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Volume XVIII, Number III, 2011
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CONTENTS Volume X VIII, Number III, 2011 EDITORIAL TEAM Alfred Naaman, Nada Naaman, Jihad Fakhoury, Dona Raad, Antoine Saadé, Lina Chamseddine, Tarek Kotob, Mohammed Rifai, Bilal Koleilat, Mohammad H. Al-Jammaz COORDINATOR Vanessa Abdelahad ART DEPARTMENT Krystel Kouyoumdjis SUBSCRIPTION Micheline Assaf, Nariman Nehmeh ADVERTISING Josiane Younes PHOTOGRAPHY Albert Saykali TRANSLATION Gisèle Wakim, Marielle Khoury DIRECTOR Tony Dib ISSN 1026-261X
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Tooth Discoloration after Bracket De-bonding: An in Vitro Study Dr. Yousef Tashkandi
DENTAL NEWS – Sami Solh Ave., G. Younis Bldg. POB: 116-5515 Beirut, Lebanon. Tel: 961-3-30 30 48 Fax: 961-1-38 46 57 Email: info@dentalnews.com Website: www.dentalnews.com www.facebook.com/dentalnews1
Pr. M.A. Bassiouny BDS, DMD, MSc, Ph.D. Director International Program, Temple University, Philadelphia, USA. Pr. N.F. Bissada D.D.S., M.S.D Professor and Chairman, Department of Periodontics, Case Western Reserve University, USA. Pr. Jean-Louis Brouillet D.C.D, D.S.O. Chairman, Department of Restorative Dentistry, Aix-Marseille II, France. Pierre Colon D.C.D., D.S.O. Maître de conférence des universités, Paris, France. Dr. Jean-Claude Franquin, Directeur de l’Unité de Recherche ER116, Marseille, France. Pr. Gilles Koubi D.C.D., D.S.O. Department of Restorative Dentistry, Aix-Marseille II, France. Pr. Guido Goracci. University LA SAPIENZA, School of Medicine & Dentistry, Roma, Italia. Brian J. Millar BDS, Ph.D. Guy’s, King’s, and St. Thomas’ College School of Medecine & Dentistry, London, UK. Pr. Dr. Klaus Ott, Director of the Clinics of Westfälischen Wilhelms-University, Münster, Germany. Wilhelm-Joseph Pertot DEA, Maître de conférence, Aix-Marseille II, France. Pr. Dr. Alfred Renk, Bayerische Julius-Maximilians-University, Würzburg, Germany. Dr. Philippe Roche-Poggi DEA. Maître de conférence des universités, Aix-Marseille II, France. Michel Sixou D.C.D., D.E.A. Department of Priodontology, Toulouse, France. Pr. M. Sharawy B.D.S., Ph.D. Professor and Director, Department of Oral biology, Medical College of Georgia, Augusta, Georgia, USA.V
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Prevalence of Severe Early Childhood Caries in Al-Jahra Area, KUWAIT Dr. S. R. Koshy, Dr. W. AL-Deeweli Distraction Osteogenesis for Augmentation of Anterior Mandibular Segment after Failed Implants Removal: A Case Report Dr. Ali Alajmi When to Decide to Remove an Endodontically Treated Tooth? Dr. Yaser Al Asousi LEBANESE UNIVERSITY International Dental Meeting - June 2-4, 2011 5th CAD/CAM & Computerized Dentistry International Conference May 12-13, 2011
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DENTAL NEWS IS A QUARTERLY MAGAZINE DISTRIBUTED MAINLY IN THE MIDDLE EAST & NORTH AFRICA IN COLLABORATION WITH THE COUNCIL OF DENTAL SOCIETIES FOR THE GCC. Statements and opinions expressed in the articles and communications herein are those of the author(s) and not necessarily those of the Editor(s) or publisher. No part of this magazine may be reproduced in any form, either electronic or mechanical, without the express written permission of the publisher.
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CONTENTS
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INTERNATIONAL CALENDAR September 21 - 24, 2011 BIDM, Beirut Int’l Dental Meeting, Congress Palace, Dbayeh, Lebanon Email: bidm@lda.org.lb Website: www.bidm-lda.com
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October 16 - 19, 2011 New Dental Era - The 3rd National Guard & 1st Endodontic Society International Conference and workshops at the Riyadh Marriott Hotel Email: ManabatM@ngha.med.sa October 26 - 28, 2011 Egyptian Dental Association The E.D.A In collaboration with Future University organize the 15th International Dental Congress set to take place from the 25th to 28th October 2011 at Cairo City Stars Hotel. Email: eda@internetegypt.com.eg Website: www.eda-egypt.org
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October 27 - 29, 2011 3rd Dental-Facial Cosmetic International Conference The event will take place at the Jumeirah Beach Hotel in Dubai, UAE Email: info@cappmea.com Website: www.cappmea.com/aesthetic2011
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January 31 - February 2, 2012 AEEDC 2012 The 16th edition of the UAE International Dental Conference & Arab Dental Exhibition AEEDC Dubai 2012 will take place at the state-of-the-art Dubai International Convention & Exhibition Centre (DICEC). Email: vaneza.santos@index.ae Website: www.aeedc.com
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ORTHODONTICS
Tooth Discoloration after
Bracket De-bonding An in Vitro Study
Dr. Yousef Tashkandi, BDS, MSc, Pr. Jan Huggare. DDS, PhD, Fadi El-Homsi. BDentTech, PhD
Materials and Methods: Twenty premolars were divided into two groups of 10 teeth each. Buccal surfaces of these teeth were divided vertically into two sites, control and test sites. Test sites were subjected to bracket bonding and de-bonding procedures. Enamel changes in colour and brightness were evaluated twice, after brackets de-bonding as a base line reading, and after 10 days of incubation in tea and coffee. Vita Easy-Shade spectrophotometer was used for recording the changes in classical shade guide and L* values (lightness). Results: The mean Classical and L* value changes in both groups, tea and coffee, showed a significant discoloration and an increased darkness in both control and test sites (p < 0.001). These changes were significantly higher in test sites for both the classical shade guide (p < 0.003) and for L* values (p < 0.001), even though these sites were significantly brighter at baseline readings (p < 0.002 for classical and p < 0.001 for L*). Tea and coffee showed similar degree of staining potential of the enamel surfaces. Conclusion: There is significant change in enamel discoloration after brackets de-bonding which affects the stability of enamel colour and brightness. Keywords: De-bonding, Classical shade, Easyshade guide, Enamel discoloration, Spectrophotometer, Tea and Coffee stain.
Introduction Multiple irreversible adverse effects and changes to enamel surfaces during orthodontic treatment can occur during etching,
bracket bonding and de-bonding procedures. These changes include; enamel loss, decalcification and formation of white spots, an increased risk of caries development, formation of enamel micro-cracks and scratches, and abrasions induced by enamel smoothing procedures(1, 2, 3, 4). Different acid etching techniques showed different levels of enamel loss with formation of enamel pores that varied in sizes (5-6 Îźm in diameter and 30-60 Îźm in depth), giving a honeycomb appearance(5, 6, 7). During the bonding procedures the adhesive resins fill these pores and form retentive resin tags or projections(8). After bracket de-bonding, several methods have been used to eliminate the remaining composite resins such as high or low speed rotary instruments with spiral 12-fluted tungsten carbide burs or ultrasonic scalers. Regardless of the method used, loss of enamel surface and presence of remaining resin tags have been reported(7). The colour of enamel surfaces is usually defined by the combined effects of intrinsic and extrinsic discolouring agents(9, 10). Long-term exposure of resin tags to extrinsic discolouring agents (from diet, tea, coffee, chlorhexidine, or iron salts) increases the risk of enamel staining. Light and chemically cured adhesives were changed in colour when they were subjected to artificial photo-aging(11). Faltermeier et al. recently reported unsatisfactory colour stability of orthodontic adhesive resins when the teeth were exposed to food colorants, as for instance tea(12). Several studies reported colour changes of composite resins after tea and coffee exposure, with more pronounced discoloration in coffee than tea(13, 14) . Similar degree of discoloration of composite resins from tea and coffee exposure was found in other studies(15, 16). The phenomenon of colour appearance is complex and encompasses both subjective and objective phenomena. It consists of three direction entities, which were described first by Sigried Forsius in 1611(17). Usually, it is described according to the MunDental News, Volume XVIII, Number III, 2011
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Abstract The purpose of this study: to assess the changes in colour and brightness of dental enamel after bracket de-bonding following 10 days exposure to discolouring solutions of tea and coffee.
