International Dentistry Australasian Edition - Vol.13, No. 1 - 2018

VOL. 13 NO. 1 IN THIS ISSUE

Nika Vafaei and Carlo Ferretti Intraosseous cavernous haemangioma of the nasal bone: A case report and literature review Maciej Zarow Contraindicated internal bleaching – what to do?

Kamal Suri Managing the failing dentition JuliĂĄn Conejo CAD/CAM implant prosthetic: Implantsupported crown restoration made of hybrid ceramics Manal Farea, Adam Husein and Cornelis H Pameijer Furcation perforation: current approaches and future perspectives Yassine Harichane The mock-up: your everyday tool Richard Field Introduction to clinical digital photography

4

Contents Volume 13 No. 1

4

Clinical

12

Clinical

Intraosseous cavernous haemangioma of the nasal bone: A case report and literature review Nika Vafaei and Carlo Ferretti

12

Contraindicated internal bleaching – what to do?

Maciej Zarow

18 28

Clinical Managing the failing dentition Kamal Suri

44

Case Report CAD/CAM implant prosthetic: Implant-supported crown restoration made of hybrid ceramics Julián Conejo

30

Clinical

44

Clinical

Furcation perforation: current approaches and future perspectives Manal Farea, Adam Husein and Cornelis H Pameijer

The mock-up: your everyday tool Yassine Harichane

52

Clinical Introduction to clinical digital photography Richard Field

58 Products

2 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 13, NO. 1

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Adelaide Dental School Community Outreach Dental Program celebrates 1000 patients!

The Community Outreach Dental Program provides dental and other health services for people who have suffered homelessness, or have difficulty accessing conventional care.

Driven by the Adelaide Dental School, the Community Outreach Dental Program attends to hundreds of patients and provides their dental and oral health students with additional clinical hours.

The program’s dental clinic was launched in September 2011, and operates weekdays within the Light Square Common Ground complex in Adelaide’s West End, which also provides accommodation and a range of other services for the homeless community.

Many University of Adelaide staff, students, private dentists and allied health professionals volunteer their time to provide this valuable service.

The last 7 years have been very successful not only providing students with necessary clinical hours but providing much needed clinical treatment to some of Adelaide’s most vulnerable people. In November 2017 they saw their 1000th patient!

The program has become an important part of the undergraduate curriculum and provides many opportunities for their students enabling them to understand the often challenging needs of the people who attend the Common Ground Clinic and importantly, help make a difference to these people’s lives by improving oral health. Through their involvement in the program, students also better understand the benefits of inter-disciplinary care and communication with a wide range of community support groups.

In the last twelve months alone, almost 200 sessions of clinical care were provided by Bachelor of Dental Surgery students and Bachelor of Oral Health students. A comprehensive range of treatment is provided by students including preventative and educational services through to restorative and prosthodontic treatment and oral surgery, supervised by volunteer dentists Drs John Reed, Greg Cocks, Jane Boroky, Stan Choimes, Susan Ravida, Ian Ridley and Keng Yeoh- who share their experience and areas of special care.

They are extremely fortunate to have had Pearl Dental provide pro bono denture fabrication and Allan Joslin a prosthetist who assists with some of the extra work. Pearl Dental laboratories have also hosted their BDS students one morning a week to give them insight into the services a laboratory provides. TAFE technician and prosthodontic students have assisted with provision of mouth guards. Various private dental clinics and organisations have generously donated stock as do Henry Schein Halas through the Henry Schein Cares Foundation on a regular basis.

In addition to working at the Common Ground Clinic, students participate in oral health screening sessions at the Red Cross, Hutt St Centre and West Care, Streetlink Youth Services, St Vincent de Paul - Migrant support services, Salvation Army Saturday night with Australian Dental Health Foundation. The sessions at St Vinnies and the Salvation Army were voluntary experiences for and out of usual clinic sessions.

Future Challenges and needs Whilst they have been very fortunate to have 7 core volunteer dentists who supervise and provide students with their wisdom and experience, they need to ensure that we can continue to support the people who need the service and therefore would welcome new volunteers in the Adelaide area.

The Henry Schein Cares Foundation will continue to support this worthy cause and we are proud to partner with Common Ground (now Housing Choices SA). The growth of the program and increasing need for treatment mean we need to ask the wider dental community for assistance to ensure that no one goes untreated. Housing Choices SA plan on taking on at least another 900 tenants, so the need for continued support for the students is crucial.

Would you like to volunteer or donate? For any further information about the clinical program please contact Margie Steffens (margie.steffens@adelaide.edu.au or +61 467 812 966). If you would like more information on the program and how people become involved https://health.adelaide.edu.au/dentistry/community/ community-outreach.

4 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 13, NO. 1

Vol. 13 No. 1 ISSN 2071-7962 PUBLISHING EDITOR Ursula Jenkins

EDITOR-IN-CHIEF Prof Dr Marco Ferrari

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

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

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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

CLINICAL

Intraosseous cavernous haemangioma of the nasal bone: A case report and literature review Nika Vafaei1 and Carlo Ferretti2

Abstract Intraosseous haemangioma is very rare, accounting for less than 1% of all osseous tumours, and it is rarer still in the nasal bone. To the best of our knowledge only 33 cases have been reported in the literature to date. Consequently it is a differential diagnosis that is often overlooked. Clinicians should be familiar with the clinical features and radiologic appearance of this tumour in order to include the diagnosis in a differential. Intraosseous haemangioma requires excision, and if necessary reconstruction depending on the extent of osseous destruction. We present a review of the literature and add a case report of the presentation, treatment and reconstruction of an intraosseous cavernous haemangioma occurring in the nasal bridge.

Key words: Haemangioma; intraosseous; nasal bone.

Introduction

Nika Vafaei BDS, MDent(MFOS), FCMFOS(SA)a

1

Carlo Ferretti BDS, MDent (MFOS), FCD(SA)MFOSa

2

a

Private Practice, Johannesburg, South Africa Corresponding author: Carlo Ferretti P.O Box 7547, Gardenview, 2047 South Africa Email: ferretti@mweb.co.za Tel: +27 11 615 9595

Haemangioma is a benign vascular tumour, believed to be a hamartoma, mesenchymal in origin.1,2 There are 2 types of haemangiomas, capillary and cavernous, the capillary haemangioma being more common. Haemangioma of bone is uncommon, and is exceedingly rare in the nasal cavity, and when it occurs, it is predominantly in the septum.2 The first case report of a haemangioma occurring in the nasal bone was described by Neivert and Bilchik in 1936.3 A review published in 1976 reported 17 cases and a subsequent review in 1992 added a further 9 cases.2,4 Since then we have found a further 7 cases reported in the literature (Table 1).2-11 Cavernous haemangioma that occurs in the nasal bone presents as a slow growing bony hard mass covered by mucosa within the cavity. The adjacent tissues are usually uninvolved.7 Cavernous haemangioma of the nasal cavity can present with a history of recurrent epistaxis and nasal obstruction, however this is uncommon with those occurring in the nasal bone. The radiographic appearance of nasal bone tumours is often “sun-burst” due to thickened linear trabeculations which radiate from a central radiolucent core.4 The computed tomography (CT) appearance of these lesions is variable with some appearing as a heterogenous soft tissue mass, whilst others as a solid homogenous mass filling the nasal cavity.

For soft tissue haemangiomas various treatments have been proposed, including radiotherapy, embolization, cryotherapy, corticosteroid treatment, sclerosing solutions and resection using YAG laser.12 For intraosseous haemangioma, surgical resection of the tumour with a cuff of surrounding uninvolved tissue has been found to be most effective. The role of preoperative angiography and embolization is controversial in intraosseous haemangiomas, as often a definite blood supply cannot be identified, and the benefits of embolization are minimal when compared with the potential risk.13 We present a case of intraosseous cavernous haemangioma occurring in the nasal

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CLINICAL

Table 1. Summary of reported cases (after McAllister 1992) Case#

Author

Age

Sex

27

Karacoaglan, N et al 1997

19

F

28

Adanali 2001

62

F

29

Hazra, T.K. 2001

16

F

30

Layoun, W 2003

31

Kargi, E 2005

60

M

Yes

1 yr

32

Stankovic, M 2008

32

F

No

1 yr

33

Cintra, BB 2008

49

M

No

14 mnths

Trauma

Follow Up

No

1 yr 1 yr

No

13 yrs

Yes

bone treated by resection and reconstructed with a diced cartilage filled fascial pouch inserted between 2 struts of rib graft.

Case Report A 67 year old female presented with a slow growing swelling on the bridge of the nose (Figure 1a & b). She first noted it 5 years ago, and she could not recall an injury which may have been causally related. She had the lesion debulked 4 years ago. Recently the swelling started increasing in size resulting in significant deformity over the nasal bridge; however no nasal obstruction or epistaxis was reported. Examination revealed a diffuse swelling on the bridge of the nose measuring approximately 2cm x 1.5cm.

The overlying skin was normal in colour and texture, with a vertical scar down the bridge of the nose from the previous

1a

Duration

surgery. The swelling was non-tender, bony hard and well circumscribed. No neurological fall out was noted.

Computed tomography revealed a heterogeneous mass approximately 3cm in diameter with osseous expansion of the nasal bridge, resulting in significant thinning of the outer cortex. The lesion appeared as a mass with trabecular coarsening that radiated in a spoke-wheel type pattern (Figure 2a & b).

Differential diagnosis included osteoma and fibrous dysplasia, although the site and age of the patient was uncommon for both lesions. A more common swelling on the midline dorsum of the nose is a dermoid cyst, however these lesions occur more frequently in a younger age group and present with a tell-tale ‘pit’ in the overlying skin.2 Other differentials included parosteal osteosarcoma based on the radiographic “sun-burst” appearance; however the indolent

1b Figure 1a & b: Pre-operative photo showing frontal and superior view of diffuse swelling of nasal bridge.

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2a

Figure 2a: Coronal cut of CT scan showing expansile osseous lesions with a 'sunburst' appearance, in the nasal bone.

2b

Figure 2b: 3D reformatted CT of lesion showing surface of nasal bridge expanded and pitted by expansile lesion.

behaviour of an intraosseous haemangioma is inconsistent with such a diagnosis, as was the patient’s age. In addition, the intact periosteum is an important feature in distinguishing this benign neoplasm from an osteosarcoma in which there is a breach in the periosteum, and likely invasion of the surrounding soft tissues. A definitive diagnosis of intrabony haemangioma required histological examination of an incisional biopsy.

An incisional bone biopsy was performed under general anaesthesia via a midline incision over the bridge of the nose.

Brisk bleeding was encountered and controlled by local methods. The biopsy confirmed the diagnosis of an intraosseous cavernous haemangioma. Definitive treatment was en bloc resection of the tumour with concurrent Figure 3: Lesion exposed via bicoronal flap.

4a

4b

Figure 4a: Extant nasal bridge with cartilage struts in situ. Diced cartilage fascial pouch (arrow) to be secured between cartilage struts. Figure 4b: Cartilage filled fascial pouch secured to adjacent remaining nasal bone.

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5a

5b

Figure 5a & b: Frontal and superior view 18 months post-operative.

reconstruction. The lesion was exposed via a bicoronal flap and, as planned, resected with a small margin of uninvolved bone (Figure 3). Resection was not accompanied by vigorous bleeding. The right 6th costal cartilage was harvested with a portion of pectoralis fascia. Two struts were cut from the costal cartilage and the remaining cartilage was morselized.

The fascia was wrapped around a 5cc syringe and the free end sutured to form a pouch into which the morselized cartilage was inserted (Figure 4a). The 2 struts were secured to the extant nasal bone bilaterally, and the cartilage filled fascial pouch was placed between the 2 struts to form the bridge of the nose and secured with sutures (Figure 4b).

Histological examination of the resected mass showed numerous large cavernous vascular channels interspersed between the bone trabeculae. There was extensive destruction of the bone. The vascular channels were lined by flattened endothelial cells and were filled with red blood cells.

The patient has been followed up for 18 months and postoperative course has been uneventful. The nasal bridge was successfully reconstituted and maintained (Figure 5a & b).

