase II therapy, the plan was to extract the tooth, use a lateral displaced flap, fabricate a temporary removable denture, perform a localized bone augmentation and finally implant placement. Proper and adequate local anesthesia was administered. Extraction of the tooth, and socket debridement were performed (Fig. 3). A full thickness lateral displaced flap was incised and advanced over the socket (Fig. 4). The vascularized flap was secured and immobilized to the palatal mucosa over the remaining bone ensuring that it was not under tension. The patient was instructed to rinse with chlorhexidine (0.12%) mouth wash twice daily for 2 weeks.

(Figure 1) Preoperative view

(Figure 2) Preoperative OPG

Postoperative healing was good. The sutures were removed 10 days after surgery. No dehiscence, infection, or necrosis was observed. 6 weeks postoperatively, the flap was covered by a healthy keratinized oral mucosa (Fig. 5) and a removable partial denture replacing the upper left central incisor was fabricated.

(Figure 3) Extraction of the tooth and socket debridement

After 3 months, adequate local anesthesia was given and decortication of the bone (on the labial surface) at the recipient site was performed to allow progenitor cells easy access to a GBR-treated site and to facilitate prompt angiogenesis. It also may enhance the physical connection between a bone graft and a recipient site. An autogenous (10mm*17mm) bone graft from the chin was prepared to be fixed at the site of osseous defect (Fig. 6). A fixation screw was placed to fix the bone graft in its position (Fig. 7). Together with cancellous bone, Bio-oss bone graft was used to fill in the space between the cortical bone graft and the palatal aspect of the osseous defect. The bone graft was covered with absorbable membrane (Bioguide) and after releasing of the Flap, the flap was secured and immobilized to the palatal mucosa over the bone graft and the absorbable membrane ensuring that it was not under tension. The patient was given prophylactic antibiotics and a non-steroidal anti-inflammatory medication. The patient was instructed to rinse with Chlorhexidine (0.12%) mouth wash twice daily for 2 weeks. After the removal of sutures, a new removable partial denture was prepared. Good tissue healing after bone graft with evidence of widened alveolar ridge was observed after 4 months of the operation. A good bone height was observed on OPG (Figs. 8, 9). The patient was given adequate amount of local anesthesia and a full thickness flap was reflected for the removal of the fixation screw and placement of a Tiolox速 dental implant (Figs. 10, 11).

(Figure 4) Full thickness advanced buccal flap

(Figure 5) The flap was covered with keratinized healthy looking oral mucosa, with areas of thick gingiva

(Figure 6) Autogenous bone graft from the chin

After 6 months, OPG showed good bone structure around the implant (Fig. 12). Simple circular incision used to expose the implant and Smile Dental Journal Volume 4, Issue 2 - 2009


Surgery (Figure 7) A fixation screw used to fix the bone graft

gingival former was attached (Fig. 13). Three weeks later, transfer was attached to the implant, and a final impression was made to be sent to the lab for abutment fabrication (Fig. 14). One week later, abutment was attached to the implant (Figs. 15, 16). After 1 year, post-operative OPG showed normal bone structure (Fig. 17). Clinical examination showed normal oral tissue around the abutment.

(Figure 8) A good bone height was gained

(Figure 9) Widened alveolar ridge


Pulpal and periodontal diseases are similar in that both involve an inflammatory process; such inflammation is caused by microbial infection. The difference between pulpal and periodontal disease is essentially shown in the route, location and severity of the inflammatory reaction. With pulpal disease, the body can tolerate inflammation up to certain point where a reversible process occurs. This is similar to gingivitis, which involves reversible inflammatory reaction of the marginal gingiva. However, irreversible inflammation of the pulpal tissues can lead to pulpal necrosis, and irreversible inflammation of the periodontium leads to tissue loss. Therefore the location and severity of the inflammation result in a variable degree of tissue involvement, which in turn helps the clinician to select the appropriate treatment plan.

(Figure 10) Implant insurtion

(Figure 11) Implant insurtion

(Figure 12 Good bone structure around the implant


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Several studies have reported successful bone and attachment regeneration with Bio-oss in periodontal defects,5,6 as well as bone regeneration around implants. The success and predictability of osteointegrated dental implants have forever changed the philosophy and practice of dentistry. In the past two decades, there has been a shift in periodontology from the philosophy of saving teeth by any mean to one of extracting compromised teeth and replacing them with dental implants for a better and more predictable long-term outcome. Endosseous dental implants and their retained prostheses have had great success over the past few decades following land mark research and development of osteointegrated implants by Branemark et al. 7-9 Initially, most prosthetic reconstructions with osseointegrated implants were limited to use in the edentulous patient, with many reports documenting excellent long-term success of implant retained prostheses for edentulous patients.10, 11, 12 Currently, the long term success of dental implants used to replace single and multiple missing teeth in partially edentulous patient is very good.13, 14, 15, 16, 17 Patient with a missing single tooth will benefit greatly from the success and predictability of endosseous dental implants. Replacement of a single missing tooth with an implantsupported crown is a much more conservative approach than preparing two adjacent teeth for a fabrication of a tooth supported prosthesis. It is no longer necessary to â&#x20AC;&#x153;cutâ&#x20AC;? health or minimal restored adjacent teeth to replace a missing tooth with a non-removable prosthetic replacement. Reported success rates for single-tooth implants are excellent.18

Surgery Conclusion

With proper treatment, the healing of an endodontic lesion is highly predictable. However the prognosis of teeth with combined Periodontal and Endodontic lesions varies because each lesion contributes to the loss of attachment. Therefore the decision to treat and retain teeth with combined Periodontal and endodontic lesion should be carefully considered in regard

(Figure 13) Gingival former. Good looking keratinized oral mucosa

(Figure 14) The transfer device being screwed directly into the implant

(Figure 15) Abutment attached to the implant

(Figure 16)

(Figure 17) OPG 1 year postoperatively


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to the overall dental treatment plan, because time and cost of combined defect treatment may be considerable and ultimately affect the prognosis.

