International Dentistry Australasian Edition - Vol. 10 No. 2

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VOL. 1 0 NO. 2 IN THIS ISSUE Crispian Scully Making sense of mouth ulceration: part five Marga Ree Vital pulp therapy with Biodentine™ in two immature, traumatized teeth Johan Hartshorne Which non-surgical treatment protocol should I use as first-line intervention against peri-implantitis? Walter Denner High quality restorations Modern nanohybrid composites – an alternative for all cavity classes Crispian Scully Making sense of mouth ulceration: part six Sigal Jacobson Direct veneers just got a whole lot easier Richard Bassed Forensic odontology – broader than just identification Michael L. Young A minimally invasive approach according to biomechanical principles of teeth

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Contents Volume 10 No. 2






Making sense of mouth ulceration: part five Crispian Scully

Vital pulp therapy with Biodentine™ in two immature, traumatized teeth Marga Ree

16 Clinical

Which non-surgical treatment protocol should I use as first-line intervention against peri-implantitis? Johan Hartshorne

24 Case Report


High quality restorations Modern nanohybrid composites – an alternative for all cavity classes Walter Denner

30 Clinical

Making sense of mouth ulceration: part six Crispian Scully

34 Clinical

Direct veneers just got a whole lot easier Sigal Jacobson


36 Clinical

Forensic odontology – broader than just identification Richard Bassed

44 Clinical

A minimally invasive approach according to biomechanical principles of teeth Michael L. Young

62 Products


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Common Ground Community Outreach Clinic – bringing dental care to Adelaide’s homeless poputation

Vol. 10 No. 2 ISSN 2071-7962 PUBLISHING EDITOR Ursula Jenkins

EDITOR-IN-CHIEF Imagine being on the streets at just 9 years old, on a cold rainy day and not yet even a teenager, you would wonder why life has dealt you such a bad hand. Melyssa, now 19, found herself in exactly that position and has struggled for the last 10 years on the streets. Going to see a dentist is not a priority or a possibility for someone like Melyssa. Thanks to the people at Common Ground in co-operation with doctors and staff at the Youth Homeless Centre – Street Link, Adelaide, Melyssa was given access to much needed dental care. She is no longer in pain and working to get her life on track. Common Ground provides tiered accommodation for people who are residentially and socially disadvantaged, providing an opportunity to rebuild healthy communities with specific support systems in place. In September 2011, they opened a Community Outreach Dental Clinic. Working in conjunction with the University of Adelaide, the clinic runs using a core group of volunteers as well as undergraduates from the dentistry, oral health, medicine and nursing departments. The significant experience gained by the students sets them up for a future career, while at the same time treatment is offered to people who would not otherwise get access to care. Since the opening in 2011, the clinic has seen over 750 patients with numerous repeat visits. They have provided basic restorative and preventative services and acrylic dentures for those who have been without teeth for many years. They are now partnering with several dental laboratories and in collaboration with TAFE prosthodontic students, providing fabrication of dentures and night guards. Common Ground aims to extend their service more broadly to Inner City Agencies to include underserved suburban areas. They plan to increase their portable equipment and require sstorage facilities in order to better service more remote areas. To help them achieve these goals, Henry Schein Halas, through the Henry Schein Cares Foundation, will be supporting a fundraising event in Adelaide in October.

Prof Dr Marco Ferrari

ASSOCIATE EDITORS Prof Cecilia Goracci Prof Simone Grandini Prof Andre van Zyl

EDITORIAL REVIEW BOARD Prof Paul V Abbott Prof Antonio Apicella Prof Piero Balleri Dr Marius Bredell Prof Kurt-W Bütow Prof Ji-hua Chen Prof Ricardo Marins de Carvalho Prof Carel L Davidson Prof Massimo De Sanctis Dr Carlo Ercoli Prof Livio Gallottini Prof Roberto Giorgetti Dr Patrick J Henry Prof Dr Reinhard Hickel Dr Sascha A Jovanovic Prof Ivo Krejci Dr Gerard Kugel Dr William H Liebenberg Prof Edward Lynch Prof Ian Meyers Prof Maria Fidela de Lima Navarro Prof Hien Ngo Prof Antonella Polimeni Prof Eric Reynolds Prof Jean-Francois Roulet Prof N Dorin Ruse Prof Andre P Saadoun Prof Errol Stein Prof Lawrence Stephen Prof Zrinka Tarle Prof Franklin R Tay Prof Manuel Toledano Dr Bernard Touati Prof Laurence Walsh Prof Fernando Zarone Dr Daniel Ziskind PRINTED BY KHL PRINTING, Singapore International Dentistry - Australasian Edition is published by Modern Dentistry Media CC, PO BOX 76021 WENDYWOOD 2144 SOUTH AFRICA Tel: +27 11 702-3195 Fax: +27 (0)86-568-1116 E-mail:

© COPYRIGHT All rights reserved. No editorial matter published in International Dentistry Australasian Edition may be reproduced in any form or language without the written permission of the publishers. While every effort is made to ensure accurate reproduction, the authors, publishers and their employees or agents shall not be held responsible or in any way liable for errors, omissions or inaccuracies in the publication whether arising from negligence or otherwise or for any consequence arising therefrom.


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Making sense of mouth ulceration: part five Crispian Scully1

In the fifth part of the series, Crispian Scully looks at the issue of gastrointestinal disorders and mouth ulceration. The clinical appearance of an oral ulcer on its own is rarely diagnostic. Any ulceration with other orofacial or extraoral lesions may be suspect. In the light of multiple causes, some systematic way of dealing with ulceration is needed, such as my system of splitting causes into: • Systemic • Malignancy • Local • Aphthae • Drugs.

Gastrointestinal disorders This article discusses the third of the systemic causes – gastrointestinal disorders. The main gastrointestinal disorders that may present with mouth ulceration include coeliac disease, and Crohn’s and related diseases.

Coeliac disease


Professor Crispian Scully CBE FMedSci DSc FDS MD is professor emeritus at UCL, London, King James IV professor at the Royal College of Surgeons, Edinburgh, Harley Street Diagnostic Centre, 16 Devonshire Street and 19 Wimpole Street, London.

Coeliac disease (gluten sensitive enteropathy) is usually an inherited disorder. People with the disease have sensitivity to gluten, a protein found mainly in wheat, and patients suffer small intestinal disease leading to malabsorption. This manifests in many ways, especially: • Haematinic deficiency • Failure to thrive • Infertility. Oral lesions may include mouth ulceration (ulcers mimic aphthae) and enamel hypoplasia in early onset coeliac disease. Coeliac disease is frequently under-diagnosed and we still see older people (even in their 60s and 70s) whose diagnosis has been missed. Diagnosis is typically confirmed by: • Anti-endomysial antibodies • Transglutaminase • Small bowel (jejunal) biopsy. Management is by antigen exclusion – a gluten-free diet.

Crohn’s disease Crohn’s disease is a heterogeneous group of chronic inflammatory disorders mainly causing regional enteritis (ileitis).


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Figure 1: Lip swelling.

Figure 2: Ulceration.

Seen mainly in Caucasians, it is increased in Ashkenazi Jews and 20% of people with Crohn’s disease have a blood relative with inflammatory bowel disease (IBD). The cause is unclear but the inflammatory response is probably mediated by factors such as tumour necrosis factor alpha (TNFα) and there are non-caseating granulomas in submucosa and lymph nodes. Microorganisms have been implicated but some may simply take advantage of damaged mucosa and inability to clear bacteria from the intestine. Crohn’s disease can affect any part of the digestive tract, from mouth to anus – as well as producing extraintestinal disease in some patients. Manifestations depend on the severity and sites affected, but typical features include: • Abdominal pain • Anaemia • Arthralgia • Diarrhoea (repeated episodes) • Non-specific constitutional signs and symptoms • Weight loss. Orofacial involvement is common and can precede intestinal symptoms. It includes: • Lip or face swelling (Figure 1) • Ulceration (may be linear) (Figure 2) • Gingival swelling (Figure 3) • Mucosal ‘cobblestoning’ and tags • Angular cheilitis (stomatitis) and split lips (Figure 4). However, because of vague and protean manifestations, Crohn’s disease is often under-diagnosed. There are no specific assays or diagnostic analyses – it is a diagnosis by exclusion. Tests include: • Faecal calprotectin (often raised) • Blood count (anaemia common) • Serum potassium, zinc and albumin (often reduced) • Erythrocyte sedimentation rate (ESR), C-reactive protein

Figure 3: Gingival swelling.

(CRP), anti-Saccharomyces cerevisiae antibodies, antineutrophil cytoplasmic antibody (ANCA) and seromucoid (often raised) • Small bowel MRI or CT; plain-film and contrast radiography • Endoscopy (sigmoidoscopy, colonoscopy) • Ultrasound • Mucosal biopsy (for granulomas). Diagnosis of intestinal Crohn’s disease can be fraught – not least because of patchy distribution, and is sometimes only confirmed after intestinal resection and histopathological examination of specimen late in the course of disease. Repeated evaluations (including sequential colonoscopies) may be required to establish the diagnosis. Treatment is by specialists with a high-fibre diet and sometimes: • Aminosalicylates (ASA), or newer 5-aminosalicylates (mesalazine, olsalazine) • Antimicrobials (metronidazole, ampicillin, ciprofloxacin, others) • Immune modifiers: corticosteroids locally (prednisolone, budesonide) or systemic corticosteroids, azathioprine, 6mercaptopurine (6-MP), or methotrexate and biologics (anti-TNFα agents [adalimumab, certolizumab pegol or infliximab]) • Thiopurines (eg, 6-MP, azathioprine) can increase risk of non-Hodgkin’s lymphoma. Up to 60% of patients with Crohn’s disease require surgery at some point.

Orofacial granulomatosis Some patients with clinical evidence consistent with oral Crohn’s disease have no intestinal symptoms of the disease and, while some may have evidence of Crohn’s disease in the intestine, others do not. Orofacial granulomatosis (OFG) is the term coined for those with no detectable gastrointestinal involvement. Orofacial lesions mimic those in Crohn’s disease and may


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Figure 4: Split, swollen lip and palatal lesions.

Figure 5: OFG facial swelling.

Orofacial lesions mimic those in Crohn’s disease and may include: • Facial or labial swelling (Figure 5) • ‘Cobblestone’ proliferation of mucosa or mucosal tags • Ulcers. Variants include: • Miescher, or granulomatous cheilitis – Lip swelling alone • Melkerrson-Rosenthal syndrome – Lip swelling – Fissured tongue – Facial palsy. OFG may sometimes result from reactions to foods or additives – most commonly: • Cinnamaldehyde • Benzoates. Like Crohn’s disease, OFG is often under-diagnosed because of vague and protean manifestations. Again, it is a diagnosis by exclusion – there are no specific diagnostic tests. Reactions to foods should be excluded by antigen exclusion/allergy tests. Gastrointestinal and other investigations are often indicated to exclude Crohn’s disease and other conditions that can produce granulomas (notably tuberculosis and sarcoidosis). If systemic Crohn’s disease can be excluded, patients still need to be kept under observation for possible Crohn’s disease development later. Management is challenging. Exclusion of offending

substances may help facial swelling resolve. Topical or intralesional triamcinolone acetonide alone or in combination with topical pimecrolimus or tacrolimus may be trialled but systemic clofazimine, dapsone, methotrexate, tacrolimus, thalidomide, other immunosuppressants or anti-TNF biologics (under physician guidance) may be needed.

References Gandolfo S, Scully C, Carrozzo M (2006) Oral medicine. Elsevier Churchill Livingstone (Edinburgh and London). ISBN 13: 29780443100376 Scully C, Almeida ODP, Bagan J, Diz PD, Mosqueda A (2010) Oral medicine and pathology at a glance. WileyBlackwell (Oxford) ISBN 978-1-4051-9985-8 Scully C, Flint S, Bagan JV, Porter SR, Moos K (2010) Oral and maxillofacial diseases. Informa Healthcare (London and New York). ISBN-13: 9780415414944 Scully C, Bagan JV, Carrozzo M, Flaitz C, Gandolfo S (2012) Pocketbook of oral disease. Elsevier, London. ISBN 978-0-702-04649-0 Scully C (2013) Oral and maxillofacial medicine. 3rd edition. Churchill Livingstone (Edinburgh). ISBN 9780702049484 Scully C (2012) Aide memoires in oral diagnosis: mnemonics and acronyms (the Scully system). Journal of Investigative and Clinical Dentistry 3(4): 262-3 Published with permission by Private Dentistry May 2014


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Vital pulp therapy with Biodentine™ in two immature, traumatized teeth

Marga Ree1



Marga Ree DDS, MSc Private Practice limited to Endodontics, Purmerend, Netherlands

If pulp vitality in a young, permanent tooth is lost before root formation is completed, the clinician is confronted with a tooth that is more prone to fracture in case of a trauma, due to the presence of a root with very thin dentinal walls. In addition, the affected tooth might exhibit a poor crown-root ratio. Therefore, it is of utmost importance that pulp vitality should be preserved in an immature tooth with pulp involvement. According to the definition of the AAE, the American Association of Endodontists, vital pulp therapy is a procedure to encourage apexogenesis. The requirements for a successful vital pulp therapy are a the presence of a noninflamed or a reversibly-inflamed pulp, the ability the control the hemorrhage, the use of a biocompatible and bioactive pulp capping material and the creation of a bacteriatight seal. Over the course of time, several materials have been used as pulp capping agents. Calcium hydroxide has traditionally been the material of choice, followed by Mineral Trioxide Aggregate (MTA). MTA is described as a first generation bioactive material. It has many advantages, but also some disadvantages.1, 2 The initial setting time is at least 3 hours. It is not easy to manipulate, resulting in considerable wasted material, and is hard to remove. Clinically, both gray and white MTA stain dentin, presumably due to the heavy metal content of the material or the inclusion of blood pigment while setting.3, 4 Efforts have been made to overcome these shortcomings with new compositions of MTA5-7 or with additives.8, 9 However, these formulations affect MTA’s physical and mechanical characteristics. Bioceramics are inorganic, non-metallic, biocompatible materials that have similar mechanical properties as the hard tissues they are replacing or repairing. They are chemically stable, non-corrosive, and interaction well with organic tissue. Bioceramic materials used in endodontics can be categorized by composition, setting mechanism and consistency. There are sealers and pastes, developed for use with gutta-percha, and putties, designed for use as the sole material, comparable to MTA. Biodentine™ is a calcium silicate cement that was developed as a dentine substitute in deep cavities.