Tooth Discoloration after Bracket De-bonding: An in Vitro Study
Karolinska Institutet Prince Abdulrahman Advanced Dental Institute (PAADI) tashkandiy@hotmail.com - +966 555 789 259
sell colour space in terms of value (L*), chroma (C*), and hue (h*), in which L* represents the brightness of the colour with a zero value of pure black and 100 of pure white. The C* denotes the degree of saturation of a colour in an object and h* represents the pure colours. Professional visual colour assessment depends on several factors such as: type of light sources, teeth surface textures, effect of the surrounding structures and other biological aspects and finally colour decision in the observers’ brain(18). Colour matching in dentistry is routinely performed visually with the traditional methods of shade selection using prefabricated shade guide tabs and colour duplication(19). Several shade guides are available on the market and one that well matches Munsell´s description is the Vita Classical shade guide. In this guide the tabs are divided into four groups with a primary group division based on hue. Group A represents the reddish brown colour, group B the reddish yellow, group C the gray, and group D the reddish gray. In each group the shade guide tabs are arranged using chroma as a base(20). Although this is the most popular and traditionally used method, it gives subjective and inconsistent results. This is because of variable viewer interpretation and environmental influences such as age and emotion of the viewer, fatigue of the human eye, level of experience, lighting conditions and also physiological variables such as colour blindness(21). In 1998, colour analysis instruments were used to provide more reproducible, faster and accurate results than visual shade matching(22, 23, 24). Spectrophotometer and colorimeter devices are now used to assess teeth colour through classical shade guides, and through generating mathematical comparable L*, C* and h* values that allows quantifying the colour(21, 24, 25). The aim of this in vitro study was to assess the changes in enamel colour and brightness after bracket de-bonding and after 10 days exposure to coffee and tea.
Materials and Methods An ethical approval of this study was obtained from the Regional Board of Ethical Vetting in Stockholm to use human teeth extracted due to orthodontic reasons.
Teeth selection: Twenty upper and lower premolars, freshly extracted for orthodontic reasons, were selected from patients 14-18 years of age. All teeth had visually intact occlusal, buccal and lingual enamel surfaces, without any visual discoloration. They were stored in physiological saline solution at 8° C until the experiment started. They were randomly divided into two groups of 10 teeth each, one group for immersion in tea and the other in coffee. Buccal surfaces of all teeth were vertically divided into two halves; one was used as a test site and the other as a control. Two orthodontic brackets (Victory, Monrovia, USA) were bonded to each test site, while control sites were left untouched (Fig 1). Fixation of teeth for spectrophotometer measurements: To enable the spectrophotometer probe (Fig 2) to assess the same area on each site during repeated measurements, both teeth and spectrophotometer tip were fastened at a fixed distance. Two changeable moulds of silicon putty material (President, Coltene, USA) were constructed for each tooth, one to assess test site and the second to assess the control site. Both moulds were constructed to allow the tip of the spectrophotometer probe to be placed at right angle to the control and test sites (Fig 3). Preparation of test surfaces: Enamel surfaces were first cleaned with a low speed rotating rubber-cup with pumice and water, and then dried thoroughly using a 3-in-1 syringe and air-drying with oil free compressed air before starting bonding procedures. Test sites were etched with 35% phosphoric acid gel (Ultra-Etch®, South Jordan, USA) according to the manufacturer instructions. Then, teeth were thoroughly washed with running water and air-dried for 20 seconds until the enamel surfaces became frosty white in appearance. A thin uniform coat of resin primer Transbond XT (3M Unitek®, Monrovia, USA) was applied to test sites and cured with a light curing device (Ortholux, LED, 3M Unitek®, Seefeld, Germany) for 10 seconds. Since the size of the bracket base was smaller than the diameter of the spectrophotometer probe, two orthodontic premo-
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Tooth Discoloration after Bracket De-bonding: An in Vitro Study
ORTHODONTICS
Fig 1: Brackets bonded on test sites. (T) = Test site. (C) = Control site. Dental News, Volume XVIII, Number III, 2011
Fig 2: Easy-Shade Spectrophotometer.
ORTHODONTICS
lar brackets were bonded vertically in test sites using adhesive composites (Transbond XT, 3M Unitek®, Light Cured Orthodontic Adhesive Monrovia, USA) according to the manufacturer instructions. The distance between the two brackets was less than 1mm and it was covered completely with adhesive resin. The excess composite materials were removed from the remaining bracket margins using a dental probe. (Fig 1). After brackets bonding, the teeth were kept in isotonic solution (Natriumklorid 9 mg/ml, Fresenius Kabi AB, Uppsala, Sweden) at 37° C for 24 hours, and then the brackets were removed with a de-bonding pliers. The remaining adhesive composites were removed by a 30- fluted carbide flat fissure burr (Morrisburgy, Canada) rotating at 20,000-30,000 rev/min. A dental probe was run over enamel test surfaces to ensure complete removal of excessive adhesive composite material. Baseline measurements for colour and brightness were registered after de-bonding, on both test and control sites. The final measurements were made after 10 days of incubation in the discolouring solutions. To protect the roots from absorbing staining solution, all roots were covered with an impression compound (Thermoplastics Impression material, Salerno, Italy), up to 1 mm above the cemento-enamel junction. The impression compound was removed and changed after five days in the staining solution. Staining solutions: To induce staining and discoloration of enamel surfaces, 10 teeth were immersed in tea and 10 in coffee media without any additives. A stock solution of tea was prepared by immersing a prefabricated (2 x 2 g) tea bag (Yellow Lipton, United Kingdom) into 200 ml of 65 degrees Celsius (°C) hot water. The coffee solution was prepared also by pouring 5 g of instant coffee Table I: Vita Classical shade guide tabs ranked in commonly known ranking from the lightest (1) to the darkest (16) Ranks
1
2
3
4
5
6
7
8
9 10 11 12 13 14 15 16
Vita Classical B1 A1 B2 D2 A2 C1 C2 D4 A3 D3 B3 A3.5 B4 C3 A4 C4 shade tabs
Fig 4: Methods and measurement sequence.