References 1. Baer PN. The case for periodontosis as a clinical entity. J Periodontol. 1971 Aug;42(8):516-20. 2. Daprile G, Gatto M, Checchi L. The evolution of buccal gingival recessions in a student population: a 5-year follow-up. J Periodontol. 2007 Apr;78(4):611-4. 3. Lindhe J. Reattachment – New attachment. In: clinical Periodontol, 2nd ed. Copenhagen: Munksgard, 1989: 410-411. 4. Glickman I. Clinical Periodontology, 1st ed. Philadelphia: Saunders; 1953. 5. Carmelo M, Nevins M, Schenk R, et al. Clinical radiographic and histological evaluation of human periodontal defects treated with Bio-Oss and Bio-Guid. Int J Periodont Restor Dent. 1998;18:321. 6. Mellonig JT. Human histologic evaluation of a bovine-derived bone xenograft in the treatment of periodontal osseous defects. Int J Periodontics Restorative Dent. 2000 Feb;20(1):19-29. 7. Brånemark PI. Osseointegration and its experimental background. J Prosthet Dent. 1983 Sep;50(3):399-410. 8. Brånemark PI, Zarb GA, Abrektsson T. Tissue integrated prostheses: osseointegration in clinical dentistry. Chicago: Quintessence 1985. Chapter 6, pg 129-143. 9. Brånemark PI, Adell R, Breine U, Hansson BO, Lindström J, Ohlsson A. Intraosseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg. 1969;3(2):81-100. 10. Adell R, Lekholm U, Rockler B, Brånemark PI. A 15 year study of osseointegrated implants in the treatment of the edentulous jaw. Int J Oral Surg. 1981 Dec;10(6):387416. 11. Adell R, Eriksson B, Lekholm U, Brånemark PI, Jemt T. Long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws. Int J Oral Maxillofac Implants. 1990 Winter;5(4):347-59. 12. Ferrigno N, Laureti M, Fanali S, Grippaudo G. A long-term follow-up study of nonsubmerged ITI implants in the treatment of totally edentulous jaws. Part I: Ten-year life table analysis of a prospective multicenter study with 1286 implants. Clin Oral Implants Res. 2002 Jun;13(3):260-73. 13. Fugazzotto PA, Gulbransen HJ, Wheeler SL, Lindsay JA. The use of IMZ osseointegrated implants in partially and completely edentulous patients: success and failure rates of 2,023 implant cylinders up to 60+ months in function. Int J Oral Maxillofac Implants. 1993;8(6):617-21. 14. Lekholm U, Gunne J, Henry P, et al. Survival of the Brånemark implant in partially edentulous jaws: a 10-year prospective multicenter study. Int J Oral Maxillofac Implants. 1999 Sep-Oct;14(5):639-45. 15. Lindh T, Gunne J, Tillberg A, Molin M. A meta-analysis of implants in partial edentulism. Clin Oral Implants Res. 1998 Apr;9(2):80-90. 16. Lindquist LW, Carlsson GE, Jemt T. Association between marginal bone loss around osseointegrated mandibular implants and smoking habits: a 10-year follow-up study. J Dent Res. 1997 Oct;76(10):1667-74. 17. Sullivan DY, Sherwood RL, Porter SS. Long-term performance of Osseotite implants: a 6-year clinical follow-up. Compend Contin Educ Dent. 2001 Apr;22(4):326-8, 330, 332-4. 18. Esposito M, Hirsc JM, Lekholm U, Thomsen P. Biological factors contributing to failures of osseointegrated oral implants. (I). Success criteria and epidemiology. Eur J Oral Sci. 1998 Feb;106(1):527-51.

Practice Management

Marketing During Economic Dental Crisis* The absolutely best time to advertise for new patients is whenever everyone else decides top pull out and lay low for a while. Dr. Ehab Heikal BDS, MBA, DBA - Manager, Morita Middle East - Lecturer, Practice Management School of Dentistry, MSA University

Before the worldwide economic crisis exploded even outside USA and reflected in our area, I would have told you that the «recession» is only in your patients ’heads’ cause of media hype. Wish I could still say the same today, as we’re in the middle of what just may be the scariest financial near-miss (disaster) the civilized world has experienced since the Great Depression. Many dentists have contacted me asking whether this will affect their business, will there be many no show ups, cancelled appointments and decrease of dental expenditure. Sure there is some minimal level of comfort hearing that others are in your same leaking boat. But when the leak turns to deluge and discomfort turns life or death struggle for your practice’s survival... knowing that others are experiencing your same fate is of little help. But do not allow yourself to indulge, since every cloud has a silver lining, you may turn this one into GOLD. Question: How should you adjust your new patient marketing efforts in the face of economic down times? Answer: The most common reaction of your colleagues will be to try to save every penny they can during tough times... cutting back or even altogether doing without new patient marketing. They figure since patients are coming in less often, and saying «NO» to recommended treatment, the best thing to do for now is «Hunker down, tighten the belt, and cut out any unnecessary expenses until times improve.» It might be counterintuitive, but what I am about to share with you could make you a fortune even during the toughest of times. Did you ever notice that there will always be some guys who do well while the rest of your colleagues seem to be having their toughest times?