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Figure 1a: Preoperative radiograph of #21 showing an immature tooth with an open apex and a complicated crown fracture. Figure 1b: Clinical picture showing a complicated crown fracture in #21.

Comparable to MTA, Biodentine™ is biocompatible and in contact with vital tissues it has been demonstrated to be bioactive and suitable to be used as a pulp capping agent.10, 11, 12 It has a higher compressive strength than MTA12 and most glass ionomer cements, a higher flexural strength and flexural modulus than MTA Angelus12 and can be applied in a bulk on dentin without any conditioning.13, 14 The material sets in 12 minutes and is capable to withstand deterioration when used as a temporary filling for

up to 6 months.15 In the opinion of the author, bioceramic materials have several advantages over MTA. In general, bioceramic materials have better clinical handling properties. The difficulties in handling of MTA have been frequently reported by clinicians.16 Another drawback of MTA is the potential for staining dentin, which has been shown in several in vitro studies,4, 17, 18 clinical investigations19, 20 and case reports,3, 21 which have shown that both white and gray MTA cause

Figure 1c: The palatal aspect of the fracture site, covered with plaque.

Figure 1d: Photograph of the fragment, showing an oblique fracture line with the palatal outline below the gum line


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Figure 1e: After a partial pulpotomy was carried out, a cotton pellet soaked in NaOCl 5% was applied to the pulp stump to stop the bleeding. Figure 1f: Clinical picture showing the hemorrhage was controlled. Figure 1g: Biodentine was used as a pulp capping material.




Figure 1h: Postoperative radiograph of the pulp cap with Biodentine, showing a material with moderate radiopacity. Figure 1i: After one week, the Biodentine had not washed out. Figure 1j: A retraction cord was packed into the sulcus to obtain a dry field and expose the subgingival margin of the palatal fracture site.





Figure 1k: Postoperative radiograph showing the teeth restored with composite resin. Figure 1l: Clinical picture of the restoration of composite core material layered with a micro-filled composite at the buccal site. Figure 1m - n: Recall radiograph at 6 and 12 months, showing continued root formation.

discoloration. To date, there have been no reports of staining of dentin by Biodentine™ or comparable bioceramic products, which has also been the experience of the author. Several studies report that bismuth oxide, which acts as a

radiopacifier in MTA as a radiopacifier,22, 23 may increase the cytotoxicity of MTA, because bismuth oxide does not encourage cell proliferation in cell culture.24 Biodentine™ contains zirconium oxide as opacifier.


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Figure 2a: Preoperative radiograph of 21 showing a class IV restoration of composite resin and an immature root with an open apex. Figure 2b: After a partial pulpotomy was carried out, a cotton pellet soaked in NaOCl 5% was applied to the pulp stump to stop the bleeding. Figure 2c: After a couple of minutes, the bleeding had stopped, which is indicative of healthy pulp tissue.




Figures 2d - e: Biodentine was used as a pulp capping material. Figure 2f: Photograph of the set Biodentine.



Case reports Patient #1 was a 7-year old female who suffered a traumatic dental injury to tooth #21 three days earlier. Her main complaints were sensitivity to warm and cold, and


Figure 2g: Postoperative radiograph showing the pulp-capped tooth restored with a composite resin. Figure 2h-i: At 6 and 18 months respectively, the patient was asymptomatic and the recall radiographs showed continued root development.

her medical history was noncontributory. Clinical examination revealed a crown fracture with pulp exposure of tooth #21 (Fig. 1a). Radiographically, #21 had an open apex and no peri-apical pathosis (Fig. 1b). The


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diagnosis was a complicated crown fracture with reversible pulpitis of tooth #21 Treatment options were discussed with the patient and her parents, and a partial pulpotomy was selected as the treatment of choice. The fragment was stored by her parents, but due to the subgingival fracture site (Fig. 1c) and missing tooth structure in the fragment itself (Fig. 1d), it was not possible to re-attach the fragment to the tooth. Local anesthesia was administered (Septanest N, Septodont, Saint-Maur-des-Fossés, France) and a partial pulpotomy was carried out with a new diamond bur in a high speed handpiece with copious water cooling. Since it was not possible to apply a rubber dam, utmost care was taken to keep a dry field and prevent saliva to contaminate the pulp tissue after the Cvek pulpotomy. A cotton pellet soaked in sodium hypochlorite 5% was applied on the pulp stump with moderate pressure (Fig. 1e). After five minutes, the bleeding had stopped (Fig. 1f), and Biodentine™ (Septodont, Saint-Maur-des-Fossés, France) was applied as a pulp capping material to a thickness of approximately 3 mm with a Dovgan MTA carrier (Hartzell and Son, Concord, CA) (Fig. 1g-h). After the material had set in approximately 20 minutes, it was used as a temporary restoration. This is one of the advantages of the use of Biodentine™ over MTA, and makes it the material of choice in these type of cases. The patient was rescheduled for a second visit. After one week, the patient returned and was asymptomatic. The Biodentine™ had fully set and had not washed out (Fig. 1i). A gingivectomy was carried out, and a retraction cord (Gingibraid, van R, Oxnard, CA, USA) was packed into the sulcus (Fig. 1j). Then a build-up of composite core material was placed (Luxacore; DMG, Hamburg, Germany), which was cut back on the buccal site and layered with a micro-filled composite (Filtek Supreme Ultra Universal Restorative, 3M ESPE, St. Paul, MN, USA) (Fig. 1k-l). Follow-up after 6 (Fig. 1m) and 12 months (Fig. 1n) showed a healthy tooth in full function with continuous root development. Patient #2 was an 8-year old male who was referred for advice and possible treatment of tooth #21. His medical history was noncontributory. Some months ago, he sustained an uncomplicated crown fracture of # 21. His dentist made

a restoration of composite resin, that had to be replaced 5 times, because it came loose every single time. For one week, the patient had experienced severe sensitivity to hot and cold food and drinks. Clinical testing confirmed that tooth #21 was very sensitive to cold. A radiographic examination revealed that #21 had an open apex and no peri-apical pathosis (Fig. 2a). The diagnosis was an uncomplicated crown fracture with a reversible pulpitis in tooth #21. Treatment options were discussed with the patient and his parents, and a partial pulpotomy was selected as the treatment of choice. Local anesthesia was administered (Septanest N, Septodont, Saint-Maur-des-Fossés, France), rubber dam was applied (Optradam, Ivoclar Vivadent, Schaan, Lichtenstein) and a partial pulpotomy was carried out with a new diamond bur in a high speed handpiece with copious water cooling. A cotton pellet soaked in sodium hypochlorite 5% was applied on the pulp stump with moderate pressure (Fig. 2b). After five minutes, the bleeding had stopped (Fig. 2c), and Biodentine™ (Septodont, SaintMaur-des-Fossés, France) was applied as a pulp capping material to a thickness of several mm with a Dovgan MTA carrier (Hartzell and Son, Concord, CA) (Fig. 2d-e). A moist cotton pellet was introduced on top of the Biodentine™, the access cavity was filled with a temporary filing, and the patient was rescheduled for a second appointment. After a week the patient returned asymptomatic. The Biodentine™ had fully set (Fig. 2f) and a build-up of composite core material was placed in the endodontic access cavity (Luxacore; DMG, Hamburg, Germany), with a top layer of a hybrid composite (Tetric Ceram, Ivoclar Vivadent, Schaan, Lichtenstein) (Fig. 2g). At the 6-month (Fig. 2h) and 18-month recall (Fig. 2i), the tooth was asymptomatic and showed apical maturation and continuous root development.

Conclusion The author has presented 2 cases in which Biodentine™ was successfully used as a pulp capping material in an immature tooth with pulp involvement. In both cases, treatment provided elimination of symptoms and continuation of root formation. In addition, no signs of discoloration were noticed after 6, 12 and 18 months respectively.


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References 1. Parirokh M, Torabinejad M. Mineral Trioxide Aggregate: a comprehensive literature review Part II – Leakage and biocompatibility investigations. J Endod 2010 Feb; 36 (2): 190-202. 2. Parirokh M, Torabinejad M. Mineral Trioxide Aggregate: a comprehensive literature review Part I – Chemical, physical and antibacterial properties. J Endod 2010 Jan; 36(1): 16-17. 3. Belobrov I, Parashos P. Treatment of tooth discoloration after the use of white mineral trioxide aggregate. J Endod 2011 Jul;37(7):1017-20. 4. Akbari M, Rouhani A, Samiee S, Jafarzadeh H. Effect of dentin bonding agent on the prevention of tooth discoloration produced by mineral trioxide aggregate. Int J Dent. 2012;2012:563203. 5. Antunes Bortoluzzi E, Juárez Broon N, Antonio Hungaro Duarte M, de Oliveira Demarchi AC, Monteiro Bramante C. The use of a setting accelerator and its effect on pH and calcium ion release of mineral trioxide aggregate and white Portland cement. J Endod 2006;32:1194–7. 6. Wiltbank KB, Schwartz SA, Schindler WG. Effect of selected accelerants on the physical properties of mineral trioxide aggregate and Portland cement. J Endod 2007;33: 1235–8. 7. Ber BS, Hatton JF, Stewart GP. Chemical modification of ProRoot MTA to improve handling characteristics and decrease setting time. J Endod 2007;33:1231–4. 8. Kogan P, He J, Glickman GN, Watanabe I. The effects of various additives on setting properties of MTA. J Endod 2006;32:569–72. 9. Jafarnia B, Jiang J, He J, Wang YH, Safavi KE, Zhu Q. Evaluation of cytotoxicity of MTA employing various additives. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;107:73944. 10. Shayegan A, Jurysta C, Atash R, Petein M, Abbeele AV. Biodentine used as a pulp-capping agent in primary pig teeth. Pediatr Dent. 2012 Nov-Dec;34(7):e202-8. 11. Nowicka A, Lipski M, Parafiniuk M, Sporniak-Tutak K, Lichota D, Kosierkiewicz

A, Kaczmarek W, Buczkowska-Radlińska J. Response of human dental pulp capped with biodentine and mineral trioxide aggregate. J Endod. 2013 Jun;39(6):743-7. 12. Natale LC, Rodrigues MC, Xavier TA, Simões A, de Souza DN, Braga RR. Ion release and mechanical properties of calcium silicate and calcium hydroxide materials used for pulp capping. Int Endod J. 2014 Mar 20. 13. Laurent P, Camps J, De Méo M, Déjou J, About I. Induction of specific cell responses to a Ca(3)SiO(5)-based posterior restorative material. Dent Mater. 2008 Nov;24(11):1486-94 14. Raskin A, Eschrich G, Dejou J, About I. In vitro microleakage of Biodentine as a dentin substitute compared to Fuji II LC in cervical lining restorations. J Adhes Dent. 2012 Dec;14(6):535-42. 15. Koubi G, Colon P, Franquin JC, Hartmann A, Richard G, Faure MO, Lambert G. Clinical evaluation of the performance and safety of a new dentine substitute,Biodentine, in the restoration of posterior teeth - a prospective study. Clin Oral Investig. 2013 Jan;17(1):243-9. 16. Parirokh M, Torabinejad M. Mineral Trioxide Aggregate: a comprehensive literature review Part III – Clinical applications, drawbacks and mechanisms of action. J Endod 2010 Mar; 36 (3): 400-13. 17. Boutsioukis C, Noula G, Lambrianidis T. Ex vivo study of the efficiency of two techniques for the removal of mineral trioxide aggregate used as a root canal filling material. J Endod 2008 Oct;34(10):1239-42. 18. Jang JH, Kang M, Ahn S, Kim S, Kim W, Kim Y, Kim E. Tooth discoloration after the use of new pozzolan cement (Endocem) and mineral trioxide aggregate and the effects of internal bleaching. J Endod 2013 Dec;39(12):1598-602. 19. Maroto M, Barbería E, Vera V, García-Godoy F. Dentin bridge formation after white mineral trioxide aggregate (white MTA) pulpotomies in primary molars. Am J Dent. 2006;19:75–79. 20. Percinoto C, de Castro AM, Pinto LM. Clinical and radiographic evaluation of pulpotomies employing calcium hydroxide and trioxide mineral aggregate. Gen Dent. 2006;54:258–261.