(Nescafe, Sweden) into 200 ml of 65°C hot water. The prepared teeth were separately put in test-tubes with 3ml of each solution at 37° C in a dark environment for 10 days. Both solutions were changed every two days. Then, teeth were brushed with a medium-bristle toothbrush, rinsed with tap-water and dried with oil free compressed air for 5 seconds before each measurement. Spectrophotometer analysis: Enamel discoloration and brightness were assessed using the Vita Easy-shade spectrophotometer (Fig 2 & 3). It uses D65 illumination for shade matching and this represents a phase of daylight with a correlated colour temperature of about 6500 K. ”Normal Mode” and” Tooth single” settings were selected. The device was calibrated with a calibration block (supplied with the device) each time when the device was switched on. Both classical shades and L* values (expressing lightness) were utilized in this study. The classical shade tabs were arranged in value order, where each shade was given a number between 1 and 16. Number 1 represents the lightest value and 16 represents the darkest (Table I). A baseline assessment was registered twice for both the control and test sites in classical shades and L* values after bracket de-bonding and cleaning of enamel surfaces. The mean of classical shades and L* was calculated for each surface. The final assessment was also registered twice after 10 days of incubaTable II: Mean Tea and Coffee Classical shade values for Control and Test sites and the difference between baseline and at 10 days
Control
at Baseline at 10 days Test at Baseline at 10 days Difference in Control Difference in Test
N 10 10 10 10 10 10
TEA Mean 13,20 14,90 12,20 15,80 1,70 3,60
SD 1,69 1,10 0,92 0,42 1,49 0,84
N 10 10 10 10 10 10
COFFEE Mean 13,50 14,50 12,20 15,10 1,00 2,90
SD 1,43 1,08 0,92 0,32 1,63 1,10
Dental News, Volume XVIII, Number III, 2011
Tooth Discoloration after Bracket De-bonding: An in Vitro Study
Fig 3B: Position and assessment of Test site.
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Fig 3A: Position and assessment of Control site.
16
Tooth Discoloration after Bracket De-bonding: An in Vitro Study
ORTHODONTICS
Fig 5: Mean Classical shade change from baseline to 10 days in Control and Test sites for Coffee and Tea.
Fig 6: Mean L* value changes from baseline to 10 days in Control and Test sites for Coffee and Tea
tion period in coffee and tea and the differences between the baselines were calculated. Fig. 4 summarizes the methods and measurement sequence.
A4, in both groups. Therefore the mean difference in changing the colour of test sites was three shade tabs (Table II). â&#x20AC;˘ Control sites were significantly changed to darker colour after 10 days in both classical shade and L* values (p < 0.001), for both tea and coffee groups. The mean classical shade of control sites was changed from B4 to C3, in both groups. Therefore the mean difference in changing the colour of control sites was one shade tab. So the mean difference in colour change between the control and test sites was two shade tabs, for both groups, which was statistically significant (p < 0.001) (Fig. 5). The mean L* values for both groups at baseline and after 10 days, and the mean difference between control and test sites are illustrated in Table III. It showed that after 10 days in media, teeth in the tea group became darker (lower L* values) than those in the coffee group (p = 0.002). Regardless of media, the mean difference in L* val-
Statistics: The data was analyzed by three-way ANOVA with repeated measures on two factors: between-group factor (which was the media: tea and coffee respectively), and the within groups factor (sites and time). The interaction between time and site was of special interest, implying to the statistical test of whether there was a significant difference between test and control sites after 10 days. Mean differences for the control and test sites after 10 days in tea and coffee were estimated from the ANOVA-model with 95% confidence intervals (CI).
Results: Regardless of media, the site and time interaction was significant in both classical shade and L* values (p < 0.001). Assessments at 10 days showed that the test sites were significantly darker than control sites in both groups for both classical shades and L* values (p = 0.003 and p < 0.001 respectively). â&#x20AC;˘ Test sites were lighter than control sites at baseline in both classical and L* values (p = 0.002 and p < 0.001 respectively). The mean classical shade of test sites was changed from A3.5 to Table III: Mean Tea and Coffee L* values for Control and Test sites and the difference between baseline and at 10 days
Control
at Baseline at 10 days Test at Baseline at 10 days Difference in Control Difference in Test
N 10 10 10 10 10 10
TEA Mean 76,88 69,46 79,27 63,31 -7,42 -15,96
Dental News, Volume XVIII, Number III, 2011
SD 4,58 4,77 3,80 4,21 6,26 3,78
N 10 10 10 10 10 10
COFFEE Mean 76,21 74,05 79,06 69,47 -2,16 -9,59
SD 2,68 2,37 2,55 2,00 1,83 2,98
Fig 7: Mean Classical value changes from baseline to 10 days for Control and Test sites of 20 teeth.
ues between control and test sites were different and the test sites became darker (lower L* values). This also was statistically significant (p < 0.001) (Fig. 6). Since all 20 teeth and both media exhibited changes in colour and increased the darkness of control and test surfaces with a statistically significant differences, the mean changes for all teeth in classical shades and L* values from baseline to 10 days are presented in Fig. 7 and 8.
Discussion: Three-way ANOVA was used to determine the repeated measures on media, sites and time respectively. As the three factor interactions were not significant, the time and media interaction was independent of sites and the site and time interaction was independent of media. Therefore the results were presented as the mean of all 20 teeth for each site. This study disclosed a great effect of tea and coffee in changing the colour and brightness of de-bonded enamel surfaces. Few studies have been conducted to reveal discoloration effects of residual resin projections after orthodontic bracket de-bonding. Since several in-vitro studies on discoloration after tooth bleaching have used coffee and tea as discolouring agents(15, 16, 26), it seemed reasonable to use these agents in this study. However, long continuous exposure time of media on enamel surfaces is not representing the actual consumption of coffee and tea by the individuals. But due to the need of accelerating the effects of these media in this study, the effect of long time use of these beverages could give similar results. The effect of tea and coffee in this study showed marked changes in colour and brightness of teeth in both control and test enamel surfaces. Whereas, some studies showed a more pronounced effect on composite resins with coffee(13, 14). The Easy-shade spectrophotometer was used to provide objective and more reproducible measurements of the change in Vita
Conclusion: The exposure of de-bonded enamel surfaces to tea and coffee, for 10 days, changed the colour and brightness of these surfaces. The discoloration was more obvious in enamel surfaces that had been subjected to bracket bonding and de-bonding. Further studies should be done to evaluate the extent of these stains in bonded and de-bonded surfaces in order to avoid the destructive effect of bonding and de-bonding procedures, and subsequently having a bonding material with high colour stability. Acknowledgements: I would like to express my sincere thanks to Professor Lars-Ă&#x2026;ke Linden and for his supervision. I also would like to thank Ms. Elisabeth Berg and Dr. Abeer Sofrata, for their help in statistics and data analysis. References available on www.dentalnews.com Dental News, Volume XVIII, Number III, 2011
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Fig 8: Mean L* value changes from baseline to 10 days for Control and Test sites of 20 teeth.
classical shade and L* values(23, 24). In addition, L* values were chosen to define the brightness and darkness effect mathematically and to support the classical shade measurements which has a more clinical significance. It has been shown that the major parameter causing color changes was in L* values rather than in chroma(27). Since baseline measurement were obtained after de-bonding and cleaning enamel surfaces from gross adhesive composites, the significant differences between control and test sites in baseline reading might be due to the effect of surface etching and the presence of remaining resin projections. These resin infiltrates also might alter the light reflection and influence the colour parameters. In a study Hintz et al. examined the bleaching effect of 10% carbamide peroxide on both control and test (bonded and debonded) surfaces for 4 hours every day for 30 days. They found that the control sites had significant colour changes at the beginning of the experiment. By the end of 30 days, these changes became insignificant and both surfaces were affected equally. It partially supports the results of the present study, in which both control and test sites were subjected to colour changes(28). Another study assessed the discoloration and staining of enamel surfaces in four media which supports the susceptibility of control sites to be stained as well as the prepared tests sites(26). Unsatisfactory colour stability and potential discoloration were found with the use of a conventional orthodontic adhesive resin; Transbond XT, which is the same kind of adhesive resin that has been used in this study(12). The discoloration of test sites in this study was probably due to the degree of water absorption of the hydrophilic resin(29). Several enamel changes occur throughout life, such as decreasing in facial enamel thickness above cemento-enamel junction(30). In addition to that, enamel surfaces of elderly people are darker and have more cracks than teeth of young people (31). These changes might alter the response of enamel surfaces to discoloration if adult teeth have been used.