Smile Dental Journal Volume 4, Issue 2 - 2009

What happens is that everyone is marketing less. Most businesses have the same reaction as the dentists. Tighten the purse strings for a while. Let us wait and see what happens. Let us «Hope» it gets better. Meanwhile the most savvy marketers know that this is one of the best opportunities to market any business. When the massive everyday clutter dies down, and your message has dramatically improved chance of being noticed by your intended recipients! Marketing at this point even costs you less. You are not competing against anyone. Imagine if Coca Cola was advertising alone in the market, No Pepsi. What will happen is that they will not advertise that heavily, and they will not need expensive actors, singers or players, yet still there message will reach the target. However, marketing is not your only option. Although your marketing expenditure should increase, yet you need to cut unnecessary expenditure, and/or improve your spending. For example, you can use savvy light bulbs; switch off equipment and appliances that are not in use and the like. You need also to learn how to forecast your requirements of supplies and materials in order to efficiently use your resources without excess or without having loads of depleted or expired materials. On the other hand, marketing is not only about advertising yourself; it is also about introducing or revealing other options for your patients. Revealing here means the options that you already have and want to notify your patients of. If patients are fleeing away from expensive treatments, what options do you have for them? Remember that one very important option is to have them accept that expensive treatment. It is not what you say; it is how you say it. So it is not what you offer; it is how you offer it. Just for your info: The Power of Promotion At the start of the 1930’s Depression, the Nestlé company was the top name in chocolate. Bad times convinced them to reduce marketing of their confections. At that same time, Hershey’s decided to increase their marketing. By Depression’s end, the power position switched—Hershey’s was the number one chocolate manufacturer—and has stayed so ever since! * From new book under publication: “Practice Management Tips”

Book Review

Fiber Posts and Endodontically Treated Teeth: A Compendium of Scientific and Clinical Perspectives

Authors: Marco Ferrari with Lorenzo Breschi and Simone Grandini

Fiber-reinforced composite posts represent a paradigm shift in restorative dentistry that emerged almost two decades ago. In combination with filled resins and adhesive technology, this addition to our therapeutic armamentarium has managed to slowly enclose on the quasi-monopoly of cast post and cores in restoring endodontically treated teeth. In his foreword, Carel Davidson justifiably underlines the need for continuous information regarding emerging and developing materials. Marco Ferrari goes further in the introduction by stating that in rapidly developing technological sectors, information may be obsolete by the time it is published. This clearly prompts the need for comprehensive publications that bridge the gap between the clinical aspect of the restorative treatment and the technological properties of materials. Restoration of endodontically treated teeth using fiberreinforced posts involves many materials, concepts, and procedures that belong to different medical and technological niches. The authors judiciously addressed the difficulty by dividing the topics in the different chapters of the book. This book is rigorous in its form and methodical in its approach. High-quality graphics illustrate appropriately the different chapters and help in visualizing several concepts or clinical situations as they favorably complete the text. The book displays an excellent balance between basic research and clinical practice and helps improving patient care by unraveling the secrets of state of the art composite and adhesive materials. It should prove a valuable reference for those dentists who are always on the lookout to improve their clinical practice as it helps bridge the gap between the technology of modern materials and the appropriate clinical application protocols. Review prepared by: Dr. Hani F. Ounsi, DCD, DESE, MSc, FICD Research Department, Lebanese University Published by: Modern Dentistry Media 176 pages; over 300 mostly colour illustrations ISBN 978-0-620-40391-7

Flash News

Microdent presents its New 3D animation CD on bone expansion

Microdent offers to dental professionals a new 15 minutes length 3D animation CD on Bone Expansion, designed for all professionals using Microdent expanders in their clinic as well as those who want to start using this technique. Following the previous 3D animation CD on Surgical Protocol, Impression Taking and Prosthesis, and with the ambitious goal of creating a full new 3D Animation CD on bone expansion, lifting and condensation, Microdent offers now the first part of this triology. The sequence shows, helped with detail explanations and legends, the entire process of bone expansion, from the initial cut until the final implant placement through all of the different stages of Bone Expansion.

Hydrorise, the innovation that did not exist Starting today, dentists can count on an innovative new impression material: Hydrorise, the first hyperhydrophilic A-silicone for any kind of impression technique in all clinical conditions. Hyperhydrophilic technology has been exclusively developed by Zhermack research, making Hydrorise extremely flowable. With a contact angle less than 10° and thanks to the effects of the AMDA System (Advanced Moisture Displacement Action), Hydrorise is able to remove fluids from the gingival sulcus and reproduce impression margins with maximum precision, like no other material on the market. The attention paid by researchers in the Zhermack impression materials development phase is focused on the companyâ&#x20AC;&#x2122;s aim to create clinically relevant products. An impression material must guarantee extremely accurate and reliable results, even in particularly difficult clinical situations. The perfect synergy between physical and mechanical properties found in Hydrorise ensures clinical success at each use. Zhermack offers the chance to pair the new conditioner Hydrosystem to optimise preparation surfaces, creating ideal conditions for use of the Hydrorise. When applied to preparations before impression taking, Hydrosystem further improves the contact angle, increasing wettability to tooth surfaces. The flowability of the silicone deep within the gingival sulcus is drastically improved. Hydrorise is available in different viscosities: putty - heavy body - regular body - light body - extra light body - monophase, each of which comes both in normal set or fast set.

SkyView brings 3D imaging into the dental surgery SkyView adopts the X-ray technique known as Cone Beam Computed Tomography (CBCT), ideal for obtaining three-dimensional reconstructions of teeth and the entire maxillofacial area.