Discussion Haemangioma of the nasal bone is very rare. To the best our knowledge only 33 cases have been reported in the literature to date. Although many patients have a history of local trauma, the causal relationship remains doubtful. Despite being uncommon, the clinical and radiographic features of nasal bone haemangioma are fairly characteristic. Clinically these tumours appear as a slowly enlarging painless mass at the base of the nasion. These tumours may result in local discomfort, but airway obstruction or epistaxis are usually absent.2,4 From the previous case reports and reviews, it occurs more frequently in females with a female to male ratio of 2:1, and the mean age at diagnosis of 39 ±12 years

(range: 16-62). These bony tumours are distinct from softtissue haemangioma, as the intranasal mucosa is generally intact, as is the nasal passage and overlying skin. The radiographic features are characteristic as a translucent area within the nasal bone in which spicules of bone radiate outwardly from the central area.,2,4 CT scan aids in determining delineation, remodelling, and destruction of bone trabeculae. Although the “sun-burst” appearance may give the impression of a more aggressive neoplasm, the clinical history would often preclude such a diagnosis. Definitive diagnosis can be made histologically based on the incisional biopsy.

Choice of the surgical approach for tumour resection depends on the location and size of the tumour.

Reconstruction is required if the size of the post resection defect will leave an unacceptable cosmetic deficit. The reconstruction of the bridge of the nose may be accomplished by several means. The technique using diced cartilage graft for nasal rhinoplasty and reconstruction has been described and used successfully since the 1960’s.14 The advantages of using this method of reconstruction is its ease of preparation, lack of rejection as it is autogenous, and easier graft manipulation to appropriate shape. Technical problems with this method include overcorrection, visibility of graft, and junctional step-offs.14 Given the rarity of these lesions, as well as the limited differential diagnoses of a slow-growing bony mass in the nasal bones, clinicians should bear in mind the possible diagnosis of an intraosseous haemangioma. Contrast CT would assist to determine the nature of the lesion in order to identity high or low flow lesions.

In conclusion, intraosseous haemangioma should be considered as a differential diagnosis when a slow growing, bony mass is noted in the nasal bone. Treatment of choice is

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surgical resection, and reconstruction with autologous grafting for nasal defects, yields good functional and aesthetic results.

Acknowledgments We would like to acknowledge Dr. Christopher Ladas who performed the nasal reconstruction.

References 1. Willis RA. The Pathology of Tumours. Butterworths, London 1976. pp 718-20.

2. Bridger MWM. Haemangioma of the nasal bone. J Laryngol Otol 1976; 90:191-200.

3. Nievert H, Bitchick EB. Primary Haemangioma of the nasal bone. Arch Otolaryngol 1936; 24:495-501.

4. McAllister RM, Rutty GN, Hancock K, Sanders R. Cavernous haemangioma of the nasal bones. J Laryngol Otol 1992; 106:264-7.

5. Hazra TK, Basu SK, Chowdhury S, Deb P. Haemangioma of the nasal bone. Indian J Otolaryngol Head Neck Surg 2001; 53(3):239-42.

6. Karacaoğlan N, Akbaş H, Eroglu L, Turan N, Demir A, Yavuz I. Haemangioma of the nasal bones. Ann Plast Surg 1997; 39(2):218-9.

7. Stankovic M, Mihailovic D, Radovanovic Z, et al.

Cavernous haemangioma of the nasal bone: reconstruction with cartilage graft. Kulak Burun Bogaz Ihtis Derg 2008; 18(6):381-383.

8. Cintra BB, Santos RMNC, Duz GL, Ferramola RB, Auras M. Haemangioma of the nasal bone: case report. Rev Bras Cir Plast 2008; 23(4): 343-346.

9. Kargi E, Babuccu O, Hoşnuter M, Babuccu B. Haemangioma of the nasal bone: a case report. Kulak Burun Bogaz Ihtis Derg 2005; 14(1-2):32-4.

10. Layoun W, Testelin S, Devauchelle B. Cavernous haemangioma of nasal bone. Rev Stomatol Chir Maxillofac 2003; 104(4):235-8.

11. Adanali G, Ayhan M, Görgü M, Erdogan B. Nasal bone destruction by a cavernous haemangioma in an elderly patient. Ann Plast Surg 2001; 47(2):216-7.

12. Webb CJ, Porter G, Spencer MG, Sissons GR. Cavernous haemangioma of the nasal bones: an alternative management option. J Laryngol Otol 2000; 114:287-9.

13. Moore SL, Chun JK, Mitre SA, et al. Intraosseous haemangioma of the zygoma: CT and MR findings. AJNR 2001; 22:1383.

14. Daniel, RK. Diced Cartilage Grafts in Rhinoplasty Surgery: Current Techniques and Applications. Plast Reconstr Surg 2008; 122(6): 1883-91.

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CLINICAL

Contraindicated internal bleaching – what to do?

Maciej Zarow1

Before the reconstruction of a root canal-treated anterior tooth, the walking bleach technique should always be considered.

In the past, a lot of root canal-treated teeth were routinely reconstructed with metal posts and crowns. Today, more conservative strategies such as internal bleaching, fibre posts, composite restorations or minimally invasive porcelain veneers represent alternative treatment options (Zarow et al, 2009).

In the case of porcelain veneers or crowns used in order to mask the dark colour of the tooth, the dental laboratory requires more tooth reduction, which significantly reduces the mechanical and adhesive properties of restorations. For longevity of porcelain veneers, the presence of enamel is crucial. The less enamel used, the lower the adhesion value of the porcelain veneer is to the tooth structure, making the final veneer restoration less predictable. Therefore, instead of reducing the tooth structure, the aim should be to try to change the colour as much as possible by bleaching internally (Meyenberg, 2006).

If the treatment plan includes a prosthetic crown, the aim of internal bleaching is to improve the colour around the cervical area and coronal portion of the root. These details will determine the final aesthetics within the gingival area. The walking bleach technique is therefore the procedure of choice in such cases. The protocol of internal bleaching was carefully described in the literature (Plotino et al, 2008; Nutting and Poe, 1963; Zarow, 2016).

The most popular and safest material for this purpose is still that which has been used routinely in clinical practice for several decades. This is a paste, prepared ad hoc, composed of sodium perborate and 3% H2O2 or distilled water. (Editor’s note: EU legislation has banned the use of sodium perborate due to its foetotoxic and cytotoxic properties [Scientific Committee on Consumer Safety, 2010].)

This article presents a case report of the aesthetic treatment in a case of a severely discoloured root canal-treated tooth, where there was a contraindication for internal bleaching.

Contraindications for internal bleaching

1

Dr Maciej Zarow, Private Practice, Kraków, Poland

The most important factor in bleaching effectiveness seems to be precise removal of all restorative materials from the access cavity without additional dentine elimination.

Dentine has to be cleaned in order to facilitate diffusion of the bleaching agent through the dentinal tubules (Plotino et al, 2008; Zarow, 2016). If a fibre post was cemented in the root canal and the pulp chamber was filled with composite resin, removing the restorative material and post can compromise the amount of sound dentine. Therefore, such a case calls for careful evaluation of aesthetic benefits versus structural sacrifice.

Other contraindications for internal bleaching include (Madison and Walton, 1990; Rotstein et al, 1991; Lado et al, 1993; Buchalla and Attin, 2007; Lin et al, 1998; Zarow et al, 2013; Baba, 2013):

12 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 13, NO. 1

CLINICAL

Figure 1: The patient’s smile.

Figure 2: Upper and lower anteriors during static occlusion.

Figure 3: Palatal view of upper central incisors.

Figure 4: Lips in the rest position.

• Discolourations caused by amalgam or other metallic materials (not bleachable) • Significant dentine loss in the cervical portion (risk of fracture and leakage of bleaching agent) • Extensive restorations • Visible cracks, especially with subgingival extension (risk of bleaching agent penetrating towards periodontal ligaments) • Young patients (<19 years old).

interferences in posteriors were removed (the patient was occlusally equilibrated).

The root canal obturation performed in the past was acceptable. The treatment plan did not consider internal bleaching, as the fibre post had been cemented in the past.

The walking bleach technique would, in this case, require the removal of sound structure, thus creating structural risk.

Therefore, the aesthetic treatment without intervention into the pulp chamber was planned.

External bleaching with 6% hydrogen peroxide (Novon Technology, Optident) was carried out on the upper and lower arch (Figures 5-8). Three weeks after external bleaching, the composite restorations were replaced and two porcelain veneers were considered to be the best possible treatment option in this case.

It can be concluded that four main benefits arose from the above-mentioned treatment plan: 1. It is easier to mask severe discolouration using laboratory techniques 2. It is much more aesthetically predictable to perform two symmetrical veneers on two central incisors

Case report A 31-year-old male patient presented to our dental clinic in order to improve the aesthetics of a severely discoloured root canal-treated right central incisor (Figures 1-4). Discolouration had been present for more than 10 years, and previous treatment had included fibre post placement.

The discoloured tooth had two old composite resin class III restorations – a mesial one, and a distal one – and also a slightly worn incisal edge (Figure 3).

The patient was deprogrammed using the Kois Deprogrammer for four weeks. Minor premature occlusal

VOL. 13, NO. 1 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION 13

ZAROW

Figure 5: Upper and lower anteriors in static occlusion after bleaching therapy.

Figure 6: Anterior guidance after bleaching therapy.

Figure 8: Radiograph of tooth UR1.

3. Performing two symetrical veneers with slightly increased buccal volume we are able to reduce the amount of tooth reduction (without exposing the dentine and without compromising the long-term adhesion)

Figure 9: Digital smile design plan before wax-up.

Figure 7: Upper anteriors after bleaching therapy.

4. We could improve the symmetry of anterior guidance with the veneers, benefitting function.

A digital smile design (DSD) plan was created and sent to the laboratory so that a wax-up could be created (Figure 9).

Then the temporary resin mock-up was made, and presented to the patient in order to discuss the final outcome (Figure 10).

After the patientâ&#x20AC;&#x2122;s acceptance, two upper central incisors were prepared for porcelain veneers with the use of a silicone index in the horizontal and vertical planes (Figures 11-13). An impression was taken using polyvinyl-siloxane material (Flexitime, Heraeus Kulzer), and the dental laboratory created two feldspathic porcelain veneers.

At the next appointment, the porcelain veneers were triedin by means of glycerin gel (Figure 14). The porcelain was then etched with 10% hydrofluoric acid for 90 seconds and cleaned in an ultrasonic bath for five minutes (Magne and Belser, 2002).

Finally, silane was applied to the dried porcelain surface in several layers, and one coat of adhesive resin was

Figure 10: Mock-up procedure (on the right) made based on Digital Smile Design and wax-up.

14 INTERNATIONAL DENTISTRY â&#x20AC;&#x201C; AUSTRALASIAN EDITION VOL. 13, NO. 1

ZAROW

Figure 11: Teeth preparation with silicone guide (horizontal plane).

Figure 12: Teeth preparation with silicone guide cutat different levels.

Figure 13: Teeth preparation with silicone guide (vertical plane).

2. It is much easier and more predicable to perform two symmetrical porcelain veneers than a single, asymmetrical one 3. Although it may seem counterintuitive, performing two symmetrical additive veneers results in a more conservative approach. Simultaneous increase of buccal volume results in decreased enamel reduction.

References

Figure 14: Porcelain veneers try in (with glycerin gel).

applied followed by gentle thinning with air. After rubber dam isolation, the porcelain veneers were cemented simultaneously with the composite resin cement (D’Arcangelo et al, 2012) (Figures 15-18).

Conclusions 1. In cases where the internal bleaching technique compromises the remaining tooth structure, other options (such as porcelain or composite veneers) should be considered

Figure 15: Porcelain veneers after cementation. Dental lab: Artur Nyga.

Baba ZN (2013) Contemporary restoration of endodontically treated teeth. Quintessence, Chicago Buchalla W, Attin T (2007) External bleaching therapy with activation by heat, light or laser – a systematic review.

Dent Mater 23(5): 586-596 D’Arcangelo C, De Angelis F, Vadini M, D’Amario M (2012) Clinical evaluation on porcelain laminate veneers bonded with light-cured composite: results up to 7 years. Clin Oral Investig 16(4): 1071-1079 Lado EA, Stanley HR, Weisman MI (1983) Cervical resorption in bleached teeth. Oral Surg Oral Med Oral Pathol 55(1): 78-80 Lin LC, Pitts DL, Burgess LW Jr (1988) An investigation into the feasibility of photobleaching tetracycline-stained teeth. J

Figure 16: Porcelain veneers after cementation – profile view.

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ZAROW

Figure 17: Patient’s appearance after cementation of two porcelain veneers.

Figure 18: Upper central incisors after porcelain veneers cementation – palatal view.

Endod 14(6): 293-299 Madison S, Walton R (1990) Cervical root resorption following bleaching of endodontically treated teeth. J Endod 16(12): 570-574 Magne P, Belser U (2002) Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach.