Tooth Discoloration after Bracket De-bonding: An in Vitro Study
ORTHODONTICS
ORTHODONTICS
Tooth Discoloration after Bracket De-bonding: An in Vitro Study
References 1. Zachrisson B U, Årthun J. Enamel surface appearance after various debonding techniques. Am J Orthod 1979; 75:121-37. 2. Sandisson R M. Tooth surface appearance after debonding. Br J Orthod 1981; 8:199-201. 3. Mizrahi E. Surface distribution of enamel opacities following orthodontic treatment. Am J Orthod 1982; 84:323-31. 4. Ogaard B, Rolla G, Arends J. Orthodontic appliances and enamel demineralization. Part 1. Lesion development. Am J Orthod Dentofacial Orthop 1988; 94:68-73. 5. Retief D H. Effect of conditioning the enamel surface with phosphoric acid. J Dent Res 1973; 52:333-41. 6. Silverstone L M, Saxton C A, Dogon I L, Fejerskov O. Variations in the pattern of acid etching of human dental enamel examined by scanning electron microscopy. Caries Res 1975; 9:373-5. 7. Hosein I, Sherriff M, Ireland A J. Enamel loss during bonding, debonding, and cleanup with use of a self-etching primer. Am J Orthod Dentofacial Orthop 2004; 126:717-24. 8. Gwinnet A J. Histologic changes in human enamel following treatment with acidic adhesive conditioning agents. Arch Oral Biol 1971; 16:731-8. 9. Watts A, Addy M. Tooth discolouration and staining: a review of the literature. Br Dent J 2001; 190:309-16. 10. Joiner Andrew. Tooth colour: a review of the literature. J Dent 2004; 32:S3-S12. 11. Eliades T, Gioka C, Heim M, Eliades G, Makou M. Color stability of orthodontic adhesive resin. Angle Orthod 2004; 74:391-3. 12. Faltermeier A, Rosentritt M, Reicheneder C, Behr M. Discolouration of orthodontic adhesives caused by food dyes and ultraviolet light. Eur J Orthod 2008; 30:89-93. 13. Luce M S and Campbell C E. Stain potential of four micro-filled composites. J Prosthet Dent 1988; 60:151-5. 14. Ertas E, Guler A U, Yucel A C, Köprulu H & Guler E. Color stability of resin composites after immersion in different drinks. Dent Mater 2006; 25:371-6. 15. Türkün L S and Türkün M. Effect of bleaching and repolishing procedures on coffee and tea stain removal from three anterior composite veneering materials. J Esthet Restor Dent 2004; 16:290-301. 16. Yazici AR, Çelik Ç, Dayangaç B, Özgünaltay G. The Effect of Curing Units and Staining Solutions on the color Stability of Resin Composites. Oper Dent 2007; 32:616-22. 17. Karamouzos A, Papadopoulos M A, Kolokethas G, Athanasiou. Precision of in vivo spectrophotometric colour evaluation of natural teeth. J Oral Rehabil 2007; 34:613-21.
Dental News, Volume XVIII, Number III, 2011
18. Sproull Rebert C. Color matching in dentistry. Part I. The three-dimensional nature of color. 1973. J Prosthet Dent 2001; 86:453-7. 19. Wee A G. Description of color, color replication process and esthetics. In: Rosenstiel SF, Land MF, Fujimoto J, editors. Contemporary fixed prosthodontics. 4th. ed. St. Louis: Mosby 2006; 712. 20. Paravina R D, Powers J M. Esthetic color training in dentistry. St. Louis: Elsevier Health Sciences 2004; 39-44. 21. Okubo Scott R, Kanawati Afli, Richards Mark W, Childress Steve. Evaluation of visual and instrument shade matching. J Prosthet Dent 1998; 80:642-8. 22. Horn D J, Bulan-Brady J, Lamar Hicks M. Sphere spectrophotometer versus human evaluation of tooth shade. J Endod 1998; 24:786-90. 23. Paul S J, Peter A, Rodoni L, Pietrobon N. Conventional visual vs spectrophotometric shade taking for porcelain-fused-to-metal crowns: a clinical comparison. Int J Periodontics Restorative Dent 2004; 24:222-31. 24. Hassel Alexander J, Grossmann Anne-Christiane, Schmitter Narc, Balke Zibandeh, Buzello Anja M. Interexaminer reliability in clinical measurement of L*C*h* values of anterior teeth using a spectrophotometer. Int J Prosthodont 2007; 20:79-84. 25. Goodkind R J, Keenan K M, Schwabacher W B. A comparison of chromascan and spectrophotometric color measurements of 100 natural teeth. J Prosthet Dent 1985; 53:105-9. 26. Oikarinen K S and Nieminen T M. Influencing of acid-etch splinting methods on discoloration of dental enamel in four methods: an in vitro study. Scand J Res 1994; 102:313-8. 27. Bagheri R, Burrow M, Tyas M. Influence of food-stimulating solutions and surface finish on susceptibility to staining of aesthetic restorative materials. J Dent 2005; 33:389-98. 28. Hintz J K, Bradley T G, Eliades T. Enamel colour changes following whitening with 10 per cent carbamide peroxide: a comparison of orthodontically-bonded/debonded and untreated teeth. Eur J Orthod 2001; 23:411-5. 29. Reise A F, Giannini M, Lovadino J R, Ambrosano G M. Effects of various finishing systems on the surface roughness and staining susceptibility of packable composite resin. Dent Mater 2003; 19:12-8. 30. Atsu Saadet Saglam, Aka P Sema, Kuckesmen H Cenker, Kilicarslan Mehmet A, Atakan Cemal. Age-related changes in tooth enamel as measured by electron microscopy: Implications for porcelain laminate veneers. J Prosthet Dent 2005; 94:336-41. 31. Hartmann Rüdiger, Müller Frauk. Clinical studies on the appearance of natural anterior teeth in young and old adults. Gerodontology 2004; 21:10-6.
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COMMUNITY DENTISTRY
Prevalence of severe
early childhood caries
in Al-Jahra area, Kuwait
S. R. Koshy, W. Al-Deeweli AL-Jahra Dental Specialty Centre, Ministry of Health, Kuwait email: aldeeweli@hotmail.com
20
PREVALENCE OF SEVERE EARLY CHILDHOOD CARIES IN AL-JAHRA
Abstract The purpose of this retrospective study was to determine the prevalence of severe early childhood caries (S-ECC) occurring in a government based pediatric dental outpatient clinics in the Al-Jahra district, Kuwait. The data was abstracted from patient records of 2005 to 2009 with decayed component taken into account. The dental records of only Kuwaiti children who were medically fit and in the 3 age groups of 0-1, 1-2 and 2-3 years of age were assessed for the study. The percentage of children with S-ECC was high at 73.8% with 31.9% examined in the 1-2 yr age group (mean age=1.07yrs) and 66.3% in the 2-3 yr age group (mean age=2.03yrs). The dental visits in the age group 0-1 yr were only 1.6% (mean age=6.9 months). The maxillary anterior teeth were the most frequently affected teeth at 82.7%. This study proves that early oral health exam and early dental treatment is required in preventive as well as restorative needs. The relatively high prevalence of S-ECC shows the need for immediate and appropriate primary preventive strategies with an emphasis on perinatal and infant oral health policies.
