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VO L. 17 N O. 1 I N T H I S I SS U E Douglas A. Terry, John M. Powers and Markus B. Blatz The injection resin technique: a novel concept for developing esthetic restorations Simran Bains The impact of eating disorders on oral health Andre W. van Zyl and Inus Snyman Masterclass in Implant Dentistry: Minimally invasive or low trauma extraction techniques Omar Ikram, Tyler Neal and Richard Mounce Endodontics: single versus multiple visit Ash Parmar Treating tooth wear: a step-by-step explanation Sam Koh Teeth whitening explained, plus top tips to maintain a white smile Ciro Gilvetti and Andrew Osafo Mouth cancer: Raising awareness of the other big ‘C’

Contents Volume 17 No. 1

Clinical

Masterclass in Implant Dentistry

Clinical

Products

The injection resin technique: a novel concept for developing esthetic restorations Douglas A. Terry, John M. Powers and Markus B. Blatz

The impact of eating disorders on oral health Simran Bains

Minimally invasive or low trauma extraction techniques Andre W. van Zyl and Inus Snyman

Endodontics: single versus multiple visit Omar Ikram, Tyler Neal and Richard Mounce

Treating tooth wear: a step-by-step explanation Ash Parmar

Teeth whitening explained, plus top tips to maintain a white smile Sam Koh

Mouth cancer: Raising awareness of the other big ‘C’ Ciro Gilvetti and Andrew Osafo

INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 17, NO. 1 1

New YWAM Dental Trailer arrives in PNG The YWAM trailer has recently made its way to the shores of Papa New Guinea. This trailer has the ability to provide dental services, training opportunities, and health education to primary and secondary schools in the National Capital District. This multi-use, mobile facility will strengthen existing services and provide an ideal learning environment in which local healthcare professionals and students can develop their skills while responding to the needs in the district. With support from Henry Schein Cares and the generous donations from Planmeca, Coltene, Ultradent & Mocom and the amazing work of the Henry Schein Service Technicians the trailer is now fully functional and ready to treat patients. This trailer has the ability to reach remote communities who previously would not have been able to access these dental services.

Vol. 17 No. 1 ISSN 2071-7962 PUBLISHING EDITOR Ursula Jenkins EDITOR Dr Andre W van Zyl ASSOCIATE EDITORS Prof Cecilia Goracci Prof Simone Grandini EDITOR-IN-CHIEF EMERITUS Prof Dr Marco Ferrari EDITORIAL REVIEW BOARD Prof Paul V Abbott 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 Roberto Giorgetti Dr Johan Hartshorne Dr Patrick J Henry Prof Dr Reinhard Hickel Dr Sascha A Jovanovic Dr Gerard Kugel Prof Ian Meyers Prof Maria Fidela de Lima Navarro Prof Hien Ngo Dr Hani Ounsi Prof Antonella Polimeni Prof Eric Reynolds Prof Andre P Saadoun Prof Errol Stein Prof Lawrence Stephen Prof Zrinka Tarle Prof Franklin R Tay Prof Manuel Toledano Dr Bernard Touati Prof Peet van der Vyver Prof Laurence Walsh Prof Fernando Zarone International Dentistry - Australasian Edition is published by Modern Dentistry Media CC, 15 Martinique, Calderwood Rd, Johannesburg 2062, South Africa Tel: +27 11 702-3195 • Fax: +27 (0)86-568-1116 E-mail: dentsa@iafrica.com www.moderndentistrymedia.com

If you have any questions about Henry Schein Cares and other projects we are involved in, please email scheincares@henryschein.com.au

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. Published in association with

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CLINICAL

The injection resin technique: a novel concept for developing esthetic restorations Douglas A. Terry,1 John M. Powers2 and Markus B. Blatz3

Douglas A. Terry, DDS Private Practice, Houston, Texas; Adjunct Professor, Department of Restorative Sciences, University of Alabama at Birmingham, Birmingham, Alabama, USA.

2 John M. Powers, PhD Clinical Professor of Oral Biomaterials, Department of Restorative Dentistry and Prosthodontics, University of Texas Health Science Center at Houston, School of Dentistry, Houston, Texas, USA.

Markus B. Blatz, DMD, PhD Professor and Chair, Department of Preventive and Restorative Sciences, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania, USA.

Correspondence: Dr Douglas A. Terry, Institute of Esthetic & Restorative Dentistry, 12050 Beamer Road, Houston, TX 77089. Email: dterry@dentalinstitute.com 4

The concept of using an injectable molding technique to manufacture various parts has been around for over a century.1,2 The first injection-molding machine was developed and patented by John and Isaiah Hyatt in 1872 for producing celluloid plastic parts.1,3 The next half-century saw the adoption of this process for the manufacture of items such as collar stays, buttons, and hair combs.3 Over the course of its development, injection molding has been used by designers and engineers for myriad applications with a host of materials, including glass, metals, confections, elastomers, and thermoplastic and thermosetting polymers, to fabricate a variety of complex shapes with high dimensional precision. It has been used in a variety of manufacturing industries, including aerospace, automotive, jewelry, avionics, biomedical, orthodontics, pharmaceutical, scientific, electronic, and computer technology. In dentistry, this technique has been used in the laboratory fabrication of prosthetic appliances such as complete dentures, partial dentures, laboratory-processed acrylic and composite provisional restorations, and ceramic restorations. 1,2 Continued developments in adhesive technologies, the design of resin composite formulations, and innovative application techniques have revolutionized the delivery of minimally invasive direct resin composite restorations while improving the practice of dentistry. In some cases, complicated layering techniques are required that are dependent on the clinician’s skill and artistic ability. The injectable resin composite technique provides a simplified, precise, and predictable method for developing natural esthetic composite restorations while reducing chair time. Although not a panacea to all restorative challenges, this technique provides the patient and clinician with an alternative approach to various clinical situations. This technique is a unique and novel indirect/ direct process of predictably translating a diagnostic wax-up or the anatomical form of the natural dentition of a preexisting diagnostic model into composite restorations. There are myriad applications for this technique using a highly filled flowable (injectable) resin

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1 Figure 1: Preoperative facial view of the maxillary anterior segment of a 63-year-old who presented with incisal wear and fracture on the maxillary anterior teeth. The patient requested a conservative esthetic enhancement without orthodontic treatment. Clinical evaluation revealed multiple diastemas and cervical corrosion on the central incisors from lemon sucking.

3 Figure 3: A clear polyvinyl siloxane matrix was fabricated to replicate the diagnostic wax-up.

composite, including emergency repair of fractured teeth and restorations; modification and repair of prototypes and provisional restorations, composite restorations (Class III,IV, and V; veneers), and pediatric composite crowns; resurfacing of occlusal wear on posterior composite restorations; establishment of incisal edge length prior to esthetic crown lengthening; orthodontic space management; development of composite prototypes for copy milling; fabrication of an implant-supported composite provisional restoration; and repair of fractured or missing denture teeth.1,4-6 In addition, this technique can be used to establish vertical dimension and to alter occlusal schemes (anterior guidance and posterior

2 Figure 2: Development of a diagnostic wax-up that established new parameters (ie, esthetic, functional) for the final restorations.

disocclusion) prior to definitive restoration.1-3 Furthermore, this noninvasive technique is an integral tool for enhancing communication between the patient and the restorative team during treatment planning.1,2,4 Developing transitional resin composite restorations using the injectable technique is an excellent method for increasing the patient’s understanding of the planned clinical procedure and anticipated final result.7 Transitional composite prototypes establish parameters for occlusal function,8 tooth position and alignment,9 restoration shape and physiologic contour,10 restorative material color and texture, lip profile, phonetics, incisal edge position, and gingival orientation. This process also eliminates confusion and misunderstanding between the patient and the restorative team during the treatment-planning stage.7 It can reduce the potential for patient dissatisfaction and litigation because the process is reversible, can be performed without preparation, and allows the patient to accept the visual and functional result before the definitive restorations are fabricated. In addition, this simple procedure helps to regulate the dimensions of the preparation design, ensures uniform spatial parameters for the restorative material, and increases the potential for a more conservative preparation design.4 This injectable technique can also be used in the development and management of soft tissue profiles and in the design of the definitive restoration.11-14 The clinician and technician can use this technique as a guide for developing a preapproved functional and esthetic definitive restoration.15 In some cases,

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Figure 4: Upon completion of the adhesive protocol, the clear silicone matrix was placed over the arch and an opacious shade A2 flowable resin composite (G-aenial Universal Flo, GC America) was initially injected through a small opening above each tooth, followed by mixing with a shade B1 flowable resin composite (inverse injection layering technique). The resin composite was cured through the clear resin matrix for 40 seconds. Figure 5: Completed composite veneer restorations with optimal anatomical form. The inverse injection layering technique allowed the establishment of harmonious proportions of the transitional restorations and the surrounding biologic framework.

these transitional restorations can be worn for months or even years during long-term interdisciplinary rehabilitation.2,4 However, this material technique should not be utilized as a final material for full-mouth rehabilitation. In certain clinical situations, this technique can be performed intraorally without anesthesia. A clear polyvinyl siloxane (PVS) impression material is used to replicate the diagnostic wax-up or the anatomical form of the natural dentition of a preexisting diagnostic model. The clear matrix can be placed intraorally over the prepared or unprepared teeth and used as a transfer vehicle for the flowable resin composite to be injected and cured.1,2 (Figs 1 to 5) Empirical Data

Flowable composite materials have been evaluated in numerous studies16-40 since their inception. Although early flowable formulations demonstrated poor clinical performance,1,16 some of the more recent studies34,37,38 indicate that the clinical performance of specifically tested next-generation flowable (injectable) resin composites have similar or improved performance to specifically tested universal resin composites. Attar and others 23 showed that different flowable composites possessed a wide range of

mechanical and physical properties. Earlier studies by Gallo et al. 24 on specific flowable resin composites suggested that these materials should be limited to small-and moderatesized restorations having isthmus widths of one-quarter or less of the intercuspal distance.31 However, Torres et al. 38 reported that, after 2 years of clinical service, no significant differences were found between Class II restorations restored with GrandioSO (VOCO) conventional nanocomposites and those restored with GrandioSO Heavy Flow (VOCO) flowable hybrid nanocomposites. A study by Karaman et al. 34 showed similar clinical performance over 24 months in restorations of noncarious cervical lesions restored with the conventional nanocomposites (Grandio, VOCO) and those restored with the flowable material (Grandio Flow, VOCO). A more recent study by Sumino et al. 37 indicated that the flowable (injectable) materials G-aenial Universal Flo (GC America), G-aenial Flo (GC America) and Clearfil Majesty Flo (Kuraray Noritake) had significantly greater flexural strength and a higher elastic modulus than the corresponding conventional nanocomposite materials, Kalore (GC America) and Clearfil Majesty Esthetic (Kuraray Noritake). The wear and mechanical properties of these specific universal injectable resin composites suggested an

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improved clinical performance compared with that of the universal composites. Several in vitro studies conducted at GC Research and Development comparing specific flowable material properties of several conventional composites found results similar to those of Sumino et al. Of the next- generation flowable systems studied, G-aenial Universal Flo (GC America) and Clearfil Majesty ES Flo (Kuraray Noritake) showed superior gloss retention and similar wear resistance to the conventional nanocomposites tested, which included Filtek Supreme Ultra (3M ESPE), Herculite Ultra (Kerr), Clearfil Majesty ES-2 (Kuraray Noritake) and G-aenial Sculpt (GC America). According to these studies, these recently developed specific nanohybrid flowable resin (or universal injectable) composite systems (ie, Clearfil Majesty ES Flow and G-aenial Universal Flo) may possess properties that meet the aforementioned mechanical, physical, and optical requisites. These properties and the clinical behavior of the biomaterial formulations are contingent upon their structure. New resin filler technology allows higher filler loading because of the surface treatment of the particles and increase in the distribution of particle sizes. The unique resin filler matrix allows the particles to be situated very closely to each other, and this reduced interparticle spacing and homogeneous dispersion of the particles in the resin matrix increases the reinforcement and protects the matrix.41-43 In addition, the proprietary chemical treatment of the filler particles allows proper wettability of the filler surface by the monomer and thus an improved dispersion and a stable and stronger bond 8 between the filler and resin. 43-47 Studies clearly indicate the importance that filler content and coupling agents represent in determining characteristics such as strength and wear resistance. Recent studies19,31,48 report that specific flowable (universal injectable) composites have comparable shrinkage stress to conventional composites. According to the manufacturers, these next-generation flowable (universal injectable) composite formulations are purported to offer mechanical, physical and esthetic properties similar to or better than those of many universal composites.49 The clinical attributes of universal flowable composites include easier insertion and manipulation, improved adaptation to the internal cavity wall 50, increased wear resistance, greater elasticity, color stability, enhanced polishability and retention of polish, and radiopacity similar to enamel. Furthermore, the clinical indications for these next-generation flowable resin composites are increasing as the properties of the materials and the bond strength of adhesives to dental 8

tissues improve. With improved mechanical properties reported,37 these highly filled formulations are indicated for use in anterior and posterior restorative applications.5 The clinical applications of these specific next-generation universal injectable composites include sealants and preventative resin restorations; emergency repair of fractured teeth and restorations; fabrication, modification and repair of composite prototypes and provisional restorations4; anterior and posterior composite restorations; composite tooth splinting;51 and intraoral repair of fractured ceramic and composite restorations.51 In addition, these composites can be used to repair denture teeth,51 establish vertical dimension, alter occlusal schemes before definitive restoration,5 manage spatial parameters during orthodontic treatment, eliminate cervical sensitivity,51 resurface occlusal wear on posterior composite restorations,51 establish incisal edge length before esthetic crown lengthening,51 develop composite prototypes for copy milling,5 and place pediatric composite crowns.6 Since the past provides information to improve the future, the lack of evidence-based research and clinical trial data on flowable biomaterials requires clinicians to evaluate the individual mechanical properties of these materials to determine whether their properties are equal or superior to those of existing materials. As the clinical performance of these next-generation flowable materials has improved over time, the research data have concurred. Although no direct correlation has been found between a material’s mechanical and physical properties and its clinical performance, 9 suggest the potential success of such a correlation might a restorative biomaterial for a specific clinical situation.16 However, clinical longevity for restorations developed with these biomaterials remains to be determined through clinical studies for each specific clinical application. Future clinical applications of this novel technique with these next-generation flowable materials may provide clinicians and technicians with alternative approaches to various clinical situations while allowing them to deliver improved and predictable dental treatment to their patients. Although the long-term benefits of this novel injectable composite technique remain to be determined, the clinical results achieved by the first author in the last 14 years and the aforementioned supporting empirical data for these next-generation nanocomposite flowables are extremely promising. Cases 1 to 5 illustrate some of the many clinical applications of the injectable resin composite technique using various highly filled formulations of flowable composite materials (Figs 6-49).