Quintessence, Chicago Meyenberg K (2006) Nonvital Teeth and Porcelain Laminate Veneers – A Contradiction? Eur J Esthet Dent 1(3): 192-206 Nutting EB, Poe GS (1963) A new combination for bleaching teeth. J South Calif Dent Assoc 31: 289-291 Plotino G, Buono L, Grande NM, Pameijer CH, Somma F (2008) Nonvital tooth bleaching: a review of the literature and clinical procedures. J Endod 34(4): 394-407 Rotstein I, Friedman S, Mor C, Katznelson J, Sommer M, Bab I (1991) Histological characterization of bleaching-

induced external root resorption in dogs. J Endod 17(9): 436-441 Scientific Committee on Consumer Safety (2010) Opinion on sodium perborate and perboric acid Zarow M (2016) Nonvital Tooth Bleaching: A Case Discussion for the Clinical Practice. Compend Contin Educ Dent 37(4): 268-276 Zarow M, D’Acangelo C, Felippe LA, Paniz G, Paolone G (2013) Endo-Prosthodontics: Guidelines for Clinical Practice. Quintessence Warszawa Zarow M, Devoto W, Saracinelli M (2009) Reconstruction of endodontically treated posterior teeth – with or without post? Guidelines for the dental practitioner. Eur J Esthet Dent 4(4): 312-327 Reprinted with permission by Aesthetic Dentistry Today April 2017

Figure 19: Patient’s smile before (left) and after (right) treatment.

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CLINICAL

Managing the failing dentition Kamal Suri1

Increasingly, the numbers of patients walking through the doors of our practices are those whose dentition is slowly in decline.

I am presented on a daily basis with patients requiring replacement of missing teeth, restoration of worn and discoloured teeth and those whose teeth are mobile and would like to be able to function adequately.

Often patients are only aware of the localised area of failure and are focused on addressing only that area of their mouth; one or two mobile teeth, one or two spaces that need to be filled, worn and discoloured anterior teeth.

As the experts, it is our responsibility to provide the patient with a solution to their problem that will have longevity, predictability and not accelerate the deterioration of the surrounding dentition and supporting structures.

Longevity and predictability of the treatment arise not only from the restoration itself but also dealing with the cause of the breakdown and deterioration so that the restoration that has been provided for the patient does not fail in the same way as the natural tooth.

This needs to be explained to the patient at the initial consultation so that they can understand why a thorough assessment and diagnosis is required.

In my experience patients invariably agree with the rational and understand that detailed examination is necessary in order to determine the correct treatment plan for them.

This allows for the practice of comprehensive dental treatment and may involve a multidisciplinary approach when necessary.

The role of occlusion

Dr Komal Suri is director of Smile Design Dental Practice in Wendover, Bucks. She is a graduate of the Kois Centre of excellence in Seattle, USA and lectures intensively in the UK. Her main area of expertise is in complex restorative and aesthetic dentistry.

1

When assessing the mode of failure of any dentition it is advisable to try and determine the root cause of the problem and secondary factors that may be accelerating the loss the loss of teeth, bone or tooth structure.

The roles of caries and periodontal disease in the deterioration of dental health have long been documented.

Although the role of occlusion is loosely recognised by many dentists, little credence is given to it either due to lack of understanding of occlusal factors, lack of knowledge of how to address the treatment and inability to explain this to the patient.

Treatment can often be more extensive if occlusal issues are taken into account (Davies et al 2001; Svanberg et al 1995), therefore better understanding of these factors and treatment modalities is needed.

Occlusal trauma Primary occlusal trauma results from excessive occlusal forces applied to a tooth or teeth with normal supporting structure.

Secondary occlusal trauma occurs when normal/excessive occlusal forces cause trauma to a tooth or teeth with reduced periodontal support.

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Figure 1: Pre-treatment, smile view.

Figure 2: Pre-treatment, retracted view.

Figure 3: Pre-treatment, central view.

Figure 4: Pre-treatment, right side view.

Figure 5: Pre-treatment, left side view

Figure 6: Pre-treatment, upper occlusal view.

Figure 7: Pre-treatment, lower occlusal view.

Figure 8a: Left lateral excursion.

Figure 8b: Left lateral excursion.

Factors precipitating occlusal trauma: • Increased bite force • Oversized masseters • Tendency to clench – relevance to jaw type • Habitual bruxism • Primary occlusal trauma • Reduced bone support • Post perio disease • Secondary occlusal trauma • Reduced number of teeth • Shortened dental arch • Lack of posterior teeth • Instability • Premature contact – posterior/ anterior • Working and non- working side interferences • Anterior tooth position

• OB – increased / reduced • Retroclined incisors • Distalised mandible • Tooth morphology in relation to envelope of function.

In order to formulate a treatment plan, the reason for the instability/destruction needs to be discovered.

This is carried out by the evaluation of the entire functioning system to determine the modes of failure and assess the risk of future failure.

The box out ‘occlusal function checklist’ (left) describes the approach, but there are specific parameters to be evaluated, as laid out in Table 1: Establishing a cause of destruction.

In order to show how occlusion can and should incorporated into a restorative treatment plan the case presented here involves a multidisciplinary approach to correct a failing dentition that involves occlusal factors.

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Occlusal function checklist ✓ Is the occlusion acceptable or unacceptable… if unacceptable then why? ✓ Is the occlusion a contributory factor to the decline of the dentition? ✓ Does the occlusion need to be addressed as part of the restorative treatment?

Table 1: Establishing a cause of destruction.

Parameters for evaluation Temporomandibular Joint

Tooth structure and position

Periodontium

Muscles of mastication

Inter-arch tooth relationship

Joint sounds

How do the teeth look in the face?

Bone levels around the teeth (compared to the norm for the patient)

Tenderness

Assessment of OVD

Pain

Assessment of the curves of Spee/Monson

Presence of lamina dura

Hypertrophy

ICP/ RCP

Limited opening

Inclination of the teeth

Periodontal ligament space

Skeletal class1,2,3

Gum health

Cross bite

Deviation on opening and Structural integrity closing Shape of the teeth

Gingival biotype Gingival scallop

Patient case - Adele Adele’s upper dentition had been restored with a combination of crowns and bridges approximately 15 years ago. An implant had been placed in the UL6 approximately 10 years ago.

Starting two years prior to the current restoration, the upper restorations and teeth began to show signs of failure. Adele had not attended the practice as often as recommended due to the distance she lived from the practice (150 miles).

After clinical examination, the failure list was as follows: • The crown on the implant in the UL6 position became loose and porcelain fractured from the crown • The porcelain on the UR1 facial surface fractured (pontic of a three-unit bridge) • UL4 became mobile and had deep pockets • UL5 crown was mobile and had pocketing • Gingival health declined • Bleeding on probing increased • Bleeding score was increased • Pocket depth increased

• BPE scores increased • Gum recession on certain teeth increased (UL4, LL6, LR6) • Aesthetics started to decline • Lower teeth were becoming slightly crowded.

Radiographic findings • Good bone levels around most teeth and the implant UL6 • Thin lamina dura present in most areas • Vertical bone loss defects around UL4, UL5, LL6 • Widened periodontal ligaments: UR6, UR3, UR2, UL1, UL2, UL3, LL5, LL7 • Radiolucency In the tooth UL5.

Occlusal findings • Group function guidance on left excursion, finishing on the UL5 (Figures 8a and 8b) • Group function guidance on right excursion involving UR1 (Figure 9) • In right lateral excursion Ul4 and UL5 non-working side interferences – palatal cusps (Figure 10) • Anterior guidance all on the UR1 (Figures 11a and 11b) • Functional mobility (fremitus) of upper anterior teeth and

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Figure 9: Right lateral excursion.

Figure 10: Non-working side interference.

Figure 11a: Anterior guidance.

Figure 11b: Anterior guidance.

Figure 12: Markings showing heavy occlusal contacts during function on UR7 and UR6.

Figure 13a: Recession around the UL4 relating to the bone loss around the tooth.

Figure 13:

Figure 14: Before treatment.

Figure 15: After lower fixed orthodontics, lower incisor was extracted.

left premolars on biting in ICP. Diagnosis • Primary and secondary occlusal trauma • Gingivitis • Caries • Localised periodontal pocketing

Prognosis A prognosis for every individual tooth was needed. The prognosis was given with a view that the tooth was left untreated.

Table 2 details the prognosis for each tooth, with Good prognosis: Teeth with good prognosis were those with good bone support – lamina dura still visible and there was less

than 10% bone loss.

Fair prognosis: The LL6 was given a fair prognosis due to the vertical bone loss pattern on the distal side. This tooth was an untreated tooth and therefore healthy. It would be unlikely that this tooth would fail in the future; it could however lose more bone if the trauma (primary occlusal trauma) on the tooth persisted. If the trauma was removed from the tooth and no further bone loss occurred the tooth would have a good prognosis. The periodontal health could be managed.

The UR6 had a narrow area of interproximal bone and significant buccal recession. This tooth was in working and non-working side interference in lateral excursion; primary occlusal trauma. The tooth was also a major retainer for a four-unit bridge.

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Table 2: Prognosis Prognosis Good

Untreated

If treated

LR 1 2 3 4 5 6 7

LL6

LL 1 2 3 4 5 7

UR6

UR 3 2 UL 1 2 3 7 8 Fair

LL6 UR6

Presence of lamina dura

Guarded

UR7

UR7

Hopeless

UL4, UL5

(UR7)

By restoring it as a single unit and reducing the interfering contacts and sharing the lateral load the prognosis of the tooth would improve.

Hopeless prognosis: UR7 had greatly reduced bone support and was therefore subject to secondary occlusal trauma. If this continued the tooth would become more mobile, lose more bone and eventually need extraction.

Extraction of the tooth would have ongoing consequences that could contribute to destabilising the bite. The lower opposing tooth could over erupt, however presence of the UR7 should be taken into account when assessing the prognosis of the UR6. If the UR7 continues to experience more bone loss it could affect the distal bone surrounding the UR6.

The decision was made to retain the tooth for now with regular periodontal maintenance and reduction in occlusal pressure.

The patient also wears a soft night guard to reduce pressure from clenching.

The UL4 and UL5 were deemed hopeless due to the bone loss and mobility around the UL4 and the fracture, caries and heavily restored nature of UL5.

Figure 16: Removal of existing restorations.

Figure 17: Refinement of the prepared teeth. Minimal veneer preparation on UL2 and UL3.

Figure 18: Extraction of hopeless teeth.

Figure 19: Provisional Luxatemp bisacryl restorations.

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Figure 20a: Definitive restorations UR2UL3. Provisional PFM four-unit bridge UR6-UR3. Provisional Luxatemp bisacryl bridge from UL6-UL3 (palatal).

Figure 20b

Treatment plan In order to create a stable dental functioning system with predictability and longevity the causes of the current destruction needed to be removed without creating new modes of accelerated destruction.

The treatment plan was formulated as follows once the diagnosis and prognosis had been discussed with the patient.

• Soft night guard to protect against excessive occlusal forces during sleep. This to be worn during hygiene therapy to reduce inflammation, pocket depth and bleeding • Hygiene therapy • OHI • Mechanical removal of plaque and tartar • Teeth with hopeless prognosis were left untreated since they were being extracted.

• Orthodontic consultation resulting in the decision to have fixed orthodontics on the lower arch to realign the teeth, alter the inclination to a more favourable stable position, and retract the lower anterior teeth • Extraction of a lower incisor to create the tooth position and arch form desired. This had been fully discussed with the patient prior to the treatment being carried out.

• Retention of the lower tooth position • Sequential restoration of the upper arch • Extraction of the hopeless teeth • Removal of failing restorations.

• Provisional restoration placement with the desired tooth inclination, morphology, length and OVD • Implant placement in the premolar areas • Definitive restorations.

Shade and characteristics After all of the treatment that had been carried out, the final stage was the communication of aesthetics and creating a

Figure 20c

smile that the patient was happy with from an aesthetic point of view.

The dentofacial appearance of the work carried out also had to be deemed successful for the entire treatment to be a success.

The initial concerns of the patient were the appearance and function (mobile teeth and cracks).

In order to communicate the desired aesthetics, the author’s book Creating Smiles was used to communicate shape, texture, translucency, and incisal edge characteristics.

Summary Lower arch • Fixed orthodontics • Lingual retention.

Upper arch • Extraction UL4, UL5 • Implant placement UR4, UR5, UL4 all with Atlantis abutments • E.max porcelain crowns UR6– UR3 • E.max Porcelain bridge UR2 – UL1 • E.max veneers UL2, UL3 • Porcelain fused to metal bridge UL4 implant – UL6 implant • Both UR7 and UL7 unrestored.