Introduction The facts of early childhood caries (ECC) and severe early childhood caries (S-ECC) have been well established. ECC is a chronic, transmissible infectious disease with a multi factorial etiology(1,2). ADA defines ECC as the presence of 1 or more decayed (non cavitated or cavitated lesions), missing (due to caries) or filled tooth surfaces in any primary tooth in a child 71 months of age or younger. In children younger than 3 yrs of age, any sign of smooth surface caries is indicative of severe ECC (S-ECC)(3). In the state of Kuwait, the prevalence of dental caries is high(4). Although various surveys have been conducted, it has been difficult to conclude with any certainty that there is a clear trend towards fewer caries free children. Most of the studies have been focused in children above 4 yrs of age(5-8), with very few done at the early childhood stages(9,10). Although there are numerous preventive programs implemented in the country for school age Dental News, Volume XVIII, Number III, 2011
children, there is a need for more health promotion and community oriented programs focusing the main efforts on the younger age groups(11). This retrospective study aims to estimate the prevalence of S- ECC in children less than 3 years of age. A statistical prevalence can help show the severity of the disease as a major health problem in the Al-Jahra area and recommendations that can be implemented as a major preventive and interceptive effort to combat the disease.
Methods The dental records of Kuwaiti children below the age of 3 yrs (0-36 months) visiting the government based pediatric clinics at the Specialty Dental Centre, Al-Jahra, Kuwait were assessed. The information was obtained by examining the data recorded at the first dental visit. All subjects were in the age range of 0-36 months of age from the time of beginning of the data collection. The records from the past 5 years were taken into account (2005-2009). Medically compromised children as well children of non Kuwaiti origin were excluded from the study. All the information had been recorded by 6 dentists in the past 5 yrs and dental caries was recorded according to the diagnostic criteria of WHO although here only the decayed component was taken into consideration.(12) Patients who had undergone any trauma to the teeth were also recorded as well as other complaints e.g., Teething, eruption delays cyst problems, supernumerary teeth, herpetic gingivostomatitis. A combination of caries and trauma was also noted with decayed teeth included under number of children with decay denoting S-ECC. Fig. 1: Comparison of examined male female patients
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COMMUNITY DENTISTRY Fig. 2: Number of patients in each age group/year
Fig. 5: % carious teeth male female
Results
Fig. 6: Carious maxillary vs mandibular central incisors
A total of 485 records were obtained with all the criteria. They were divided according to the age groups and male vs. female (Fig.1 and 2). Overall males were higher in number at 56% whereas females were 44%. The average ages in each group are shown in table 1 Table 1: Average ages of patients
0-1 yrs
22
PREVALENCE OF SEVERE EARLY CHILDHOOD CARIES IN AL-JAHRA
Years 2009 2008 2007 2006 2005
M 0.00 0.70 0.90 0.00 0.00
F 0.00 0.00 0.00 0.90 0.20
1-2 yrs M 1.07 1.08 1.07 1.09 1.08
F 1.07 1.06 1.09 1.08 1.06
2-3 yrs M 2.03 2.04 2.09 2.00 2.04
F 2.10 2.03 2.04 1.97 1.96
There was a significant difference in the percentages of children in the various age groups brought to the pediatric dental clinics. An almost negligible 1.6% of the children less than 1 year of age were seen, whereas almost 66.3% of the records accounted for children above 2 years of age (Fig.3) The main difference of course is in the comparison of children who are caries free and those affected by caries (Fig.4). 73.8% of the children exhibited caries where as only 12.1% was caries free. In the 1-2 year and 2-3 year age group there was only 3.56% of children caries free. Although the 0-1 year age group exhibited no caries, all of them presented at the clinics for either trauma or other oral problems. This would account for the percentage of decay to be slightly higher than if only the 1-2 year and 2-3 year age groups were taken into account. (Fig.5) The percentage of teeth most affected was also calculated with primary maxillary central incisors affected the maximum in 82.7% of the children. The mandibular primary incisors were the least affected indicative of a high occurrence of nursing caries. (Fig.6) Fig. 3: Percentage of age groups examined
Dental News, Volume XVIII, Number III, 2011
Fig. 4: Caries vs caries free
The occurrence of trauma was also tabulated from 2005-2009 (table 2). 12.3% of the children suffered trauma. The males in all three age groups were affected more by trauma when compared to the females. (Fg.7) A total of 13 children exhibited trauma along with caries (2.6%). The trauma may have occurred due to the weakening of the tooth structure due to decay. Table 2: Occurrence of trauma according to the age groups (%) Years 2009 2008 2007 2006 2005
0-1 yrs
1-2 yrs
2-3 yrs
0.00 33.30 33.30 100.00 0.00
13.60 17.10 23.30 32.00 42.80
7.69 10.70 9.20 12.50 15.00
There were other oral conditions that were evaluated during data collection (table 3). These were mainly seen in the 0-1 and 1-2 year age groups (Fig.8)
Discussion In this study, the young age of the children and dental caries exhibited clearly shows that the disease process is severe. A high caries rate of 73.8% in a small section of the population with maximum carious involvement of the maxillary incisors and minimal infliction on mandibular anteriors is indicative of nursing caries as the cause of S-ECC(15). The present study has taken just a small percentage of the total population in the Jahra governorate. An average birth rate of Kuwaiti children in the Jahra area from 2005-2009 is shown in table 4. Of this only 2.2% of the population Fig. 7: Gender distribution affected by trauma
COMMUNITY DENTISTRY
Teething Eruption cyst Eruption hematoma Delayed eruption Herpetic Gingivostomatitis Mandibular shift Dentinogenesis imperfect Bohnâ&#x20AC;&#x2122;s nodules Mucocele Partial anodontia Pericoronitis
5 9 3 3 7 1 1 2 1 1 1
has been taken into account.(18) A high prevalence of S-ECC in the small part of the population shows a dangerous trend in the increase of total caries rate. There is a need to formulate a concise plan and protocol to battle caries. Previous studies done in Kuwait in kindergarten children have shown a 12% experience in nursing caries(16). A 1995 study showed 26% of the children belonged to the high caries group with a dmft > 5(17) inspite of the study population belonging to a higher socio economic group. The Al-Jahra governorate is one of the areas in Kuwait with a lower social class and residence, both factors which are known to relate to caries prevalence and oral health behaviors.(13,14) Further studies are required to assess the knowledge, attitude and practice of the parents/caregivers in relation to oral health of the very young children. Most adults believe that a child under school age is too young for enforcing tooth brushing and oral hygiene habits. They believe the primary teeth are temporary and therefore not important to deserve care. It is imperative to improve public knowledge of oral hygiene to promote dental care for the very young children.
Maxillary anterior teeth have been shown to be the most affected by decay. In a study done in Arizona maxillary anterior caries developed as early as 10-12 months of age whereas fissure caries of molars were detected as early as 13-15 months of age and posterior proximal caries by 19-21 months(24). When there is such an early loss of teeth in the upper anterior region there might be abnormal swallowing and speech sounds, delay or acceleration of permanent teeth eruption, eating difficulty and development of orthodontic problems. Dental problems in early childhood have been shown to be predictive of not only future dental problems but also on growth and cognitive development by interfering with comfort, nutrition, concentration and school participation. Dental caries presentation in 3-4 year old children can identify those children and tooth surfaces that will be at the greatest risk for future caries development(35,36).
Children born in Al-Jahra Governorate
Total no. of children born in Kuwait
The best predictor of caries at older ages is DMFT at a younger age. Caries levels follow trend lines for each level of caries(37). As age increases, due to self awareness, change in dentition and increased exposures to dental care, there may be a decrease in the amount of caries. But habits like poor diet patterns and lack of oral hygiene measures which are established in early childhood can contribute to increase in caries in adulthood.