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21. Jacobovitz M, de Lima RK. Treatment of inflammatory internal root resorption with mineral trioxide aggregate: a case report. Int Endod J. 2008 Oct;41(10):905-12. 22. Camilleri J, Montesin FE, Brady K, Sweeney R, Curtis RV, Ford TR. The constitution of mineral trioxide aggregate. Dent Mater. 2005 Apr;21(4):297-303. 23. Park JW, Hong SH, Kim JH, Lee SJ, Shin SJ. X-Ray

diffraction analysis of white ProRoot MTA and Diadent BioAggregate. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Jan;109(1):155-8. 24. Camilleri J, Montesin FE, Papaioannou S, McDonald F, Pitt Ford TR. Biocompatibility of two commercial forms of mineral trioxide aggregate. Int Endod J. 2004 Oct;37(10):699-704

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Which non-surgical treatment protocol should I use as first-line intervention against peri-implantitis? Johan Hartshorne1

A critical appraisal of a systematic review and meta-analysis: Faggion CM, Listl S, Frühauf N, Chang H-J, Tu Y-K. (2014) A systematic review and Bayesian network meta-analysis of randomized clinical trials on non-surgical treatments for peri-implantitis. Journal of Clinical Periodontology, Accepted article, doi: 10.1111/jcpe.12292

Summary Systematic review conclusion: All combinations of non-surgical approaches for treating peri-implantitis showed small but more significant probing pocket depth reduction than debridement only. There is insufficient evidence to rate any particular non-surgical treatment for peri-implantitis as providing significantly better performance than debridement alone. Critical appraisal conclusion: Removal of biofilm by means of mechanical or automatic debridement and reducing bacterial load with adjunctive use of antimicrobial agents, without altering the implant surface, remains the standard of care for first-line intervention to any non-surgical treatment approach for peri-implantitis. At this stage of time the efficacy and validity of mechanical or automatic debridement methods for removing biofilm as well as adjunctive antimicrobial therapies remain unknown and needs to be tested by properly executed RCT’s. Implications for clinical practice: Currently there is no gold standard non-surgical treatment protocol. Clinicians, however, should be committed to monitoring and maintaining peri-implant health through continuous assessment and the provision of individualized supportive care. Patient motivation and proper oral hygiene practices to limit infection is very important.

Clinical question “In patients with peri-implantitis, what is the clinical effect of other non-surgical approaches in comparison to sub-gingival scaling in terms of clinical attachment level and pocket depth changes compared?”

Review methods 1

Johan Hartshorne B.Sc., B.Ch.D., M.Ch.D, M.P.A. Ph.D. (Stell), FFPH.RCP (UK), Visiting Professor, Department of Periodontics and Oral Medicine, University of Pretoria, Pretoria, South Africa.


Methodology The reviewers conducted the systematic review of the literature according to the PRISMA1 and AMSTAR 2 guidelines. The network meta-analysis was conducted in accordance with the guidelines for good research practices for indirect treatment comparisons. 3 Search strategy and study selection Two independent reviewers searched the following electronic databases: [MEDLINEPubmed, SCOPUS, CINAHL, DARE, Biosis Preview and Web of Knowledge, up to and including 1 January 2014 to identify articles that met the inclusion criteria. In addition they searched for grey literature (IADR meetings, clinical,


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CLINICAL, Pro-Quest Dissertation Abstracts and Thesis database and Opengrey ( for potential studies and clinical trials in progress. They also conducted a manual search of relevant journals from January 2000 to January 2014. No language restrictions were used. The two independent reviewers assessed the full-text of potential articles for inclusion into the study. Disagreements on inclusion of a study were resolved by discussion between the reviewers until consensus was achieved. They also screened the reference lists of included randomized controlled trials (RCT’s) for relevant studies. The investigators recorded all studies that were rejected as well as the reason for exclusion. Eligibility and exclusion criteria The reviewers searched for RCT’s in humans and non-surgical approaches for treating peri-implantitis. RCT’s without any intervention or with treatment outcomes other than clinical attachment level (CAL) and probing pocket depth (PPD) changes were excluded. All other study designs, animal, and in-vitro studies were excluded. Studies investigating surgical approaches and those with duplicated data were also excluded. Outcome measures and data extraction The reviewers used two endpoints to assess the clinical effect of non-surgical peri-implantitis therapies: CAL and PPD. Two independent reviewers extracted the data from the included studies. Data was double-checked and any disagreement on data extraction was resolved by discussion between reviewers until consensus was achieved. They contacted the authors of the original studies for clarification of dubious data and request for unpublished data. Data analysis Network meta-analysis (NMA) was conducted using the Bayesian random-effects hierarchical model that incorporates information from both direct and indirect comparisons of multiple therapies in a single analysis. Standard metaanalysis of direct pair-wise comparisons were also performed and compared to results from the NMA. To be valid, interventions in a NMA should be connected. The NMA based on CAL was not connected, and therefore its assessment was not feasible. Therefore, only results in PPD changes were reported. Studies with split-mouth design were separated from those with parallel group design in order to take account of potential correlation between treatment effects of treatment

groups with split-mouth RCT’s. The reviewers also made adjustments for studies that reported results from site level data analysis by calculating appropriate standard errors using the number of patients. Consistency amongst the network was statistically investigated. They also used a comparison-adjusted funnel plot to assess whether smaller studies produced larger treatment effects. The treatments were ordered by defining the comparisons of an active treatment versus placebo (debridement) only. Risk of bias of the included RCT’s was assessed according the Cochrane Collaboration risk of bias assessment tool.4 Three reviewers were subjected to a training phase prior to the risk of bias assessment. The overall quality of the evidence within the pair-wise meta-analysis was graded using the GRADE approach.5

Main results The search process yielded 11 RCT’s studies eligible for the NMA. Ten of the RCT’s had a parallel group design and one study used a split-mouth design. The NMA compared the PPD between 8 different treatments namely: (i) debridement + chlorhexidine, (ii) photodynamic therapy, (iii) debridement and antibiotics, (iv) air abrasive system, (v) Vector ultrasonic system, (vi) debridement and periochip, (vii) Er:YAG laser monotherapy, and (viii) debridement alone (control). Overall, the examined combinations of therapeutic approaches generated greater PPD reduction than isolated debridement (control) alone. The differences between the combinations however, were very small. The reviewers ascribed the small differences in outcomes between therapies to heterogeneity amongst RCT’s. The results from the NMA indicated that debridement in conjunction with antibiotics achieved the greatest additional PPD reduction in comparison to debridement only (0.490 mm 95% Credible Intervals [CrI]: -0.647 to 1.252). The second greatest additional PPD reduction was provided by the combination of debridement and periochip (0.400 mm 95% CrI: -0.843 to 1.629) more PPD reduction than debridement only. Debridement and antibiotics achieved greater PPD reduction (0.262 mm 95% CrI: -1.260 to 0.771) than debridement combined with a chlorhexidine gel. Large CrI indicated considerable uncertainty. Results from the NMA were in general comparable to those from the pair-wise meta-analysis. The network funnel plot showed only small study bias. No inconsistency was found within the network. In general there was a low to moderate risk of bias across all included studies. Three studies were considered to be at


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high risk of bias, because one of the authors was working for a company supporting the respective study. Seven studies were industry supported. Overall, the quality of the evidence was considered very low by the GRADE assessment. The main reasons for grading the evidence as very low were the risk of bias limitations and imprecision within the included studies. A statistically significant heterogeneity was found amongst the RCT’s (p= 0.046; I2 = 46.1%)

Conclusion The authors of this review concluded that all combinations of non-surgical therapies for treating peri-implantitis generated small but more significant PPD reduction than debridement alone. However, they also stated that the results should be interpreted with caution due to the large credit intervals. They also pointed out that currently available evidence does not support the valuation that any particular non-surgical treatment for peri-implantitis performs better than debridement alone. The authors received financial support and declared no potential conflict of interest with respect to the authorship and/or publication of this review.

Commentary Background and importance Peri-implantitis is an inflammatory lesion of the surrounding peri-implant tissues with loss of supporting bone and clinical signs of inflammation (bleeding and/or suppuration on probing)6, primarily caused by bacteria from dental biofilm.7,8 The prevalence of peri-implantitis is estimated to be in the order of 10% of implants and 20% of patients 5 to 10 years after implant placement.9 The high prevalence rate and the lack of standard mode of care make it an important disease entity.10 Currently the basis for non-surgical peri-implantitis therapy is mechanical or automatic debridement of the implant surface to remove the adhered biofilm and chemical decontamination to reducing the bacterial load below the threshold level for causing disease.11 Various debridement protocols in combination with adjunctive therapy have been proposed to achieve the abovementioned goal. Generally they involve mechanical or automatic debridement of the implant surfaces using either curettes (i.e. carbon fibre or titanium), ultrasonic or air abrasive devices or lasers. These treatment modalities are either used alone or in combination with an antimicrobial therapy based on antibiotics (locally

or systemically) or antiseptics such as chlorhexidine.12 Successful peri-implantitis treatment outcome is considered as absence of PPD ≥ 5mm, no BoP with light pressure and no suppuration, in addition to no further bone loss.8 The latter authors proposed that if these criteria can be met, no further intervention other than non-surgical maintenance care would be required. If the latter criteria cannot be met, surgical intervention is required. This study is the first attempt to combine and compare the data of available RCT’s of different non-surgical therapeutic protocols for peri-implantitis in a meta-analysis. Are the results valid? The methodological rigor of this review was excellent and in a class of its own. However, the methodological quality of the individual RCT’s included in this review had several basic limitations and weaknesses that affected the quality of the evidence presented. Overall, there was marked variability and inconsistencies between the studies for all outcomes measured. This is likely due to differences in the sample population characteristics, definition of peri-implantitis, characteristics of the interventions used, and inconsistencies with measurement of primary and secondary outcomes. Various risk factors were excluded from the study including smoking, poor oral hygiene, untreated periodontal disease, and diabetes that could modify both initial outcome of treatment as well as the long-term outcome.9,13 Some of the studies were lacking information on the presence or absence of clinical inflammation (bleeding or suppuration on probing) in the inclusion criteria and therefore had to be discarded as an outcome measure in the metaanalysis. Consequently the only clinical endpoint used in this meta-analysis was PPD. This raises some concern because reduction of PPD might not indicate that therapies will be effective in the long-term neither is there any proof of evidence that reduction of PPD after non-surgical therapy will reduce implant failure.14 Overall, there was a lack of uniformity in the assessed treatment regimens. Some interventions simultaneously involved both mechanical and chemical treatment of implant surfaces in order to remove bacterial plaque, whilst other therapies were based on single or repeated application. Another potential limitation of the present meta-analysis is the short follow-up (up to 12 months) as this hinders more definitive conclusions about the efficacy of therapies. Whilst clinical healing could be expected to be complete by 3 months following cause related therapy15 (i.e removal of the


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biofilm), detectable changes in radiographic marginal bone levels may not be apparent at this time.8 Long-term RCT’s remain desirable. The number of studies included in the review were relatively insufficient, potentially leading to fragile probabilities.16 Adding on a study to the meta-analysis could tip the probability scale in any direction. Most domains presented a low risk of bias. However, one domain (allocation concealment) was considered a high or unclear risk of bias in 9 of 11 RCTs assessed. Estimates of treatment effects may be inflated when allocation concealment is not preserved. 17 Additionally, three of the RCTs included in the meta-analysis were considered at high risk of reporting bias because authors involved in the studies were working for the companies supporting the study at the time of the study and the findings from these studies suggest more positive or favourable results for therapies supported by industry. The high level of variability, lack of consistency, and risk of bias, does not lend support to the validity of the results. However, the results of the NMA were consistent to those from pair-wise meta-analysis, thus supporting the validity of the results. Additionally, the comparison-adjusted funnel did not support biases towards larger effects in smaller trials. Overall, the weaknesses of the study were greater than its strengths, thus questioning the validity of the results. What were the key findings? All the combinations of therapeutic approaches generated greater PPD reduction compared to using debridement alone. The differences between the combinations however ranged between small and considerable uncertainty, and therefore may not be clinically relevant, thus indicating that any decision-making regarding choices for best treatment approach should be done with caution. The Vector ultrasonic system had the greatest probability to be ranked as the best non-surgical therapeutic approach for peri-implantitis. However, two other approaches, debridement with periochip and photodynamic therapy, presented with similar probabilities. Although ranking of therapies are helpful in practical decision-making, caution should be exercised due to sparse evidence and limitations in the included studies. How are the results of this review applicable in clinical practice? Treating peri-implantitis effectively through a non-surgical approach has great significance to the patient because this

could mean saving or losing an implant. A non-surgical approach as opposed to a surgical approach also means less discomfort, less morbidity and reduced cost. Postoperative complications and early implant failures are important patient outcomes because of health, inconvenience and cost implications thereof. As a general rule, antibiotic prophylaxis is always indicated when there is an important risk of infection, either because of the characteristics of the surgical procedure (i.e. type and duration of surgery), because of the patient’s local or systemic infection risk (i.e. diabetes, immunodeficiency’s, inflammatory arthropathies), or for patients with postbacteraemia focal infection risk factors (i.e. infectious endocarditis, infection of joint prostheses). Most of the individual studies had specific exclusion criteria, including patients who smoked, patients with full mouth plaque scores or full mouth bleeding scores above 20%, pregnant or lactating women, patients who had taken systemic antibiotics in recent months prior to treatment, patients with implants with < 2mm keratinized mucosa or no keratinized mucosa. Consequently, the results reported should be interpreted with caution and may not apply to all patients in the practice situation. Availability and accessibility to the technologies assessed in this review may also be limited due to high cost of equipment and skills training required.