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Case 1 - Developing the Functional Composite Prototype (Figures 06-14)

12 6 Figure 6: Preoperative facial view of the maxillary anterior segment of a patient who presented with incisal wear and fracture on the maxillary anterior teeth.

7 Figure 7: Development of a diagnostic wax-up that establishes new parameters (ie, esthetic, functional) for the final restorations.

Figure 8: Clear PVS matrix (Memosil 2, Heraeus Kulzer) was fabricated to replicate the diagnostic wax-up.

Figure 9: Flowable composite resin material (Filtek Supreme Ultra, 3M ESPE) was injected through a portal in the matrix, allowing the material to completely cover the conditioned unprepared enamel surface.

Figures 10, 11, 12: Functional resin composite prototype was completed and inspected in centric relation and protrusive and lateral excursions.

13 Figure 13: Functional resin composite prototype established the optimal esthetic parameters for a natural smile.

14 Figure 14: Facial view at 6-year follow-up.

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Case 2 - Orthodontic Space Management (Figures 15 - 22)

Figure 15, 16: Preoperative facial view prior to interdisciplinary orthodontic treatment of 11-years-old, who presented with a tooth size discrepancy on the maxillary anterior segment and caries present on the proximal surfaces of the maxillary lateral incisors. During orthodontic and restorative evaluation, the patient and parent were explained the significance of achieving specific space requirements so the orthodontist could position the teeth in the most optimal restorative position that will require a minimal preparation design. It is important that the appropriate and anticipated result be decided prior to the placement of the orthodontic appliances.

Figure 17: After review with the patient, parent, and orthodontist, a diagnostic wax-up was designed to modify the size and shape of the maxillary lateral incisors. This waxup allowed the restorative team to evaluate form and function.

17 Figure 19: After the adhesive protocol is completed, the clear silicone matrix was placed over the arch and shade A-1 flowable resin composite (G-aenial Universal Flo, GC America) was injected through a small opening above each tooth. The resin composite was cured through the clear resin matrix on the incisal, facial and lingual aspect for 40 seconds.

18 Figure 18: A clear PVS matrix was fabricated to replicate the diagnostic wax-up. A small opening was made above each tooth that was to be restored using a needled-shaped finishing bur (ET Series bur, Brasseler USA).

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Case 2 - Orthodontic Space Management (Figures 15 - 22) contd.

Figure 20, 21: Completed resin composite restorations with optimal anatomical form for the 11-year-old patient. The composite injection technique allowed the establishment of harmonious proportions of the transitional restorations and the surrounding biologic framework. Use of the technique for tooth size discrepancies in the preorthodontic treatment-planning stages simplifies technique the understanding and management of this restorative dilemma for the patient and the interdisciplinary team.

22 Figure 22: Seven-year follow-up of composite transitional restorations after orthodontic treatment. Note the minimal wear.

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Case 3 - Restoring Posterior Primary Tooth with an Injectable Composite Crown (Figures 23-30)

Figure 23, 24: Preoperative occlusal view and radiograph of the primary mandibular second molar of 78-year-old patient with an existing Class II composite restoration and caries on the distoproximal surface of the tooth. Upon initial consultation with periodontist, the recommended treatment included an implant and bone graft, and the patient needed to temporarily discontinue his warfarin regimen. After subsequent medical history and radiographic review and discussion with the patient and periodontist, it was decided that the injectable resin technique would be a viable alternative treatment for this clinical situation, and the patient agreed.

Figure 26: Adhesive preparation design included removal of preexisting defective composite restoration and carious dentin and enamel; occlusal reduction of 1.5 to 2 mm; a circumferential chamfer 0.3 mm in depth; vertical proximal, buccal and lingual walls with slight convergence toward the occlusal; all internal and external line angles rounded and cavity walls smoothed; and unsupported enamel walls removed to improve the path of material flow.

Figure 25: A clear PVS (ExaClear, GC America) matrix was fabricated to replicate the preoperative diagnostic model, and an opening was made above the primary mandibular second molar with a tapered diamond bur (6847, Brasseler USA).

Figure 27: After the injection process was completed, the matrix was removed and the excess polymerized resin composite was scoured on the facial, lingual and interproximal regions with a scalpel blade (#12 BD BardParker, BD Medical) and removed with a scaler. The occlusal composite sprue was removed using an 8-fluted pyramidalshaped finishing bur (H274, Brasseler USA).

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Case 3 - Restoring Posterior Primary Tooth with an Injectable Composite Crown (Figures 23-30) contd.

Figure 28, 29: Completed primary composite crown. The radiograph reveals ideal proximal contours and contacts with an optimal marginal integrity at the restorative interface.

30 Figure 30: Clinical follow-up at 18 months. The patient was pleased with the results achieved using this minimally invasive injection technique.

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Case 4 - The Single Anterior Implant- Immediate Placement Technique (Figures 31-36)

31 Figure 31: Facial view of the maxillary anterior segment and surrounding tissue of a 28-year-old patient.

32 Figure 32: Diagnostic wax-up was used for presurgical planning of the interrelationship between the definitive restoration and the oral structures and to fabricate the provisional restoration.

33 Figure 33: Prefabricated zirconia abutment was placed and secured in position, and the access opening was sealed. Sterilized Teflon tape was applied on the adjacent teeth to separate the abutment, and glycerin was applied to the entire surface of the abutment.

34 Figure 34: A clear silicone matrix was placed over the anterior segment of the maxillary arch, and an opacious shade A3 flowable resin composite (G-aenial Universal Flo, GC America) was injected through the small opening above the abutment, followed by a translucent A3 flowable resin composite. The resin composite mix was cured through the clear matrix on the occlusal, buccal, and lingual aspects for 40 seconds each using an LED curing light.

35 Figure 35: Biointegration of the provisional composite crown with the peri-implant architecture after 3 months.

36 Figure 36: Final results after placement of the implant-supported restoration, revealing optimal hard and soft tissue integration.

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Case 5 - Restoring Anatomical Form and Color (Figures 37-49)

Figure 37: Preoperative facial view of the maxillary anterior segment of a 47-year-old patient who presented with cosmetic concerns regarding his smile. The patient requested a conservative esthetic enhancement without orthodontic treatment. Figure 38: A clear polyvinyl siloxane matrix was fabricated to replicate the diagnostic wax-up using a non-perforated tray. A small opening was made above the lateral incisor that was to be restored using a tapered diamond bur (6847, Brasseler USA). It is important to clean the internal surfaces with a microbrush to prevent silicone debris incorporating into the flowable material. Figure 39: After intraenamel preparation and adhesive protocol, the clear silicone matrix was placed over the maxillary arch and an opacious shade A1 flowable resin composite (G-aenial Universal Flo, GC America) was initially injected through a small opening above the preparation, followed by mixing with a shade B1 flowable resin composite (injection layering technique). The resin composite was cured through the clear resin matrix on the incisal, facial, and lingual aspects for 40 seconds, respectively.

Figure 40: The completed resin composite veneer with optimal anatomical form. Figure 41: At the following appointment, the final restoration was completed by using a composite cutback technique. The artificial enamel layer of the composite veneer was removed and a corrugated chamfer 0.3 mm in depth was placed around the entire margin with a long, tapered diamond. Figure 42: The entire composite surface was etched with 37.5% phosphoric acid (Gel Etchant) for 15 seconds and rinsed for 5 seconds. Etching of the existing composite cleans the surface.

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Figure 43: Silane was applied to the composite surface and lightly air dried. An adhesive was applied to the composite surface and allowed to dwell for 10 seconds, air dried for 5 seconds, and light cured for 10 seconds using an LED curing light.

Figure 44-46: Internal characterization was performed according to the appearance of the contralateral tooth and a shademapping diagram. A diluted gray tint (Renamel Creative Color, Cosmedent) was placed along the incisal edge and proximal regions with a size 08 endodontic file and light cured for 40 seconds. A diluted white tint (Renamel Creative Color, Cosmedent) was placed along the incisal edge, proximal regions, and in the body with a size 08 endodontic file, and light cured for 40 seconds to stabilize the color and prevent mixing of the tints. A diluted yellow tint (Renamel Creative Color, Cosmedent) was placed at the cervical and in the incisal third with a size 08 endodontic file, and light cured for 40 seconds. It is the color variation from these modifiers and tints that creates the three-dimensional effect and the nuances within the incisal edge.

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Figure 47, 48: A new clear silicone matrix fabricated after the connective tissue surgical procedure was placed over the anterior segment of the maxillary arch and a clear translucent flowable resin composite (Amaris Flow HT, VOCO) was injected through a small opening over the artificial dentin layer. The resin composite was cured through the clear resin matrix on the facial and incisal aspect for 40 seconds each.

49 Figure 49: Three-year follow-up of the composite resin veneer with an ideal anatomical form and color. Note the nuances in the incisal edge created by using the composite cutback technique.

Conclusion

In the past, with the use of conventional resin composites and the direct bonding technique, the clinician had to combine the hybrid and the microfill because of the inequities of the materials of the time. However, polychromatism was

achieved from this early concept of anatomic stratification with successive layers of different restorative composites of varying refractive indexes, shades and opacities. 52-57 This development of the polychromatic restoration from the inequities of the different composite resin systems (hybrid

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and microfill) stimulated scientists, researchers, clinicians and manufacturers to explore and develop restorative materials that are not only applied in relationship to the natural tissue anatomy, but that have similar physical, mechanical, and optical properties to that of tooth structure.53,58 Today, these highly filled formulations of injectable composite materials can be used to improve adaption and color integration as a result of internal adaptation and the mixing of colors. As we compare the old and the new in history, only the material of time with the proper technique can provide optimal natural esthetic restorations. Knowledge of a concept of the past and a desire to create are limited by the materials clinicians have available to them for restorative procedures. Advancements in resin composite technology continue to improve the practice of dentistry. Continuing technological breakthroughs allow the clinician not only to comprehend the building blocks of the ideal composite restoration but also to implement and maximize the potential of new materials to attain more predictable and esthetic results. Although new ideas and concepts continually flood the marketplace, one should not discount the power a new biomaterial may have on planning, design or procedure. These developments promise to simplify the clinical applications for esthetic and restorative techniques and ultimately improve the level of health care provided for the contemporary dental patient. Only the passage of time can determine the long-term benefits of these new flowable resin formulations.1 The clinical applications provided in this article demonstrate the potential of these flowable nanoparticle composite formulations to expand treatment options for a wider range of clinical situations. References 1. Terry DA. Restoring with Flowables. Chicago, IL; Quintessence Publishing: 2016. 2. Terry DA, Geller W. Esthetic and Restorative Dentistry. Chicago, IL; Quintessence Publishing: 2018. 3. Bryce DM. Plastic Injection Molding: Manufacturing Startup and Management, vol V. Dearborn, MI: Society of Manufacturing Engineers, 1999. 4. Terry DA. Developing a functional composite resin provisional. Am J Esthet Dent 2012;2:56–66. 5. Terry DA, Powers JM. A predictable resin composite injection technique, part I. Dent Today 2014;33:96,98–101. 6. Terry DA, Powers JM, Mehta D, Babu V. A predictable resin composite injection technique, part 2. Dent Today 2014;33:80,82,84,85. 7. Terry DA, Leinfelder KF, Geller W. Provisionalization. In: Aesthetic