General • Condylar position CR • No change in OVD • Provision of a soft night guard if pt clenches in times of stress

Results The result of the treatment has been: • An improvement in OHI and gum health - from 58% bleeding score to 10% • A reduction in pocket depth and BPE score • A reduction of excessive pressureon the teeth

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Figure 21a: Uncovering of implants four months after placement.

Figure 21b

Figure 22a: Restoration of Ankylos implants with Atlantis abutments and E.max crowns.

Figure 22b

Figure 22: Restoration of Ankylos implants with Atlantis abutments and E.max crowns.

Figure 23: Fully restored and rehabilitated dentition.

• • • •

Adele now has as much improvement in dental health as could be achieved. The improvement in function and aesthetics has increased her confidence both in terms of her tooth structure (not being afraid that teeth will break or fall

Adaptive mobility within normal limits Improvement of guidance patterns Increased stability of bite Improvement of aesthetics.

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out) as well as when she communicates with people.

Conclusion In approaching any dental treatment, the aim should be to improve the patientâ&#x20AC;&#x2122;s dental health. This can also extend to improvement of the physical health and mental wellbeing.

The aim of treatment should be to improve the prognosis of the teeth and related structures and reduce the overall risk of any form of dental disease.

There are certain parameters within which we need to work and there are anatomical constraints that we cannot escape.

We can do our best for the patient in ensuring that the treatment plans we offer and the subsequent treatment we deliver creates a stable, functional and aesthetic end point.

The human body continues to change and adapt, we need to try and maintain any deterioration or adaptation of

the dental functioning system within normal limits and not be the cause of its acceleration.

By adopting a comprehensive approach, treatment can be properly planned, delivered in a phased manner and executed to a high standard.

The maintenance and aftercare programme will help ensure ongoing success of the treatment delivered.

References Davies SJ, Gray RJ, Linden GJ, James JA (2001). Occlusal considerations in periodontics. Br Dent J 191(11): 597-604 Svanberg GK, King GJ, Gibbs CH (1995). Occlusal considerations in periodontology. Periodontol 2000. 9: 106-17 Reprinted with permission by Implant Dentistry Today, November 2017

CASE REPORT

CAD/CAM implant prosthetic: Implant-supported crown restoration made of hybrid ceramics Julián Conejo1

The rigid anchoring of the implant body in the jaw bone means that implant-supported restorations lack the buffer function of the elastic fiber apparatus of natural teeth.

Superstructures made of VITA ENAMIC can absorb masticatory forces due to their dentine-like elasticity, helping to take pressure off the implant and the antagonist teeth.

VITA ENAMIC IS blanks (VITA Zahnfabrik, Bad Säckingen, Germany) have an integrated interface to adhesive/titanium bases. This allows one-piece, screwed abutment crowns without a cement gap, reducing the risk of peri-implantitis. The following case report describes restorations using abutment crowns step by step.

1. Diagnostics and immediate implantation A 45-year-old patient complained of pain in region 25 when chewing. During the clinical examination of the endodontically treated tooth, a vertical root fracture was diagnosed. Clinical and radiological diagnostics showed no signs of inflammation.

For that reason, an extraction method designed to protect the bone and an immediate implant were chosen. The tooth could be extracted with the greatest possible bone content. During the inspection of the extraction cavity, an entirely intact buccal bone lamella was found. After careful examination of the alveoli, the immediate implantation could be carried out. Since the primary stability was more than 35 N/cm2, immediate loading with a screwed provisional temporary restoration without occlusal contact was possible in order to form the soft tissue during the healing process.

2. CAD/CAM fabrication

1

Dr. Julián Conejo, Philadelphia, USA

VITA® and other VITA products mentioned are registered trademarks of VITA Zahnfabrik H. Rauter GmbH & Co. KG, Bad Säckingen, Germany.

After three months of osseointegration, the soft tissue region at 25 showed a naturally formed emergence profile. Immediately after the temporary restoration was removed, the gingival development was recorded with the CEREC Omnicam (Sirona Dental, Bensheim, Germany). A scan post was then screwed onto the implant and a scan body was positioned on it. After a radiographic control of the fit, the three-dimensional implant position was scanned. A VITA ENAMIC IS blank was selected for the production of the final restoration. The morphology of the definitive abutment crown on the virtual model included a natural design with the CEREC software 4.4 so the soft tissue received optimal support. After the restoration was milled, manual polishing was performed with the VITA ENAMIC polishing set at a low speed. This resulted in a smooth surface in the transmucosal region.

3. Luting and integration The adhesive base was sand blasted with aluminum oxide (50 micrometer, 3.0 bar), the interface and the screw channel of the VITA ENAMIC crown were etched with 5% hydrofluoric acid for 60 seconds. In order to form reliable adhesion with the dualcuring

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Figure 1: After the removal of the Figure 2: To preserve the soft tissue Figure 3: A scan post was screwed into the temporary restoration, region 25 showed structure, scanning was carried out implant. a naturally formed emergence profile. immediately after the temporary restoration was removed.

Figure 4: A scan body was positioned on Figure 5: The implant position was Figure 6: The abutment crown was the scan post and a radiographic control recorded with the 3-D scanner CEREC constructed virtually for optimal soft tissue support. was performed to check the fit.

Omnicam.

adhesive material PANAVIA V5 (Kuraray, Noritake), an MDP primer was applied to the relevant titanium and hybrid ceramic components before attachment. The finished restoration was then bolted at a torque of 35 N/cm2. The screw head was covered with gutta-percha and the screw channel was sealed with direct composite material. The final

radiographic control showed ideal bone conditions and a very good fit between the titanium base and the hybrid ceramic, thanks to the ready-made interface of the VITA ENAMIC IS blank. During the follow-up appointment after one year, the patient expressed that the hybrid ceramic abutment crown had a positive natural feeling.

Figure 7: The CAD/CAM machined and Figure 8: The final result shows harmonic Figure 9: The X-ray check showed ideal polished abutment crown was screwed in integration of the hybrid ceramic abutment bone conditions and fit. at a torque of 35 N/cm2. crown into the soft tissue and the adjacent teeth.

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Furcation perforation: current approaches and future perspectives Manal Farea,1 Adam Husein2 and Cornelis H Pameijer3

1

Manal Farea is a dentist with a BDS degree from Sana’a University, Sana’a, Yemen in 2003. She received her MSc degree in endodontics from Universiti Sains Malaysia (USM), Malaysia in 2010. In 2015, she completed her PhD degree at the USM in regenerative endodontics. Dr Manal was granted a scholarship from Sana’a University, Yemen in 2007 and a fellowship from USM in 2011.

2

Professor Dr Adam Husein is a senior lecturer in the restorative unit (prosthodontics) and the dean of School of Dental Sciences, Universiti Sains Malaysia. He got his BDS from University of Adelaide, Australia in 1996. In 2004, he optained his graduate diploma in clinical dentistry, doctor in clinical dentistry and fellowship of the Royal Australasian College of Dental Surgeons (FRACDS) from the University of Adelaide.

Cornelis H Pameijer DMD MScD DSc PhD graduated from the University of Utrecht with a DDS in The Netherlands in 1967 and went on to further his studies at Boston University in the USA. He is currently professor emeritus at the University of Connecticut in Farmington, Connecticut, USA. He has lectured extensively worldwide and has published more than 300 publications in mostly peer-reviewed journals.

3

During root canal treatment many procedural accidents may occur of which perforation of the root canal system plays a significant role. Perforation is defined by the American Association of Endodontics (AAE) Glossary of Endodontic Terms (2003) as a mechanical or pathological communication between the root canal system and the external tooth surface, which is caused by caries, resorption or iatrogenic factors. It has been identified as the second greatest cause of endodontic failure that accounts for 9.6% of all unsuccessful cases (Pitt Ford et al, 1995).

As a result of furcation perforation, destruction of the periodontal tissues may occur, which ultimately lead to loss of the tooth (Arens, Torabinejad, 1996; Tsesis, Fuss, 2006). The prognosis of the tooth depends upon several factors: 1. The severity of initial damage to the periodontal tissue 2. The location and size of perforations 3. The bacterial contamination 4. The sealing ability or cytotoxicity of the repair materials (Tsesis, Fuss, 2006; Sinai, 1977; Balla et al, 1991).

Even if a biocompatible material is used to treat a perforation, extensive injury may cause irreversible damage to the attachment apparatus at the furcation area (Sinai et al, 1989).

In large perforations, the complete sealing of the defect with a repair material is problematic and allows irritants to continuously penetrate into the furcation area (Balla et al, 1991). Perforations close to the gingival sulcus produce persistent inflammation and a down-growth of sulcular epithelium into the defect (Tsesis, Fuss, 2006). Sinai (1977) stated that coronally located perforations including furcal perforations were more serious than those in the middle and apical third of a canal. It is the objective of this review to collect and review the data that is available in the scientific literature and to reach a conclusion as to the best treatment options.

Methods Retrieval of literature An English-limited Medline search was performed of articles published from 2002 to 2015. The searched keywords included ‘perforations and endodontics’, ‘furcation perforation’, ‘root canal and perforation’, and ‘perforation and mineral trioxide aggregate (MTA)’. Then, a hand search was done of the references of collected articles to determine if more papers relevant to the topic should be included.

Results A total of 820 articles were found, which, in order of their related keywords, accounted for the following: perforations and endodontics: 285; furcation perforation: 92; root canal and perforation: 299; and perforation and mineral trioxide aggregate (MTA): 144.

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Figure 1: This illustration depicts a furcation perforation repair using stem cells, scaffold and growth factor.

This method has the potential to open new avenues in furcation repair treatment in the foreseeable near future. This image relates to the text under ‘future perspectives for the perforation repair’ on page 40.

Perforation repair techniques and their prognosis Surgical and non-surgical approaches have been utilised for periodontal tissue re-establishment at the perforation site. In both surgical and non-surgical approaches, two factors should be considered: 1. An appropriate material selection 2. The use of a matrix (Clauder, Shin, 2009).

The repair material should be selected based on the following criteria: • Perforation site accessibility • Biocompatibility (be nontoxic and noncarcinogenic) • Ability to induce osteogenesis and cementogenesis • Moisture control • Easy handling • Aesthetic considerations (Clauder, Shin, 2009; Bryan, Woollard, Mitchell, 1999; Yildirim et al, 2005; Samiee et al, 2010).

Matrix use Controlling haemostasis and placement of the repair material in the perforation site without extrusion into surrounding periodontal structures are essential prerequisites for the

success of a perforation repair. In order to achieve a fluidtight seal, haemostasis has to be controlled (Clauder, Shin, 2009). Delayed perforation repair can lead to extrusion of repair materials as a result of breakdown of the surrounding periodontium that is replaced by granulation tissue. Thus, in an attempt to avoid extrusion of the repair material, internal matrices such as calcium sulphate, hydroxyapatite, collagen, demineralised freeze-dried bone and Gelfoam have been used (Clauder, Shin, 2009; Roda, 2001; Bargholz, 2005).

The internal matrix concept was introduced by Lemon (1992) in order to adequately seal the furcation perforation and avoid extrusion of the material. He also recommended the use of hydroxyapatite as a matrix under amalgam.

Calcium sulphate and calcium hydroxide prevented extrusion of composite resin when used as a furcal repair material (Imura et al, 1998). In 1999, Jantarat and colleagues demonstrated that amalgam placed with plaster of Paris as a matrix for furcal perforation repair improved its sealing ability. Hapset (65% non-resorbable hydroxyapatite and 35% plaster of Paris) and hydroxyapatite showed similar healing responses when used as internal matrices under amalgam (Rafter et al, 2002). Rafter et al (2002) further

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Figure 2: The three key elements of dental tissue engineering are stem cells, scaffolds and signals.

reported that there was marked extrusion of amalgam into the underlying bone with an associated severe inflammatory response when used alone without a matrix.

Although it has been reported that without using an internal matrix the optimal strength and excellent sealability of MTA was achieved in the presence of moisture (Arens, Torabinejad 1996; Holland et al, 2001; Torabinejad et al, 1994), conflicting results have been reported by some authors regarding the use of an internal matrix under MTA. In 2004, Kratchman suggested that the perforation site should be soaked with sodium hypochlorite after haemostasis had been achieved and that a physical barrier such as collagen or calcium sulfate must be used at the perforation site to prevent MTA from being packed into the bone.

According to Bargholz (2005), excellent clinical results were achieved when collagen matrix was used under MTA. A study by Al-Daafas and Al-Nazhan (2007) showed that calcium sulfate prevented extrusion of the repair material.