CBCT has the advantage of acquiring images with just one partial rotation of the source-detector system using a variable-field image intensifier which provides maximum contrast and maximum definition. When compared to more updated tomography techniques such as hospital CT scans, less time is needed to perform the examination and, above all, the patient is exposed to a considerably lower Xray dose, comparable to those of the commonly used panoramic X-ray systems. - A three-in-one solution - Absolute diagnostic precision - Efficiency from all angles - Easy installation in the operatory


Smile Dental Journal Volume 4, Issue 2 - 2009

Flash News

Revo-S®an endo “REVOlution” Intended for the initial endodontic treatment, Revo-S® innovates with only 3 instruments. Highly performing and very simple, this sequence is adapted for most root canal anatomies. The first two files, SC1 and SC2 are dedicated to root canal cleaning and shaping. The third file, SU, recapitulates the action of the first two files, thus respecting the tapered shape of the canal, resulting in adequate canal preparation with an apical finishing of 6%. Revo-S® features an innovating and unique characteristic: its asymmetrical section initiates a snake-like movement of the instrument inside the canal thus increasing flexibility and reducing the stress on the files. The instrument functions in a cyclic way: 1. Cutting 2. Debris elimination 3. Cleaning This sequence performs a very good upward elimination of the dentin debris, and an improved cleaning. For a successful canal preparation, the apical finishing is essential: MICRO-MEGA® offers an additional solution adapted with specific instruments: AS30, AS35, AS40. They allow widening efficiently the apical preparation with respect of the pre-established 6% taper, without changing the preparation obtained using the standard sequence (SC1, SC2, SU). This finishing allows a better flow of the irrigating solution for a more efficient disinfection. Moreover, the obturation is facilitated by the improved access. Revo-S® files are available with Classic and InGeT® shafts.



New desobturation instruments

Sonic Tips: A great leap forward in oral surgery In close collaboration with Dr. Ivo Agabiti, Pesaro/Italy, Komet has developed brand new surgical sonic tips (SFS).

“Desobturation” prior to “retreatment”: because access must be made, the entrance of the canal is “desobturated” to reach inside the canal itself so that it could be properly retreated.


A new special launching set has been prepared. It contains 2 instruments: - 1 x D-RaCe 1 (DR1) – ISO Ø 30, .10 taper, very short, 15/8 mm, with an ACTIVE (cutting) tip. - 1 x DR2 – Ø 25, .04 taper, standard 25/16 mm length, with a Safe (rounded) tip. The instruments have a characteristic new “Chrominox” alloy shank, with grooves and a white rubber stopper. Instructions for use and additional cleaning & sterilisation tips are included.


- Assortment of 4 instruments ( 2 DR1 + 2 DR2 per pack). - Individual packs (6 of the same diameter and taper). D-RaCe will desobturate most canals, whatever the filling used.

Smile Dental Journal Volume 4, Issue 2 - 2009


The sonic tips produce very fine cuts to allow maximum conservation of dental substance. They only cut on hard substance, thus conserving the soft tissue and allowing unobstructed view of the operative site. Possible applications include the gentle removal of the periodontal ligament of a tooth in its alveolar compartment from all sides within the course of an extraction, root separation in case of an extraction of a tooth with more than one root, apicectomies, splitting of the crest and lateral incisions, sinus elevation and the creation of a sinus window. All in all, the sonic tips provide the optimum preconditions for controlled, effective and economic work in oral surgery.


What makes these innovative tips so special is that they use the drive of the dental air turbine, i.e. the oscillating movement of the “sonic” hand piece (e.g. KaVo SONICflex) is generated by air pressure. The elliptical, three-dimensional movement allows excellent substance removal and therefore effective work.

Flash News


The company ANTHOGYR, created more than 60 years ago, in 1947, benefits from a very strong experience and worldwide reputation, through its wide range of dental instruments and implants such as: AXIOM®: new implant system features a unique conical abutment connection for a significant and intuitive connection. With its sub-crestal positioning, AXIOM provides a better aesthetic management of restorations. ANTHOFIT®: with its internal octagon connection, this implant is easy to use in mouth, flexible and adapts over time. Available in straight or tapered shape with a BCP body treatment, it is recommended for juxta-crestal positions. The neck surface treatment helps to promote attachment to bone at this level. MONT BLANC CONTRA ANGLES®: the new range delivers at last all the features you expected! The new technological achievements allow easier access and better visibility in mouth. Full range for general dentistry, i.e 5:1, 1:5 and 1:1, and implantology 1:20, with or without light. IMPLANTEO®: this brushless motor has been designed to complete any implant and surgical procedures. TORQ CONTROL®: the manual dynamometrical declutching wrench Torq Control allows very precise tight locking of the prosthetic parts on implants. With its adjusting knob, it allows 7 tightening torque values from 10 to 35 Once the desired torque is reached, the tightening is automatically stopped.

Now on iTunes U Nobel Biocare today announced it is making free training and educational material available to dentists, dental specialists, students and patients on its new site found on iTunes U on the iTunes Store. Nobel Biocare is the first med-tech company to have its own presence on iTunes U. T&E (Training & Education) is one of Nobel Biocare’s main strengths. One of the key trends in education on which Nobel Biocare wants to continue to build its reputation is the rapid development of e-learning. Found in the “Beyond Campus” section of iTunes U, Nobel Biocare’s Training & Education program will provide easy, state-of-the-art on-demand e-learning. Beginning today, users can search and download training and education material directly from the site, and then experience it on their Mac or PC, or sync with iPod or iPhone to learn anywhere, anytime. Today, Nobel Biocare already maintains T&E partnership agreements with twenty-four leading dental universities worldwide through its University Partner Program, a peer-to-peer collaboration that assists academic dental institutions to integrate the latest Crown, Bridge, and Implant coursework into their undergraduate programs. iTunes U is a dedicated area within the iTunes Store ( featuring free educational content such as course lectures, language lessons, lab demonstrations and more. iTunes software, a free download, is required.