and Restorative Dentistry: Material Selection and Technique. Houston: Everest, 2009. 8. Heymann HO. The artistry of conservative esthetic dentistry. J Am Dent Assoc 1987:14E–23E. 9. Gürel G. The Science and Art of Porcelain Laminate Veneers. Berlin: Quintessence, 2003. 10. Baratieri LN. Esthetics: Direct Adhesive Restoration on Fractured Anterior Teeth. São Paulo: Quintessence, 1998. 11. Donovan T, Cho G. Diagnostic provisional restorations in restorative dentistry: The blueprint for success. J Can Dent Assoc 1999;65:272–275. 12. Preston JD. A systematic approach to the control of esthetic form. J Prosthet Dent 1976;35:393–402. 13. Yuodelis RA, Faucher R. Provisional restorations: An integrated approach to periodontics and restorative dentistry. Dent Clin North Am 1980;24:285–303. 14. Saba S. Anatomically correct soft tissue profiles using fixed detachable provisional implant restorations. J Can Dent Assoc 1997;63:767–768,770. 15. Terry DA, Geller W. Esthetic and Restorative Dentistry: Material Selection and Technique, ed 2. Chicago: Quintessence, 2013. 16. Bayne SC, Thompson JY, Swift EJ Jr, Stamatiades P, Wilkerson M. A characterization of first-generation flowable composites. J Am Dent Assoc 1998;129:567-577. 17. Labella R, Lambrechts P, Van Meerbeek B, Vanherle G. Polymerization shrinkage and elasticity of flowable composites and filled adhesives. Dent Mater 1999;15:128-137. 18. Tabassian M, Moon PC. Filler particle characterization in flowable and packable composites [abstract 3022]. J Dent Res 1999;79:213. 19. Baroudi K, Silikas N, Watts DC. Edge -strength of flowable resin-composites. J Dent 2008;36:63-68. 20. Ikeda I, Otsuki M, Sadr A, Nomura T, Kishikawa R, Tagami J. Effect of filler content of flowable composites on resin-cavity interface. Dent Mater J 2009;28:679-685. 21. Irie M, Tjandrawinata R,Lihua E, Yamashiro T, Kazuomi S. Flexural performance of flowable versus conventional light-cured composite resins in a long-term in vitro study. Dent Mater J 2008;27(2):300-309. 22. Estafan AM, Estafari D. Microleakage study of flowable composite resin systems. Compend Contin Educ Dent 2000;21:705-708. 23. Attar N, Tam LE, McComb D. Flow, strength, stiffness and radiopacity of flowable resin composites. J Can Dent Assoc 2003;69:516-521. 24. Gallo JR, Burgess JO, Ripps AH, et al. Clinical evaluation of 2 flowable composites. Quintessence Int 2006;37:225-231. 25. Dukić W, Dukić OL, Milardović S, Vindakijević Z. Clinical comparison of flowable composite to other fissure sealing materials: A 12 months study. Coll Antropol 2007;31:1019-1024. 26. Baroudi K, Saleh AM, Silikas N, Watts DC. Shrinkage behavior of flowable resin-composites related to conversion and filler-fraction. J Dent 2007;35:651-655.

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27. Celik C, Ozgünaltay G, Attar N. Clinical evaluation of flowable resins in non-carious cervical lesions: Two-year results. Oper Dent 2007;32:313-321. 28. Kubo S, Yokota H, Hayashi Y. Three-year clinical evaluation of a flowable and a hybrid resin composite in non-carious cervical lesions. J Dent 2010;38:191-200. 29. Turner EW, Shook LW, Ross JA, deRijk W, Eason BC. Clinical evaluation of a flowable resin composite in non-carious Class V lesions: Two-year results. J Tenn Dent Assoc 2008;88:20-24; quiz 2425. 30. Xavier JC, Monteiro GQ, Montes MA. Polymerization shrinkage and flexural modulus of flowable dental composites. Mater Res 2010;13:381-384. 31. Gallo JR, Burgess JO, Ripps AH, et al. Three-year clinical evaluation of two flowable composites. Quintessence Int 2010;41:497503. 32. Yu B, Lee YK. Differences in color, translucency and fluorescence between flowable and universal resin composites. J Dent 2008;36:840-846. 33. Clelland NL, Pagnotto MP, Kerby RE, Seghi RR. Relative wear of flowable and highly filled composite. Journal Prosthet Dent 2005;93:153-157. 34. Karaman E, Yazici AR, Ozgunaltay G, Dayangac B. Clinical evaluation of a nanohybrid and a flowable resin composite in noncarious cervical lesions: 24-month results. J Adhes Dent 2012;14:485492. 35. Ilie N, Hickel R. Investigations on a methacrylate-based flowable composite based on the SDR technology. Dent Mater 2011;27:348-355. 36. G-aenial Universal Flo:Editor’s Choice.Dental Advisor. 2011:19. 37. Sumino N, Tsubota K, Toshiki T, Shiratsuchi K, Miyazaki M, Latta M. Comparison of the wear and flexural characteristics of flowable resin composite for posterior lesions. Act Odont Scand 2013;71:820827. 38.Rocha Gomes Torres C, Rego HMC, Costa Perote LC, et al. A split-mouth randomized clinical trial of conventional and heavy flowable composites in Class II restorations. J Dent 2014;42:793-799. 39. Zaruba M, Wegehaupt FJ, Attin T. Comparison between different flow application techniques: SDR vs flowable composite. J Adhes Dent 2012;15:115-121. 40. Lokhande NA, Padmai AS, Rathore VP, Shingane S, Jayashanker DN, Sharma U. Effectiveness of flowable resin composite in reducing microleakage: An in vitro study. J Int Oral Health 2014;6:111-114. 41. Bayne SC, Taylor DF, Heymann HO. Protection hypothesis for

composite wear. Dent Mater 1992;8:305-309. 42. Turssi CP, Ferracane JL, Vogel K. Filler features and their effects on wear and degree of conversion of particulate dental resin composites. Biomaterials 2005;26:4932-4937. 43. Lim BS, Ferracane JL, Condon JR, Adey JD. Effect of filler fraction and filler surface treatment on wear of microfilled composites. Dent Mater 2002;18:1-11. 44. Venhoven BMA, de Gee AJ, Werner A, Davidson CL. Influence of filler parameters on the mechanical coherence of dental restorative resin composites. Biomaterials 1996;17:735-740. 45. Condon JR, Ferracane JL. In vitro wear of composite with varied cure, filler level, and filler treatment. J Dent Res 1997;76:1405-1411. 46. Condon JR, Ferracane JL. Factors effecting dental composite wear in vitro. J Biomed Mater Res 1997;38:303-313. 47. Beatty MW, Swartz ML, Moore BK, Phillips RW, Roberts TA. Effect of microfiller fraction and silane treatment on resin composite properties. J Biomed Mater Res 1998;40:12-23. 48. Cadenaro M, Marchesi G, Antoniolli F, Davidson C, De Stefano Dorigo E, Breschi L. Flowability of composites is no guarantee for contraction stress reduction. Dent Mater 2009;25:649-654. 49. Yamase M, Maseki T, Nitta T, et al. Mechanical properties of various latest resin composite restoratives [abstract 464]. J Dent Res 2010; 89(special issue A). 50. Yahagi C, Takagaki T, Sadr A, Ikeda M, Nikaido T, Tagami J. Effect of lining with a flowable composite on internal adaptation of direct composite restorations using all-in-one adhesive systems. Dent Mater J. 2012;31:481-488. 51. Terry, DA. What other restorative material has so many uses: Flowables: Int Dent (Africa Ed) 2012;3:42-58. 52. Terry DA. Natural aesthetics with composite resin. Mahwah, NJ; Montage Media Corporation: 2004. 53. Terry DA. Restoring the incisal edge. N Y State Dent J 2005;71:30-35. 54. Terry DA, McLaren EA. Stratification: Ancient art form applied to restorative dentistry. Dent Today 2001;20:66-71. 55. Terry DA. Dimension of color: Creating high-diffusion layer with composite resin. 2003;24(suppl 2):3-13. 56. Terry DA. Developing natural aesthetics with direct composite restorations. Pract Proced Aesthet Dent 2004;16:45-52, quiz 54. 57. Dietschi D. Free-hand composite resin restorations: A key to anterior aesthetics. Pract Periodont Aesthet Dent 1995;7:15-25. 58. Rinn LA. The Polychromatic Layering Technique: A practical manual for ceramics and acrylic resins. Carol Stream, IL: Quintessence,1990:11-30.

Reprinted with permission by QDT, Quintessence Publishing: Terry DA, Powers JM, Blatz MB. The Injection Resin Technique: A Novel Concept for Developing Esthetic Restorations. QDT 2020:3-17

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CLINICAL

The impact of eating disorders on oral health Simran Bains1 Approximately 1.25 million people get diagnosed and enter inpatient treatment for eating disorders in the UK. Of those people, 89% are female. Figures published by the Health and Care Information Centre showed a national rise of 8% in the number of inpatient hospital admissions in the 12 months prior to October 2013. The average treatment cycle lasts six years with an average relapse rate ranging from 9% to 65%. Eating disorders are one of the leading causes of mental health related deaths (4% to 20%). They carry an overall cost of £15 billion per annum to healthcare services. The dental team has a vital role in the management of eating disorders. This is due to the strong link with poor oral health, particularly erosive tooth wear. Therefore, it is paramount that dental professionals have an understanding of eating disorders and their manifestations. They should be aware of any abnormal behavioural or psychological changes in their patients designed to avoid food. Anorexia nervosa

Simran Bains BDS MFDS RCS

The World Health Organization (WHO) defines anorexia as a disorder characterised by deliberate weight loss, through an aversion to food, induced and sustained by the patient. An altered body image drives anorexia. You can make a diagnosis when an individual presents with less than 85% of their target weight. There are two clinical subtypes: • A restrictive type: you associate this with a specific psychopathology. Already thin patients impose a low weight threshold on themselves, resulting in under nutrition of varying severities • Binge and purge type: when the person regularly engages in binge eating followed by purging aided by laxatives, self-induced vomiting or strenuous exercise. The average prevalence of anorexia nervosa is 0.3% and incidence of new cases to be eight per 100,000 per year. The average onset of anorexia nervosa is 16-17 years of age. Diagnosis of females is 10 times more common than males. Bulimia nervosa The WHO defines bulimia nervosa as a syndrome characterised by repeated bouts of overeating, followed by vomiting or use of purgatives. You can make a diagnosis when this occurs more than twice a week for at least three months. Body weight may be within or greater than normal limits; if this drops then anorexia becomes a part of the condition. The average prevalence of bulimia nervosa is 1% and incidence of new cases to be 12 per 100,000 per year. The average onset of bulimia nervosa in a WHO mental health survey was 20.6 years.

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CLINICAL

Behavioral cues

Signs that someone may have anorexia nervosa

Signs that someone may have bulimia nervosa

Missing meals, avoiding fatty foods, eating small amounts

Obsessive calorie counting

Difficulty concentrating

Taking appetite suppressants, laxatives and diuretics

Leaving the table immediatly after a meal to vomit – brillle nails

Repeatedly weighing themselves or checking their body in a mirror

Excessive exercise

Physical problems – fatigue, dizziness, hair loss, dehydration, absence of menstruation and constipation

Osteoporosis

Obsessive attitude towards food/ eating

Overcritical attitude to their weight and Habitually going to the bathroom shape after eating where the person appears flushed – may have calluses on their knuckles (from forcing fingers down their throat to bring on vomiting) Physical problems – fainting, dehydration, muscle cramps, absence of menstration, abnormal bowel functioning, irregular heart beat

Psychological cues

Obsessive attitude towards food and eating

Unrealistic opinions about body weight and shape

Depression

Low self-esteem

Anxiety

Social isolation

Table 1: Eating disorder behavioural and psychological cues

Oro-dental effects of eating disorders Erosion

A definition of dental erosion is: ‘The irreversible loss of dental hard tissue by a chemical process not involving bacteria.’ Extrinsic acids include fruit juices and carbonated drinks, while intrinsic acids include those from gastro-oesophageal reflux disease and self-vomiting. Patients with an eating disorder commonly present with dental erosion and those who self-induce vomiting are 5.5 times more likely to experience dental erosion than healthy patients. The pH of gastric acid is 2.9. This is below the critical pH of 5.5 required to dissolve enamel.

Erosive lesions are predominantly found on palatal surfaces of upper anterior incisors (46%). Following this are occlusal surfaces of the lower molars (36.6%) and buccal surfaces (21.8%). Patients with an eating disorder consume high quantities of low-pH beverages, such as herbal teas, soft drinks and apple cider vinegar. Acidic sports drinks are frequently consumed during strenuous periods of exercise and carbonated drinks are consumed to decrease the reflex stimulus for hunger. Diarrhoea is induced with high amounts of fresh fruit.