However, an unfavourable inflammatory reaction – epithelial tissue migration into the defected perforation and the inability to induce bone regeneration – were detected. Thus, the authors concluded that using calcium sulphate as an internal matrix for MTA is not recommended. When used as an internal matrix for furcal perforation repair, calcium sulfate and Collaplug (Calcitek, Carlsbad, CA) did not improve the sealing ability nor reduce the incidence of MTA overextension. Therefore, the authors concluded that these two materials are not recommended as an internal matrix for MTA (Zou et al, 2008). Furthermore, calcium sulfate and hydroxyapatite did not improve the sealing ability of MTA

when used as internal matrices for furcation perforation repair (Taneja, Kumari 2011).

Materials used for furcation perforation repair In an attempt to repair a furcation perforation, several materials such as amalgam, tricalcium phosphate (TCP), hydroxyapatite, gutta percha, calcium hydroxide, zinc oxideeugenol-based cement (IRM and Super-EBA), glass ionomer cement, composite resins, resin-glass ionomer hybrids, demineralised freeze-dried bone and MTA have been used over the years (Arens, Torabinejad, 1996; Balla et al, 1995; Bryan, Woollard, Mitchell, 1999, Yildirim et al, 2005; Salman et al, 1999). However, none fulfil all requisite qualifications for an ideal biomaterial.

Balla et al (1991) reported that no hard tissue was formed at the furcation perforation defect site when treated with either tri-calcium phosphate, hydroxyapatite, amalgam or calcium hydroxide (Life); instead, the defect site was occupied by epithelium and acute inflammatory cells (Balla et al, 1991). MTA is water-based cement that is derived from Portland cement (type I). It was introduced as a root-end filling material in the early 1990s (Torabinejad, Watson, Pitt Ford, 1993; Torabinejad, Chivian, 1999). It was subsequently determined that it was a suitable material for various clinical applications such as pulp capping, repair of furcal perforations as well as root-end closure (Sinai et al, 1989; Torabinejad et al, 1995). MTA promotes periradicular tissue regeneration (Pitt Ford et al, 1995; Yildirim et al, 2005; Holland et al, 2001; Zhu, Xia, Xia, 2003; Noetzel et al, 2006) and it differs from other

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materials by its ability to promote cementum regeneration, thus facilitating the regeneration of the periodontal apparatus (Pitt Ford et al, 1995; Arens, Torabinejad, 1996). Its biocompatibility nature is suggested by its ability to form hydroxyapatite when exposed to simulated body tissue fluid (Sarkar et al, 2005).

Two commercial forms of MTA are available; Proroot MTA (Dentsply Tulsa Dental), which is available in both gray or white form, of which the latter contains a lower amount of iron, and MTA-Angelus (Angelus) (Asgary et al, 2005). MTAAngelus was introduced to address the long setting time from two hours for Proroot MTA to 10 minutes for MTA-Angelus.

MTA-Angelus contains 80% Portland cement and 20% bismuth oxide, with no addition of calcium sulfate, while Proroot MTA is composed of 75% Portland cement, 20% bismuth oxide, and 5% calcium sulfate dehydrate (Hashem et al, 2008). The constituents of the Portland cement are minerals, amongst which the most important are dicalcium silicate, tricalcium silicate, tricalcium aluminate, tetracalcium ironaluminate and dehydrated calcium sulfate (Oliveira et al, 2007; Asgary et al, 2009a). The only significant difference between the dominant compounds of white and gray MTAs and associated Portland cements is bismuth oxide, which is present in MTAs (Asgary et al, 2009a; Asgary et al, 2004).

It has been reported that the sealing ability of MTA (Loma Linda University, Loma Linda, CA) was significantly better compared to amalgam in preventing leakage of Fusobacterium nucleatum through furcal perforations (Nakata, Bae, Baumgartner, 1998). When used to seal a large furcation perforation, Proroot MTA with/without internal matrix and MTA-Angelus with internal matrix showed the lowest dye absorbance compared to zinc oxide-eugenol cement (IRM) with/without internal matrix and MTA-Angelus without internal matrix. Additionally, the authors reported that IRM without internal matrix had the highest dye absorbance (Hashem, Hassanien, 2008). However, white and gray MTA (Dentsply Tulsa Dental) showed no significant differences in microleakage when used for furcal perforation repair (Ferris, Baumgartner, 2004; Hamad, Tordik, McClanahan, 2006).

Furcal perforations have been repaired with Proroot gray MTA (Dentsply) and Geristore (Denmat). Geristore has been used as a root end filling material and in the restoration of subgingival surface defects such as root surface caries and iatrogenic perforations, surgical repair of root perforations and as an adjunct in guided-tissue regeneration (GTR) (Mehrvarzfar et al, 2010). It also leaked significantly less than amalgam (Mehrvarzfar et al, 2010). In the aforementioned study, the authors reported that the sealing

ability of MTA and Geristore was reduced when bioglass was used as a matrix underneath.

Sluyk, Moon and Hartwell (1998) assessed the effect of time and moisture on setting, retention and adaptability of MTA when used for furcal perforation repair. Findings showed that MTA adaptation to perforation walls increased in the presence of moisture. They further suggested that a moistened matrix can be used under MTA to prevent underor overfilling of the material. Furthermore, Main et al (2004) indicated that MTA provided an effective seal for root perforations.

Yildirim et al (2005) investigated the histologic response to MTA and Super EBA (Bosworth Company) when used in furcation perforation repair in dogs. In their study, less inflammation and new cementum formation was observed with MTA compared to Super EBA, which demonstrated connective tissue repair without inflammation. Similar abilities to seal furcal perforations were observed for both Portland cement and MTA (De-Deus et al, 2006; Noetzel et al, 2006) evaluated histologically the inflammatory reactions and tissue responses to experimental tricalciun phosphate (TCP) and MTA when used as repair materials in furcation perforations in dogs. Results showed no significant differences between MTA and TCP in terms of bone reorganisation or deposition of fibrous connective tissue.

Thus, MTA is considered the gold standard and material of choice for perforation repair and has demonstrated good potential for clinical success. However, it has some disadvantages, including the inability to degrade to allow for replacement with natural tissues, low resistance to compression over the long-term, extended setting time, poor handling, and difficult insertion into cavities because of its granular consistency, while additional moisture is required to activate the cement setting, and lastly, the high cost, despite its widespread use (Torabinejad et al, 1995; Chng et al, 2005; Kogan et al, 2006; Coomaraswamy, Lumley, Hofmann, 2007; Parirokh, Torabinejad, 2010). Many dental materials have been demonstrated in the literature to exhibit cytotoxic effects during setting. Low cell numbers were demonstrated in vivo with freshly mixed MTA (pH=10.2) compared to preset MTA (pH=12.5) (Tronstad, Wennberg, 1980). However, histologically, no difference in bone and cementum regeneration was observed after periradicular surgery in dogs between fresh and preset Proroot MTA (Apaydin, Shabahang, Torabinejad, 2004).

In 2006, Asgary and colleagues introduced a new endodontic cement, a calcium-enriched mixture (CEM) cement. Major components of CEM cement powder are

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51.75 wt.% calcium oxide, 9.53 wt.% sulfur trioxide, 8.49 wt.% phosphorous pentoxide, and 6.32 wt.% silicon dioxide; whereas the minor essential constituents are aluminium oxide > sodium oxide > magnesium oxide > chlorine. CEM cement has a similar pH but an increased flow compared to MTA. However, working time, film thickness and price are considerably less (Asgary et al, 2008a). Unlike MTA, mixed CEM cement releases calcium and phosphate ions and forms hydroxyapatite not only in simulated body tissue fluid but also in normal saline solution (Asgary et al, 2009a; Amini et al, 2009).

Although the chemical composition of CEM cement and MTA are different, they have similar clinical applications (Asgary et al, 2008b; Asgary et al, 2008c; Asgary et al, 2009b; Asgary, Ehsani, 2009c). Similar to MTA, CEM cement had low cytotoxic effects on different cell lines (Asgary et al, 2009d). However, it showed a better antibacterial effect comparable to calcium hydroxide (Asgary et al, 2008d). Similar sealing ability was demonstrated by both Proroot MTA and CEM when used to repair furcal perforation of primary molar teeth (Haghgoo et al, 2014).

Non-surgical approach When a perforation repair is indicated, it is recommended to first attempt an intracoronal approach (non-surgical) to preserve the periodontium thus increasing the chances of success (Regan, Witherspoon, Foyle, 2005). Generally, perforations coronal to the crestal bone fall into the category of a non-surgical approach. The use of a surgical microscope operated at high magnification and with ample illumination allows for better management of perforation repairs (Kratchman, 2004; Daoudi, Saunders, 2002).

A surgical approach may complicate the treatment and lead to loss of periodontal attachment, chronic inflammation and furcal pocket formation (Arens, Torabinejad 1996).

Experience has shown that buccally located perforations are easier to repair than lingual or proximal lesions. Lingual located perforations, especially in the mandible, should be treated non-surgically or orthodontically. If they are not responding to treatment, the tooth should be extracted (Regan et al, 2005). If a tooth can be extruded orthodontically to a point where the perforation reaches a supragingival level, repair of the defect will be greatly facilitated (Smidt, LachishTandlich, Venezia, 2005). Whether clinically practical or not, one case of intentional reimplantation was reported after repair of the perforation was performed on the extracted tooth (Poi et al, 1999).

In cases of large perforations, bleeding should be

controlled first using sterile saline. Alternatively, calcium hydroxide, calcium sulphate, or collagen has been used (Clauder, Shin 2009). For bleeding control, non-specific intravascular clotting agents should be avoided as they may lead to alveolar bone damage and delay in healing (Lemon, Steele, Jeansonne, 1993). In cases of perforations that are infected or perforation sites that need further enlargement and cleaning, burs or ultrasonic tips may be used. However, ultrasonic tips are preferable as they are gentler to the adjacent periodontium tissues (Pitt Ford et al, 1995; Arens, Torabinejad, 1996; Clauder, Shin, 2009). For cleaning of infected perforations, 2.5% sodium hypochlorite has been used (Arens, Torabinejad, 1996), however, sterile saline is indicated in large perforations (Clauder, Shin, 2009). To avoid blockage of the canals with repair material, gutta percha points, paper points, cotton pellets or an easily removable material (such as Cavit) should be placed over the canal orifices (Clauder, Shin, 2009).

A resin-bonded material such as Geristore (Denmat) is recommended to restore subgingival defects (Clauder, Shin, 2009), which also serves as an adjunct to GTR (Abitbol et al, 1996; Behnia, Strassler, Campbell, 2000). It is less sensitive to moisture than conventional glass ionomer cement while a drier environment improved the results (Cho, Kopel, White, 1995). Adhesive materials can be used in supracrestal perforations, whereas MTA is preferable in subcrestal perforations (Clauder, Shin, 2009). If a perforation defect involves bone destruction (intraosseus defect), a barrier is needed to facilitate controlled placement of the repair material. This is not necessaary if the defect does not include an intraosseus defect (Clauder, Shin, 2009). If MTA is used a moist cotton pellet should cover the material to allow setting of the material. After perforation repair the final restoration can be placed either after one day or one week. Once repair has been achieved the root canal(s) can be cleaned, shaped and filled (Pitt Ford et al, 1995; Arens, Torabinejad, 1996).

If a perforation is present in the middle third of the root, the canal(s) should be prepared first before closing the defect to avoid blocking the canal. With the aid of an operating microscope, obturation of the canal apical to the defect should be done first, followed by filling the remainder of the canal and the perforation site with MTA (Clauder, Shin, 2009). Alternatively, the root space beyond the perforation can be maintained by means of a file or gutta percha cone.

In case a file is used, it should be loosened after finishing the repair procedure to allow easy removal before the MTA is fully set (Clauder, Shin, 2009). The other option is to use

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Surgical intervention (external approach) is indicated in areas that are not accessible by non-surgical means alone, cases that have not responded to non-surgical treatment or in repairing a perforating resorption (Regan et al, 2005). The surgical approach is performed by reflecting a flap at the perforation site followed by cleaning and preparing the perforated area and finally packing the repair material (Alhadainy, 1994).

During the surgical repair procedures, cortical bone damage is involved, which may result in reduced success of the corrective surgical procedure. Thus, a GTR technique has been recommended for successful treatment outcomes by using either non-resorbable or resorbable membranes as a barrier (Duggins et al, 1994; Barkhordar, Javid 2000; Rankow, Krasner, 1996; Dean et al, 1997; Leder et al, 1997). This barrier guides selected cells to populate at the perforation defect, ie, placing the barrier between the gingival tissue and the perforation defect will facilitate the repopulation of the defect by periodontal ligament cells and other osteogenic cells and prevents the colonisation by gingival cells (Linde et al, 1993; Sandberg, Dahlin, Linde, 1993). A resorbable membrane is generally preferable, as it does not need a second surgical procedure to remove it.