Smile Dental Journal Volume 4, Issue 2 - 2009

Bad Mouth Breath? Your worries are


HiGeen developed long lasting pleasant taste mouthwash that helps killing bacteria which may cause bad mouth breath, in addition to powerful active ingredients that prevent plaque accumulation which leads to gingivitis. A broad spectrum microbicidal solution for use in case of mouth and throat infections caused by bacteria, fungi or virus. Non-staining, non-irritating and non-sensitizing formula. Could be used in case of bacterial or viral infections which cause sore throat. For routine use to promote oral hygiene. Contains 1% Povidone Iodine. With Black Current Flavor.

Why Higeen Mouthwash

1. Different pleasant tastes, potent refreshing effect 2. Does not cause dental stains, can be used up to 4 times daily 3. Fights dental caries 4. Reduces dental plaque and fights gingival diseases 5. No need for dilution


brings V3 system to Middle East Triodent V3, the world’s leading sectional matrix system for Class II composites, is now available in the Middle East. Triodent recently signed agreements with four companies that will distribute products in the region. They are Arab Medical and Scientific Alliance Shocair (Syria, Palestine, Jordan and Lebanon), Dubai Medical Equipment (United Arab Emirates, Oman and Qatar), Kazemeini Trading (Iran) and Issam Bureau Group (Iraq). Triodent also distributes in Egypt through Extra Care. Triodent is the maker of the V3 Sectional Matrix System, which has been named by key opinion leaders and the dental media in the United States as the best such system on the market. Company founder, CEO and V3 inventor Dr. Simon McDonald said he was delighted that the V3 system was now available to dentists in the Middle East. The development of a distribution network in the Middle East would not have been possible without the tireless work of Dr. Haval Al-Atroushi, Triodent’s Middle East manager. Triodent’s mantra is “innovative, simple, smart”. That is not for show, Dr. McDonald says, but because he firmly believes the future of the company lies in finding easier, better ways for dentists to do their jobs. In the past year the success and growth of the company has allowed him to focus even more on research and development.


for Children

As part of GSK activities in Jordan; GSK has launched its new children’s toothpaste SENSODYNE PRONAMEL for Children through many activities elaborating the significance of the Pronamel. Pronamel toothpaste is recommended for its optimized fluoride formulation; its daily protection against acid erosion and caries; its low abrasiveness; neutral PH and its minty taste.

AEEDC, Dubai 2009 Dubai, UAE / 10 – 12 March 2009 The UAE International Dental Conference & Arab Dental Exhibition - AEEDC Dubai 2009, was held between the 10th and the 12th of March 2009 at the Dubai International Convention and Exhibition Centre. Mr. Abdul Salam Al Madani, Executive Chairman of AEEDC® Dubai and Dr. Burton Conrod, President of the World Dental Federation (FDI), had signed a memorandum of understanding on March 11th, 2009, in the presence of Dr. Tariq Khoory, Director of Dental Department at the Dubai Health Authority, and a number of local and international representatives. The FDI represents one million Dentists Worldwide, and now the MOU will provide Continuing Learning Programs to dentists who are registered members of the FDI and AEEDC® Dubai. AEEDC® Dubai was granted an exclusive authorization in the Middle East and North Africa to employ this program. The Speech of His Highness Sheikh Hamdan Bin Rashid Al Maktoum, Deputy Ruler of Dubai, Minister of Finance, President of the Dubai Health Authority was delivered by Dr. Tariq Khoory, Director, Dubai Dental Centre, Dubai Health Authority, on behalf of HE Qadhi Saeed Al Murooshid, Director General of the Dubai Health Authority, through which he stated “this commitment is in line with the vision and the wisdom of H.H. Sheikh Mohammed Bin Rashid Al Maktoum, Vice-President, Prime Minister of United Arab Emirates, Ruler of Dubai, His Highness taught us that” The word ‘impossible’ is not in leaders’ dictionaries. No matter how big the challenges, strong faith, determination and resolve will overcome them”. Dubai Health Authority with the support and commitment of all shall ensure that AEEDC® Dubai shall become the Number 1 Event by 2020.

H.H. Sheikh Hamdan Bin Rashid Al Maktoum, Deputy Ruler of Dubai, Minister of Finance and President of the Dubai Health Authority Inaugurates AEEDC® Dubai 2009