Clinical resolution Clinicians involved with dental implant treatment must have a comprehensive understanding of the need for on-going maintenance and peri-implant health, peri-implant disease, the assessment thereof, and correct diagnosis and early interception of disease, as well as appropriate skills and tools for managing these complications. Non-surgical peri-implantitis therapy as first line treatment plays a pivotal role in the treatment of peri-implant disease. Removal of biofilm by means of mechanical or automatic debridement, and reducing bacterial load to levels compatible with peri-implant health by means of adjunctive use of antimicrobial agents without altering the implant surface, remains the standard of care for first-line intervention to any non-surgical treatment approach for peri-implantitis. At this stage of time the efficacy and validity of mechanical or automatic debridement protocols for removing biofilm as well as adjunctive antimicrobial therapies for reducing bacterial load remain unknown and needs to be tested by properly executed head-to-head RCT’s.


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Disclosure Dr Johan Hartshorne is trained in clinical epidemiology, biostatistics, research methodology and critical appraisal of research evidence. This critical appraisal is not intended to, and do not, express, imply or summarize standards of care, but rather provide a concise reference point for dentists to aid in understanding and applying research evidence from referenced early view or pre-published articles in top ranking scientific publications and to facilitate clinically sound decisions as guided by their clinical judgement and by patient needs.

References 1. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analysis of studies that evaluate healthcare interventions: explanation and elaboration. Brit Med J 2009; 339: b2700. 2. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, Hamel C, Porter AC, Tugwell P, Moher D, Bouter LM. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic review BMC Med Res Methodol 2007; 7: 10. 3. Jansen JP, Fleurence R, Devine B, Itzler R, Barret A, Hawkins N, Lee K, Boersma C, Annemans L. Interpreting indirect treatment comparisons and network meta-analysis for health care decision making: Report of the ISPOR task force on indirect treatment comparisons good research practices: Part 1. Value in Health 2011; 14: 417-428. 4. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. B Med J 2011; 343: d5928. 5. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, Schunemann HJ and GRADE Working Group. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Brit Med J 2008; 336: 924- 926.

6. Lindhe J, Meyle J. Peri-implant diseases: Consensus report of the Sixth European Workshop on Periodontology. J Clin Periodontol 2008; 35: 282-285. 7. Lang NP, Berglundh T. Peri-implant diseases: where are we now? – Consensus of the Seventh European Workshop on Periodontology. J Clin Periodontol 2011: 38(Suppl): 178-181. 8. Heitz-Mayfield LJ, Mombelli A. The therapy of peri-implantitis: A systematic review. Int J Oral Maxillofac 2014; 29(Suppl): 325-345. 9. Mombelli A, Muller N,Clonca N. The epidemiology of peri-implantitis. Clin Oral Implants Res 2012; 23(suppl. 6): 67-76. 10. Renvert S, Roos-Jansaker AM, Claffey N. Non-surgical treatment of peri-implant mucositis and peri-implantitis: A literature review. J Clin Periodontol 2008; 35: 305-315. 11. Tomasi C, Wennstrom JL. Full mouth treatment vs the conventional staged approach for periodontal infection control. Periodontol 2000 2009; 51: 45-62. 12. Fuguero E, Graziani F, Sanz I, Herrera D, Sanz M. Management of peri-implant mucositis and peri-implantitis. Periodontology 2000 2014; 66: 255-273. 13. Heitz-Mayfield LJ. Peri-implant diseases: Diagnosis and risk indicators. J Clin Periodontol 2008; 35: 292-304. 14. Faggion CM Jr, Listl S, Tu YK. Assessment of endpoints in studies of peri-implantitis treatment – a systematic review. J Dentistry 2010; 38: 443-450. 15. Heitz-Mayfield LJ, Salvi GE, Mombelli A, Faddy M, Lang NP. Implant complications research. Antiinfective surgical therapy of peri-implantitis. A 12-month prospective clinical study. Clin Oral Implants Res 2012; 33: 205-210. 16. Mills EJ, Thorlund K, Ioannidis JP. Demystifying trial networks and network meta-analysis. Br Med J 2013; 346: f2914. 17. Schultz KF, Chalmers I, Hayes RJ, Altman DG. Empirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. J Amer Med Assoc 1995; 273: 408-412.


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High quality restorations Modern nanohybrid composites – an alternative for all cavity classes Walter Denner1 Tooth-coloured, direct restorations play an indispensable role in dental treatment today. Apart from the clinical advantages of restorative composite, such as minimally invasive preparation and stabilisation of the tooth by adhesive bonding of the restoration, it is primarily patients’ demands for “invisible” restorations that have led to this material becoming the restorative material of choice today. Initially, restorative composites were used only in the anterior region. Since then however their use has become state of the art in the posterior region as well. The positive results achieved in recent years in numerous long-term studies, particularly with hybrid composites, speak for themselves.1, 2 The reason for these positive clinical results, apart from the improvement in adhesive bonding techniques, is the significant improvement in the physical properties of the hybrid composites compared with the older microfilled and macrofilled composites. Nanohybrid composites were developed from microhybrid composites by the use of nanofillers, a step which led to a significant increase in the filler content of the materials and a considerable improvement in their physical properties.3, 4 Since then very promising clinical data for these nanohybrid composites has become available for the posterior region as well.5 –7 The restorative material GrandioSO (VOCO), which has only recently been launched on the market and which is to be used in this clinical case, is one of the latest nanohybrid composites to be developed. 1

Dr Walter Denner

Contact: Dr Walter Denner Flemingstr. 5 36041 Fulda, Germany E-Mail:

Clinical case A 33-year-old female patient presented at our practice, expressing the wish to have the old, inadequate amalgam restorations and inlays in the aesthetically relevant area replaced by “invisible” restorations. Following a clinical assessment, the taking of bitewing X-rays and a detailed examination of the situation, it was decided to replace the amalgam restorations and non-precious metal inlays in the maxillary premolars (Figs. 1, 9) by composite restorations. Since neither the clinical nor the X-ray findings gave

Figure 1: Extensive amalgam restorations on 14, 15.

Figure 2: Placement of rubber dam and removal of the old restorations.


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Figure 3: Attachment and wedging/bracing the sectional matrices. Application of the bonding agent to tooth 15.

Figure 4: Building up the mesial marginal ridge; 1st occlusal increment.

Figure 5: Precontoured restoration on tooth 15.

Figure 6: Attaching the sectional matrices to tooth 14. Application of the bonding agent.

any indications that complications were likely, it was possible to restore both quadrants at the same time at one session. Before treatment was carried out, the shade of the teeth was compared in daylight with the shade guide included with the system. The shade was determined before (completely) isolating the operating site because the moisture loss makes the teeth appear unnaturally bright and, moreover, the contrasting colour of the rubber dam gives a false impression of the tooth shade. The isolation of the area to be treated by the rubber dam neatly shields the operating site from the oral cavity, enabling the dentist to work effectively and tidily. This separation of the operating site is an enormous benefit both for the dentist and the patient, especially for larger restorations. The 1st quadrant was restored first. In order to do this, the rubber dam was secured on tooth 16 by means of a clamp and the old amalgam restorations and inlays were removed (Fig. 2). The sectional matrices used (Compositight, Garrison)

were secured by a clamping ring (Palodent, Dentsply) and adapted with wooden wedges. Great care should be taken in adapting the matrices accurately because this will minimise excesses. This will pay off later because less time and effort will have to be spent finishing the restoration. The application of the bonding agent (Futurabond DC, VOCO) was followed by the incremental filling of the cavity in tooth 15 with the nanohybrid composite GrandioSO in shade A3. To do this, the Class II cavity was initially transformed into a purely occlusally limited cavity by building up the distal (Fig. 4) and mesial marginal ridges. The pleasant, non-sticky consistency of GrandioSO facilitates the adaptation of the material and the contouring of the proximal walls in this procedure. After completion of the proximal walls it was possible to remove the matrices and the clamping rings for a better overview. The composite GrandioSO was placed in individual increments into the cavity, which was now purely occlusal, with each increment being polymerised


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for ten seconds by blue light. The individual layers are formed anatomically correctly in this process, i.e. following the occlusal relief as closely as possible. This saves much time in the subsequent finishing. Figure 5 shows the precontoured restoration of tooth 15 after it had been placed. A similar procedure was then carried out in tooth 14. The sectional matrices were attached and wedged (Fig. 6), the bonding agent applied, dried with an air stream and polymerised. The proximal walls were again reconstructed initially, and the occlusal restoration was then incrementally filled and precontoured (Fig. 7). Figure 8 shows the completed restoration after polishing and checking the occlusion. After the restorations had been completed in the 1st quadrant, the rubber dam was secured on tooth 26 to restore the 2nd quadrant and the old restorations in tooth 24 and tooth 25 were excavated (Fig. 10). Caries Marker (VOCO) was used to ensure a complete excavation of caries. Sectional matrices were attached to tooth 25 and

the self-etch adhesive Futurabond DC was then applied to both cavities and cured. After the distal marginal ridge on tooth 25 had been built up, the mesial wall was reconstructed and the deep distal box was filled in several horizontal layers. At the same time, the buccal followed by the palatal part of the occlusal cavity in tooth 24 was restored with GrandioSO A3. The cavity in tooth 25 was filled with additional increments of GrandioSO to match the tooth’s anatomy and was then finished (Fig. 11). After the restorations had been completed, the rubber dam was removed, the static and dynamic occlusion checked and finally all restorations were polished with silicone polishers to a high-lustre. Figs. 8 and 12 show the completed, aesthetically attractive restorations. Modern nanohybrid composites enable the dentist to carry out restorations which are both minimally invasive and durable, and which combine the necessary stability with the optimum aesthetic effect required by the patient, especially for the posterior tooth.

Figure 7: Precontoured restorations before finishing.

Figure 8: Completed restorations of the 1st quadrant.

Figure 9: Restorations to be replaced (amalgam, non-precious metal inlay) on 24, 25.

Figure 10: Placement of rubber dam and excavation of the old restoration.


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Figure 11: Placement of additional increments of GrandioSO into the cavities of 24, 25.

Figure 12: Completed, highly aesthetic restorations of the 2nd quadrant.


or Traditional Microhybrid Resins Oper. Dent. 34, 551-557 (2009) 5. Celik, C., Arhun, N., Yamanel, K.: Clinical Evaluation of Resin-based Composites in Posterior Restorations: Two Year result Oper. Dent. 35, 399-406 (2010) 6. Krämer, N., Reinelt, C., Richter, G., Petschelt, A., Frankenberger, R.: Nanohybrid vs. fine hybrid composite in Class II cavities: clinical results and margin analysis after four years. Dent. Mater. 25, 750 – 759, (2009) 7. Garcia-Godoy, F., Krämer, N., Feilzer, A.J., Frankenberger, R.: Long-term degradation of enamel and dentin bonds: 6-year results in vitro vs. in vivo. Dent. Mater. 26, 1113-1118 (2010)

1. Hickel, R., Heidemann D., Staehle H.J., Minnig P., Wilson N.H.: Direct composite restorations: extended use in anterior and posterior situations. Clin. Oral. Invest. 8, 43-44 (2004) 2. Manhart, J., Chen, H. Y., Hamm G. und Hickel, R.: Review of the clinical survival of direct and indirect restorations in posterior teeth of the permanent dentition Oper. Dent. 29, 481-508 (2004) 3. Beun, S., Glorieux, T., Devaux, J., Vreven, J., Leloup, G.: Characterization of nanofilled compared to universal and microfilled composites Dent. Mater. 23, 51-59 (2007) 4. Moraes, R.R., Goncalves, L.S., Lancellotti, A.C., Consani, S., Correr-Sobrinho, L., Sinhoreti, M.A.: Nanohybrid Resin Composites: Nanofiller Loaded Materials


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Making sense of mouth ulceration: part six

Crispian Scully1

Skin disorders The main skin disorders that may present with mouth ulceration include particularly lichen planus, but also: • Pemphigus • Pemphigoid • Dermatitis herpetiformis • Linear IgA disease • Epidermolysis bullosa • Erythema multiforme.

Lichen planus


Professor Crispian Scully CBE FMedSci DSc FDS MD is professor emeritus at UCL, London, King James IV professor at the Royal College of Surgeons, Edinburgh, Harley Street Diagnostic Centre, 16 Devonshire Street and 19 Wimpole Street, London.

This article discusses lichen planus – the most common skin disease with oral lesions, and the last group of the systemic causes of mouth ulceration (skin disorders). Lichen planus (LP) is a common mucocutaneous disorder; an inflammatory autoimmune-type of disease that can affect stratified squamous epithelia – the skin, oral mucosa and genitalia. Lichen planus usually affects persons aged between 30 and 65 years, with a slight female predisposition. Tumour necrosis factor-alpha (TNFα) homozygous polymorphisms may cause cutaneous lesions. The antigen(s) responsible are unknown and studies looking for any causal bacteria, fungi and viruses have proved negative. Antigen-processing cells (Langerhans cells) appear first and lead to a mononuclear inflammatory cell infiltrate, in the upper lamina propria, mainly of CD8+ T-cells that release T-cell cytokines such as TNFα and interferon-γ (IFNγ), cause apoptosis and vacuolar degeneration in basal keratinocytes, and lysis in the epithelial basement membrane zone (EBMZ). The clinical appearance of an oral ulcer on its own is rarely diagnostic though in lichen planus, white lesions are typically also seen (Figure 1). Lichen planus is often asymptomatic but may cause mild oral discomfort or burning sensations especially when eating or drinking substances that are acidic or spicy. For some, discomfort can be severe. Lichen planus presents orally mainly with bilateral white lesions – of which there are six clinical types, often mixed (Figure 2):


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Figure 1: White lesions are invariably seen in lichen planus.