However, in some cases, titanium-tented membrane or a supporting graft material is needed to prevent collapsing the membrane into the defect (Abitbol et al, 1996).

Healing after intentional perforations in dogs’ teeth was evaluated after repair with either MTA or Sealapex (Kerr) (Holland et al, 2001). Most samples sealed with MTA showed new cementum deposition and an absence of inflammation. In 2010, Samiee and colleagues reported that cementum-like hard tissue was formed using either MTA or CEM cement in the furcation perforation in dogs in the presence of a mild inflammatory response. The authors concluded that both materials showed a similar favourable biological response in furcation perforation repair.

Zairi et al (2012) compared the inflammatory reactions and tissue response of furcal perforations in dogs’ teeth to growth factors, TGFβ1, basic fibroblast growth factor (bFGF), osteogenic protein-1 (OP-1) and IGF-I, with MTA or IRM as controls. The authors reported that a clear stimulatory effect on cementum formation and inhibition of collagen capsule formation was exerted by the growth factors.

However, MTA exhibited better results than the growth factors. Based on that, the authors suggested a further study comparing the effects of application of growth factor mixture with MTA and MTA alone on tissue healing and regeneration.

In a case report, Bains et al (2012) used tissue engineering principles for the furcation perforation repair of the pulpal floor of the right mandibular first molar of 39-yearold male patient using MTA and platelet-rich fibrin (PRF). The authors reported that this combination was able to repair the perforation defect and regenerate the lost periodontium in the furcation area effectively. A case report (Eghbal, Fazlyab, Asgary, 2014) was published describing the nonsurgical endodontic management of an extensive perforation of the floor of the pulp chamber in a first mandibular molar of a 28-year-old Caucasian female using CEM cement. The authors reported that CEM was able to induce hard tissue formation, ie bone and cementum.

Cementum regeneration and role in the periodontium reconstruction

Cellular tissue engineering approach for cementum regeneration

Cementum formation is very essential in the furcation perforation repair process (Pitt Ford et al, 1995; Clauder, Shin, 2009; Samiee et al, 2010; Zairi et al, 2012). Pitt Ford and colleagues (1995) evaluated the histologic response to experimentally induced furcation perforations in dog mandibular premolars repaired by either MTA or amalgam and found that most of the MTA samples showed no inflammation and cementum deposition, whereas with the use of amalgam, moderate to severe inflammation with no cementum deposition was present.

A proposed therapeutic approach was reported by the removal of autologous cells from the patient’s periodontal ligament (PDL), culturing of the cells in vitro, which were then placed back onto the exposed root coated with chemo attracting factors, subsequently covering the area with an artificial basement membrane (Terranova, 1990). However, it is unknown whether this method produced the desired effect. Lekic and colleagues (2005) reported that rat periodontal and bone marrow cells were able to differentiate into periodontal ligament fibroblasts, osteoblasts and

a gutta percha point and soften it with heat to the dentinal wall opposing the perforation. MTA is then placed at the defect site (Clauder, Shin, 2009). Perforations at the apical one-third are quite challenging and difficult to manage.

Successful treatment cannot always be achieved for all cases necessitating apical surgery or extraction of the tooth to remedy the problem (Clauder, Shin, 2009).

Surgical approach

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cementoblasts when transplanted into periodontal wounds in rats, thus contributing to periodontal regeneration.

Regeneration of cementum, PDL and alveolar bone have been observed using auto-transplantation of bone marrow derived mesenchymal stem cells (BMMSCs) (Kawaguchi et al, 2004) or periodontal ligament cell sheet (Akizuki et al, 2005) into periodontal osseous defects in dogs. However, the principle disadvantage of cell sheets is their delicate structure and difficult handling during surgery (Li, Jin, 2015).

Furthermore, the harvest of bone marrow (BM) is a highly invasive and a painful procedure for the donor. Moreover, it has been reported that the number, proliferation and differentiation potential of BMMSCs decline with increasing age (Kern et al, 2006).

It has been reported that cementoblast-biodegradable poly(lactic-co-glycolic acid) (PLGA) polymer sponge-treated defects showed complete bone bridging and PDL formation, whereas minimal evidence of osteogenesis was exhibited by follicle cell-treated defects along the root surface of athymic rats (Zhao et al, 2004). Periodontal ligament stem cells (PDLSCs) have the ability to differentiate into cementoblast and osteoblast (Isaka et al, 2001; Seo et al, 2004) and have shown potential therapeutic applications in periodontium regeneration. However, the very low number of these cells residing in the PDL is indicative of the difficulty acquiring a sufficient number for regenerative treatment remains and is an issue that remains unresolved (Maeda et al, 2011). Primary cultures of PDLSCs yielded small cell numbers, therefore before application, PDLSCs must proliferate at least 12 population doublings (Zhu, Liang, 2015). Additionally, it has been found that the proliferation and migration ability and differentiation potential of PDLSCs decreased with increasing age (Zhu, Liang, 2015).

Apical tooth germ cells conditioned medium were able to provide the cementogenic microenvironment and induced the cementoblastic differentiation of PDLSCs (Yang et al, 2009). Hertwigâ&#x20AC;&#x2122;s epithelial root sheath (HERS) cells, or their secreted products, were able to induce PDL cells differentiation along the cementoblastic lineage in vitro (Zeichner-David et al, 2003). Several in vivo studies have also shown the potential capability of PDLSCs to form cementum and PDL-like tissues (Yang et al, 2009; Liu et al, 2008; Feng et al, 2010; Park, Jeon, Choung, 2011).

or improve tissue function or a whole organ (Langer, Vacanti, 1993). Tissue engineering aims to stimulate the body either to regenerate tissue on its own or to grow tissue outside the body, which can then be implanted as natural tissue (Nadig, 2009).

Triad components Regenerative endodontics can be defined as biologically based procedures designed to replace damaged structures, including dentine and root structures, as well as cells of the pulp-dentine complex (Murray, Garcia-Godoy, Hargreaves, 2007). This approach consists of the following interactive triad: 1) an appropriate cell source; 2) a supportive matrix (scaffold); and 3) inductive biological factors or signals (Figure 1). To create regenerative therapies, these disciplines are often combined rather than used individually (Murray, Garcia-Godoy, Hargreaves, 2007).

Future perspectives for the perforation repair Reconstruction of the lost attachment via regeneration of the periodontium components, such as cementum, PDL and bone, is essential in the repair of perforated areas.

Replacement of the lost cementum (cementogenesis) is very critical and enhances the reattachment of the fibres of the periodontal ligament. Several studies have been published that demonstrate the ability of different materials to repair furcation perforations, albeit with variable success rates.

However, during recent years, there has been a paradigm shift from conventional to regenerative endodontic therapy and repair of the periodontium is not an exception. To date, to the best of our knowledge, no studies have been published in the literature reporting on the effect of the triad application (stem cells, scaffold and growth factor) for furcal perforation repair and the response of surrounding tissues (cementum, PDL and alveolar bone). We propose a stem cellbased tissue engineering approach for furcation perforation repair through enhancing of stem cell differentiation along the cementoblastic lineage in association with scaffold and growth factor. The suggested biomimetic approach is illustrated in Figure 2. This will have the potential to open a new era and strategy in endodontic and periodontal tissue engineering therapies.

Conclusions Regenerative therapy Tissue engineering is an interdisciplinary field that applies the principles of engineering and life sciences toward the development of biological substitutes that restore, maintain,

Perforation of the pulp chamber floor of multi-rooted teeth constitutes a perplexing and frustrating problem. It is a major cause of endodontic treatment failure. A furcation perforation has to be regarded as an endodontic and periodontal

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problem. The inflammatory response in the periodontium, leading to irreversible loss of periodontal attachment in the area, can result in loss of the tooth if the perforation is not successfully repaired. To re-establish the periodontal tissue in the perforation site, surgical and non-surgical techniques have been utilised.

For furcation perforation repair, several materials have been used with varying results. However, the stem cell-based tissue engineering approach is very promising and is suitable for furcation perforation repair. This approach has the potential to revolutionise the practice of regenerative endodontics in the future and may therefore save many teeth that would otherwise have to be extracted due to a poor to hopeless prognosis.

Moreover, it will help and assist in designing regenerative therapies based on sound biological principles, which can be applied in both endodontic and periodontal specialties.

Acknowledgements This study was financially supported by the Universiti Sains Malaysia Research University Grant 1001/PPSP/813058, PRGS (1001/PPSG/8146005) and short-term grants (304/PPSG/ 61312012 and 304/PPSG/61312018) from the School of Dental Sciences, Universiti Sains Malaysia.

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J Endod 21:349-53 Torabinejad M, Watson TF, Pitt Ford TR (1993) Sealing ability of a mineral trioxide aggregate when used as a root end filling material. J Endod 19:591–5 Tronstad L, Wennberg A (1980) In vitro assessment of the toxicity of filling materials. Int Endod J 13:131–138 Tsesis I, Fuss Z (2006) Diagnosis and treatment of accidental root perforations. Endod Topics 13:95–107 Yang ZH, Zhang XJ, Dang NN, Ma ZF, Xu L, Wu JJ, Sun YJ, Duan YZ, Lin Z, Jin Y (2009) Apical tooth germ cell-conditioned medium enhances the differentiation of periodontal ligament stem cells into cementum/periodontal ligament-like tissues. J Periodontal Res 44:199–210 Yildirim T, Gencoglu N, Firat I, Perk C, Guzel O (2005) Histologic study of furcation perforations treated with MTA or Super-EBA in dog’s teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100:120–124 Zairi A, Lambrianidis T, Pantelidou O, Papadimitriou S, Tziafas D (2012) Periradicular tissue responses to biologically active molecules or MTA when applied in furcal perforation of dogs’ teeth.

Int J Dent 1–9 Zeichner-David M, Oishi K, Su Z, Zakartchenko V, Chen LS, Arzate H, Bringas P (2003) Role of Hertwig’s epithelial root sheath cells in tooth root development. Dev Dyn 228:651–663 Zhao M, Jin Q, Berry JE, Nociti FH Jr, Giannobile WV, Somerman MJ (2004) Cementoblast delivery for periodontal tissue engineering.

J Periodontol 75:154–161 Zhu W, Liang M (2015) Periodontal ligament stem cells: current status, concerns, and future prospects. Stem Cells Int 11 Zhu YQ, Xia WW, Xia L (2003) Histological evaluation of repair of furcation perforation in dogs using mineral trioxide aggregate.

Shanghai Kou Qiang Yi Xue 12:47–50 (Abstract) Zou L, Liu J, Yin S, Li W, Xie J (2008) In vitro evaluation of the sealing ability of MTA used for the repair of furcation perforations with and without the use of an internal matrix. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 105:661–65

Reprinted with permission by Endodontic Practice August 2017

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The mock-up: your everyday tool Yassine Harichane1 For a wax-up, also known as a diagnostic wax model, laboratory wax is used to create an aesthetic concept based on a patient’s plaster model. However, the aesthetic and functional use is limited. From an aesthetic perspective, even though the wax does not reproduce the tooth shade perfectly, it facilitates visualisation of the shape and position of the teeth in the concept.

As far as function is concerned, even when a high-performance articulator is used, it is still difficult to replicate the full range of masticatory movements.

The mock-up, essentially a ‘preview’ produced from composite, is a technique all too rarely employed by dentists, but which proves exceptionally practical in a wide variety of situations in routine clinical practice. It offers a preview of the intended aesthetic result and as such plays a decisive role in treatment planning (Marus, 2006; Vargus, 2006; Pena et al, 2009).

The mock-up phase follows validation of the wax-up. In this phase, the concept model is adapted directly in the mouth following validation on the plaster model (Magne and Belser, 2004; Magne and Magne, 2006). This facilitates transfer of the wax-up data from the patient model directly into the mouth (Hollar, 2008; Peyton and Arnold, 2008).

The trial fitting in the mouth offers the opportunity of verifying the concept from an aesthetic, functional, and psychological perspective. This last aspect is of particular significance, considering that it imparts an important principle into patient acceptance, namely being able to first try out a solution and then make an educated final decision.

In this way, the patient plays an active role in the decision-making process, which considerably improves communication (Willhite, 2006).