Miss Solange Sfeir, Dr. Mhd Al-Jishi and his spouse & Dr. Burton Conrad


Smile Dental Journal Volume 4, Issue 2 - 2009

Prof. Yousef Talic & Prof. Howard Lieb with Mrs. Lieb

Dr. Mohammed Al-Darwish; President of Qatar Dental Society & Miss Solange Sfeir

Noble Medical Equipment, official distributor of Smile in UAE

Zhermack Italy

Dental X Italy

ASA Dental Italy

Mocom Italy

FKG Switzerland


Bisco USA

Live surgery

Friadent Germany

Cefla Group Italy

Piro Trading USA

Micro-Mega stand

Lumineers USA

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Dental Show Cologne, Germany / 24 – 28 March 2009 IDS continues to grow: More than 106,000 visitors experienced an international trade fair full of momentum and the innovations of 1820 exhibitors. International participation increases to 65% - 10 percent more foreign exhibitors - Dental industry stable - 1100 new products The IDS broadened its significance as a global trade and communications platform even further. Companies presented themselves on 138,000 square metres of exhibition space. News and Innovations: With more than 1100 presentations, new products and advancements, the International Dental Show 2009 once again demonstrated its potential as an international innovations platform. According to Dr. Martin Rickert (VDDI), this was made up of three main trends. First: natural teeth are being kept for as long as possible through early and comprehensive diagnostics and minimally invasive treatment methods. Second: if dentures are necessary, they should look as natural as possible and offer the highest aesthetics and functionality. Thirdly: the digitisation and networking between practice and laboratory increase efficiency in the economic production of dentures. German Dental Association: «Latitude to invest must be maintained»: Dr. Peter Engel, President of the German Dental Association (BZÄK): «In times of such general economic downturn, it is simply fantastic that a counterpoint like the IDS 2009 can be created. The trade fair’s success is an encouraging sign for our progressive profession, but at the same time it should also serve as a reminder to politics to make it easier for us to invest. Every two years, the IDS makes Germany the centre of the dental world. The joint appearance, similar to the presence at the German Dentists’ Day, proved itself according to Peter Engel. Speaker’s Corner: With Speaker’s Corner, the IDS was again building on 2005’s successfully incorporated trade meeting as a highlight of the supporting programme. There, during each day of the fair, IDS exhibitors, ranging from global market leaders to new players in the market, presented information on new products, services and manufacturing technology. The next IDS - 34th International Dental Show - will take place from 22nd to 26th of March 2011. The German Association of Dental Technicians (VDZI) and the German Dental Association (BZÄK) will again be organising the expert supporting programme.

ESCD Strategy Meeting on March 27th, from left: - Dr. Daniel Baketic – ESCD Country Chairperson Croatia, Zagreb - Prof. Dr. Kurt Vinzenz – ESCD Chairperson for Interdisciplinary Aspects, Vienna/Austria - Dr. Dobrina Mollova – Congress Organizer DFCCIC 2009, Dubai/UAE - Dr. Wolfgang Richter – President ESCD, Salzburg/Austria


Smile Dental Journal Volume 4, Issue 2 - 2009

- Miss Solange Sfeir – Marketing Manager “Smile Dental Journal”, Amman/Jordan - Prof. Dr. Martin Joergens – ESCD Country Chairperson Germany, Düsseldorf/Germany - Dr. Mona Kakar – ESCD Country Chairperson India, Mumbai/Serbia - Dr. Igor Ristic – ESCD Country Chairperson Serbia, Belgrade/Serbia - Dr. Fadi Khuffash – ESCD Country Chairperson Palestine, Ramallah/Palestine

Dr. Dobrina Mollova & Dr. Mohamad El Kalach

Asa Dental Italy

FKG Switzerland


Mocom Italy


Dental X Italy

Saratoga Italy

Silfradent Italy


Zhermack Italy

Xenon Germany

Miss Solange Sfeir

Sultan Healthcare


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Riyadh, KSA / 20 – 22 April 2009

“New Dental Era”

Under the Patronage of His Royal Highness Lieutenant-General Prince Meteb Bin Abdullah Bin Abdulaziz Al Saud the Deputy Assistant Chief of the National Guard for Military Affairs, the Saudi Dental Society organized in cooperation with the Department of Dental Services in the National Guard - the central region, “the 20th Saudi Dental Society and the 2nd National Guard International Conference & workshops”, during the period of 24th-26th of Rabea Al.Thani 1430 AH/20th-22nd of April 2009, at the King Fahd Cultural Center in Riyadh. Conference goal was to introduce all what is new in dentistry that dental practitioners will find beneficial thus enabling them to serve their patients better relying on up to date scientific bases. The Conference covered many topics, such as Endodontics, Implantology, Orthodontics, and Aesthetic Dentistry, several workshops for dental technicians and technical assistance were also held. The number of attendees which exceeded 1400 practicing dentists from the Gulf area and other Arab countries and the remarkable scientific program made this year’s congress so special. 11 distinguished speakers from USA, Switzerland, Australia, Germany, Greece and Italy, as well as local speakers from Saudi universities and from different health sectors in the Kingdom presented their lectures to the audience. The scientific program also included presentations of the latest scientific researches prepared by recently graduated dentists and postgraduate students. Alongside the conference, an international exhibition with more than (36) local and international representatives for (250) global companies was held in 1000 m2 area. Main Sponsors of the congress were Colgate Palmolive Arab Company Ltd. and Al Jazirah Vehicles Agencies Company.

H.R.H. Lieutenant-General Prince Meteb Bin Abdullah Bin Abdulaziz Al Saud during the opening ceremony


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Dr. Ali Bin Abdullah Al-Ahdab & Prof. Yousef Talic

Prof. Abdullah Al-Shammery

Prof. Stephen Cohen

Dr. Antoine Karam; President of Lebanese Dental Association

Dr. Ibrahim Ismail Ali; Chairman of Kuwait Dental Association

Prof. Magid Amin

Miss Solange Sfeir

Dr. Rajaâ&#x20AC;&#x2122; Kadhim, President of Bahrain Dental Society & Dr. M. Jishi