Figure 2: Lichen planus reticular and erosive.

Figure 3: Lichenoid reaction to amalgam.

Figure 4: Lichen planus and cancer.

• Reticular, network of raised white lines (striae) • Papular • Plaque-like, white patches simulating leukoplakia • Red atrophic areas – or desquamative gingivitis • Erosive/ulcerative – persistent, irregular • Bullous (rare; possibly superficial mucoceles). The rash, if present, is characterised by lesions, which are: • Purple • Polygonal • Pruritic (itchy) • Papules – often crossed by fine white lines (Wickham’s striae). Lichen planus may also involve: • Anogenital mucosae: – ‘Vulvovaginal-gingival syndrome’ (Pelisse) – Peno-gingival syndrome – Anal LP

• Nails: uncommon ridging, shedding or destruction • Scalp: uncommonly affected • Eyes: rare conjunctival involvement. Lesions that are clinically and histologically similar to lichen planus – termed ‘lichenoid lesions’ – are sometimes caused by: • Drugs, especially NSAIDs • Dental restorative materials (Figure 3) • Chronic graft-versus-host disease • Infection with hepatitis C virus • Other systemic disorders (eg, hypertension, diabetes). Lichenoid reactions may be unilateral. Differential diagnosis includes: • Lupus erythematosus • Chronic ulcerative stomatitis • Keratosis • Carcinoma.


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A firm diagnosis of LP relies on lesional biopsy and histopathological examination. A physician opinion is indicated if: • There is HCV infection • There is other systemic background • Drugs are implicated • There is skin, genital or ocular involvement. In the management of lichen/lichenoid lesions, it may be wise to consider removal of amalgams, but no tests (eg, patch tests) will reliably help guide this decision. Symptoms can often be controlled with topical medications such as benzydamine hydrochloride (0.15%) spray or mouthrinse and 2% lidocaine gel. There is no evidence base for many of the therapies associated with lichen planus: Mild lichen planus • Topical aloe vera may help symptomatically • Topical corticosteroids are the mainstay • Initial use of a high potency drug such as clobetasol, fluocinonide or fluticasone, followed by a lower potency drug (eg, hydrocortisone hemisuccinate, betamethasone, triamcinolone acetate or fluocinolone). Moderate lichen planus (severe or extensive oral involvement) • Topical ciclosporin along with a high or super potent t opical corticosteroid • Topical tacrolimus. Severe lichen planus (in multiple sites) • Systemic corticosteroids (prednisolone, deflazacort), or other immunomodulatory agents (eg, mycophenolate mofetil

or biologics). Lichen planus, and especially lichenoid lesions, have a small malignant potential – probably in less than 1-3% and predominantly in non-reticular lesions and on tongue (Figure 4). NICE guidelines clearly state that patients with oral lichen planus should be monitored for oral cancer as part of the routine dental examination.

References Gandolfo S, Scully C, Carrozzo M (2006) Oral medicine. Elsevier Churchill Livingstone (Edinburgh and London). ISBN 13: 29780443100376 Scully C, Almeida ODP, Bagan J, Diz PD, Mosqueda A (2010) Oral medicine and pathology at a glance. WileyBlackwell (Oxford) ISBN 978-1-4051-9985-8 Scully C, Flint S, Bagan JV, Porter SR, Moos K (2010) Oral and maxillofacial diseases. Informa Healthcare (London and New York). ISBN-13: 9780415414944 Scully C, Bagan JV, Carrozzo M, Flaitz C, Gandolfo S (2012) Pocketbook of oral disease. Elsevier, London. ISBN 978-0-702-04649-0 Scully C (2013) Oral and maxillofacial medicine. 3rd edition. Churchill Livingstone (Edinburgh). ISBN 9780702049484 Scully C (2012) Aide memoires in oral diagnosis: mnemonics and acronyms (the Scully system). Journal of Investigative and Clinical Dentistry 3(4): 262-3 Scully C (2013) RULE for cancer diagnosis. British Dental Journal 215: 265-6 Published with permission by Private Dentistry June 2014


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Direct veneers just got a whole lot easier Sigal Jacobson1

Many of us still remember the past generation composites. Reproduction of the natural characteristics of a tooth was difficult because of the lack of available shades as well as the less-than ideal physical qualities of the materials. Since that time, various aesthetic composite resin materials have been introduced that possess exceptional colour characteristics and improved physical qualities. Given a composite’s advantages, why is direct composite veneering of teeth so frequently overlooked in favor of the porcelain veneer option? One would first assume that the artistic ability needed to reproduce the correct contour, shape, and shine would pose a major deterrent in participating in the process. Dentists will often state that composite veneering is time-consuming and cost-ineffective, with results that are not predictable and sometimes disappointing. This author is happy to report that Dental Art innovations, an Australian company, has recently introduced a unique product called Uveneer. The Uveneer system is a complete set of translucent templates that allows easy and fast reproduction of anterior tooth anatomy in the form of a composite veneer. The Uveneer uses innovative technologies that help the dentist to achieve a refined, anatomically correct, high-gloss restoration in a fraction of the time than if done freehand. Results are both reproducible and predictable. The operator needs to press the clear template onto the composite that has been applied to the prepared tooth, cure, and remove the Uveneer template. The result will be a shiny and anatomically correct tooth surface. The Uveneer kit includes all anterior teeth and premolars in both upper and lower arches. Two sizes, large and universal, are provided, according to research on smile design sizes and proportions. The Uveneer is made from a medical-grade translucent plastic that does not adhere to the composite resin and is both reusable and autoclavable.



Sigal Jacobson, DMD

This young woman was embarrassed to show her teeth. Tooth No. 10 is an implant crown restoration with poor match to the rest of the dentition (Figure 1). The treatment option she was offered by another dentist to get satisfactory cosmetic results was a porcelain work on all 4 incisors. This approach proved to be beyond her budget, since her resources were diminished by her implant treatment. The treatment plan offered in this case by the dentist was 3 composites veneers on teeth Nos. 9, 8, and 7 with Uveneer system. The correct template is chosen (Figure 2). Note that its size and shape corresponds nicely to the tooth to be veneered, No. 9. The teeth to be veneered required little preparation as they are retroclined. After the insertion of retraction cord and sectional matrixes, the tooth was etched for 15 seconds (Figure 3). The tooth is sprayed with water for 5 seconds and gently dried. The adhesive system is then applied and cured for 20 seconds. (This was done with VOCO America’s Futurabond U.) A composite resin is then applied to the tooth labial surface without curing yet. (This was done with Danville Materials’ ZNano. Figure 4).


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Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Figure 6.

Figure 7.

Figure 8.

Figure 9.

A small amount of flowable composite is applied into the template by using VOCO America’s GrandioSO and pressed onto the uncured composite that has been laid on the tooth. Excess is removed from the periphery using a probe. Then light cure throughout the template while pressing for 30 seconds by using Ultradent Products’ VALO LED curing light (Figure 5). The template is then removed. Retraction cord and separators are also removed. Residual excess is cleaned from the periphery with flame-finishing diamond burs (Figure 6). The Uveneer template will generate the shine (also assisted by the blocking the oxygen-inhibiting layer) and the correct anatomy of the tooth (Figure 7). The same procedure was repeated for teeth Nos. 7 and 8 (Figure 8). Three composite veneers with the Uveneer system were

completed on 3 teeth—Nos. 7, 8, and 9—in less than an hour. Everyone was very excited by the results (Figure 9).

Conclusion By combining today’s improved composite materials with the Uveneer’s innovative and unique delivery technique, dentists can now create smile solutions that were not possible before. The result is conservative, functional restorations with excellent aesthetics in a fraction of the time that it previously took. For additional information, call Dental Art innovations at (888) 771-0479 or visit Dr. Sigal Jacobson, DMD is the inventor of the Uveneer system. She is based in Melbourne, Australia, and has run her private clinic. Published with permission by Dentistry Today 8/14


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Forensic odontology – broader than just identification Richard Bassed1

Nowadays, most people will associate forensic dentistry primarily with identification and bite mark analysis. These areas do indeed form the majority of an odontologist’s workload. There are, however, other aspects of the discipline that are just as important but perhaps less well known. These include cranio-facial trauma analysis, age estimation for both living and deceased individuals, dental manifestations of child abuse, dental malpractice investigations, as well as dental insurance fraud. Forensic odontology is an integral part of the medico-legal process. With this comes a responsibility borne by forensic odontology practitioners for the requisite education, qualifications and ongoing training. Courts and legal institutions now require that we have evidence-based research upon which we can rest our findings and conclusions. In addition to knowledge of the law, we have to have knowledge of human anatomy and its relationship to injury patterns and interpretation. Knowledge of bite mark patterns due to assault, trauma and sexual abuse, as well as child abuse injury manifestations, is also required, as is knowledge of assessment techniques used when the age of an individual is unknown. Finally, there is a need to have knowledge of human identification methods, principles and practices, as well as mass disaster identification procedures and protocols, and the ethical issues involved in the examination and management of dead bodies, and to have an understanding of human rights issues involved in war crimes investigations. All of these require thorough knowledge of cranio-facial anatomy, dental anatomy, dental and skeletal development, injury interpretation and medico-legal report writing. It is also important to have a good understanding of the law relating to the practice of dentistry, the coronial system, and the criminal justice system. As the majority of the forensic odontology caseload concerns the identification of unknown deceased individuals, most discussion in this article will concentrate on this. Honouring the dead is a fundamental precept in all societies. The extent of this communal attention to the deceased varies across the world, but in essence every person hopes that his or her remains will be treated with respect after death. This respect for the dead includes, for many societies, robust identification of the deceased so that relatives and friends are able to treat the remains with appropriate ceremony and are able to visit the resting place of the deceased whenever they wish. So important is the perception of personal identification in almost all societies that authorities will go to extraordinary lengths


Dr Richard Bassed is a senior forensic odontologist and Head of Human Identification Services at the Victorian Institute of Forensic Medicine in Melbourne in Australia.

Figure 1: Comparison of ante-mortem (AM) and post-mortem (PM) radiographs, leading to a positive identification.


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to ensure that deceased individuals are not interred in unmarked graves, or cremated without a name. To be buried anonymously goes against all of our religious, cultural and ethical belief systems, and implies that a life unremembered and unmourned was really a life without consequence. William Gladstone, Prime Minister of Britain in the mid-1800s, encapsulated this sentiment better than most when he said, “Show me the manner in which a nation cares for its dead and I will measure with mathematical exactness the tender mercies of its people, their loyalty to high ideals, and their regard for the laws of the land.” Hal Hallenstein, the Victorian State Coroner from 1986 to 1994, also had firm views concerning the importance of human identification, articulated in the following quotation: “It is a hallmark of our civilisation that we regard it as an affront, an indignity, an abrogation of our responsibilities, that a person could live amongst us, die and be buried without a name.” In fact, the importance of identification of the deceased is enshrined in the Victorian Coroners Act 2008 (Section 67), which states “A coroner investigating a death must find, if possible, the identity of the deceased, the cause of death, and the circumstances in which the death occurred.” Positive identification of the deceased not only satisfies a commitment to probity, but also resolves many legal issues surrounding an individual’s death, such as inheritance and life insurance. If a deceased person remains unidentified, then technically he or she will not be declared dead for a number of years, thus creating further distress to families who not only are unable to put their lost loved one to rest, but may suffer financially as well. Personal identification of the deceased, and occasionally the living, is achieved through a variety of scientific and sometimes unscientific methods. Practitioners from forensic science, forensic medicine, law enforcement and coroners’ offices apply their own particular set of skills to an identification problem in order to arrive at an answer. The most common


2a Figures 2a–c: A more difficult case highlighting that sometimes a degree of interpretation is required.

method used to identify the deceased in all jurisdictions is undoubtedly visual recognition by a relative or close friend. There is continual debate concerning the veracity of this method, given the propensity for error, which has been well documented, especially in mass casualty events and in situations in which the deceased has suffered trauma to the face. From the forensic medical/scientific perspective, visual recognition is not proof of identity, but is only presumptive.