It is important to note that communication with the dental technician is also optimised in the process, which promotes smooth cooperation between the practice and the laboratory. It is only possible to implement minimal corrections directly on a wax-up, whereas the dentist is free to make aesthetic changes to the mock-up by adding or removing materials generally available in the dental practice (Simon and Magne, 2008).

In addition, the mock-up can also be used to check the occlusion in the mouth in order to validate the accuracy of the wax-up. Following any corrections, a duplicate of the mock-up is sent to the laboratory. The dental technician now has additional information at their disposal, with which they can achieve a predictable aesthetic result.

Dr Yassine Harichane, Private Practice, Quebec, Canada 1

Figure 1: Cartridge with composite (Structur 3, Voco).

self-curing

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Figure 2: Preoperative situation, smile.

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Figure 3: Preoperative situation, intraoral in occlusion.

Figure 4: Preoperative situation, intraoral in non-occlusion.

Treatment plan

to the laboratory, where it serves as a reference for the final production of the concept.

Mock-ups are suitable for treatment in the anterior region requiring corrections to the shape of teeth through the addition of material, and to a lower extent also adaptation of the position of the teeth. The main indications are thus loss of substance on vital teeth, missing individual teeth, diastema or other congenital aesthetic defects, which permit a bioaesthetic approach (Dietschi, 2011).

Once a diagnosis has been established and the type of treatment selected, the dentist orders a wax-up based on the patient’s tooth model. Of course, they also need to inform the dental technician in the laboratory of what they expect in terms of shape and position, but not yet the shade.

The first step is for the dentist to validate the wax-up on the model; this allows them to make any necessary corrections directly in the practice using suitable materials. In such cases it is always worth asking the dental technician to send additional wax with which any corrections requiring addition of material can be performed.

The wax-up is then shown to the briefed patient (it is a 3D simulation of the concept design), making sure to mention the reservations (the tooth shade cannot be replicated in a wax-up) and compared with the plaster model without waxup in order to demonstrate the improvements objectively.

Once the patient has accepted the wax-up and any necessary corrections have been made, the wax model is transferred from the plaster model into the patient’s mouth in order to simulate the treatment intraorally. These steps are described in the ‘step by step’ section.

The mock-up is shown to the patient in order to determine the optimal tooth length and the general proportions of the new smile. It is still possible to make corrections at this stage.

Following any corrections, the dentist and patient approve the mock-up and an impression is taken, which is then sent

Materials Mock-ups are easy to produce in routine clinical practice as long as there is sufficient material available and the user masters the necessary skills in advance. In this article, we describe a technique in which self-curing composite (Structur 3, Voco) (Figure 1), which is usually employed in the production of temporary crowns, bridges and inlays/onlays, is deployed in the scope of an off-label use.

In contrast to laboratory wax, which is used for wax-ups, the visual properties of this material allow reproduction of the natural tooth shade (within a sufficiently large range from A1 to A3.5 including the shades B, C and Bleach Light).

The mechanical resistance of the material makes it possible to simulate the occlusion of the mock-up in the mouth.

Self-curing composites are similar to conventional lightcuring composites. As a result, the composite can be adhered to the mock-up in order to compensate for defects or change the shape (tooth elongation, curvature of vestibular tooth surface, incisal cut-back, etc). The retention occurs mechanically, ie, no cement is required. In contrast to a temporary crown, the mock-up is ultimately destroyed upon removal.

Step by step The clinical case presented here to illustrate the workflow was a consultation for aesthetic reasons. The patient wanted to improve his smile considerably without resorting to invasive techniques (we restrict ourselves here to the implementation of a mock-up in the maxilla). The first step involves taking a number of photos in order to analyse the initial clinical situation with the patient (Hinet et al, 2011) (Figures 2-4).

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Figure 5: Wax-up without preparation of the teeth.

Figure 6: Silicone wax-up impression.

Figure 7: Verification of the accuracy of the wax-up impression.

Figure 8: Filling of the impression with self-curing composite (Structur 3, Voco).

A plaster model serves as the basis for production of the wax-up (Figure 5). An impression is taken of the wax-up (Figures 6 and 7), which is used in the mouth as a guide for the implementation of the mock-up.

The guide is tried in the mouth and any necessary corrections made with a scalpel. The shade of the self-curing composite (Structur 3, shade A1, Voco) is now selected in accordance with the patient’s expectations and the tooth shade of the natural teeth.

The impression is filled with the composite (Figure 8) and inserted in the mouth (Figure 9). The impression is removed at the earliest 1.5 minutes after mixing is started (Figure 10).

However, final processing can only be performed after four minutes.

The shape is adjusted either by means of contouring in conjunction with water cooling as in the case of conventional composites, or by filling defects with a flowable composite (Grandio Flow, Voco) (Figures 11-13). Finally, the structure and dynamics of the occlusion are verified.

As soon as all adaptations have been completed, the

mock-up is presented to the patient for his aesthetic approval: shape, position and tooth shade. If necessary, further adaptations can be effected in the same way, ie, via contouring or filling with composite.

The data are sent to the laboratory as photos (portrait, smile and intraoral) (Figure 14) along with an impression of the mock-up and the analysis of the smile. The dental technician in the laboratory then has the necessary and sufficient aspects at their disposal to produce the actual prosthetic restoration in accordance with the patient’s and dentist’s wishes (Reshad et al, 2008).

At the end of the treatment session, the question remains as to what to do with the mock-up. The dentist has the choice between two possibilities. One option involves removing the mock-up and permitting the patient to leave the practice with the restored initial clinical situation. No invasive or irreversible interventions were performed and the patient is happy to have ‘tried out’ his future smile without having to sacrifice any tissue or be anaesthetised.

The other option is to allow the patient to leave with the

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Figure 9: Insertion of the impression with self-curing composite.

Figure 10: Occlusal view of the mock-up following removal of the impression and all excess material.

Figure 11: Filling of a bubble in the mock-up with flowable composite (Grandio Flow, Voco).

Figure 12: Curing of the flowable composite.

mock-up still inserted. This allows him to show off his new smile to his nearest and dearest and to verify its acceptance in social situations. Furthermore, this also enables the patient to test the articulation and masticatory loads in daily life.

At this point, it must be reiterated that the material is suitable for situations of this type as it was developed for the production of temporary crowns (Magne and Belser, 2004).

It is down to the dentist to decide how long the mock-up can remain in the patient’s mouth, whilst it goes without saying that special attention must be paid to exceptional oral hygiene. From the perspective of the psychological period for visual acclimatisation and functional aspects, one week appears to be a practical time (Magne and Belser, 2004; Magne and Magne, 2006).

A waiting period with temporary restorations makes it possible to assess the required result, but is not indicated in clinical cases with conservative or non-invasive approaches. In future, the patient will be able to ‘try out’ their new smile in order to get used to it quickly, and even go home wearing it to test it extensively from an aesthetic, functional and psychological perspective. Patient compliance increases as they can follow the treatment plan more calmly and is better informed.

In addition to improved patient communication, communication with the dental technician is also facilitated.

Thanks to the impression and photographs of the mock-up in the mouth, the dental laboratory has a wealth of invaluable information at its disposal which was not systemically provided in the past (Reshad et al, 2008).

The dental technician is then not only able to test the waxup from a functional perspective (structural and dynamic occlusion, position of the free margin for the articulation, lip support), but also from an aesthetic perspective (tooth shade, shape and volume of the teeth, smile symmetry, smile alignment with regard to facial aesthetics). The userfriendliness of the material means this technique is suitable for use in routine clinical practice.

Discussion The mock-up technique offers a whole range of advantages.

The quick, cost-effective method allows the patient to assess the desired result in his own mouth (Bloom, 2007). Until now, patients went along with dentists’ decisions without being actively involved in the treatment plan, which occasionally resulted in unexpected results and possible conflicts.

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Figure 13: Surface of the mock-up at tooth UL1 following filling of the defect.

Figure 14: Postoperative situation, occlusion check.

For the dentist, this technique is just as easy to perform as the production of temporary crowns. There is also no need for a rubber dam as the mock-up is produced under the same conditions as for a temporary crown. In addition, this noninvasive technique requires neither preparation nor retention, nor bonding, nor anaesthesia.

The patient will certainly appreciate this tissue-preserving approach. As such, the patient will perceive the treatment as more of an adventure (Hollar, 2008). Of course, however, mock-ups as a speciality are not without their restrictions.

The indication is restricted to prosthetic restorations in the anterior region, with severe malformations representing a contraindication, as the teeth may be positioned outside of the shape of the wax-up; the technique is also not indicated in cases where ameloplasty is required (too long or too heavily curved tooth).

As production of a mock-up requires a certain degree of dexterity; it should be initially practised on a plaster model before work is performed directly in the patient’s mouth. The therapeutic treatment of a patient may require a longer period of time; even though the mock-up phase can be very informative and useful for patient communication, it remains an additional, facultative phase.

Dentists who do not use self-curing composites for temporary restorations could also view procurement of these materials as an additional cost factor. However, it is worth weighing up the fact that the mock-up could considerably improve patient compliance in an extensive treatment and thus the investment could indeed be worth it.

Nothing is more frustrating for a dentist than investing time and effort in the development of a long, complex treatment plan only for it to be rejected by the patient because it fails to meet his or her expectations.

Final remarks Mock-ups constitute a simple, reversible technique that can be easily performed in routine clinical practice. As a preview made of composite, it allows validation of the planned prosthetic restoration in the mouth from an aesthetic, functional and psychological perspective.

This opens up a whole new dimension to the patient, as they are able to ‘try out’ their future smile, and is thus better able to imagine what the end result will be like. Patient compliance increases and the dentist-patient relationship benefits.

From the dental laboratory’s perspective, this method provides the dental technician with additional information, which allows them to tailor their work precisely to the patient’s and dentist’s expectations. The improved communication reinforces the cooperation between the dentist, patient and dental technician.

This article was originally published in Dental Tribune Study Club No. 03-2015. Further publication with the kind permission of the author and Oemus Media.

Care to comment? @AesDenToday

References Almog D, Sanchez Marin C, Proskin HM, Cohen MJ, Kyranides S, Malmstrom H (2004) The effect of esthetic consultation methods on acceptance of diastema-closure treatment plan: a pilot study. J Am Dent Assoc 135(7): 875881 Bloom D (2007), Visual Diagnostic Try-ins: Beyond Dental Imaging. J Cosmet Dent 23(3): 112-118 Dietschi D (2011) Current status & future perspectives for the use of composite resins in the smile frame. J Cosmet Dent 27(3): 112-127

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Hinet M, Harichane Y, Grossetti F, Guez B (2012) La photographie dentaire au quotidien. Info Dent 5: 14-17 Hollar S (2008) The ‘trial smile’ experience. J Cosmet Dent 24(3): 106-110 Magne P, Belser UC (2004) Novel porcelain laminate preparation approach driven by a diagnostic mock-up. J Esthet Restor Dent 16(1): 7-18 Magne P, Magne M (2006) Use of additive wax-up and direct intraoral mock-up for enamel preservation with porcelain laminate veneers. Eur J Esthet Dent 1(1): 10-19 Marus RD (2006) Intraoral mock-up: Using composite for anterior aesthetics. AACD Monograph: Significant Science, Magnificent Art 3: 87-89 Pena CE, Viotti RG, Dias WR, Santucci E, Rodrigues JA, Reis AF (2009) Esthetic rehabilitation of anterior coronoid teeth: comprehensive approach for improved and predictable results. Eur J Esthet Dent 4(3): 210-224 Peyton JH, Arnold JF (2008) Six or more direct resin

veneers case for accrediation: hands-on typodont exercise.

J Cosmet Dent 24(3): 38-48 Reshad M, Cascione D, Magne P (2008) Diagnostic mock-ups as an objective tool for predictable outcomes with porcelain laminate veneers in esthetically demanding patients: a clinical report. J Prosthet Dent 99(5): 333-339 Simon H, Magne P (2008) Clinically Based Diagnostic Wax-up for Optimal Esthetics: The Diagnostic Mock-up. J Calif Dent Assoc 36(5): 355-362 Vargus M (2006) Conservative aesthetic enhancement of the anterior dentition using a predictable direct resin protocol. Pract Proced Aesthet Dent 18(8): 501-507 Willhite C (2006) Freehand resin bonding: Clinical technique for diastema closure. AACD Monograph: Significant Science, Magnificent Art 3: 77-80 Reprinted with permission by Aesthetic Dentistry Today August 2017

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Introduction to clinical digital photography Richard Field1

Introduction Dental photography is not a new revelation. It has been the cornerstone of aesthetic and restorative treatment planning for many years. Traditional 35mm photography in general, not just in dental environments, was always regarded as somewhat of a specialist art in itself (Ahmad, 2009).