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BAINS

Tips and advice for patients •Reduce intake of acidic drinks •Reduce intake of citrus fruits •Avoid alcohol •After self-induced vomiting, chew sugarfree gum or rinse with water, milk or antacid preparation. Avoid brushing teeth •Check the patient’s medication is not contributing xerostomia •Prescribe artificial saliva for xerostomia (AS Saliva Orthana spray, Ccmed; Salivix pastilles, Galen). Caries

The extent of the effect of caries affecting individuals with eating disorders remains unclear. Some studies state vomiting may have an effect on the risk of caries both directly and due to having a reduced salivary flow rate. During periods of bingeing, bulimics will often consume foods they usually deny themselves – such as foods high in carbohydrates and sugar. This nourishes cariogenic microbes, thus initiating the carious activity. Studies show not all bulimics display a higher number of decayed, missing, and filled teeth (DMFT) than controls suggest. Although bulimics have a higher level of S mutans, they are unable to metabolise below pH4.2. Vomiting creates a low pH, which creates a lower caries incidence. Saliva

Saliva plays a fundamental role in the maintenance of oral health through lubricating and neutralising intraoral acids. A reduced salivary rate is usually from vomiting, xerostomia due to taking antidepressants, and dehydration from excessive exercise. It is important to gain a thorough medical history prior to treating a patient with an eating disorder. Therefore, you can establish reasons behind a diagnosis and incorporate this into the patient’s prevention and treatment plan. Individuals with a salivary flow rate of <1ml/min are five times more likely to develop dental erosions than those with high flow rates. Salivary flow can elevate pH due to an increased concentration of bicarbonate and improved neuralising effect, thus acting as a diffusion barrier against acid erosion. Parotid enlargement

Although commonly associated with self-induced vomiting, the precise cause of sialadenosis remains unclear.

The prevalence of a patient with an eating disorder who has an enlarged parotid gland range from 0 to 80% and the onset of swelling usually follows a binge purge episode by two to six days. It is important to note that vomiting behaviour can still be present even if the salivary glands are not enlarged. Soft tissue lesion

It is widely accepted that any underlying systemic disease may manifest in oral tissues prior to becoming evident systemically. Nutritional deficiencies can often result in candidiasis, angular cheilitis, glossitis and oral mucosal ulceration. Trauma to the mucosa of the pharynx and soft palate arises as a result of inserting foreign objects into the oral cavity to induce vomiting. Dental management

As healthcare professionals, we should be non-judgmental and empathetic when managing, educating and counselling patients. Many patients may feel embarrassed to admit they have an eating disorder and not ready to admit to selfinduced vomiting. Unexplained weight loss, gynaecological problems, lethargy and fatigue represent signs of a possible eating disorder. You can monitor tooth wear using study casts and photographs. Pain relief, improved appearance and reduced sensitivity are some of the ways that dentists may motivate the patient to abstain from self-induced vomiting. Toothbrushing after vomiting is inadvisable as a demineralised surface is susceptible to abrasion from the toothbrush. Currently, there is no contraindication to restore the patient’s eroded dentition while their vomiting is not under control. Composite restorations are not acid soluble. You should make the patient aware that if purging does continue, dissolution of tooth surfaces around the restoration would occur. Antidepressants can influence a patient’s salivary flow rate, so liaising with the patient’s medical practitioners is imperative. Severe cases of anorexia nervosa and bulimia nervosa involve nutritional provision and psychotherapy inpatient treatment. Less severe cases encompass outpatient psychotherapy and medical monitoring. This article first appeared in Clinical Dentistry and has been reprinted with permission. Bains S (2022) The impact of eating disorders on oral health. Clinical Dentistry 2(1): 86-87

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Masterclass in Clinical Practice Introduction

Implant Dentistry with Dr Andre W van Zyl1 Dr Inus Snyman2

Minimally invasive or low trauma extraction techniques

Implant placement after the loss of teeth has become a standard procedure. Low trauma removal of teeth is an essential skill for clinicians wanting to do implant placement afterwards. It is often erroneously called atraumatic extraction. No extraction can be atraumatic, and this term should not be used. Although these techniques were developed because of the need to preserve alveolar bone for immediate or delayed implant placement, it should be our aim for all extractions. After all, why would anyone perform an extraction where unnecessary damage is done to the alveolus? Most implant patients are older persons, and with age the coronal alveolar bone volume decreases.1 This further emphasizes the need for low trauma extraction, to preserve what little bone there is. Low trauma extraction does not guarantee the preservation of the alveolar bone, as the thickness of the socket walls will determine the amount of resorption after removal of a tooth. A thick socket wall is regarded as one of more than 1mm.1 Less than this and most of the socket wall will disappear as it will consist of bundle bone only. Bundle bone is a tooth related structure and will resorb after loss of a tooth. This resorption will occur within 4-8 weeks after tooth extraction.1 If the socket walls are to be used to contain bone filler material as a barrier against soft tissue invasion in ridge augmentation, the implant should be placed immediately or delayed for 2-4 weeks if acute infection at time of tooth removal prevents immediate placement. Once the socket wall has resorbed, contour augmentation becomes a more challenging procedure (see figure 1). Contour augmentation will support aesthetic soft

Andre W. van Zyl MChD (Oral Medicine & Periodontics) Private Practice, Hermanus, South Africa

Inus Snyman BChD, PDD (Implantology), PGDipDent (Oral Surgery), PGDipDent (Implantology), MChD, FCD(SA) OMP Private Practice, Stellenbosch, South Africa

Figure 1: Loss of complete facial wall requires extensive augmentation for implant placement and is a complex procedure.

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tissue contours and provide the recommended minimum of 2mm bone wall thickness around a dental implant.1 To perform a low trauma extraction, one2amust have an intimate knowledge of the anatomy of not only every tooth, but also the alveolar bone and tooth socket. Where the bone is thick enough to allow a minimal widening of the socket, it may aid in moving the root as well as gain entry for a root elevator tip. To plan this properly, a CBCT scan has become indispensable. Objectives of Low trauma extraction: 1. Preserve an intact tooth socket.

This requires the removal of the tooth or root without lifting a flap. Lifting a flap will lead to bone resorption due to the removal of blood supply.2 In addition, no vertical bone height should be removed in order to extract a root and horizontal bone removal to allow an entry point for a luxator should only be done where the bone width is sufficient. A recent review found that socket seal techniques after root removal may help in preserving socket walls, but more studies are needed to evaluate this.3 Introducing more procedures to the removal of a root/tooth also defeats the objective of low trauma surgery and increases the cost of an already expensive procedure. The objective is to remove the root or tooth in a flapless manner, without suturing. This will keep the muco-gingival dimensions intact for improved aesthetic outcome and regenerate gingiva across the dimensions of the socket. Adequate gingiva is important in implant stability, and it has been shown that sufficient gingival width and thickness is essential in peri-implant bone stability.4, 5

Figure 2: Pre-operative view of tooth 36 showing infection and a fractured root

2. To benefit immediate or early implant placement with augmentation.

Having an intact socket 2b wall helps to contain any bone filler used in jump-gap augmentation. If no acute infection is present at the time of root removal, immediate implant placement may be considered. In a case where acute infection does exist, careful curettage of the socket can be done with 2-4 weeks of healing allowed to clear any residual infection, before placing an implant. Eight weeks after flapless low trauma removal, the facial socket wall will have undergone significant resorption and the absence of a facial socket wall will increase the complexity of contour augmentation as well as the cost. It will resorb more in thin periodontal phenotype patients and where prior facial wall defects existed.6 This emphasizes the importance of pre-surgical planning using CBCT to assess the socket wall thickness. Technique:

Before attempting any low trauma removal, the anatomy of the root/s should be studied from all viewpoints to determine the thickness of all 4 socket walls, the number of roots, the shape and length of roots and any anatomical complications such as sinus or inferior alveolar nerve involvement. The presence of any pathology around the roots should also be determined. The CBCT should be scrolled through carefully in both axial, cross-sectional and panoramic views. In multiple rooted teeth, the axial slicing will show at what level the roots can be separated for individual low trauma removal of each root. It will also show whether a root is round and therefore

Figure 3: After removal of the crown of tooth 36, the roots are sectioned through the furcation

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Figure 4: Radiograph showing sectioning without removal of interradicular bone

Figure 5: Post-operative view showing removal of tooth and no debris remaining in socket.

possible to rotate, versus a more difficult triangular or figure eight root shape. Axial slicing will also show the volume of interdental and interradicular bone which will determine if a purchase point may be prepared for root luxators, without harming the tooth supporting bone needed for the implant/augmentation (see case presentation below of removal of root 13). By removing each root individually, the interradicular bone can often be preserved, adding to the total bone volume for socket healing. Splitting a mandibular molar is easier than a maxillary molar, as not only does it have two roots instead of three but removing a small section of the interradicular bone is much easier and will ease the elevation of the two roots. Figures 2-5 show sequential

images to demonstrate the low trauma removal of tooth 36. The worst-case scenario in difficult multi-rooted tooth removal, is to remove bigger sections of the interradicular bone rather than to harm the facial or palatal socket walls. This will still leave a confined bony defect surrounded by 4 bony walls, even if all the interradicular bone is removed. It can therefore only heal with bone, even though it may take longer than if the interradicular bone was left intact.

Figure 6: Benex vertical extraction attached to root 24. The force is distributed to the adjacent healthy teeth. Periotomes should still be used to sever the dental fibres to aid the extraction process.

Instrumentation:

1. Periotomes Periotomes are fine tipped instruments to sever the dentogingival fibres as well as the most coronal periodontal ligament fibres. 2. Root luxators Each clinician will have their favourite root luxators, but Coupland numbers 1-3 will take care of most situations. The elevator is inserted into the coronal portion of the periodontal ligament space and using a gentle backand-forth rotational movement the root is loosened by tearing the periodontal ligament fibres. 3. Piezo surgical unit: periotome and saw tips This is almost indispensable to remove difficult to reach roots, badly decayed roots, or broken root tips. With fibre-optic lighting to aid vision it enables widening of the socket with low trauma by removing bundle bone only. 4. Miller socket curettes After removal of a root, the socket should be curetted down to the most apical section. The curettes should be chosen to match the root tip dimension, thereby ensuring effective debridement. Always confirm that all debris is

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cleaned out by a post-operative radiograph (Figure 5). 5. Benex® extraction system The Benex® vertical extraction pulley system (Benex, Luzern, Switzerland, https://www.benex-dent.com) is one of the lowest trauma techniques to remove a severely broken down/fractured root. It is ideally suited for single rooted teeth in the aesthetic zone.7 (Figure 6) Conclusion

Low trauma extraction should not involve an open flap approach, should not include bone removal with a bur and should ideally not involve suturing other than to stabilise the papillae. If more than Bundle bone needs to be removed it should be limited to interradicular bone in multi-rooted teeth or interdental bone if the interdental space allows it, otherwise it may cause irreversible damage. It requires specialised instruments as listed above. Forceps extraction should not be used other than in a gentle back and forth rotation movement with round roots. Cone beam computed tomography is an essential tool to study the anatomy beforehand, determine the degree of difficulty to be expected and to assess possible anatomic complications. CBCT and specialised instruments are not luxuries, but essentials in limiting trauma to the alveolus and ensure a successful dental implant placement. References

1. Braut V, Bornstein MM, Belser U, Buser D. Thickness

of the anterior maxillary facial bone wall-a retrospective radiographic study using cone beam computed tomography. Int J Periodontics Restorative Dent. 2011;31(2):125-31. 2. Fickl S, Kebschull M, Schupbach P, Zuhr O, Schlagenhauf U, Hurzeler MB. Bone loss after full-thickness and partialthickness flap elevation. J Clin Periodontol. 2011;38(2):157-62. 3. López-Pacheco A, Soto-Peñaloza D, Gómez M, Peñarrocha-Oltra D, Alarcón MA. Socket seal surgery techniques in the esthetic zone: a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials. Int J Implant Dent. 2021;7(1):13. 4. Linkevicius T, Puisys A, Linkeviciene L, Peciuliene V, Schlee M. Crestal Bone Stability around Implants with Horizontally Matching Connection after Soft Tissue Thickening: A Prospective Clinical Trial. Clin Implant Dent Relat Res. 2015;17(3):497-508. 5. Puisys A, Linkevicius T. The influence of mucosal tissue thickening on crestal bone stability around bone-level implants. A prospective controlled clinical trial. Clin Oral Implants Res. 2015;26(2):123-9. 6. Chen ST, Darby I. The relationship between facial bone wall defects and dimensional alterations of the ridge following flapless tooth extraction in the anterior maxilla. Clin Oral Implants Res. 2017;28(8):931-7. 7. Hong B, Bulsara Y, Gorecki P, Dietrich T. Minimally invasive vertical versus conventional tooth extraction: An interrupted time series study. J Am Dent Assoc. 2018;149(8):688-95.

Case Presentation: Low trauma removal 13

Figure 7: Cross section of failed bridge anchor showing almost no buccal bone volume and thick palatal bone

Figure 8: Axial view of 13 showing root prominence and thin facial wall indicating it is Bundle bone only

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Figure 9: Clinical view with bridge removed showing extensive subgingival caries and soft tissue infection

Figure 10: Root removed in one piece with Miller socket curettes shown adjacent to compare shape and size with root size. If socket curette is too big it will not reach the apical portion of the socket for effective debridement

Figure 11: Postoperative view showing intact palatal bone wall

Figure 12: Postoperative view showing residual debris in socket

Figure 13: The preoperative CBCT is used to identify 3D position of debris. Even so it took twenty minutes of careful curettage of the socket before getting the gutta percha out while preventing destruction of buccal bone

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Figure 14: Axial view after removal of root with the purchase point prepared by piezo visible disto-palatal of socket

Figure 15: Postoperative cross section view showing intact bone wall after low trauma removal of root, even though the buccal wall is less than 1mm in thickness.