4587 4628 4380 4136 3883
53417 52995 51532 50578 48459
The establishment of an early visit to the dentist can also help with proper diet counseling as an integral part in prevention of ECC. Similar to dietary instructions for children of all ages, the primary emphasis is on sugar intake frequency. But there are
Table 4:
Years 2009 2008 2007 2006 2005
Various risk factors have been attributed to the occurrence of S-ECC(20,21,25). Increased caries activity and ECC have been associated with lower maternal level of education and increased family size (22) and family income (23). Evidence of maternal transmission of streptococcus mutans in S-ECC has been detected at 41%(40). Perinatal oral health care recommendations have been put forward by AAPD(38) as maternal oral health is of great significance to nursing caries prevention.
Dental News, Volume XVIII, Number III, 2011
PREVALENCE OF SEVERE EARLY CHILDHOOD CARIES IN AL-JAHRA
Table 3: Oral conditions
According to the ADA(19) the first dental visits should be by the childâ&#x20AC;&#x2122;s first birthday. The average age of examination here in children below 1 year of age was 5.5 months. The difference in the number of children below 1 yr of age who have attended the clinic when compared to the higher age groups is highly significant. There was no caries seen in the 0-1 year ages showing that parents brought the child for examination due to other reasons such as teething and not for a regular checkup. The overall increase in the caries rate of maxillary anteriors through the age groups showed that although the teeth were affected by the age of 1, the child was brought to the dentist only when decay was visible or causing symptoms. This further reinforces the need for establishing the need for early infant oral health care visits to the dentist. (graph 6 )
23
Fig. 8: Oral conditions
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COMMUNITY DENTISTRY
Pediatricians and family physicians can play a significant role in the initiation of dental care in very young children. The committee on Standards for Child Health care of American Academy of Pediatrics recommends inspection of mouth, teeth and gums at every pediatric visit(34). Advice on infant feeding practices and weaning can be given by pediatricians at the age specific visits. Dental attendance before the age of 2 is uncommon unless dental symptoms are present. However contact with other health professionals is high. Primary care providers who have contact with children well before the age of 1st dental visit may be well placed to offer anticipatory advice to reduce the incidence of ECC(35). In Kuwait, the primary health centers and immunization centers can play a big role in preventions they often see the children
Prenatal and baby clinics, obstetricians and gynecologists should be equipped with information regarding perinatal maternal dental health and its significance in dental caries in infants. Establishments of maternal and child health care centers can come along with promotion of general health of child and mother and help in educating the public about the need for early oral health(33). The present study shows the high prevalence and how severe the situation is affecting such young children. Most of the conditions are largely preventable with simple measures. Although no statistical data has been collected to show the factors attributing to the decay, diet and pattern of feeding will definitely play a major role in the caries formation at such an early age. Infant bottle feeding habits (either allowing the child to sip from a bottle during the day or put to sleep at night) as a significant determinant for both anterior caries and S-ECC(38). Evaluations of early childhood caries programs have shown to reduce dental care experience with administration of preventive measures in very young children(41).
Conclusion An immediate need for interceptive and preventive program which starts with perinatal oral health and early dental intervention is required in Al-Jahra area in Kuwait. The importance of infant oral health care visits is of utmost need as shown by the high prevalence of S-ECC. The protocol for these visits must be established and laid down with dentist playing a vital role as the main source of information and guidance to the parents/caregiver. Dentists should emphasize more on the preventive approach rather than only on a therapeutic level. The high prevalence of S-ECC with characteristics of nursing caries points toward a trend in increased childhood caries and subsequent consequences. Protocols for establishing infant oral health care centers with qualified personnel to impart counseling and preventive measures in regards to oral health during infancy will help in lowering the rate of a disease such as S-ECC which is mainly preventable. Children are our most precious resource. Their optimal oral health should be provided not only on a therapeutic but a preventive basis early in life itself.
References 1. Veerkamp JSJ, Weerheijm KL. Nursing â&#x20AC;&#x201C; bottle caries. The importance of a developmental perspective. J Dent Child 1995;62:381-6 2. Hallett KB, Oâ&#x20AC;&#x2122;Rourke PK. Early childhood caries and infant feeding practice. Community Dent Health 2002;19:237-42. 3. American Academy of Pediatric Dentistry Vol 30. Reference Manual 2008/09. No. 7:13. 4. Behbehani JM, Scheutz F. Oral health in Kuwait. International Dental Journal (2004) 54:401-8. 5. Glass RL. Kuwait National Dental Health Survey. Part 1. The oral health of school
children 6-16 years of age in Kuwait 1982.Kuwait:Ministry of health, 1982 6. Vigild M, Skougaard M, Hadi RA et al. Dental caries and dental fluorosis among 4-,6-,12- and 15-year-old children in kindergartens and public schools in Kuwait. Community Dent Health 1996;13:47-50. 7. Soparkar P, Rose L, dePaola PF. A comprehensive dental survey of Kuwaiti school children. Kuwait: Ministry of Health, 2001. 8. Al-Mutawa S, Al-Duwairi Y, Honkala E et al. The trends of dental caries experience of children in Kuwait. Dent News 2004;9:9-13. 9. Al-Dashti AA, Williams SA, Curzon ME. Breast feeding, bottle feeding dental Dental News, Volume XVIII, Number III, 2011
PREVALENCE OF SEVERE EARLY CHILDHOOD CARIES IN AL-JAHRA
Pediatric dentists have traditionally counseled parents on the issues regarding diet and its relation to teeth. With establishment of infant oral health care visits, specific information regarding breast/bottle feeding, weaning time, dietary F supplements, fruit juice and cereal consumption and use of sippy cups can be imparted to the parents at that critical period of time. This diet counseling recommendation bears merit since a longitudinal study has shown that 3 yr old children with carious lesions had more frequent consumption of cariogenic foods at 12 months of age (28). The prevalence of ECC increases with age and is strongly related to between meal snacking and cariogenic diet(29, 30). High risk dietary practices appear to be established early probably by 12 months of age and are maintained throughout early childhood(31). The behavior of children will also be definitely affected with more invasive dental treatment experienced at an earlier age due to ECC. 30-60 month old caries active children have shown more behavior problems when compared to caries free children(42). Dental counseling should be mainly concentrated on infant feeding practices, diet management and snacking patterns, tooth cleaning and fluoride management(33).
from infancy. An infant oral health care centre can be started in conjunction with these primary care establishments thus providing a comprehensive health care aspect towards counseling and prevention.
25
however other infant-specific dietary issues that must also be addressed during the infant oral health visit(27). This study shows the poor attendance of patients below the age of 1 and a significant increase in the number of patients as well as caries rate in the 1-2 year age group. Similarly there was almost a 50% increase in the number of children in the 2-3 year age group.