The monetary cost of a single exposure, once you added up the cost of the film and the processing, was such that it would put most clinicians off photographing every case.

Waiting several weeks for negatives to be returned from processing, only to find that the picture was inaedquate, was a further disincentive.

Digital photographic technology has made dental photography much more accessible and practical for everyday use.

Instead of costly negatives and film processing, which takes weeks before seeing the results, we have reusable memory cards and LCD screens on the backs of the camera, enabling us to see our photographs instantly, allowing us to quickly rectify any mistakes.

Although digital dental photography can still be daunting, with the appropriate basic kit, basic standardised settings, a little basic camera knowledge and some practice, everyone is able to take beautiful and consistent dental photographs.

Basic Kit When buying a camera for clinical dental photography, there may be a temptation to get an off-the-shelf compact ‘point and shoot’ camera or one of the more specialised dentally orientated ‘point and shoot’ cameras.

However, one of the cornerstones of good clinical dental photography is consistency, and compact setups can make it difficult to achieve consistent results. The author recommends a customised setup consisting of a DSLR camera body, a dedicated macro lens, and a macro flash. This combination of equipment allows complete control of all aspects of the photograph and as your dental photography evolves, the setup can be adjusted and adapted to suit your growing needs and skills.

DSLR camera body

Dr Richard Field Private practice, Bristol and London, UK. www.drfield.co.uk.

1

If you are a keen photographer and envisage yourself using your camera outside of work as a hobby, then by all means go for a high-end full frame camera. If, however, the camera will only be for use in your surgery, then a lower-end cropped sensor camera body is perfectly adequate.

Most DSLR cameras have sensors that exceed the minimum requirements in respect of megapixels count – 10 megapixels or more will be sufficient. The most important aspect is that the camera is comfortable to hold, as once you have attached the lens and flash, the setup becomes quite heavy.

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Some of the lower-end models have a smaller hand grip, which can be awkward to hold, but otherwise the photograph quality is more than adequate.

Lens After choosing the camera body, you will need to select a macro lens. The strict definition of a macro lens is ‘a lens which will produce a life-sized image on a full frame sensor when taken at a magnification ratio of 1:1’ – a bit like a dental periapical radiograph.

It is important that the lens has a ‘fixed focal length’, ie, not a zoom lens. The macro lens needs to have a manual focus override so you can set the magnification ratios and have a ratio window so you can consistently set these ratios.

This is important for you to keep the consistency of each exposure you take.

Some cheaper lenses have only fully automatic focusing.

The ideal macro lens to have is one with a focal length of 100 or 105mm, as this will enable the operator to stand at comfortable distance from the patient.

A 50mm or 60mm lens would also work; however, the operator would need to be positioned very close to the subject to obtain only the smile on the image.

Flash With macro photography, it is important to have enough light in order for photographs to be properly exposed and give a

shadowless image. The inbuilt flash on the camera tends to produce a shadow over the lower teeth figure from the upper incisors, and the surgery lighting alone is insufficient for dental photography.

The ideal is using a separate flash that is positioned towards the front of the lens. A ring flash variant is the traditional option for dental photography and these flash units come in both ‘wired’ and ‘wireless’ options, depending on your camera functionality.

Setup In order to obtain consistent photographs, the camera must be set in manual mode, not automatic mode. This gives the operator complete control over all aspects of the photograph rather than the camera altering settings on its own.

Image Quality A camera is capable of recording multiple different image formats. The two useful formats for dental needs are JPG and RAW. A JPG is a lower quality image; however, it is acceptable for most clinical situations. A RAW file is effectively a digital negative. It is a very large file size (up to 10 times the size of a JPG) and is sometimes requested for awards entries, exam case presentations, and medicolegal cases.

It is possible to set your camera to record JPG, RAW, or both at the same time, depending on your preferences.

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Glossary of terms • DSLR – digital single-lens reflex camera. Digital version of the traditional SLR high-end film camera • Sensor – the light sensitive area inside the camera that records the image. Effectively the ‘film’ in a digital camera - Available in ‘cropped’ or ‘full frame’ - Full frame sensors are the size of a 35mm film negative whereas a cropped sensor is a smaller sensor and only records a portion of the image of a full frame sensor, hence the term ‘cropped’ - This article will assume ‘cropped sensor’ as there is little clinical benefit of a full frame sensor over a cropped sensor • Megapixel (one million pixels) sensors will be described as having ‘X’ megapixels - The total number of pixels that make up the recorded image - The larger the number, the sharper the image - Unless photos are being enlarged to billboard size or being cropped (where you only show a small part of the original image, the number of pixels is not clinically relevant as long as the camera has more than 10 megapixels • Exposure – two definitions: - Taking a photograph can also be referred to as ‘an exposure’, ie, you have exposed the film/sensor to light - In photography, the term ‘exposure’ refers to how bright the image is. ‘Over exposed’ means too bright or too much light; ‘underexposed’ means too dark, or too little light • Depth of field – this describes how much of the image is ‘in focus’

White Balance The ‘white balance’ is the setting that allows the camera to reproduce objects that are white in real life, as white in the photograph. If the camera is set to auto white balance (AWB), often the resulting image is either too orange (warm) or too blue (cold), but more importantly may not be consistent in before and after images, which can be problematic when recording colour.

Natural daylight is in the region of 5,500K (Kelvin), similar to the colour temperature to the light from the ring flash.

Depending on the functionality of your camera, you will be able to set you camera to record close to this. Changing the settings from AWB to the ‘flash’ or ‘daylight’ settings will give a realistic colour temperature for dental photography.

Basic settings Consistently well exposed and in focus pictures rely on three elements: ISO, shutter speed, and aperture. A change in one of the three will have an impact on the others, so all three elements must be set in harmony for the type of photograph you wish to take. Luckily for dental photography, as we are shooting in a very controlled environment, we only ever need to change aperture. The ISO and shutter speed always stay the same.

ISO Sometimes called ASA, ISO is a measure of the sensor’s sensitivity to light. The lower the number, the less sensitive

the sensor, but the less grainy (noisy) the image. ISO follows a common scale across all cameras: 100, 200, 400, 800, 1,600, etc. The more advanced the camera, the higher the ISO will go. Increasing the ISO allows for a photograph to be taken in lower light conditions; however, the higher the ISO the more ‘image noise’ there is, resulting in a grainy photograph.

As we are working with a flash at close range, there is plenty of light, so the ISO can be set to 200 and in most cases this will never need to be changed.

Shutter speed Shutter speed is a measure of the amount of time that the sensor is exposed to light. It is measured in fractions of a second, eg, 1/125 or 8 milliseconds.The longer the shutter is open, the greater the chance of motion blur.

In dental photography, you will always be working with a flash, so the shutter speed can be kept high, which reduces the chance of motion blur. A shutter speed of 1/125 should be used if the camera is capable of syncing to the flash at that speed. Some lower-end models are only capable of synching the flash at 1/60.

Aperture The aperture is the size of the hole at the end of the lens when the photo is being taken. It is expressed in ‘f’ numbers or ‘f-stops’, ie, f2.8, f4, f5.6. The smaller the number, the larger the aperture, and the more light is allowed to enter

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Figure 1

Figure 2

Figure 3

Figure 4

the camera. The larger the aperture, the smaller the depth of field, ie, the less of the photograph that is in focus (Figure 1).

If too large an aperture is selected for intraoral photography, often the posterior teeth will not be in focus compared with a smaller aperture, where both the posterior and anterior teeth will be in focus (Figures 2 and 3). This is the only camera setting that will be changed on a regular basis: • Full face - more light is needed as you are standing further back from the subject. Set aperture to f10 • Smile and all intraoral shots – aperture of f25.

often do not retract far enough, hence hiding the first molars (Figures 4 and 5).

High quality intraoral dental mirrors A large occlusal adult mirror is preferable as this allows the mirror to be positioned without fingers present in the photograph. If only small occlusal mirrors are available, the use of a mirror handle is advised, as again this allows for positioning with no fingers in the shot. For buccal segment shots, thinner buccal mirrors are also available.

The use of a mirror cage is advised as these mirrors are easily scratched while cleaning, rendering them useless.

Clinical Kit There are some additional accessories required to aid in the taking of high quality, reproducible clinical photographs.

Retractors Retractors are necessary as it is not professional to have fingers (gloved or ungloved) visible in photographs.

Retractors come in many shapes and sizes. In the author’s opinion, the best are the ‘V-shaped’ type as they allow full retraction of the buccal segment, allowing for visualisation of the molar relationship. The standard ‘C-shape’ retractors

Contrastors Contrastors are used to improve the quality of the upper anterior views by obscuring the tongue and teeth in the lower arch (Figure 6). They are available in ridged metal and flexible silicone. The silicone is preferable due to lower reflection and improvement in patient comfort.

Backdrop A dedicated photo studio is the ideal setup but is not always a possibility in general practice. Having a blue or black cloth

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Figure 5

Figure 6

Figure 7

to hold behind the patientâ&#x20AC;&#x2122;s head while full-face shots are being taken is an inexpensive and effective way of improving the quality of the shots (Figure 7).

Conclusion Digital photography done correctly can have a huge positive effect on your dental practice. It can help you communicate with your patients and gain their confidence in you. It also provides a detailed record of your cases.

contemporary revolution. Int J Clin Pediatr Dent 6(3): 193-196 Goodlin R (2011) Photographic-assisted diagnosis and treatment planning. Dent Clin North Am 55(2): 211-227 Kiran DN (2010) Digital photography in dentistry. Indian Journal of Stomatology 1: 77-80 Ross B (2016) Digital photography in dentistry: Tools and techniques to help your patients and improve your practice. Dentistry IQ www.dentistryiq.com/articles/2016/01/digital- photographyin-dentistry-the-tools-and-techniques-you-need-to-help-your-patients-and -improve-your-practice.html [Accessed 2 August 2017] Sharland M (2013) Improving your image...then and now.

Digital photography in dentistry. Dent Update 40(4): 333-334

Further reading Ahmad I (2009) Digital dental photography. Part 1: an overview.

Br Dent J 206(8): 403-407 Desai V, Bumb D (2013) Digital dental photography: A

Reprinted with permission by Aesthetic Dentistry Today 10/2017

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ANESTHESIA CONSIDERATIONS FOR THE ORAL AND MAXILLOFACIAL SURGEON

SHORTCUTS IN ESTHETIC DENTISTRY

Authors: Matthew Mizukawa, Samuel J McKenna & Luis G.Vega Although office-based anesthesia administration has been essential in the evolution of outpatient surgery, it is becoming more complex as people live longer and with more comorbid diseases. The purpose of this book is to strengthen the margin of safety of office-based anesthesia administration by helping practitioners determine whether the patients they treat are good candidates for office-based anesthesia. This book is organized into three sections. The first section provides a review of the principles of anesthesia, including the pharmacology of anesthetic agents, local anesthesia, patient monitoring, preoperative evaluation, the airway, and management of emergencies and complications. The major organ systems of the body are reviewed in section two, and the most common comorbid conditions that affect these systems are described in terms of their pathophysiology, diagnosis, management, and anesthesia-related considerations. Section three reviews patient groups that warrant special consideration in the administration of office-based anesthesia, such as geriatric, pediatric, pregnant, and obese patients. Spiral-bound and featuring tabs for quick and easy reference, this important book belongs on the shelf of every clinician who provides anesthesia in the office setting.

Q-5120849; 482 pp; 101 illus

Author: Ronaldo Hirata This clinically driven text focuses on the difficulties of esthetic restorative dentistry with the aim of revealing simple and practical solutions to common questions and problems. Each chapter is organized into a series of questions the reader may have; the book then answers these questions in detail using scientific evidence and case presentations. The author presents streamlined procedures step by step and provides numerous tips on how to implement the concepts described. Restoration strategies include guidance on recontouring, stratification schemes, layering techniques, characterization, occlusal concepts, and more. Accessible and minimalist in its approach, this deceptively thorough book demystifies contemporary esthetic dentistry and outlines simple and effective solutions for clinical practice.

Clinicians will find themselves referring back to this text long after the first read-through for quick, easy-to-find answers and solutions to some of esthetic dentistry's most common problems.

Q-5120848; 688 pp; 3,588 illus

All products available from: HENRY SCHEIN HALAS • Tel: 1300 65 88 22 • www.henryschein.com.au

58 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 13, NO. 1

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All products available from: HENRY SCHEIN HALAS • Tel: 1300 65 88 22 • www.henryschein.com.au

60 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 13, NO. 1