Theory of human identification Methods used to achieve positive human identification can be separated into two broad categories. The first consists of those methods that are presumptive for identification, such as circumstantial evidence, property associated with the body, and visual recognition. These methods involve a high degree of subjectivity and rely on identifiers that are not intrinsic to the body itself, are dependent on lay interpretation, and therefore can be falsified or mistaken (commonly known as secondary identifiers). The second category relies on scientific analysis of identifiers that are intrinsic to the body, such as dental restorations, fingerprints, DNA, and verifiable medical records (primary identifiers). These involve characteristics that can be



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Figure 3: An example of cranio-facial trauma in a homicide case. Accurate injury description can be vital in these cases.

objectively appraised and compared to ante-mortem exemplars in both a quantitative and a qualitative way and that are difficult or impossible to falsify. Of all the scientific methods, molecular biology is the only method that can mathematically quantify the degree of certainty for a particular match, with the other methods (including odontology) being somewhat dependent on more subjective methodology and expert opinion. This reliance on even a small level of subjectivity can raise issues in courts when lay people do not have a deep understanding of the methods employed in an expert’s conclusion. Confusion can arise from the fact that there is often no unanimous indication regarding which and how many characteristics are necessary in order to achieve a positive identification. The recurrence of discordant features excludes identity; the occurrence of several concordant features commonly observed within the population does not allow a final judgment on identification, whereas even a few features rarely observed can lead to a positive match. An example of this is a case in which the written dental chart describes amalgam restorations in each first molar. If the same is found in the deceased, is this sufficient evidence to confirm identity? Definitely not, as many people share this restoration pattern. If, however, we also have ante-mortem radiographs of those restorations displaying the exact shape, size and location within each tooth, and these compare favourably with the post-mortem radiographs, then few would argue that a positive match cannot be confirmed. There is, however, still

no way to quantify this match, to put a probability ratio or a percentage certainty to it. It may be necessary in some cases to compare all of the teeth in a mouth in order to arrive at a match. In other cases, a single tooth with an unusual or complex restoration may be sufficient. It has long been the wish of identification experts to be able to quantify such matches, but no reliable method has yet been devised and so a degree of expert subjectivity is still required. Prior to the availability of scientific methods applicable to the issue of positive human identification, the only real option for relatives and friends to recover the mortal remains of their loved ones was to visually examine them, and make a decision regarding whether the person before them was indeed who they believed him or her to be. On the face of it, positive human identification by visual recognition would seem to be a fairly simple matter, as long as the deceased has undamaged facial features. We can all recognise people who are well known to us by their facial features and mannerisms, even in poor light and at odd angulations. This has been shown to be true in many studies concerning the recognition of living people via CCTV security footage. Why then are there documented cases of misidentification through visual recognition of the deceased, even of intact and undamaged faces? The process of visual recognition is complex and until quite recently not well understood. Clues as to the identity of an individual, either living or deceased, rest not only with the physical structure of the face, but also with the variety of facial expressions, the display of various mannerisms, and the context in which the individual is seen. A deceased person has lost all facial expression, animation, and context and simply looks different from when he or she was alive. Incipient decomposition changes may also be present and go unrecognised. Couple this with the stress and trauma being experienced by the identifier, who may well have never seen a dead body before, and it is easy to see how someone may make a mistake. This is compounded by the way visual identifications are often performed, in that the deceased is presented to the identifier to confirm what the authorities already believe they know.

Identification methods Visual recognition, despite the lack of scientific validity and the propensity for error, will for all practical purposes remain as a major method for positive human identification. When it is determined that visual recognition is not an option, usually because of trauma, incineration, decomposition, or multiple deaths resulting from a single incident, then forensic practitioners are able to rely on more scientific means to


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determine identity. The common methods employed include molecular biology, medical record comparison, fingerprints, and dental record comparison. DNA profiles are encrypted sets of numbers that reflect a person’s DNA make-up, which can also be used as the person’s identifier. Although 99.9% of human DNA sequences are the same in every person, enough of the DNA is different to distinguish one individual from another, unless they are monozygotic twins. DNA profiling uses repetitive sequences that are highly variable, called variable number tandem repeats (VNTRs), particularly short tandem repeats. VNTR loci are very similar in closely related humans, but so variable that unrelated individuals are extremely unlikely to have the same VNTRs. In situations in which a full nuclear DNA profile is not attainable, for example in ancient or degraded remains, mitochondrial DNA analysis may be used, although with less certainty. Identification using DNA evidence relies on the comparison of an ante-mortem sample (reference sample) with a post-mortem sample, and may include direct comparison of the decedent’s DNA (e.g. Guthrie cards or an ante-mortem blood sample), or a comparison with relatives’ DNA (parents, children or siblings), to arrive at a conclusion. The conclusions of molecular biologists are expressed as a probability ratio and are thus scientifically quantifiable as to the strength of the match. With any DNA technique, the cautious juror should not convict on genetic fingerprint evidence alone if other factors raise doubt. Contamination with other evidence (secondary transfer) is a key source of incorrect DNA profiles, and raising doubts as to whether a sample has been adulterated is a favourite defence technique. Identification using fingerprints (friction ridges) relies on an examination of ante-mortem prints already on file with authorities (exemplars), or more commonly comparison with latent prints retrieved from an object the subject of the examination was known to have touched. Fingerprint identification involves an expert, or an expert computer system operating under threshold scoring rules, determining whether two friction ridge impressions are likely to have originated from the same finger or palm (or toe or sole). The validity of forensic fingerprint evidence has been challenged by academics, judges and the media. While fingerprint identification was an improvement on earlier anthropometric systems, the subjective nature of matching (especially when incomplete latent prints are used), despite a very low error rate, has introduced an element of controversy. Medical record comparison can be used for identification purposes when there is sufficient ante-mortem evidence of unique medical intervention or disease. Examples include the discovery of medical prostheses, such as pacemakers and

Figure 4: Age estimation using a standard atlas of development results in an age range that can either lead to identification or help police in limiting their search criteria for a missing person in the case of discovered unknown remains.

prosthetic hips, which will have engraved on them serial numbers, which can then be reconciled with ante-mortem surgical notes.

Dental identification When good quality ante-mortem dental records are available for comparison with post-mortem examination findings, positive identification is a relatively simple matter (Figs. 1a & b). For many cases, however, such a simple resolution is not so easily achieved. Often ante-mortem dental records are incomplete or many years old or there are no radiographs. Couple this with incomplete remains or remains damaged by fire and/or trauma and the difficulties are magnified (Figs. 2a–c). Reproducing the exact angulation and aspect of an antemortem radiograph in a post-mortem radiograph, taken in less than ideal circumstances, can also be challenging. In order to reach conclusions to these difficult identification puzzles, the forensic dentist not only needs a solid grounding in all of the techniques available, but also requires a level of experience and, in the early years, a degree of mentoring. Dental identification is not only achieved using comparison of restorations; other features of the teeth and maxillofacial skeleton may also be employed. Root morphology, sinus configuration, unusual crown shape, and pulp chamber morphology are all factors that can be considered in the absence of restorations, as long as there are high-quality antemortem images with which to make a comparison. Study


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Figures 5a–c: Multiple development sites used for age estimation of late teenage individuals: in this case, the third molar, the medial clavicular epiphysis, and the spheno-occipital synchondrosis, all of which are useful age indicators in the late teenage years.

models, sport mouth guards, partial dentures, orthodontic appliances and photographs of the dentition are all useful aids for a forensic odontologist and are employed with varying degrees of certainty, depending on the circumstances of the case. Personal identification via dental record comparison is similar to fingerprint analysis in that there is, as discussed above, an element of subjectivity involved in the matching process. Where dental identification differs, and is perhaps easier to comprehend for lay people, is in the nature of the evidence being compared. With dental evidence, matches are commonly assessed by comparing both ante-mortem and post-mortem radiographs of easily identifiable man-made (and most often handmade) restorations. Unlike the minute nature of the whorls and swirls of fingerprint evidence, dental radiograph comparisons are often so obviously similar that any reasonable person is able to say that the images belong to the same person.

Other aspects Aside from identification case work, odontologists are asked to provide medico-legal opinions on a variety of topics as outlined in the introduction. Bite mark interpretation is probably the most recognisable of these to the lay audience and involves the assessment of injuries to the skin that are suspected

of being caused by human teeth. This area of forensic practice is fraught with difficulty, as the highly subjective nature of the conclusions reached is almost completely based upon opinion rather than scientific research. There are so many problems associated with the interpretation of bite marks that to describe them all here is beyond the scope of this introductory article. Cranio-facial trauma analysis is a growing area of forensic odontology practice, and involves examination of both living and deceased individuals and the provision of opinions concerning accurate anatomical description of the injuries (Fig. 3), degree of force (mild, moderate severe), and direction of force application. Occasionally, opinions are also sought regarding the exact nature of the weapon used, although caution needs to be exercised in this regard, as unless the implement bears unique characteristics that are imparted to the body interpretation will be very difficult. This area of odontology practice predicates a thorough knowledge of cranio-facial anatomy, the biomechanics of bone, and the effect on anatomical structures of various degrees of force. Age estimation has always been a function of the forensic odontologist, and traditionally has been based upon interpretation of dental development and comparison with published standards for tooth development (Fig. 4). The majority of age estimation work has concentrated on the ageing of children up to 15 years. Beyond this age, dental development becomes relatively unreliable, as only the third molar is available for assessment, and this tooth is notoriously variable in its development. It has been recognised recently, however, that published standards for tooth development may not be as accurate as assumed, owing to the fact that they were constructed many decades ago and in other parts of the world, and therefore may bear little resemblance to modern populations. Considerable work is currently underway to address this issue, with new population datasets being established around the world. Odontologists are also researching the ability to estimate more accurately the age of older individuals, around the adult/child demarcation age of 18 years. This is being achieved through the use of multifactorial approaches, where the third molar and various other skeletal development sites are assessed together in order to arrive at an estimate (Figs. 5a–c). This is seen as important research in light of the increasing need to determine the legal status of individuals such as asylum seekers, accused human traffickers who may be children and risk being incarcerated in an adult prison, child soldiers, and victims of sexual assault in developing countries, all of whom are unlikely to possess proof of age documentation. It has been shown that more than half of all cases of child


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abuse involve cranio-facial injuries, perhaps owing in part to the significance of the face and mouth in communication and nutrition. Forensic odontologists are rarely involved in these difficult cases, but despite this play an important role in injury description and providing help with determination of causation. All of the principles involved in cranio-facial trauma analysis for adults are applicable here, but with emphasis on the developing anatomy and different biomechanical characteristics of the child facial skeleton. Dental malpractice and insurance fraud investigations are increasing, partly owing to greater public awareness of what constitutes a dentist’s duty of care and responsibility to patients, and partly owing to our increasingly litigious society. For this aspect of practice, the odontologist requires thorough knowledge of the various pieces of legislation relating to dental practice, the professional codes of conduct, and the latest information on treatment modalities, as well as good medico-legal report writing skills.

Conclusion Forensic odontology is capable of providing rapid and relatively cost-effective identification of the deceased, as long as reasonable ante-mortem dental records are available. In countries such as Australia, the laws concerning medical record-keeping ensure that dental records are, in the main, of good quality and easily retrieved in the event they are required. In other countries, this may not be the case, and identification of the deceased in some parts of the world

represents a serious and ongoing issue for governments and humanitarian organisations. Good record-keeping is not only of benefit to forensic practitioners, but also relevant to improved health services and outcomes for patients in general, so part of the work of odontologists includes educating health authorities in less developed parts of the world to encourage good record-keeping. The benefit of good record-keeping can be seen in recent mass fatality incidents, such as the Victorian Black Saturday bushfires, where, despite the availability of a well-resourced DNA capability, more than half of all victims were identified by dental record comparison. The scope of forensic odontology is broader than identification alone and encompasses a range of activities, anything in fact where the practice and theory of dentistry intersect the law. To be a competent practitioner in this discipline requires not only a comprehensive understanding of odontology theory and technique, but also a degree of knowledge and experience in a variety of forensic fields, including law, pathology, clinical forensic medicine, molecular biology and anthropology. The forensic odontologist encounters all of these disciplines in different case scenarios, and in order to understand how the odontologist can contribute best to an investigation he or she needs to comprehend the capabilities and limitations of these fields. Editorial note: A list of references is available from the publisher.

Reprinted with permission by Cone Beam 1/2015


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A minimally invasive approach according to biomechanical principles of teeth Michael L. Young1

Introduction Traditionally, the practice of dentistry has been a reparative model. We have waited for disease to express itself, and then repaired it. What if we could predict who would express a disease and prevent it from happening in the first place? How would this approach affect the long-term oral and overall health of the dental patient? Many of our patients tell us, “If it’s not broken, don’t fix it.” Patients are often unaware of the conditions in their mouths because there isn’t an associated disability, and they won’t accept a solution to a problem they don’t have. Thus teeth at risk may remain untreated until a quality of life issue has occurred, such as pain, infection or a fractured tooth. According to Geurtsen, Schwarze, & Gunay (2003), root fractures are the third leading cause of tooth loss. Tooth loss is a quality of life issue. Loss of a tooth ideally requires replacement, which necessitates further expenditures and procedures. Failure to replace the tooth has consequences, which may lead to further cost and need for treatment or loss of additional teeth. The consequence of the reactive approach to dental care is, at best, a lesser prognosis for the tooth and, at worst, loss of the tooth. This may be avoidable with a paradigm shift to a wellness model of practice. A wellness model is proactive and preventative. If we can identify a dental condition that increases risk to the tooth and patient, and treat the condition prior to its consequence, we’re effectively reducing risk. The effect is an improved prognosis. Subsequently, health-care costs will be reduced and quality of life improved.

Biomechanical principles Tidmarsh said in 1979 that teeth are like prestressed laminates. They flex but can return to their natural state. However, under prolonged loading, teeth can permanently deform. Grimaldi said in 1979 that there is a relationship between how much tooth structure has been lost and deformation. Cavity preparation or endodontic access destroys the pre-stress state. Teeth can then 1

Dr. Michael L. Young Private Practice, Sterling Heights, Mich, USA


Figure 1a: Pre-operative photo: Diagnosis of structurally compromised teeth. Figure 1b: Pre-op: Measuring intercuspal distance of filling #3. Figure 1c: Pre-op: Measuring intercuspal distance of filling #4.