Dr. Hamad Al Harthy; Chairman of Oman Dental Society

Dr. Ahmad Othman Rizk; Chairman of Sudanese Dental Association

During the Gala dinner

Al-Turki Medical Group KSA



Salima Medical & Laboratories KSA


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5th Arab German Implantology Meeting 3rd Syrian Annual Implantology Meeting Damascus, Syria / 08 â&#x20AC;&#x201C; 10 April 2009 The Arab German Implantology Meeting DGZI was held from 8-10 April 2009. The fifth meeting was organized together with the Syrian Dental Association and the in Damascus, Syria. The Syrian Dental Association counts 16,000 members. At the moment there are 2,200 practicing dental specialists who obtained their dental education in Germany or in other European countries. Prof. Safouh Al Buni, President of Syrian Dental Association, invited the presidents of the Dental Associations of all Arab countries to this congress to discuss future plans and to declare the foundation of the Arab Implantology Association. The DGZI board members Dr. Rolf Vollmer, Dr. Rainer Valentin, and Dr. Roland Hille attended the meeting. They were accompanied by renowned speakers from Germany, Jordan, Lebanon, Egypt, Sudan, and Saudi Arabia. A complete dental implantology spectrum was covered, including sinus lift, immediate loading, complications, smoking, bone substitute materials, and aesthetics. The conference room was fully occupied with more than 450 participants. The evening events took place in typical Syrian style and atmosphere. A dental fair completed the event.

Dr. Safwan Jaber, Dr. Deeb Hazimeh & Prof. Sofouh Al Buni

Arab delegates & guests

Speakers & Presidents of Dental Associations

Prof. Safouh Al Buni, Dr. Mazen Tamimi & Dr. Rafi Al Jobory

Silfradent, Smile & Xenon

Dr. Safwan Jaber, Dr. Jihad Abdallah, Dr. Refat Al Kubaissy & Dr. Raâ&#x20AC;&#x2122;ed Abutteen


Prof. Abdullah Al-Shammery & Dr. Mazen Tamimi



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1st International Dental Congress Beirut Arab University

“ Recent Advances in Dentistry: New Horizons & Beyond ...” Beirut, Lebanon / 01 – 03 May 2009 Under the High Patronage of His Excellency The President of the Republic of Lebanon; General Michel Sleman, the Beirut Arab University 1st International Dental Congress was held in the heart of downtown Beirut and on the waterfront of the Mediterranean Sea in Beirut International Exhibition and Leisure Center (BIEL). The scientific program was designed to present a range of topics which were of special interest to the clinicians with distinguished medical professionals from inside and outside the Arab world selected from among the most prestigious in their fields to provide a stimulating variety of scientific activity.

Dr. Abdel Aziz Fayed Ismail, Dr. Medhat Abdallah, Prof. Amr Galal El-Adawi

During the opening ceremony

Saudi Delegate presenting a trophy to the President of BAU/IDC

Opening ceremony


During the opening ceremony


Dr. Omar Bahgat & Prof. Abdella

President & Members of LDA



Dr. Issa Bader, Prof. M. Sherine Elattar & Prof. Yousef Talic

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AOIA Advanced Implantology Course “Evidence based science for success in sinus grafting”

“The Sinus lifting – Disc Implant debate” Cairo & Alexandria, Egypt / 4 - 7 May, 2009 Alexandria Oral Implantology Association (AOIA), the pioneer of every new technique in implantology, is always honored to present different points of view, performed by expert doctors from all over the world. The AOIA was delighted to receive it’s guest, Prof. Stefan Ihde from Switzerland, the expert for dental implants/ basal implants, in one of its advanced courses, under the theme of: “The Sinus lifting- Disc Implant debate”. A two days course was given by Dr. Idhe in Cairo on the 4th & 5th of May about Disc Implants, followed by two days course on the 6th & 7th of May about Sinus lifting, Given by Prof. Mohamed Fata and Dr. Bassam F. Rabie, at the luxurious PresiDental Esthetics Institute (PDE). On the first day, Dr. Ihde introduced the basal implant technology: Lateral & Crestal approach, through his lecture, followed by a live surgery performed by Dr. Ihde, with the help of the PDE teamwork. Full mouth rehabilitation to an edentulous patient was made by inserting 8 implants in the maxilla, trying to prove the possibility of: “placing implants in posterior Maxilla without the need to performing complicated & advanced procedures like Sinus lifting.” said Dr. Ihde. On the second day further explanation was provided through a workshop on sheep ribs, using Dr. Ihde’s unique Disc implants system. On the other hand, Sinus lifting course started on the third day, where Prof. Mohamed Fata gave an introduction to sinus

On the fourth day, a sinus elevation live surgery was performed by Dr. Rabie using piezosurgery technology, after which a discussion session about the surgery and the use of piezosurgery technology in sinus elevation was held. A Scientific day was made in Alexandria 6th of May 2009, at Hilton Green Plaza. Dr. Stefan gave a lecture defending his idea, by explaining the scientific bases of the system. At the end of the course a workshop was made showing to the candidates the technique of Disc implant placement on sheep ribs. Over 50 doctors from Egypt and the Middle East have attended the course between Cairo & Alexandria. The course was supported by Mrs. Therese Baraka; general manager of Denterprise S.A.R.L., and the agent of ALLFIT® implant system. All AOIA courses & events are accredited by the International Congress of Oral Implantology (ICOI). For more information about our regular courses and to check the association latest news please visit our website:

Prof. El-Attar, Mrs. El Debs & Dr. Ihde

Dr. Ihde during the workshop

During the live surgery

Participants during the workshop


Prof. Mohamed Fata lecturing

Dr. Bassam Rabie lecturing


elevation, followed by a lecture by Dr. Bassam F. Rabie titled “Evidence based science for success in sinus grafting”. Dr. Rabie’s Lecture extended to discuss other aspects related to sinus lifting including types of grafts, techniques of sinus lifting, biomechanics for sinus grafts and finally the use of piezosurgery in sinus elevation.