COMMUNITY DENTISTRY caries in Kuwait, a country with low-fluoride levels in the water supply. Community Dent Health 1995 12:42-47. 10. Babeely K, Kaste LM,Husain J et al. Severity of nursing-bottle syndrome and feeding patterns in Kuwait. Community Dent Oral Epidemiol 1989 17:237-9. 11. Morris RE, Gillespie G, Dashti A et al. Early childhood caries in Kuwait: Review and policy recommendations. East Meditter Health J 1999 5:1014-22 12. World Health Organization. Oral Health Surveys: Basic Methods, 4th ed. Geneva, Switzerland: WHO;1997. 13. Qin M, Li J, Zhang S, Ma W. Risk factors for severe early childhood caries in children younger than 4 years old in Beijing, China. Pediatr Dent 2008;30(2):1228. 14. Huntington NL, Kim J, Hughes CV. Caries-risk factors for Hispanic children affected by early childhood caries. Pediatr Dent 2002;24:536-42. 15. Marino R, Bonze K, Scholl T, Anhalt H. Nursing bottle caries: Characteristics of children at risk. Clin Pediatr 1989;28:129-31. 16. Soparker P, Tavares M, Husain J, Babeely K, Behbehani J, Al Za’abi F et al. Nursing bottle syndrome in Kuwait. J Dent Res 1986;65(Sp Iss IADR):745 17. Murtomaa H, Al Za’abi F, Morris RE, Metsaniitty M. Caries experience in a selected group of children in Kuwait. Acta Odontol Scand 1995;53:389-91. 18. Civil Service Commision: Kuwait 2005-2009 19. American Academy of Pediatric Dentistry. Guideline on Infant Oral Health Care: Pediatr Dent Sp Issue: Reference Manual 2009;31(Special Issue):95-9 20. Reisine S, Douglass JM. Psychological and behavioural issues in early childhood caries. Community Epidemiology 1998;26:32-44 21. Smith RE, Badner VM, Morse DE, Freeman K. Maternal risk indicators for childhood caries in an inner city population. Community Dent Oral Epidemiol. 2002;30:176-81 22. Schroth, Robert J, Moffatt, Micheal EK. Determinants of Early Childhood Caries (ECC) in a rural Manitoba community: A pilot study. Pediatr Dent 2005;27(2):114-120 23. Vachirarojsian T, et al. Early childhood caries. Comm Dent and Oral Epidemiol 2004;32(2):133-42 24. Douglass JM, Tinanoff N, Tang KMN, Altman DS.Dental caries patterns and oral health behaviors. Commun Dent Oral Epidemiol. 2001;29(1):14-22 011-1125. AdNunn gioielleria Dental News ME, Dietrich T 205x130 et al. Prevalence of ECC among 29-04-2011 very young urban 16:18 Boston children compared with US children. J Pub Health Dent 2009;9(3):156-62 26. Robke FJ. Effects of nursing bottle misuse on oral health. Prevelance of car-
ies, tooth malalignments and malocclusions in North-German preschool children. J Orofac Orthop.2008;69:5-19 27. Nainar SMH, Mohummed S. Diet counseling during the infant oral health visit. Pediatr Dent 2004;26(5):459-62 28. Persson LA, Holm AK, Arvidsson S, Samuelson G. Infant feeding and dental caries: A longitudinal study of Swedish children. Swed Dent J. 1985;9:201-6 29. Rossenblatt A, Zarzar .The prevalence of ECC in 12-36 months old children in Recife, Brazil. ASDC J Dent Child 2002;69(3):319-24 30. Botlyoung J, Deuksang M et al: Early Childhood Caries: prevalence and risk factors in Seoul Korea. J Public Health Dentistry 2003;63(3):123-128 31. Douglass JM.Dietary determinants of dental caries and dietary recommendation for preschool children: J Public Health Dent 2000;60(3):207-9 32. Nowak AJ, Casamassimo P. Using anticipatory guidance to provide early dental intervention. J. Am. Dent. Assoc 1995;126:1156-63 33. Tandon S, Koshy S. Infant oral health care. Kerala Dent J.1997;20(4):115-22 34. Johnson DC. The role of pediatrician in identifying and treating dental caries. Pediatr. Clin.North.Am 1991;38(5):1173-81 35. Gussy MG, Water EG, Walsh O, Kilpatrick NM. Early childhood caries: Current evidence for etiology and prevention. J of pediatrics and child health 2006;42(12):37-43 36. O’Sullivan D, Tinanoff N. The association of early dental caries patterns with caries incidence in preschool children. J of Pub Health Dent 1996;56(2):81-3 37. Sheiham A. Impact of dental treatment on the incidence of dental caries in children and adults. Comm Dent and Oral Epidemiol 1997;25(1):104-112 38. Hallett KB, O’Rourke P. Pattern and severity of early childhood caries. Pattern and severity of early childhood caries. Comm Dent and Oral Epidemiol 2006;34(1):25-35 39. American Academy of Pediatric Dentistry. Guideline on Perinatal oral health care. Pediatr Dent :Reference Manual 2009-2010;31(6):90-4 40. Stephen C, Ruby JD, Moser S, Momeni, S, Smith A et al. Maternal transmission of mutans streptococci in severe- early childhood caries. Pediatr Dent 2009;31(3):193-201 41. Minah G, Lin C et al. Evaluation of an early childhood caries prevention program at an urban pediatric clinic. Pediatr Dent 2008;30(6):499-504 Pagina 1 42. Williamson R, Oueis H, Casamassimo PS, Thikkurissy S. Association between early childhood caries and behavior as measured by the child behavior checklist. Pediatr Dent 2008;30(6):505-9
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Dental News, Volume XVIII, Number III, 2011
IMPLANT DENTISTRY
Distraction Osteogenesis for
Augmentation of Anterior
30
Distraction Osteogenesis for Augmentation of Anterior Mandibular Segment
Mandibular Segment after Failed Implants Removal Dr. Ali Alajmi D.D.S, M.S.c Boston University School of Dental Medicine, Department of Periodontology email: adentist1972@yahoo.com
ABSTRACT One major challenge implant surgeons are often faced with, is large edentulous areas which have insufficient bone volume for the purpose of implant placement. There are several methods that have been used to augment the defected sites. Most commonly guided tissue regeneration (GTR), and autogenous bone particulate, or block graft. But these methods have several major disadvantages in GTR which has limited ability when it comes to generate adequate bone height predictably, and the complication of membrane exposure, and the possibility of infection of the site, or graft loss. On the other hand, autogenous bone grafting has predictable results, but might cause a major discomfort for the patient at the donor site, also it has a high cost. So, a different method has been developed by using distraction devices, which induces acceptable increase in bone volume for the implant surgeon for the correction of severe defects, and possible implant placement in the future. A case report is presented describing the use of alveolar distraction to augment a vertically deficient alveolar ridge at the anterior mandible after implants failure at the mandible lateral incisors.
INTRODUCTION
History of Distraction Osteogenesis Gravel Ilizarov a Russian orthopedic surgeon, is considered to be the father of distraction osteogenesis (DO) in the 1940s and 1950s. Professor Ilizarov was able to illustrate that a long bone could be cut and stretched if only the appropriate device and protocol could be established. In 1988, Professor Ilizarov presented his work in the US and in 1992 McCarthy reported the first cases in the mandible. In 1992, McCarthy, Schreiber and Karp applied this concept to treat hemifacial microsomia by distracting the mandible. In 1996, Block, Chang and Crawford described the first alveolar distraction in dogs and in the same year, Chin and Dental News, Volume XVIII, Number III, 2011
Toth applied alveolar distraction to humans. Ilizarovâ&#x20AC;&#x2122;s work is based on the well-known law of tension-stress, the principle whereby gradual traction on living tissues can, under certain conditions, stimulate the regeneration and active growth of those tissues i.e., tension forces stimulate histogenesis.
Implications of Distraction Osteogenesis The first advantage of distraction osteogenesis is that it has more potential to regenerate bone compared to bone grafting. Secondly, distraction osteogenesis does not require a second surgical site for the donor site, which reduces discomfort, treatment time, and the cost of the procedure. Thirdly, distraction osteogenesis creates a vital bone of excellent quality for the placement of implants, which is not always the case with autogenous or allogeneic bone grafting. Finally, the greatest advantage of distraction osteogenesis for mandibular augmentation may not be related to bone, but soft tissues which are lengthened together with the bone tissue.
Limitations of Distraction Osteogenesis The downside of distraction osteogenesis is that there must be a minimum quantity of bone about 5 mm of the transport and anchorage segment in order to have adequate strength to withstand force of mobilization and transport. In addition, expansion occurs only in the direction of transport (Vector). The patient must also cooperate with the activation process.