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Figures 2a–c: Depth cut bur #3. Figures 3a: Final depth cuts. Figures 3b: Final depth cuts, occlusal view. Figures 4 & 5: Gross occlusal reduction with KS7 #3. Figures 6 & 7: Gross occlusal reduction with KS7 #4.

deform greater and are more susceptible to fracture. Too much flexing makes them crack. Larson, Douglas and Geistfield (1981) showed that a restoration that takes up just one-third of the intercuspal distance is less than one-half of the strength of an unrestored tooth. The load required to fracture a tooth was the same if the restoration involved only the occlusal surface or included the mesial and distal surfaces as well. Geurtsen, Schwarze and Gunay (2003) agreed that the risk of cuspal fracture increases considerably when the isthmus width of a restoration is 50 per cent of the

intercuspal distance. They stated that amalgam or resin composite restorations should not exceed one-fourth to onethird of the intercuspal distance. The more tooth structure that is removed in cavity preparations, the more the tooth flexes under increasing loads.1 Teeth with cuspal fractures may still be restored; however, the prognosis will be lower and less than ideal because there is less remaining natural structure to retain a crown and withstand the flexing from functional and non-functional forces. These teeth may last for years. However, they may eventually fracture at the gingival crest or below, because

8a Figure 8a: Final occlusal reduction frontal view.

8b Figure 8b: Final occlusal reduction occlusal view.


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Figure 9a: Measuring remaining enamel ring after occlusal reduction #4. Figure 9b: Measuring remaining enamel ring after occlusal reduction #3. Figure 9c: Occlusal reduction lateral view. Figures 10–12: Breaking contacts and removing remainder of existing filling.

of further cracks and propagation of those cracks. Teeth with history of endodontic treatment are at an increased risk of subgingival fracture, rendering the tooth non-restorable or with a poor prognosis.2 Therefore, it’s important to prevent these cracks from forming at all. How do we prevent too much flexing in these teeth and prevent cracking? Some have wondered whether a bonded inlay restoration would strengthen the tooth and prevent cuspal fracture.

A study of bonded inlay restorations under static load testing in maxillary premolars with large MOD preparations concluded that bonding ceramic or composite will not strengthen the tooth.3 A bonded resin or ceramic inlay will not prevent cuspal deformation and fracture. However, bonded ceramic onlays have been shown to be an effective answer in restoring posterior teeth.4,5 Bakeman and Kois (2009) stated that all porcelain,







Figure 13: Blending occlusal and interproximal #4. Figures 14a & b: Blending occlusal and interproximal #3. Figures 15a & b: Final preparations occlusal views. Figure 15c: Final preparations lateral view. 46 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 10, NO. 2

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Figures 16 & 17: Tissue management with Viscostat. Figures 18–21a: Gingival retraction.

adhesively retained restorations offered the possibility of limited or no removal of tooth structure on the axial wall, while covering the cusps. The result is a tooth with more remaining original structure, less flexure under force and thus less risk of permanent deformation and fracture.

It is important to preserve as much enamel as possible, as failure rates of adhesively retained restorations increase the more the tooth preparation involves the dentin.6 In addition, the size of the remaining enamel ring after occlusal reduction is an important determinant between an adhesively or cohesively retained approach in tooth preparation.





Figure 21b: Final gingival retraction, occlusal view. Figure 22a: Scanning preparations. Figure 22b: PlanScan screenshot of scanning preparations.


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Figure 23: Scanning preparations. Figure 24a: Scanning opposing teeth. Figure 24b: PlanScan screenshot of scanning opposing teeth. Figure 24c: Opposing model screenshot.

Increased occlusal reduction, or occlusal reduction on a worn tooth, results in a preparation with a reduced enamel ring width. A decrease in the size of the enamel ring

thickness from 1.5 mm to 1 mm increased the failure rate dramatically. An enamel ring of less than 1 mm in width would be a contraindication for an adhesively retained










Figure 25a: Scanning buccal bite. Figure 25b: Screenshot of scanning buccal bite. Figure 26a: Screenshot of buccal bite. Figure 26b: Screenshot of occluded models. Figure 26c: Screenshot of preparations in density view. Figure 26d: Screenshot of orientation of preparation model. Figure 26e: Tracing margins. Figure 26f: Tracing margins in ice view. Figure 26g: Initial proposal of restoration for #4. 50 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 10, NO. 2

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Fig. 26l


Figures 26h & i: Initial proposal of restorations for #3 and #4. Figure 26j: Restorations #3 and #4, checking material thickness in occlusal view. Figure 26k: Checking material thickness of #4 in facial view. Figure 26l: Using rubber tooth tool to adjust the anatomy of #4. Figure 26m: Using rubber tooth to adjust the distofacial cusp height of #3.

restoration, and a cohesively retained restoration would then be required.7 A restoration bonded to enamel also provides a margin with reduced or no microleakage.8

Summary Aminian and Brunton (2003) stated: “The removal of sound tooth structure is an unfortunate biological compromise. The conservation of sound tooth structure, therefore, represents an appropriate strategy to minimize biologic risk.” Adhesively retained restorations offer the possibility to be

more minimally invasive while restoring a tooth to natural appearance and function. More conservative removal of tooth structure also means there is less risk to the pulp. The converse is true in that cohesively retained restorations are more invasive. Removal of more structure increases pulpal risk, decreases strength and increases tooth flexure, which may lead to fracture. Tooth preparation is also more important as retention and resistance form is essential to retain the crown. A laboratory can fabricate minimally invasive, adhesively







Figure 26n: Using rubber tooth tool to adjust the distal marginal ridge height of #4. Figure 26o: Using smooth tool to smooth the facial of #3. Figure 26p: Using smooth tool to smooth the facial of #3. Figure 26q: Checking occlusal contacts, location and strength, #3. Figure 26r: Checking interproximal contact strength #4. Figure 26s: Final restorations, occlusal view in PlanScan. VOL. 10, NO. 2 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION 51

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Figure 26t: Final restorations, lateral view in PlanScan. Figure 26u: Final restorations #3, slice view facial to lingual. Figure 26v: Final restoration #4, slice view facial to lingual. Figure 26w: Final restorations, lingual view. Figure 26x: Milling preview.

retained restorations. However, chairside CAD/CAM technology can fabricate excellent restorations of the same quality in the same visit. This means the challenge of fabricating a provisional for a tooth preparation that lacks retention and resistance form is eliminated. In addition, it has been shown that patients prefer a digital impression technique in lieu of the traditional impression method.9–13 Yuzbasioglu, et al (2014), also determined that the digital impression method was faster than


the traditional method. This finding was also verified by Patzelt, Lamprinos, Stampft and Att (2014), who indicated that workflow efficiency was improved using a digital impression technique.

Case report This patient presented for restorations of teeth #3 and #4 (Fig. 1a). Because of the size of the existing restorations, these teeth were diagnosed as structurally compromised (Figs. 1b, c). The prognosis without treatment was fair.


Figure 26y: Try-in of restorations, occlusal view. Figure 26z: Try-in of restorations lateral view.


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Figure 27: Isolation for seating of restorations using Isolite. Figures 28 & 29: Application of Mulitlink Automix Primer. Figs. 30 & 31: Application of Liquid Strip.

The restorations were to be completed with PlanScan chairside CAD/CAM technology in the same visit. Local anesthesia was achieved with 1.7 cc 2 per cent Lidocaine with 1:100,000 epi, buffered with Onset sodium

bicarbonate inj., 8.4 per cent, USP neutralizing additive solution. Depth guide cuts were made using a 330 bur, which has a 2 mm cutting surface (Figs. 2a–3b). This ensures 2 mm of


33a Figure 32: Curing restorations. Figures 33a–c: Checking occlusion. 54 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 10, NO. 2




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Figure 34: Polishing. Figures 35a & b: Final restorations occlusal view.

occlusal reduction to accommodate 2 mm of material thickness on the occlusal surface of the restoration. Gross occlusal reduction was completed using a KS7 bur to the depth cuts (Figs. 4–8b, 9c). Adequate clearance was verified with a 2 mm prep check from Common Sense Dental Products. After gross occlusal reduction was completed, the remaining enamel ring was measured (Figs. 9a, b). The enamel rings were noted to be 1.5 mm, and the teeth were prepared for adhesively retained restorations. If the enamel rings were less than 1 mm, the teeth would have been prepared on the axial walls to create retention for cohesively retained crowns. The remainder of the existing composite resin in #3 and the amalgam in #4 were removed. The occlusal surfaces of the preparations were blended into the interproximal areas using a KS2 bur to create smooth preparations (Figs. 10– 15c). There was no retention or resistance form prepared to retain the restorations. Tissue management was obtained with ViscoStat Clear, gingival haemostatic gel, 25 percent (m/m) aluminum chloride (Figs. 16 & 17). Gingival retraction was obtained using a two-cord system. First, a #00 size cord from Ultradent was placed on the mesial and distal of both preparations (Figs. 18 & 19). Additional haemostatic gel was used prior to the second cord. The second cord was #2 size cord from Ultradent (Figs. 20 & 21a). A minimum of four minutes with both cords in place is needed for adequate retraction of the soft tissue (Fig. 21b). While waiting four minutes for gingival retraction, the opposing teeth were scanned with the PlanScan wand to create a digital model (Figs. 22a–24c). The buccal surfaces were then scanned with the teeth fully occluded in

maximum intercuspal position. This scan was used along with the scan of the preparations and the opposing teeth to create a model for the occlusion (Figs. 25a–26c). Prior to scanning the prepared teeth, the second cords were rinsed and removed. The cords were left wet to lower the risk of disturbing the tissue upon removal. The #00 cords were left in place during the scanning of the preparations, and the teeth were dried to allow accurate scanning. The preparation model was examined in data density view to verify adequate data was obtained during the scanning of the preparations (Fig. 26c). Any areas lacking adequate data were scanned further until adequate data was obtained. Next, orientation of the preparation model was performed (Fig. 26d). Orientation is for optimal design, not path of insertion. The margins were then traced and viewed in ICE mode, which provides a rendering of the scanned images for a clear view of the margins, teeth and tissues (Figs. 26e, f). The initial proposals for the restorations were made using Library A and autogenesis, which is morphogenesis of the library tooth with the neighbouring teeth (Figs. 26g–i). Material thickness of the proposed restorations was checked (Fig. 26j, k). Tools were then utilized to improve the initial proposal to the desired result. The rubber tooth tool was used to make minor adjustments to the anatomy (Figs. 26l–n). The smooth surface tool was used to smooth the surfaces (Figs. 26o, p). The location and strength of the occlusal contacts were checked and adjusted (Fig. 26q). Interproximal contact strength and location was then verified and adjusted as needed (Fig. 26r). The final proposals were then verified prior to milling (Figs. 26s, t, w). The slice plane view was used to check


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Figures 36a & b: Final restorations, lateral view.

the space between the tooth preparation and the restoration (Figs. 26u, v). This is done to check for possible areas that may prevent the final restoration from completely seating on the preparation or for areas that may be over milled. Overmilling reduces the thickness of the material. This view also illustrates the lack of preparation on the axial wall and the minimally invasive approach taken. The location of the sprues were noted and adjusted as needed in the milling preview (Fig. 26x). The fit of the restorations was then verified intraorally prior to final seating (Figs. 26y, z). Occlusion can be verified intraorally with e.Max CAD prior to crystallization and any staining and glazing. Checking occlusion with Empress CAD blocks prior to bonding in place is not recommended. The restoration for #3 was then glazed and crystallized in a Programmat CS2 furnace (Ivoclar Vivadent). The restoration was allowed to cool to room temperature upon completion of glazing and crystallization. The restoration was then cleaned with a steam cleaner. Five percent hydrofluoric acid was used to etch the e.max restoration for 60 seconds. The Empress restoration was etched for 20 seconds. The etchant was rinsed with a steam cleaner. Ivoclean (Ivoclar Vivadent) was applied for 20 seconds on both restorations to clean their internal surfaces. Monobond Plus primer (Ivoclar Vivadent) was applied to the internal surface of the restorations for 60 seconds. The primer was lightly air dried after 60 seconds, taking extra care not to allow primer on the outside surfaces of the restorations. The teeth were isolated using Isolite (Fig. 27). Multilink Primer A/B was scrubbed onto the entire bonding surfaces using a microbrush for 30 seconds. Excess material was dispersed

with blown air until the mobile liquid film was no longer visible, leaving a glossy appearing surface (Figs. 28 & 29). An OptraStick Application Aid (Ivoclar Vivadent) was used to seat the restorations on the teeth because onlays and partial crowns can be difficult to handle. Initial tack curing was completed using a Bluephase curing light (Ivoclar Vivadent) for three seconds at each interproximal area. The resin was then removed easily using a 36/37 scaler from Brasseler. Liquid Strip (Ivoclar Vivadent), a glycerine gel that prevents an oxygen-inhibited layer of the resin cement, was applied to the margins prior to final curing (Figs. 30 & 31). Final curing of the restorations was then completed (Fig. 32). The initial #00 cords were removed after final curing so proper tissue management could be maintained until curing was completed. Occlusion was checked with the patient chair at a 45degree angle. Bausch articulating paper, horseshoe shape, 200 microns thick, was used first, and the patient was instructed to chew on the paper as if chewing gum. Next, the patient was instructed to tap straight up and down on red Troll Foil articulating foil. Any marks from the chewing strokes that weren’t covered by the red paper were removed to eliminate interferences and reduce the risk of material fracture (Figs. 33a–c). The restorations were then polished (Fig. 34). For #3 e.max restoration, the burs were NTI Cera Glaze - green, blue and yellow, in order. The green prepolisher was not used on the Empress restoration for #4. The final result was minimally invasive restorations that appear and function naturally, while decreasing risk of tooth fracture, and minimize further risk to the teeth. (Figs. 35a–36b).