Smile Dental Journal Volume 4, Issue 2 - 2009

Memorial picture

Local Events




Irbid Dental Conference

Irbid, Jordan / 18 â&#x20AC;&#x201C; 20 March 2009

Memorial lecture

Dr. Ghada Bassil & Dr. Yehya Kamal

Basamat Pharmadent

During the opening ceremony

Jitico for Medical Supplies

Exhibition view

As part of its policy, the JDIG held 3 Consecutive Courses: - The 3rd Comprehensive Dental Implant Course (December 2008, March 2009) - The 3rd Clinical Dental Implant Course (December 2008, March & April 2009) - Advanced Dental Implant Course (April 2009)

Trophy presentation ceremony


Smile Dental Journal Volume 4, Issue 2 - 2009


6th Jordanian Orthodontic Congress Dead Sea, Jordan / 02 – 03 April 2009

“Beauty in the Eyes of the Orthodontist”

The 2 day conference witnessed a fusion of notable speakers’ knowledge and experience from international and local orthodontists who provided a unique opportunity to evaluate the latest achievements in the orthodontic field.

Dr. Hazem Al-Ahmad, Dr. Eyad Omary, Mr. David Rihani & Dr. Samer Qaqaa’

During one of the lectures

RaCe: A New Concept in Ni-Ti Endo Rotary Treatments Amman, Jordan / 08 - 11 June 2009 FKG Dentaire, a fast growing Swiss company specialized in Endodontic instruments, is now actively launching its’ well known RaCe rotary NITI instruments in Jordan. Having moved to a larger and modern facility, FKG Dentaire is now seeking for a larger market share in Middle East. In collaboration with RoseDent Company and the Jordanian Endodontic Society, a promotion program for the Ni-Ti Rotary such as RaCe, D-RaCe and S-Apex was held in Bristol Hotel. Dr Shahram Azimi; Endodontist from Azad Dental School located in Tehran/Iran was invited to lecture 120 Jordanian dentists on 8th June and by direct participation of Mr. Jean-Pierre Treyvaud; International Sales Manager of FKG. Six sessions of hands-on courses was succeeded on following three days. Having launched a new version as BioRaCe, FKG Dentaire seeks to provide a complete range of endodontic NITI rotary products to rising demand of dentists in the region.

Dr. Sharam Azimi, Mr. Moh’d Owais & Mr. Jean-Pierre Treyvaud


Smile Dental Journal Volume 4, Issue 2 - 2009


2Annual Congress nd

Faculty of Dentistry / University of Jordan

Amman, Jordan / 04 – 06 June 2009 Under the patronage of the president of the University of Jordan Prof. Khaled Al-Karaky, the Faculty of Dentistry at the University of Jordan held its 2nd Annual Congress on Thursday 4th of June 2009. The congress program consisted of twenty papers in all dental specialities presented by invited speakers from the United States and Egypt, speakers from the faculty of dentistry’s teaching staff, the royal medical services, and the private sector. In addition to the scientific program, a major exhibition for Dental Suppliers was held during the Congress, showcasing the latest in dental materials and supplies currently available. The congress also consisted of the following post-congress courses which were held on Friday and Saturday 5th and 6th of June 2009:

Prof. Lamis Rajab & Dr. Amin Khresat

1. An update and a review in prosthodontics: Prof. Steven Morgano (USA) 2. Esthetic treatment concepts from bleaching to composites: Prof. Wolfgang Richter (Austria) 3. Contemporary orthodontic mechanics: Dr. William Hohlt (USA) 4. A full-day hands-on course on all-ceramic crowns & FPDs: Dr. Mohammad Al-Rabab’ah (Jordan) 5. Niti rotary instrumentation: a new vision of endodontics (hands-on course): Dr. Ibrahim Abu Tahun (Jordan) Prof. Dia’ Arafa & Dr. Zaid Al-Bitar

Dr. Wolfgang Richter & Dr. Lara Bekaeen


Smile Dental Journal Volume 4, Issue 2 - 2009

During the opening ceremony


By the Arab Dental Federation Dr. Mohammad Al-Jishi, President of the Arab Dental Federation, announced the foundation of three Arabic dental establishments that are supervised by the Arab Dental Federation.

Dr. Mohammad Al-Jishi & Dr. Rafi Al Jobory

The main objectives of these societies are to better serve dentistry in general, and help to improve the capabilities and skillfulness of Arab dentists through joining these establishments: 1- The Arab Academy for Continuous dental Education: Administrator: Prof. Abdullah Al-Shammery Fax: +966 1 2933098 E-mail: 2- The Arab Academy for Dental Implantology:

Prof. Wahib Moussa & Prof. Abdullah Al-Shammery

Administrator: Dr. Mohammad Safwan Jaber Fax: +963 1 17833990 E-mail: 3- Endodontic Arab Society: Administrator: Dr. Ibraheem Abu Tahun Fax: +962 6 5515100 E-mail:

Dr. Mohammad Al-Jishi President of the Arab Dental Federation P.O.Box: 617 Manama-Kingdom of Bahrain Fax: +973 17290959 E-mail: Dr. Refat Al Kubaissy, Dr. Mohammad Safwan Jaber & Prof. Safouh Al Buni

Smile Dental Journal - Volume 4 - Issue 2  

Smile Dental Journal - Volume 4 - Issue 2

Smile Dental Journal - Volume 4 - Issue 2  

Smile Dental Journal - Volume 4 - Issue 2