Figure 16: NSK Variosurg 3 piezo handpiece is equipped with LED light enabling vision in difficult to reach areas and is a low weight handpiece, easy to manoeuvre

Figure 17: The periotome tip on left (0,7mm thick) and the bone surgery “saw” tip (0,6mm thick) enabling the enlargement of socket by removing bundle bone only

Figure 18: Tooth 16 with periodontal ligament space clearly visible Figure 19: Periotome inserted within a gingival sulcus will enter the coronal part of the periodontal ligament space. This will sever the dento-gingival fibres as well as the most coronal periodontal ligament fibres Figure 20: The bone surgery “saw” tip inserted into the periodontal ligament space- showing how it is possible to enlarge the socket or create a purchase point for a root elevator, without removing any tooth supporting bone other than bundle bone. This is possible for interdental and interradicular bone.

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CLINICAL

Endodontics: single versus multiple visit Omar Ikram1, Tyler Neal2 and Richard Mounce3

Introduction This article was written to guide endodontic clinicians making decisions regarding one visit versus multiple visit treatment. It is broken into two sections: single and multi-visit endodontic therapy. Written from two different clinical viewpoints, it addresses the indications, contraindications, advantages and disadvantages of each. Single visit endodontic therapy: Omar Ikram Much time has been spent investigating and researching the healing or maintenance of periapical health, commonly called ‘success’, of single visit versus multiple visit root canal treatment. The consensus is that there is no significant difference in success rates of either treatment modality (Sathorn et al, 2005; Figini et al, 2008). Given that there is no obvious difference in success rates between one or multiple visits, an analysis of the possible advantages of each protocol is appropriate. The clinical presentation and the patient’s individual circumstances should always be considered first and foremost in clinical decision making. The practical advantages of multiple visit root canal treatment include:

Dr Omar H Ikram BDS (Otago), MClinDent (London), MRD (Edinburgh), FRACDS, Specialist Endodontist, Private Practice, Sydney, Australia

Tyler Neal, Student, Roseman Dental School, South Jordan Utah (USA)

Dr Richard Mounce, DDS, Specialist Endodontist. Private Practices in Alaska and Oregon, USA

Figure 1: Apparently ‘simple’ canal anatomy in LL7 (lower left second molar) that is amenable to treatment in one visit using the appropriate techniques. The patient was asymptomatic and did not have any contraindications to treatment

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Figure 2a: Severe calcification in LL2 (lower left lateral incisor). LL2 is treatment planned for an orthograde root canal therapy attempt followed by surgery on LL2-LR1 for curettage, biopsy, and retro-fill of these teeth. This figure is prior to the non-surgical attempt to treat LL1

Figure 2b: After the unsuccessful attempt to locate the canal in LL1 and prior to attempting LL2. Both LL2 and LL1 are inherently challenging given the calcification. Multi-visit therapy is virtually assured. A CBCT was taken and a canal not visible in either of these teeth until the apical third (as in the 2D images provided)

• The antimicrobial benefit of calcium hydroxide • The protein denaturing properties of calcium hydroxide, which aid pulp tissue dissolution when sodium hypochlorite is used as the irrigant • The opportunity to monitor clinical symptoms, soft tissue and or radiographic healing prior to obturation and definitive restoration • Decreased operator and patient fatigue.

for a patient? From most important to least important, factors to consider before deciding on single or multi-visit treatment include: 1. Anatomy of the tooth being treated 2. Skill of the operator 3. Experience using modern endodontic equipment 4. Radiographic size of the periapical lesion 5. Teeth with sinus tracts 6. Cracked teeth 7. Patient factors.

The practical advantages of single visit treatment include: • Patient convenience • Reduction of dental materials. The reduced number of visits also reduces the materials required and thus reduces costs • Reduction of the potential for microleakage between treatment visits. With single visit root canal treatment, the definitive core restoration should be placed after shaping and canal disinfection under the rubber dam. This removes the need for temporary restorative materials and reduces the potential for coronal leakage between appointments. With these advantages in mind, when would I consider providing a multiple visit or a single visit root canal treatment

1. Anatomy of the tooth being treated Success rates are highest if we can prepare and then close the access cavity definitively. In general, the extraction of a root canal treated teeth due to a failure of the shaping, disinfection and obturation is relatively rare in comparison to removal due to fracture (Vire, 1991; Salehrabi and Rotstein, 2004). However, when failure of root canal treatment occurs, the most common reason is unlocated anatomy (Nair, 2004; Siqueira, 2001). If the canal(s) is easier to locate and clean, then single visit treatment might be a possibility. If the anatomy is complex, I

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IKRAM / NEAL / MOUNCE

Figure 3a: UL6 (upper left first molar) was previously treated and has been chronically tender to chewing for many years. CBCT revealed four canals obturated. The decision was made to attempt retreatment in one visit if possible. Access revealed coronal leakage under the previous build up as a result of an unset composite and lack of adaptation of the composite along the pulpal floor

Figure 3b: Postoperative radiograph after retreatment that was accomplished in one visit. The patient’s symptoms resolved immediately

would be more inclined to schedule a multiple visit treatment – with the aim of the first visit being to locate and negotiate this complex anatomy and then see resolution of signs and symptoms.

If a cone beam scan is taken prior to treatment then this may also help reduce the time spent looking for extra canals, such as lingual canals in lower incisor teeth, or second mesiobuccal canals in upper molar teeth.

2. Skill of the operator To be able to carry out root canal treatment in a manner that is efficient and of a good standard, the operator needs to negotiate the anatomy. In single visit root canal treatment, operator and patient fatigue are often high. To be able to complete single visit treatment, I have found that a chair time of approximately two hours on a conscious patient is usually the maximum for most able-bodied patients. For single visit treatment to be an option, the operator needs to be able to perform all the treatment within this approximate time. To be able to shape, disinfect and obturate with three or more root canals in this time frame the skill of the operator must be extremely high.

4. Radiographic size of the periapical lesion Teeth with periapical lesions above 5mm in diameter have a reduced success rate (Ng et al, 2011) and therefore it is my preference for these to be treated over multiple visits so that the clinical or radiographic healing can be evaluated during the treatment. If healing is not occurring, then the patient is free to decide whether to persist with treatment and possible apical surgery after filling the canals, or to proceed with extraction. By doing this, the patient can make an informed choice before definitive filling of the canals and restoration of the tooth.

3. Experience using modern endodontic equipment There are some teeth that can be treated with low-level magnification, but the magnification and illumination of an operating microscope speeds up treatment. Use of a motor driven root canal preparation system also reduces preparation time.

5. Teeth with sinus tracts Teeth with sinus tracts have a lower chance of radiographic healing (Ng et al, 2011). It is helpful to see healing of these after shaping and disinfection of the root canal system prior to filling the canals and restoring the tooth definitively. If a sinus tract does not heal or improve after eight weeks, I will generally re-medicate the canals. If it fails to heal after this, discuss the option of apical surgery with the patient further, if it is appropriate, or the possibility of extraction.

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IKRAM / NEAL / MOUNCE

Figure 4: Purulent drainage (from the palatal canal of this upper molar), which is an absolute contraindication for single visit endodontic treatment (image courtesy of Dr Ikram) upper right lateral incisor can be seen

Figure 6: Severe bleeding upon access of this molar tooth. An inability to stop the bleeding in such irreversibly inflamed clinical cases is an absolute contraindication to one visit treatment (image courtesy of Dr Ikram)

6. Cracked teeth Due to the unpredictable nature of treating cracked teeth, my preference is to see resolution of the symptoms before filling the canals and restoring the tooth. Therefore, these are the teeth that I almost always treat over multiple visits. 7. Patient factors Patients lead busy lives, often travel long distances to the

Figure 5: Coronal fracture through the distal marginal ridge of this lower molar that reaches the pulpal floor. Such a fracture is a clear indication for extraction (image courtesy of Dr Ikram)

practice, and can have special medical needs. These are often under researched, with regards to their influence on the treatment we provide and yet play a big role in the patient’s preferences. If the patient requires antibiotic cover, intravenous sedation, general anesthetic or is travelling a long distance, my preference is to treat the patient in a single visit. On the other hand, if the patient has difficulty sitting still for long appointments – such as those with Parkinson’s disease, chronic back pain or when treating pediatric patients – my preference is to perform root canal treatment over multiple visits, to reduce length of chair time. All these considerations are part of the treatment planning process, but should never compromise our goal to provide the best care (Figures 1-6).

Multi-visit endodontic treatment: Tyler Neal and Richard Mounce A decision must be made in every endodontic case as to whether the procedure can be completed in one visit or requires multiple visits. This decision can be complex, as while there are few absolute contraindications to one visit treatment, there are a larger number of arguable and relative clinical contraindications.

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IKRAM / NEAL / MOUNCE

Aside from clinical considerations, the diagnostic skills and clinician experience, as well as the patient’s ability to tolerate the procedure, all impact the visits required. This second section of the article will review the absolute and relative contraindications to single visit treatment and address the preparation and expertise needed to optimise the number of visits. Such optimisation should increase possible one visit treatment, increase healing and clinical success, and diminish flare-ups that might otherwise result. One visit therapy is optimal for more important reasons than simply patient convenience. Fewer visits equate to fewer injections. In addition, single visit therapy eliminates repeated coronal access. Repeated access runs the risk of excessive and unnecessary tooth structure removal, leading to longer term fracture risk. In addition, each additional access increases iatrogenic risk (perforation, separated files, canal transportation etc).

Contraindications As mentioned, there are few, if any, absolute contraindications to one visit treatment, but these include: • Apices that cannot be made clean and dry in one visit • Preoperative fluctuant swelling • Preoperative numbness especially in the lower arch • A lack of patient cooperation when a second visit would allow optimal treatment either by referral possibly with IV or oral sedation. More specifically, if a patient has severe preoperative percussion sensitivity, fluctuant swelling, cellulitis, numbness, induration, among other possible scenarios and combinations of these entities, there is an undue risk of severe pain, worsening swelling and infection with possibly fatal consequences in rare cases if endodontic therapy is provided in one visit. Case dependent, in some of the aforementioned scenarios, incision and drainage may be required prior to initiation of endodontic therapy, or the tooth might be best extracted, especially in the presence of a rapidly spreading fluctuant infection among other conditions. Consultation with an oral surgeon in these clinical situations is often beneficial. Caution and clinical judgement are advised. When evaluating a case, it is critical to manage patient expectations, one aspect of which is one versus two visit treatment. Obviously, the greater the number of complexities and risks, the greater the probability of requiring two visits. For example, in a patient with limited opening, one who cannot be fully reclined, severe calcification, tooth rotation and

tipping, severe canal curvature, open apices, trauma cases, crown or bridge access, a history of local anaesthesia challenges, severe dental anxiety, among a host of other clinical and patient related factors, the possibilities for two visit treatment increases, especially as the experience level of the clinician decreases. Patients who tell of previous procedural difficulties, especially related to an inability to obtain profound local anaesthesia should be heard and taken seriously. While all of the above are relative issues, and often managed efficiently in the hands of a specialist, it is not always clear to the clinician preoperatively to what degree any of these issues will ultimately combine or conspire to make the treatment better approached in one visit or more.

Case considerations Aside from the above parameters, several additional case types lend themselves to multiple visits: • Complex retreatment • Some trauma cases • Combined orthograde and surgical procedures. While managing dental trauma is beyond the scope of this article, complex retreatment is noteworthy. Separated files, calcified canals, missed canals, perforations, iatrogenic misadventures (especially canal transportations of all types), removal of previous canal filling materials, and access through crowns and bridges, post removal etc will all take longer and require optimal disinfection techniques relative to first time orthograde techniques in irreversibly inflamed vital cases. Complicating complex retreatment is the degree and duration of coronal leakage. Long-term coronal leakage is correlated with highly organised bacterial biofilm that is significantly more challenging to remove than vital inflamed pulp. As a result, disassembly of the previous root canal, remediation of the iatrogenic issues internally within the tooth, optimising disinfection, and obturation of the canal system may require two visits instead of one. Recently, the ‘zero apicoectomy’ technique has been introduced that advocates completion of the orthograde treatment, curettage of the apical lesion, biopsy, and flap closure, without apicoectomy and retrofill, all in one visit. The technique requires a judgement that the orthograde treatment is adequate and, with apical curettage, likely to heal. While the technique is controversial in some quarters, initial case reports and research are encouraging.

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IKRAM / NEAL / MOUNCE

In addition, some clinicians have advocated for multiple applications of calcium hydroxide in cases with a sinus tract, fistula, or a radiographic present periapical lesion, as alluded to by Dr Ikram in the first section of this article. Diminution of the lesion and/or closure of the fistula is used as a condition for case completion and an indication that healing is occurring. While the concept is clinically sound, and will not cause harm, there is no literature-based proof that this multi-visit approach is optimal to ensure healing of the case. In any event, optimal clinical results have their genesis in a comprehensive preoperative examination, assurance of restorability, a pulpal and periapical diagnosis, informed consent, use of a surgical operating microscope, ultrasonics, activated and copious irrigation, and placement of a coronal seal under the rubber dam. From the specialist viewpoint, the above steps are the standard of practice, and ultimately the legal standard of care. Starting a case without these capabilities and skills inherently limits the possibilities for successful treatment and will necessarily take longer than using these principles and organisation from the start of the case.