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Editorial note: This article was published in CAD/CAM C.E. Magazine No. 01/2014.

References 1. Gonzalez-Lopez S, DeHaro-Gasquet F, VilchezDiaz MA, Ceballos L, Bravo M. Oper Dent. 2006; 31(1):33–38. 2. Fennis WM, Kuijs RH, Kreulen CM, Roeters FJ, Creugers NH, Burgersdijk RC. Int J Prosthodont. 2002; 15(6):559–563. 3. St-Georges AJ, Sturdevant JR, Swift EJ Jr, Thompson JY. J Prosthet Dent. 2003; 89:551–557. 4. Magne P, Belser UC. Porcelain Versus Composite Inlays/Onlays; Effects of Mechanical Loads on Stress Distribution, Adhesion, and Crown Flexure. Int J Periodontics Restorative Dent. 2003; 23:543–555. 5. Bakeman E, Kois J, Posterior, All-Porcelain, Adhesively Retained Restorations. Inside Dentistry. 2009: 20–33. 6. Dumfahrt H, Schaffer H. Porcelain Laminate Veneers. A Retrospective Evaluation After 1 to 10 Years of Service: Part II—Clinical Results. Int J Prosthodont. 2000; 13(1):9–18. 7. Kois DE, Chaiyabutr Y, Kois JC. Comparison of Load-

Fatigue Performance of Posterior Ceramic Onlay Restorations Under Different Preparation Designs. Compendium Contin Educ Dent. 2012; 33(3):2 –9. 8. Tjan AH, Dunn JR, Sanderson IR. Microleakage Patterns of Porcelain and Castable Ceramic Laminate Veneers. J Prosthet Dent. 1989;61(3):276–282. 9. Yuzbasioglu E, Kurt H, Turunc R, Bilir H. Comparison of Digital and Conventional Impression Techniques: Evaluation of Patient’s Perception, Treatment Comfort, Effectiveness and Clinical Outcomes. BMC Oral Health. 2014. 30;14:10. 10. Patzelt SB, Lamprinos C, Stampf S, Att W. The Time Efficiency of Intraoral Scanners: An In Vitro Comparative Study. J Am Dent Assoc. 2014; 145(6):542–551. 11. Geurtsen W, Schwarze T, Gunay H. Diagnosis, Therapy, and Prevention of the Cracked Tooth Syndrome. Quintessence Int. 2003;34(6):409–417. 12. Aminian A, Brunton PA. A Comparison of the Depths Produced Using Three Different Tooth Preparation Techniques. J Prosthet Dent. 2003;89(1):19–22. 13. Larson TD, Douglas WH, Geistfeld RE. Effect of Prepared Cavities on the Strength of Teeth. Oper Dent. 1981;6(1):2–5.


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Admira® Fusion – the first purely ceramic-based restorative material With Admira Fusion VOCO presents the worldwide first purely ceramic-based universal restorative material. This is made possible by the innovation of combining the proven nanohybrid technology with that of the ORMOCER®s developed in cooperation with the Fraunhofer Institute for Silicate Research ISC. Having launched Admira, the first ORMOCER®-based restorative system, as early as 1999, and having followed it up with Grandio, the first nanohybrid composite, in 2003, intensive research has now enabled VOCO to combine the advantages of both restorative systems. Silicon oxide forms the chemical base for the new nanohybrid ORMOCER® restorative material Admira Fusion, not only for the fillers but also – and this represents the innovative research achievement – for the resin matrix. This unique ”Pure Silicate Technology“ offers several remarkable advantages in one: for example, the fact that Admira Fusion, in comparison with all restorative composites of market relevance, shows by far the lowest level of polymerisation shrinkage (1.25 % by volume) and, coupled with that, extremely low shrinkage stress. The ORMOCER®s (”Organically Modified Ceramics“) used in the manufacture of Admira Fusion make it highly biocompatible, as there is no content of classic monomers, some of which might otherwise escape after polymerisation. The light-curing, radiopaque nanohybrid ORMOCER® has an 84 % (by weight) content of inorganic fillers and covers a broad spectrum of indications. This includes, among others, class I to V fillings, reconstruction of traumatically damaged anteriors, locking or splinting of loose teeth, as well as core build-ups and the fabrication of composite inlays. Admira Fusion’s particularly high colour stability gives it an additional edge and allows its absolutely universal use – for highest demands in both the anterior and posterior regions. Being a very homogeneous material, it offers outstanding handling and is compatible with all conventional bonding materials. The restorative system is complemented by Admira Fusion x-tra, which allows for increments of up to 4 mm in thickness while delivering absolutely identical physical values. The fast-track version also has a convincing, low level of volume shrinkage, as well as outstanding biocompatibility. The universal shade U further simplifies handling, as it provides aesthetic results in the posterior range by adapting, chameleon-like, to the surrounding dental substance. Admira Fusion and Admira Fusion x-tra are available in syringes and also caps for direct application.

Admira Fusion, the worldwide first purely ceramic-based restorative material. 60 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 10, NO. 2

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Highly aesthetic restorations in the anterior and posterior region with Admira Fusion

Figure 1: Enamel-dentine fracture on tooth 21.

Figure 2: Aesthetic result after polishing.

Figure 3: Insufficient amalgam restorations in teeth 46 and 47.

Figure 4: Finished, polished restorations (clinical photos: Dr Sanzio Marques, Passos/Brazil).


• Thanks to the most innovative ORMOCER® technology – by far the lowest polymerisation shrinkage (1.25 % by volume) and particularly low level of shrinkage stress in comparison to all conventional restorative composites – inert, so highly biocompatible and extremely resistant to discolouration • Completely universal – meeting highest demands in anterior and posterior regions – perfect coordination of translucence with opacity for natural results – the optimal selection of shades enables highly flexible working using either the single or multiple shade system • Excellent handling, simple high-lustre polishing procedure coupled with high surface hardness guarantee first-class long-term results • Compatible with all conventional bonding agents

• Class I to V restorations • Base in class I and II cavities • Reconstruction of traumatically damaged anteriors • Facetting of discoloured anteriors • Correction of shape and shade for improved aesthetic appearance • Locking, splinting of loose anteriors • Repairing veneers, small enamel defects and temporary C&Bmaterials • Restoration of deciduous teeth • Core build-up • Composite inlays

Advantages • The worldwide first purely ceramic-based restorative material – pure Silicate Technology, i.e., fillers and resin matrix based purely on silicon oxide – contains no classic monomers

Manufacturer: VOCO GmbH, P.O. Box 767, 27457 Cuxhaven, Germany,, Contact VOCO Australia & New Zealand: Tel. 0401 747 037


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CLEARFIL MAJESTY™ ES Flow is a new, light-cure, universal flowable composite that is more than a liner/base. With its superior durability and esthetics, CLEARFIL MAJESTY™ ES Flow can be used for all cavity classes including occlusal surface restorations. CLEARFIL MAJESTY™ ES Flow contains special submicron fillers that are treated with a proprietary silane coupling agent, giving the product excellent mechanical properties and high polish retention. Available in shades A1, A2, A3, A3.5, A4, KA6, B1, B2, XW, W, A2D and A3D. These shades correspond with CLEARFIL MAJESTY™ ES-2 shade guide.

Zirlux ST1 is a high translucency, strong, aesthetic Zirconia material that can be milled for full contour anterior and posterior crowns, bridges, frameworks and inlays. Zirlux® ST1 is available in multiple sizes and thicknesses making it an ideal choice for various milling machines, laboratories and milling centres. Simple staining and short drying time create the perfect colour for full contour restoration. Zirlux ST1 is available in 98.5 or 95mm diameter as well as 89 x 71mm puks and Cerec mandres blocks.





The Art of Wet Grinding The N4 Impression is a brandnew wet grinding machine for glass ceramics and composites which has been newly developed from scratch. Its highest precision and the quick drive units – common characteristics of all vhf machines – are combined here with a closed liquid cooling system in an extremely compact housing. First-class grinding results are produced in shortest time with the N4 Impression. The cooling lubricant is led through eight liquid nozzles which are arranged at the spindle and cools the whole tool evenly from the tip to the shank at all machining stages. The flexible gaiter at the spindle it furthermore guarantees that all the liquid will remain solely in the working chamber of the machine.

Ceramic fluid for maximum process reliability Ceramic materials that support longer modelling offer clear benefits to dental technicians, particularly in the case of largespan restorations. If the material also remains smooth during layering, without any loss of stability, then important criteria have been met for a perfect layering result. VITA MODELLING FLUID RS surpasses these requirements, as well as ensuring maximum process reliability thanks to lower shrinkage during firing. This mixing liquid for all VITA VM 9, VM 13 and VMK Master materials facilitates a pleasantly smooth consistency and ensures moist processing over a long period as well as effective stability. This fluid is therefore perfectly suited for use in larger restorations and multi-unit bridges.





The EQUIA Forte system consists of EQUIA Forte Fil and EQUIA Forte Coat. EQUIA Forte Fil is a high strength, fast setting, aesthetic glass ionomer restorative which features a significant increase in fracture toughness (flexural energy) and flexural strength. EQUIA Forte Coat completes the EQUIA Forte restoration providing a smooth laminated surface with remarkable strength and impressive wear resistance. EQUIA Forte™ Coat is designed for optimum wetting, strong adhesion, and has excellent colour stability and stain resistance.

CLEARFIL™ Universal Bond is a single component, light cured bonding agent indicated for all direct and indirect restorations in combination with all etching techniques (Total-Etch, Self-Etch or Selective-Etch). CLEARFIL™ Universal Bond is also indicated for the surface treatment of zirconia and silica-based glass ceramics. CLEARFIL™ Universal Bond can be mixed with CLEARFIL™ DC Activator to become a dual-cure adhesive, thereby making this product truly a “Universal” adhesive for all restorative procedures.

All products available from: HENRY SCHEIN HALAS • Tel: 1300 65 88 22 • 62 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 10, NO. 2

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No compromises, perfect performance. Heavy-duty proven quality. VITA continues its successful tradition of building excellent furnaces customers can rely on with the V60 i-Line. Representing a new level of VITA quality, the V60 meets the demands of international customers for a robust, heavy-duty furnace perfectly. A state-of-the-art touch interface and the tried-and-tested VITA quartz firing muffle guarantee optimal firing results. The clean, no-frills design make the VITA V60 a real workhorse, functioning 24/7 under the most extreme conditions with amazing reliability. Easy to maintain, easy to handle and made in Germany, the V60 i-line sets new standards around the world.

Root Canal Shaping - Innovative and accurate The CanalPro Apex Locator is characterized by its brilliant, coloured 3D panel and its accuracy of measurement. The ergonomic design and easy operation allow comfortable use. • Virtual Apex Function to mark a predetermined position at the required distance from the apex • Audio feedback with volume control • Built-in demo mode • Auto-off after 5 min. without use • Built-in self-test for a fast function control • Rechargeable battery





The Isovac dental isolation adapter is perfect for rounding out other operatories with easy-to-use oral control. Like the Isolite and Isodry you can take advantage of all the benefits of our award winning Mouthpieces. The strong, ultra lightweight Control Head Assembly is constructed of an easy-to-clean autoclavable polymer. Dual vacuum controls enable the operator to focus continuous hands-free vacuum suction either in the upper or lower quadrant, allowing better control moisture and oral humidity. The adapter quickly attaches to Saliva Ejector line in the operatory. The Isovac is the perfect solution for practices to add an affordable and versatile alternative for oral control.

This tooth coloured, fluorescent and radiopaque bulk composite provides a perfect amalgam replacement and alternative to glass ionomer cements, compomers and conventional filling therapy. Owing to its dual curing properties, fillings with Fill-Up! can be administered in arbitrary filling depth without the need of an additional covering layer. Fill-Up! is applied in only one single layer and finished with rotary instruments. The material is easy and quickly polishable to high gloss and is therefore your perfect choice for all Class I and II fillings, cavity lining and core build-ups – every time when a fast and aesthetic restoration is needed. Fill-Up! Deep, Fast, Perfect!





MI Varnish™ is a 5% NaF varnish enhanced with 2% RECALDENT (CPP-ACP) to give an exceptional fluoride varnish that releases more bio-available fluoride, calcium and phosphate. Perfect brush, optimum flow Packaged with the “perfect application brush”, MI Varnish gives clinicians the smoothest and easiest fluoride varnish application experience. Smooth, translucent and tasty. Once applied, MI Varnish has a beautiful smooth consistency and a neutral shade with natural translucency. The great tasting strawberry and mint flavours mean MI Varnish will be your patient’s first preference as well.

Visible precision with attention to detail High contrast AFFINIS heavy body BLACK EDITION, offers optimal stability with fast pressure build-up, ideal for an excellent die effect. The impression can be read exceptionally well in combination with gold or silver AFFINIS PRECIOUS. This unique colour and contrast combination presents details precisely and supports the qualitative assessment of the impression result. AFFINIS PRECIOUS impression materials have an innovative and unique surface affinity, thus wetting tooth and gingiva quickly. The excellent flow properties of AFFINIS PRECIOUS captures all critical surface details of the preparation, even under the most difficult moist conditions. The self-contouring consistency prevents air pockets and virtually excludes any air voids or distortions.

All products available from: HENRY SCHEIN HALAS • Tel: 1300 65 88 22 • 64 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 10, NO. 2

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