Said differently, in the right hands, using the right equipment and concepts, the vast majority of cases can be treated in one visit, as Dr Ikram mentioned. Recognising those cases that should be broken into more than one visit – mostly to improve the level of canal disinfection through canal location, remediation of previous iatrogenic problems, resolution of infection and swelling, and provision of a coronal seal at the time of treatment – will make both single and multiple visit treatments as successful as possible.

Summary his article has presented the case for single visit and multi-visit endodontic treatment. Emphasis has been placed on preoperative diagnosis, possessing the correct clinical skill sets and technology to manage single visit treatment where appropriate and profound local anaesthesia. This article first appeared in Clinical Dentistry and has been reprinted with permission. Ikram O, Neal T, Mounce R (2021) Endodontics: single versus multiple visit. Clinical Dentistry 1(6): 57-63

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CLINICAL

Treating tooth wear: a step-by-step explanation Ash Parmar1

Case report

The patient in this case, aged 39, presented with discoloured teeth that were showing signs of wearing down. He was concerned about the long-term implication of not correcting the problems. He was also interested in improving the appearance of his smile. The photographs in Figure 1 show the preoperative condition. Baseline clinical records

The patient completed a detailed questionnaire. We then performed a comprehensive initial assessment that included the following diagnostic records: • A dental panoramic radiograph and full mouth series of periapical radiographs • Full series of digital photographs • Upper and lower silicone impressions (using Honigum by DMG) (Figure 2) • Centric relation (CR) record (using Luxabite and also O-Bite; after the muscles were deprogrammed using a custom-made NTI appliance) • Facebow record (Denar system) • Stick bite record (using O-Bite) • Diagnostic mock-up in the mouth (using Luxaflow) • A silicone impression of the mock-up • Extraoral assessment (muscles and temporomandibular joint [TMJ]) • Joint vibration analysis (JVA) to assess the TMJ • T-Scan (computerised occlusion assessment) • Full intraoral assessment, including tooth by tooth review, occlusion review, periodontal assessment (including six-point pocket charting) •Smile analysis. Table 1

UR1

UR2

Width (mm)

Height (mm)

Table 2 Ash Parmar, BDS Private practice, Chigwell, Essex, UK Email: ash@smiledesignbyash.co.uk

UR4

UR3

UR2

UR1

UL1

UL2

UL3

UL4

8.11mm

9.45mm

9.77mm

10.95mm

11.39mm

9.69mm

10.53mm

9.44mm

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CLINICAL

Figure 1: Preoperative photographs

At rest

Left-hand side smile

Lower

Lower, anterior

Left-hand side, retracted

Right-hand side, retracted

Right-hand side smile

Upper, anterior close up

Full face

Occlusal

Anterior, retracted

Smile

The following information is a summary of the clinical findings at assessment. Extraoral

There was some tenderness around the sternocleidomastoid and masseter muscles on the left side (score of two out of 10 regarding discomfort on palpation). There was also slight retrodiscal pain on the left side of the TMJ (score of four out of 10). It was difficult to get the patient to go into CR (by the bilateral manipulation technique). The maximum opening (inter-incisal measurement) was 47mm, and the maximum right and left movement of mandible was about 9mm. The overjet was 3.5mm, and the overbite was 1.5mm. In the right lateral excursion, there were contacts on the palatal surfaces of UR2 and UR3 as well as a non-working side contact on UL7 (mesiopalatal cusp). In the left lateral excursion, there were contacts on the UL3 and UL4 as well as a non-working side contact on UR7 (mesiopalatal cusp). The patient can be considered as a ‘destroyer’ (wear evident on incisors, canines and first premolars), as opposed to an ‘avoider’ (whereby a patient has posterior occlusal interferences and causes wear on only the anterior teeth).

There was evidence of abfraction on UR4, UR5, UL3, UL4, LL3, LL4, LR5; this indicates heavy occlusal forces. There were also some teeth with broken fillings and decay. There were minimum periodontal problems (pockets 2-3mm, mostly with good oral hygiene). Good root fillings were present within UR4 and UL6, and LL5 had an apical area (ie, root canal treatment was required). Cosmetic assessment

The patient had the following concerns: • Different coloured crowns • Teeth thinning down • Wanted whiter teeth • Unhappy with lower teeth (tiny, uneven sizes, poor colour) • LL5 darker, possibly mobile. He had never tried whitening in the past and had never had any orthodontic work. Teeth were not sensitive. The lips were classed as having a normal fullness on the upper one and a fuller lower lip and not being symmetrical on smiling fully. The patient also showed 10 upper teeth on smiling fully. Improved fullness was required for UR3, UR4, UR5, UL3, UL4, and UL5. The amount of upper incisor showing at rest was -1mm. Because the patient was aged 39, it was decided to

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incisors) and 5M2 (upper canines). The patient desired a shade of 1M1. Analysis of function, and occlusion and treatment planning

Figure 2: Preoperative silicone impression

increase the incisal edge length of the central incisors by about 2.5-3mm. The lower incisors being worn down also needed to be increased by about 1.75mm. The CEJ to CEJ measurement was 10mm and the distance of the upper vestibule to the upper incisal edge was 22mm. Table 1 indicates the dimensions of the upper central incisors. On saying ‘F’ and ‘V’ sounds, the edges of the upper central incisors fell onto the vermillion border of the lower lip. On saying the ‘E’ sound, less than half of the upper incisor was showing. On saying the ‘J’ sound, a few millimetres of space were evident between the mesiobuccal cusp of the first molar and the opposing tooth (this is an important observation – space in the molar region [eg, 2-3mm+] on saying ‘J’ indicates to the clinician that the vertical dimension can be opened up successfully). The midline was mid facial and slightly canted to the left side. The labial inclination of the incisor teeth was 90o to the respective occlusal plane. The preoperative shade of the teeth (using the Vita 3D Master shade guide) was 5M1 (upper

To obtain an accurate pre-tooth contact CR record, it is important to first deprogramme the facial muscles by wearing a night-time custom made deprogramming device (eg, NTI appliance). This will relax the muscles and allow easy manipulation of the mandible. The CR record was then recorded using a ‘composite ball technique’, and Luxabite and O-Bite materials. Upon analysis of the articulated study casts and the clinical photographs, it was decided that a reorganised approach would be the most satisfactory way of treating this case (ie, the need to alter the vertical the case using CR rather than centric occlusion [CO]). This was indicated because we needed to lengthen the upper teeth by 2.5mm for aesthetic reasons (ie, -1mm showed at rest before treatment and the aim was to show 1.5mm in the final restored case). The lower anterior teeth also had signs of moderate wear, and many teeth had older, failing restorations. Therefore, the patient would benefit by having almost the entire mouth treated. The lower left first premolar required root canal treatment. Aims and sequence of treatment

• Periodontal treatment (with the hygienist) • Diagnostic records and a mock-up (use of Luxaflow to simulate the incisal edges of the front four teeth, ensure

Figure 3: Mock-ups

Anterior, retracted

Left-hand side, retracted

Face

Right-hand side, retracted

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At rest

UR1 measurement

PA R M A R

Figure 4: Wax-ups and prep guides

Prep guide, lower

Prep index, upper

Lower wax-ups, occlusal

Lower wax-ups

Upper wax-ups, anterior

Upper wax-ups

•

the dental centre line is correct and add material to get the correct amount of buccal fullness for the premolar teeth (Figure 3) Creation of laboratory made diagnostic wax-ups for treating 19 teeth (upper 10 anterior teeth, and lower nine anterior teeth) simultaneously Use of a hard tissue laser to improve gingival outlines (ie, soft tissue recontouring and removal of bone to create the correct biologic width). Teeth treated in this manner were the front upper and lower incisors. Approximately three weeks’ time was allowed for healing to occur Preparation of 19 teeth, treatment records and the creation of the upper and lower anterior trial smiles with Luxatemp (shade B1) Review of temporary restorations for aesthetic, occlusal and phonetic reasons. A second review appointment was required to ensure modifications made to the temporaries regarding the aesthetics were acceptable

• Fitting of 19 restorations • Review of fitted restorations, occlusal equilibration, final polishing and finishing. New silicone records and bite registration for wax-ups of posterior teeth • Preparation, review and fitting of posterior restorations (seven molars and the lower left second premolar that required root canal treatment and a post/core) • Review of posterior restorations and occlusal equilibration/finishing. New impressions, facebow and CR bite for fabrication of a hard acrylic lower splint for night-time wear. Final photographs were also taken • Hygiene appointment after the restorative treatment • Annual dental examinations and four monthly hygiene maintenance visits recommended thereafter. Preparation of the teeth

During stage one, the 19 teeth were prepared using conventional techniques for porcelain restorations. Old

Figures 5A and 5B: Preparations

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Figure 6: CR bite (Luxabite)

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Figure 7A and 7B: CEJ to CEJ measurement

Figure 8A and 8B: Facebow (anterior and lateral)

Figure 9: Stick bite

Figure 10: Stump shade

fillings and any decay were removed. The teeth were restored, if necessary, using Luxacore as a composite core material. The amount of tooth preparation was controlled using depth cuts and putty indices made from the diagnostic waxups (Figure 4). A speed increasing handpiece was used to ensure smooth preparations and well-defined margins cervically (Figure 5). The molar control bites (at the correct CR position) and the preoperative O-Bite sectional bites were used to verify the bite position and therefore appropriate interocclusal clearance. Records at the preparation visit

• Upper and lower Honigum master impressions (using rigid trays and a two-stage technique) • CR records at the correct vertical dimension (verified by the CEJ-CEJ measurement) using Luxabite and O-Bite (Figures 6 and 7)

• Facebow record (Denar) (Figure 8) • Stick bite (O-Bite and a Benda brush placed horizontally parallel to the interpupillary line) and a photograph (Figure 9). Note the patient is standing with a horizontal reference plane (ie, the door behind the patient’s head). The following records were taken after the teeth were prepared: • Preparation shade (shade of prepared teeth using Ivoclar’s shade guide) recorded with digital photographs (Figure 10). Temporary restorations (the trial smile) were then made using Luxatemp (shade B1) (Figure 11). NB: Preop CEJ-CEJ (UR1 and LR1) = 15.3mm (with lower control bite in situ). This was coincident with the wax-ups. Final bites in CR on the day of the preparation showed the CEJ-CEJ measurement to be 15.66mm. Impression technique

My preferred impression technique, which works very predictably, is as follows.

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Figure 11: Temporaries

- After tray selection (rigid trays are ideal, eg Heatwave from Optident), Honigum adhesive is applied to the trays. The dental nurse will get ready two cartridges of Honigum Light material (regular set), one of the large tips will have the small, curved tip attached at the end for syringing around the teeth preparations. - The dental nurse will begin by mixing a scoop each of the Honigum Rigid base and catalyst, and place this in the tray. A piece of clingfilm is placed on top. The dentist then seats this in the mouth fully and waits till it sets. - A Coltene putty knife is used to cut excess material away (eg, posteriorly in the palate area), or to remove undercuts. 00 Ultrapak retraction cords (from Ultradent, Optident) dipped in Racestryptine solution can then be placed around the crown margins, leaving the cords there for four to five minutes. - After removal of the cords, the teeth are dried and Honigum wash material is syringed around the margins, the prepared teeth and onto the occlusal surfaces of the other posterior teeth. In the meantime, the nurse will have introduced the Honigum wash from the second delivery gun into the putty. The tray is then seated fully and left in the mouth for about five and a half minutes. I have found this technique to give superior, predictable margins. I also take digital 3D scans and a bite scan using the 3shape Trios scanner. I occasionally use Expasyl (Kerr) and the soft tissue diode laser (Biolase Epic) for retraction

techniques to achieve an accurate impression. Figure 14 shows the quality of the trimmed master models. Creating the trial smile

The requirements to create well-fitting temporary restorations are: • Accurate, articulated, aesthetic and functional wax-ups • Relined rigid putty and wash impressions of wax-ups (laboratory made using Honigum putty and Honigum light body material) • Acid etch • Gluma desensitiser (Kulzer) • Optibond FL2 (partially filled bonding resin. Note: Luxaflow can also be used for this step. • Luxatemp Fluorescence (B1 or other colour) • Luxaflow (B1 or matched colour) • Luxaglaze • Light-curing machine • Articulating paper • Burs. The steps involved using the above are: • Isolate and dry the teeth • Spot etch the centre of each prepared tooth with the acid gel for 10 seconds. Wash and dry lightly • Apply a thin layer of Gluma desensitiser for about 15 seconds. Gently dry with moisture free air • Apply a thin layer of Optibond FL2 and gently blow air.

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discs (3M) • Apply a thin layer of Luxaglaze with the supplied brush for 30 seconds and light-cure each tooth for 20-30 seconds • Apply some Vaseline on the patient’s lips; let them have a rinse and wow them with their new smile by letting them have a first look in a large mirror.

Figure 12: Laboratory models of anterior preps

The review appointment

Figure 13: T-Scan

Light-cure each tooth for 10 seconds • Load the putty index with Luxatemp • Place accurately in the mouth and hold in place for 2.5 minutes (from the start of mixing) • Remove the putty index • Remove excess Luxatemp material cervically (both buccally and palatally) using a Mitchell’s trimmer, a sickle scaler and fine diamond burs • Add Luxaflow to any voids (such as small air blows) and to any areas that require changes (eg, making teeth longer, making embrasures smaller etc) • Check and adjust the occlusion • Smooth the temporaries with fine grades of Sof-Lex

A review appointment is normally carried out a few days later. On this visit, it is important to review the appearance and to get the patient’s feedback. Minor aesthetic changes can be carried out by adding Luxaflow or making teeth shorter using Sof-Lex discs. The occlusion is again verified, and the speech is evaluated. The following records were taken: • Honigum impressions or digital scans of the approved temporaries • Occlusal verification (T-Scan and articulating paper) • An interocclusal O-Bite record (temporaries to temporaries in CR) • Full series of digital photographs • An accurate shade record (or alternatively can be done by the ceramist at the laboratory) • Accurate heights of the front six anterior teeth (up to 0.01mm accuracy using a digital calliper) • A laboratory prescription of additional comments, changes etc. The patient also signed a form to give consent to the shade selected at this stage. Approved heights of the temporaries (after two review appointments) were as per Table 2.

Figure 14: Occlusion check

Figure 15 a - e: Posterior preps, impressions and master model

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Figure 16: Final full face shot, anterior retracted, full smile, lateral view, close up

Changes to ‘approved temps’ (ie, comments to the ceramist technician) were: • Make UR1 vertical, slanting mesially • Make UL5 longer • Remove some buccal fullness UL4 • Make UR3 slightly shorter (and less bulky looking) • Make UR2 look wider (and more symmetrical to UL2) to make upper incisors look more balanced • LR3 seems bulkier at the incisal edge • UR3 looks too straight labially (buccal contour needed). Fitting of the porcelain restorations

The laboratory constructed Emax (Ivoclar) all ceramic restorations. The trial smiles were carefully removed, and the teeth were cleaned with pumice and Hibiscrub. The restorations were tried for assessment of fit and aesthetics. Teeth were isolated with rubber dam, and the upper 10 restorations were fitted with Vitique base and catalyst (low viscosity) transparent shade. This was repeated for the lower nine restorations under rubber dam isolation. The restoration margins were finished and all the excess deposits of cement were removed and the teeth checked interproximally with floss. The occlusion was checked to ensure multiple, even contacts in maximum intercuspation; canine guidance; and multiple, even contacts anteriorly in protrusive guidance. Note that there would have been spaces interocclusally in

the molar areas at this time. After the anterior restorations were fitted, CEJ-CEJ was measured at 15.66mm, identical to the preparation day, indicating a great result by the dental technician. Review appointment and equilibration

A review appointment a few days later gave the opportunity to review the newly fitted porcelain restorations. The occlusion was further equilibrated using T-Scan, which is computerised occlusion evaluation software (Figure 13). This equipment – in conjunction with certain fine quality articulating papers (Bausch) (Figure 14) – is the most sophisticated and accurate way of making occlusal changes. First, 100-micron blue articulating paper (with transculase bonding agent) is used, followed by eight-micron red foil (ink being an additional five microns). There will be a blue halo, with a red ‘bullseye’ – this is the precise spot to adjust. Any adjusted areas were polished with porcelain polishing burs (Shofu friction grip burs). Diamond polishing paste was used to create the final lustre. New silicone impressions, and an interocclusal bite registration was taken to create laboratory made wax-ups for the posterior teeth. The posterior teeth

It is now relatively straightforward to treat the posterior teeth (eight teeth) in CR. The old, faulty restorations and

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decay were removed as before. Treatment records were taken for the construction of laboratory made all porcelain restorations. Figure 15 shows the posterior preparations, impression and master model. These were then fitted with Vitique base and catalyst (low viscosity) A2.5 shade (for a more natural end result). New Honigum impressions, CR bite registration record using Luxabite and a Denar facebow record were taken to create a lab-made, lower, hard acrylic appliance for night-time wear. Final review appointment

The final review appointment was to check all the restorations, interproximal areas, further occlusal refinements using T-Scan and articulating papers. The final postoperative digital photographs were taken, as well as the hard acrylic appliance fitted (equilibrated so that there were multiple, even contacts in maximum intercuspation; canine guidance; multiple, balanced contacts on the incisors in protrusive guidance; and no non-working side contacts in excursions).

We then issued the patient with a referral pack and a card with the before and after pictures of the smile. This is an important moment in the patient’s life and the entire team celebrates the patient’s new smile! The final postoperative photographs were also taken (Figure 16). Summary

Our goal was to create a beautiful and healthy smile. This occurs when there is excellence in assessment, diagnosis, treatment planning and actually doing the dentistry. I am indebted to Mr Rob Storrar of Amdecc Dental Laboratory in Basildon, Essex who skilfully and artistically created these beautiful ceramic restorations, and to the patient in this case who was excellent throughout all the treatment stages. Reprinted with permission by CLINICAL DENTISTRY / March 2022

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ADVERTORIAL

Top tips in local anaesthesia Ian Corbett¹

Introduction Successful local anaesthesia is paramount to almost all that we do in clinical dentistry. Dental injections and dental pain are frequently cited by patients as reasons for nonattendance. If we can achieve pain-free dentistry, we also gain patient satisfaction, as well as making our work less stressful..

Measuring Local Anaesthesia success 1. Soft tissues. Anaesthesia of the soft tissues is usually rapid and taken as a good sign that the anaesthetic is working, particularly following an inferior alveolar block. It is worth explaining to patients that the sensation may not be as noticeable with maxillary injections as this is often expressed as a concern that the injection hasn’t worked. Similarly, take time to reassure patients about the loss of swallowing sensation with palatal blocks as this can be disconcerting.

2. Pulpal. Presence of soft tissue anaesthesia is no guarantee of pulpal anaesthesia. Always check that you have achieved the actual anaesthetic effect you were aiming for. 3. Experimental. When reading articles on anaesthesia, the success rates quoted often seem quite low. This is usually due to the strict criteria applied to the definition of success in such studies, often requiring absolute loss of pulpal sensation, generally measured using electronic pulp testing, over a prescribed length of time.

4. Clinical. Clinically successful anaesthesia is defined as being able to carry out the required treatment with no discomfort for the patient. This will largely be dictated by the procedure, with a simple occlusal restoration requiring little anaesthesia compared to accessing an inflamed pulp.

Ian Corbett, FDS (OS) RCSED, PhD, BDS Hons, BSc Hons Consultant Oral Surgeon and Honorary Senior Lecturer in Oral Surgery. Fellow in Oral Surgery of the Royal College of Surgeons of Edinburgh, UK

5. Electronic pulp testing. Pulpal anaesthesia can be assessed using an electronic pulp tester. A small current is applied to the crown of the tooth, ideally on the buccal surface, using a small amount of toothpaste to ensure good contact, the circuit being completed by the patient making hand contact with the tester. The current can be slowly increased until the patient responds. Absolute pulpal anaesthesia will illicit no response by the patient with the tester at its maximum setting. It should be noted that molar teeth may give a poor response without anaesthesia and that coronal restorations may make testing problematic. 6. Thermal. A simple method of determining anaesthesia is application of a thermal stimulus, and

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ADVERTORIAL

a cotton pledget cooled with a volatile gas spray is the best option for this challenge. Like electronic pulp testing, coronal restorations may enhance or reduce sensation in a non-anaesthetised tooth, depending on their conductivity. Heated materials, such as gutta percha, run the risk of damaging soft tissues.

7. Proprioception. Pressure sensation is maintained and tapping the tooth is not a useful indicator of anaesthesia. Patients frequently mistake the sensation of pressure as failure of anaesthesia. Inform the patient of what to expect, ‘I’m only numbing one tooth today, not your lip’, ‘you may feel pushing or pressure, that’s normal, we only numb pain’.

8. Reflect. Take time to consider what went well. We often spend too much time dwelling on what didn’t work to identify actions and patterns that lead to success.

Combatting Anaesthesia failure 1. Consideration.

infiltration. Combining the two routes gives pupal anaesthesia in excess of 90%. For lower anterior teeth, splitting the dose between buccal and lingual infiltrations overcomes accessory nerve supplies and increases success.

5. PDL. The periodontal ligament (PDL) injection is a misnomer. Placing the needle in the periodontal ligament space and injecting under pressure pushes anaesthetic through the canals in the socket wall and is essentially an intraosseous injection. The technique relies on pressure and resistance to injection should be felt. If anaesthetic flows out from the gingival margin, reposition the needle. The solution does not actually flow around the PDL space, and so the technique is most effective if repeated at several points around the tooth. This is more reliable than crestal infiltration but may lead to a temporary extrusion of the tooth or damage to the periodontal ligament. 6. Crestal.

Tell the patient how you want them to respond if they feel unpleasant sensations, for example ‘raise a hand’, as it is important that the patient is aware that they can halt the procedure. We are often too focused to note subtle cues that the patient is uncomfortable.

2. Don’t repeat an IANB. A correctly placed IANB of one cartridge should work. There is no benefit in increasing the volume. Only repeat if you suspect you were in the wrong place, for example noting a high or posterior foramen on a panoramic radiograph. Try and anticipate anatomic variation.

3. Wait. There is a proportion of patients who are slow responder following an IANB. Such patients may take more than 15 minutes to go numb, rather than the usual five to 10 minutes. Repeating an IANB is probably only allowing time for the first one to work. Be patient and allow time for the anaesthetic to work while you prepare for your procedure. Make a note for next time.

4. Infiltrate. The effects of an IANB and buccal infiltration are cumulative. An IANB with articaine or lidocaine is around 60-70% effective at achieving pulpal anaesthesia in healthy mandibular molar teeth. A similar success rate is seen with an articaine buccal

In the molar region, bony porosities are present in the crest of the alveolar bone. Infiltration in the interdental papilla may allow anaesthetic to enter the bone surrounding the socket. This simple technique may not always work but could be worth a try.

7. Intraosseous. This is the supplementary technique that is most effective for anaesthesia in teeth with inflamed pulps. Choose a system that you are familiar and comfortable with. Anaesthesia should be rapid and effective with small volumes.

8. Analgesia. Recent studies have suggested that the success rate in inflamed/infected pulps is increased by pre-emptive analgesia. The use of a non-steroidal anti-inflammatory (NSAID), where medical history allows, is most effective, followed by paracetamol. Opioid analgesia is least effective.

9. Antibiotics. The aim of treatment should always be elimination of the source of infection, such as a necrotic pulp or the tooth itself, which should avoid the need for antibiotics. Local anaesthetic is not contraindicated in the presence of infection, being unlikely to cause spread of infection. Failure of anaesthesia in the presence of infection is now thought to be caused by inflammatory mediators rather than change in environment such as pH.

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10. Be confident.

5. Distract, distract, distract.

Patients pick up on non-verbal cues, especially when anxious and with a heightened awareness. Be positive and act with confidence, as this reassures the patient that you are in control, which you are; you have the necessary skills and techniques to overcome failure.

Keep talking, ask questions, squeeze the lip, let older children choose the surgery music selection – use anything to distract from the injection itself.

6. Anatomy.

Thin cortical and connective small dimensions tissue provide a simple Colorized SEM bone shows Colori route for infiltration anaesthesia. Paediatric anaesthesia 1 physically attached to the Laser-Lok surface. shows 1. First impressions matter. Unfortunately, the first experience of a dentist for some 7. Chase anaesthesia. children will still be when they present with decay and pain If more than one tooth or buccal and lingual/palatal .You have a unique opportunity to influence the future dental anaesthesia is needed, give the first infiltration in the sulcus anxiety of these patients at this stage. and the next towards the periphery of the anaesthetised area Good technique and anaesthesia can produce a positive and continue this until all the necessary tissues are covered. experience that can be reinforced at subsequent visits. A single negative experience is very difficult to reverse. 8. Articaine. Yes, you can use articaine for infiltrations in children. There is published evidence of articaine efficacy and safety in 2. Think about dose. children. As with adults, use lidocaine for blocks. Product Remember, little people, little dose. Anaesthesia should be information leaflets suggest that articaine should not be used calculated on weight – most parents will have an idea of in those under four years old. The high protein binding and their child’s weight. rapid serum esterase breakdown give articaine as good, if Be aware of how much anaesthetic you have given, not a better, safety profile as lidocaine in children. especially when working in more than one quadrant, as the maximum dose may be quickly reached. 9. Aftercare considerations. 3. Take time to talk with the child. Prolonged soft tissue anaesthesia can be a problem. SelfLower your chair, talk to the child – not the parent – and find inflicted post-anaesthetic trauma is one of the main reported an interest or topic that engages. Also, beware of parentlocal anaesthetic complications in children. Explain how their projected anxiety. lips may feel strange in age-appropriate language. Avoid Use positive, non-jargon language, avoiding words such saying: ‘Be careful you don’t bite your lip’ – no one can then as needle, painful and hurting. Neurolinguistic programming avoid the temptation of trying it! A sugar-free ice pop can be is an amazing tool and worth finding out more about. a useful distraction postanaesthetic; the ice giving a similar numbing sensation to anaesthetic. 4. Get topical. Use topical anaesthetic, which is very effective in combination Supported by Septodont with1.infiltration anaesthesia,Evidence and, although only providingTissue With a research interest and international in theML fieldNevins, M Ca Human Histologic of a Connective Attachment to a Dental Implant.recognition M Nevins, surface anaesthesia, can have a useful placebo or distractor of dental anaesthesia, having published extensively, lectured Dentistry. Vol. 28, No. 2, 2008. 2. Histologic evidence of a connective tissue attachment to laser microgrooved ab effect when used before a block. internationally, and awarded a European Federation for the Guze, DMD, Papply Schupbach, PhD, MLbud, Nevins, DMD, MMSc. Accepted for publication: No. 3, 2010. 3. Dry the mucosa, on a cotton roll or and leave Advancement of Anaesthesia in Dentistry IJPRD, prize, MrVol Ian30, Corbett A proof-of-principle canine instudy. Nevins, ML Nevins, L Gobbato, HJ Lee it forLaser-Lok® a minimum ofmplant/abutment one minute. Wipe offsystem: prior to injection. shares his thoughts on all M things anaesthesia – from solutions

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Teeth whitening explained, plus top tips to maintain a white smile Sam Koh

Introduction

Tooth whitening. A procedure performed by so many dental professionals, it is one of the most commonly-encountered topics when patients come to see me. It is generally one of the first things they mention when I ask them what they want to improve about their smile. However, for so long post-graduation, I wasn’t completely sure of how tooth whitening worked, and what information to provide to patients. With the explosion of products and information sources, the space appears to be getting very confusing and cluttered, to both patients and professionals. I thought we would further explore this area of dentistry and highlight some really important information and tips you can pass on to your patients the next time they ask you. What forms tooth colour, and why do our teeth get more yellow over time?

Dr Sam Koh is a general dentist in private practice, with special interests in Cosmetic Dentistry and Orthodontics. Dr Koh has been awarded with prestigious fellowships from the International Academy of DentoFacial Esthetics in New York, the Pierre Fauchard Academy in London, as well as a fellowship in Orthodontics. He is the co-founder of the Young Dentist Hub, a mentor for DentalX, and a speaker/Key Opinion Leader for several dental companies. Dr Koh is a founding member of the Colgate Advocates for Oral Health Editorial Community.

Teeth are not naturally white in colour. They are obviously formed with different layers – Enamel, dentine and pulpal tissue. Generally speaking, the outer enamel modulates the value, or whiteness, of the overall tooth structure, whereas the dentine gives us the majority of the hue and chroma of the tooth (the colour and intensity of that colour respectively). Hence, one of the factors we must consider in order to keep teeth white with age is to try and maintain a healthy enamel surface and prevent tooth wear, whether it be mechanical wear (for instance, from the foods we eat, over-brushing teeth or parafunction), or from acidic wear from the foods and drinks we ingest. As the outer enamel layer wears down, the more the yellow colour of the dentine will show through. As teeth start to wear or decay, the smooth enamel surface also becomes increasingly rougher, allowing more stain to get trapped on and within the tooth. How does tooth whitening actually work?

Stains are formed by chromogens, which are chemical compounds capable of producing pigments on tooth structures, either extrinsically or intrinsically. Tooth whitening products therefore work by either removing the external surface stains, bleaching the internal tooth stains, or both. External stains are mostly attributed to environmental stains caused by things like smoking, food and beverages. Removing external surface stains is relatively easy, and involves mechanical removal of the surface stain and plaque using abrasive ingredients such as silica, found in tooth and polishing pastes.

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Internal stains require something to penetrate the tooth surface to whiten the large organic chromogens within the tooth structure. This is done using either hydrogen peroxide, or carbamide peroxide (which breaks down into hydrogen peroxide). The oxidation of hydrogen peroxide reacts with the large chromogens to break down their bonds, thus forming a lighter-coloured compound1. What are the best ways to maintain white teeth?

Tooth discolouration is multifactorial. Prevention is always best! The best ways to maintain healthy white teeth are to obviously identify the causes of tooth discolouration as mentioned above and then try to prevent or minimise their effects on our teeth: Plaque, calculus, and dental decay You can help to maintain your white teeth by brushing with a fluoride-containing toothpaste, flossing, and rinsing daily to mechanically remove the surface plaque accumulation, as well as protect and harden the surface enamel from decay, acids and wear. You also want to avoid foods that are high in sugar or acid, which can either create an environment for the bacteria that cause dental decay, or cause acid wear of the enamel. Most whitening toothpastes and mouth rinses may be able to remove some of the extrinsic stains on your teeth but only peroxide-based teeth whitening agents can remove the stubborn extrinsic stains and the intrinsic stains that cause your teeth to look discoloured. Colgate Optic White is a great product which contains hydrogen peroxide, unlike a lot of whitening toothpastes, so may be able to remove both extrinsic and intrinsic stains at the same time. Food & drink You may also want to tell your patients to avoid certain foods and drinks that are tannin-rich, which include: • Tea and coffee • Red wine • Soft drinks and cordials • Fruits and vegetables that have strong colouration such as beetroots and berries • Sauces (soy, tomato, curries) I like to use the analogy of washing a white tee-shirt when discussing tooth whitening and discolouration. Brushing and flossing are like putting your white clothes through the wash regularly to keep them white. However, if you’re not careful and keep eating stain-causing foods, then your nice white clothes will eventually stain and you will then need to potentially bleach them. If you’re too rough with your clothes, then eventually they’ll wear thin and you’ll start to see the underneath as they discolour. If you are going to eat foods that stain your teeth, then it’s always a great idea to quickly

Colgate Optic White

rinse or drink plain water as quickly as possible to limit the interaction with your teeth, similar to when foods stain your white tee shirt! Tooth whitening tips

Here are some tips to help your patients get the best out of peroxide-containing tooth whitening products: 1. Always use a professionally-recommended product from a reputable brand, not simply one endorsed by a “celebrity” on social media. 2. If using a take-home kit be sure your patient knows to use custom-made trays, and make sure they use the gel for the indicated length of time. 3. Remove surface plaque by brushing teeth with plain water, and then pat the teeth dry before application of the whitening product, which will better allow the whitening product to contact and penetrate into teeth. 4. For the period whilst whitening teeth as well as a few days after, avoid foods and/or drinks that can stain teeth, as they will undo all the hard work that the whitening has accomplished by allowing the stains back onto/into teeth. 5. Once teeth are white, maintain a healthy oral regime to minimise plaque accumulation and acid wear. A great product I always recommend is Colgate Optic White, which will both mechanically remove the extrinsic stains/plaque as well as intrinsic stains with hydrogen peroxide in the formula, as well as keep your teeth healthy and acid-resistant with its fluoride-containing formulation. References

1. Carey, C. (2014). Tooth Whitening: What We Now Know. J Evid Based Dent Pract. 14 Supp, 70-76. https://www.sciencedirect.com/science/article/abs/pii/ S1532338214000499?via%3Dihub

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Mouth cancer: Raising awareness of the other big ‘C’ Ciro Gilvetti1and Andrew Osafo2 Intrtoduction

The past 19 months have been extremely challenging due to the COVID-19 pandemic. In spite of this, it is important that we do not forget about the other ‘big C’ – cancer. Mouth cancer is a serious and debilitating disease that can devastate lives and prematurely end them. As dental professionals, we are in a prime position to raise awareness of mouth cancer and educate the public about this devastating condition. Are we doing this? This article will review the signs and symptoms of mouth cancer, discuss how to perform a mouth, head and neck cancer examination and highlight some ways to raise awareness of mouth cancer. Signs and symptoms of mouth cancer

Dr Ciro Gilvetti DDS MFDS MClinDent OS AFHEA DipOral Medicine SAS Grade Oral Surgeon, Private Practice, London, UK

Dr Andrew Osafo BDS (Lond), Dip Sedation FIADFE Dental adviser for the Care Quality Commission and Mouth Cancer Foundation ambassador. Private Practice, Maidenhead, UK

The signs and symptoms of mouth cancer include: • Persistent pain in the mouth • White or red patches in the mouth • A sore or ulcer in the mouth that does not heal within three weeks • Lumps and swellings in the mouth, head or neck • Difficulty in chewing or moving the tongue or jaw • Chronic hoarseness or sore throat that persists more than six weeks • Unexplained tooth mobility. Almost all mouth cancers are preceded by visual changes of the oral mucosa (Mignona et al, 2002). Those changes are often accompanied by changes of the texture of the oral mucosa. Early detection of mouth cancer results in a 90% survival rate compared to 50% in late detection of mouth cancer. According to the Oral Health Foundation’s State of Mouth Cancer UK Report 2020/2021: ‘Awareness of the major signs and symptoms for mouth cancer are as low as 23%’. Mouth, head and neck cancer examination

The Mouth Cancer Foundation recommends dental professionals carry out a mouth, head and neck screening on every patient over the age of 16 at least once a year. The authors describe a thorough systematic mouth, head and neck examination. The examination requires: • A pair of gloves • Good lighting • Gauze. The screening is divided into two components: extraoral and intraoral.

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Figures 8-10: Lip examination

Figures 11 and 12: Buccal mucosa, retromolar area and upper and lower vestibule

Figures 1-7: head and neck examination

Extraoral examination

The head and neck are visually inspected for any signs of asymmetry, scars or lumps or skin abnormalities. It is important to look, listen and feel every area that is being examined. The neck examination can be conducted one side at the time or both sides contemporary. A gentle pressure is applied by two finger tips to identify

any asymmetry or indurated lump. It is generally started at the level of the submental nodes, moving to the submandibular then upper middle and lower cervical area. Supra clavicular, posterior cervical and the parotid glands are also inspected and palpated. Those areas are also referred as levels I to VI (Figures 1-7).

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GILVET TI / OSAFO

Figures 13-18: Tongue examination – dorsum, lateral borders, ventral, tip of tongue

Intraoral examination

All dentures should be removed before the examination. The examination of the oral cavity can be conducted with the use of mirrors or clinician’s fingers as retractors. Fingers allow the clinician not only to visualise the oral mucosa but to also feel at the same time if there are any areas of induration within the soft tissue or changes of texture of the mucosa. The lower lip is pulled downward and the upper lip upwards and manipulated with the thumb and index finger (Figures 8, 9 and 10). The right and left buccal mucosa are pulled away, one side at a time, to allow the inspection of the retromolar area and the upper and lower vestibule (Figures 11 and 12). The tongue is thoroughly inspected, as it is the most common area of mouth cancer presentation. The use of a white gauze is extremely helpful as it allows clinicians to stretch the tongue to both sides to inspect lateral borders and ventral area of the tongue (Figures 13-17). The floor of the mouth is another area of the oral cavity at high risk of cancer presentation. The index finger can be used to lift the side of the tongue and explore the mucolingual fold and floor of the mouth. The bimanual palpation of the floor of the mouth can be done using one or two fingers of each hand trying to gently compress between them the floor of the mouth and the neck to look for lumps and fixed lesions. Gingival tissues are generally inspected visually during the

manipulation of the lips and inspection of the buccal mucosa. The patient is then asked to lift the tip of the tongue to allow visual inspection of the ventral area of the tongue and the roof of the mouth (Figure 18). With a gentle and firm pressure of one finger to the dorsum of the tongue, the patient is asked to say the vocal ‘ahhh’, the posterior wall of the oropharynx and the tonsillar area can be exposed for inspection (Figure 19). The roof of the mouth is inspected directly by asking the patient to lift the chin up (Figure 20). Dental mirrors can be used to inspect areas of the oral cavity that are difficult to be examined directly like the lingual side of the lower jaw and the maxillary tuberosity. A thorough systematic mouth, head and neck examination can be completed in less than five minutes. The Mouth Cancer Foundation and Oral Health Foundation have videos that shows a mouth, head and neck examination taking place. We encourage you to watch these videos. It is also vital that we inform our patients of the risk factors of mouth cancer, which include: • Tobacco use • Heavy alcohol use • Excessive sun exposure to lips • Human papillomavirus • History of cancer • Weakened immune system.

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Figure 19: Oropharynx and the tonsillar area

Figure 20: Roof of the mouth

Figure 21: Ulceration of tongue (left side) with raised and rolled borders

Suspicious areas

Conclusion

If any unusual findings are discovered during the examination, a review appointment should be made for two weeks after the initial examination. The size, shape, colour, texture and the position of the suspicious areas should be recorded. It is also a good idea to take clinical photographs of the area of concern. The oral mucosa generally heals itself in two weeks, if the suspicious areas are still present at the review appointment, the patient should be referred for further investigation. Highly suspicious lesions (Figure 21) should be referred urgently under the two weeks wait referral pathway.

Our goal should be to detect mouth cancers before our patients present with symptoms. Early detection and diagnosis of mouth cancer dramatically improves survival rates and also makes treatment and rehabilitation easier. Systematic and regular screenings save lives.

Self-examination

Mouth cancer self-examination is recommended by a number of organisations. The Mouth Cancer Foundation launched Bite Back at Mouth Cancer, which is a head and neck cancer check that can be carried out by anyone, at any time. The self-examination should be carried out by everyone over the age of 16 years, ideally once a month. Dental professionals should encourage patients to visit www.mouthcancerfoundation. org/self-examination for a pictorial step-by-step guide and further details.