Indication of Distraction Osteogenesis In alveolar distraction the main indication is the vertical augmentation of the ridge with or without soft-tissue deficiency. DO has an advantage over other techniques such as guided bone regeneration and onlay bone grafting in that it can predictably generate more
IMPLANT DENTISTRY
32
Distraction Osteogenesis for Augmentation of Anterior Mandibular Segment
Failed Implants removal :
Fig 1: This intra-oral view of the anterior mandibular defect shows significant loss of alveolar ridge height at buccal area.
Fig 2: This intra-oral view of the anterior mandibular defect shows significant loss of alveolar ridge height at lingual area.
Fig 3: Preoperative panoramic radiograph shows significant vertical bone defect is evident in the anterior mandible.
left side
right side
Fig 8-9: Implants were removed
Fig 4-5: Preoperative panoramic radiograph shows significant vertical bone defect around the mandible implant, left and right side
than 5 mm of alveolar height2, 3. In addition, the mucosa also develops with increase of vestibular height. Thus the technique is useful in either optimization of esthetic looks in the anterior or increasing the volume of bone before implant takes place in the posterior. Both distraction osteogenesis and onlay bone grafting are applied in the event that traumatic defects occur in complex multidimensional alveolar and mucosal deficiencies. There may be less bone available to distract in extremely atrophic areas. This requires onlay bone graft to be done first and then the grafted area can be vertically distracted after 16 weeks healing. However, in cases of mild to moderate horizontal atrophy, distraction osteogenesis can be done first, followed by onlay bone grafting, or guided tissue regeneration.
Materials and Method The purpose of this patient report is to use a clinical case to demonstrate the preoperative planning, surgical technique, treatment protocol, and application of alveolar ridge augmentation with the distraction device in partially edentulous ridges for improvement of esthetic areas, after failed implants. A 47-yearold female patient complained of pain around her lower implants that were done in a private clinic about 18 months ago. Her medical history was found to be noncontributory to her present complaint because she has no known drug allergies and neither was she on any kind of medication. The patient drinks only occasionally but has no history of tobacco use. Intra-oral examination revealed severe destruction of soft and hard tissues around the mandible lateral incisors implants (Fig.1 and 2). Radiographic findings showed severe bone loss almost to the apex of the two implants at the mandible lateral incisors (Fig. 3 to 5). Based on the clinical examination, it was determined Dental News, Volume XVIII, Number III, 2011
Fig 6-7: Full thickness flap was raised to expose the defected site and the implants.
Fig 10-11: Bone graft (Bio-Oss and DFDBA) and resorbable membrane (Bioguard) were placed to cover the defect after implants removal.
Fig 12: Primary closure of the flap was achieved with continuous locked sutures.
that the patientâ&#x20AC;&#x2122;s implants had to be removed first, and then reconstructed with alveolar DO to gain vertical height. Clinical features of this case included severe alveolar bone and soft tissue deficiency.
Alveolar Distraction Technique It is a four steps technique involving: a) Full thickness flap to expose the alveolar defect. b) Latency period 7 to 10 days. (The latency period is the time from surgery until distraction is activated). c) Distraction, during which, bone is transported incrementally at the rate close to 1 mm/day. d) Time for consolidation, typically 2 months, before the device is removed. The entire Alveolar distraction process takes 2-3 months from the time of initial surgery to the time when devices are removed, and possible implants placement.
IMPLANT DENTISTRY
34
Distraction Osteogenesis for Augmentation of Anterior Mandibular Segment
Fig 13: Morphology of the ridge 3 months after bone grafting although implants could have been placed, the restorations would have been long, unattractive, and difficult to clean.
Fig 16: The appearance of the titanium distraction device before placement. Its components include 2 fixation plates, each with counter-sunk screw holes and a smooth vertical sleeve fixed to the lower member (base plate). The upper (distraction) plate is attached to the threaded adjustment post housed within the sleeve, and its upward movement is governed by the hex-topped post. A longhandled wrench turns it clockwise in order to activate the system.
Fig 14: Preoperative panoramic ra- Fig 15: Preoperative diagnostic diograph. A significant vertical bone cast of the case. defect is evident in the anterior mandible.
Discussion
Distraction protocol The distraction/postoperative protocol typically include the following phases: a latency period, device activation, a consolidation period (Fig. 24).
Latency period This latency period is typically 5 to 7 days long. Factors that may affect the duration of the latency period include the age of the patient, the extent of tissue trauma created during surgery, and the healing rate for the patient.
Fig 17-18: A horizontal vestibular incision is used to expose the bone without vertical release incision a full thickness flap is elevated on the buccal aspect only, taking care not to reflect the tissue on the alveolar crest or towards the lingual . Fig 19: 3 bone cuts are made (2 vertical at the lateral borders of the distractor, and 1 horizontal between the 2 fixation plates) using a saline-cooled, oscillating saw. The forefinger of the surgeonâ&#x20AC;&#x2122;s other hand is placed firmly against the lingual mucoperiosteum to guide saw-cut depths and to avoid perforation of the mucosa. This lingual flap is the only source of vascular supply, and its sanctity must be preserved
Device activation Following the latency period, the device is activated; this is done with the ratchet wrench and adapter, screwdriver handle, and straight driver, or with a temporary activation tool. The pitch on the threaded distraction rod is 0.4 mm, so one complete turn equals this vertical distance. Typically, patients are distracted one or two turns (0.4 to 0.8 mm) on a daily basis until the desired amount of vertical distraction has been achieved. Because a clinician can evaluate using only tactile feedback generated by the device, it is recommended that the clinician activate the device in the dental office. Distraction results in vertical elevation of the transport segment, which enlarges the regeneration chamber. Because the chamber is surrounded by vital bone on four sides Fig 24: Alveolar Distraction â&#x20AC;&#x201C; Timeline
Fig 20: Placing and twisting an osteotome accomplish the final release of the transport segment of bone.
Fig 21-22: When the transport segment has been fully mobilized, the distraction device is attached and stabilized with the aid of additional bone screws.
Fig 23: Primary closure after distractor placement Dental News, Volume XVIII, Number III, 2011
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IMPLANT DENTISTRY Table1: HVC ridge classification. Subclassification Class I Classification Horizontal (H) Defects
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Class III Classification Combination (H+V) Defects
Small (s) ≤ 3 mm; medium (m) 4–6 mm; large (l) ≥ 7 mm.
and by periosteum on two sides.
Consolidation period When the desired height of the alveolar crest is achieved, distraction ends and consolidation begins. The threaded rod is left in place for the duration of consolidation, which lasts about 12 weeks; longer consolidation periods may improve results by limiting the amount of relapse. During this time, bony union occurs across extremely hard and duraosteotomy margins (the vertical osteotomy cutZirconium lines and in the dioxide is anZirconium dioxide is an extremely hard and duradistraction zone), and the gingiva expands to ble the new alveolar ble material. In the dental laboratory, manual material. In the dental laboratory, manual bone volume3, 7. rework of CAD/CAM processed parts is a standparts is a standAccording to this classification in table 19, therework present caseof hasCAD/CAM processed ard procedure. The dentist, too, needs instruments both horizontal and vertical defects and the defect larger than with hightoo, substance removalinstruments capacity and long ardis procedure. The dentist, needs 7 mm. Therefore, it is a class III ridge defect. service life, e. g. for corrections on ZrO₂ restora-
9. HVC ridge deficiency classification: a therapeutically oriented classification. Wang L, Al-Shammari Int J Perio Rest Dent. 2002 Aug; 22(4):335-43.
Dental News, Volume XVIII, Number III, 2011
ZR371M.314.025
ZR862.314.016
ZR371M.314.025
ZR862.314.016
with high substance removal capacity and long tions, trepanation of ZrO₂ crowns or for separatConclusion ing ZrO₂ restorations. comprehensive service life, e. g. for corrections on Thanks ZrO₂torestoraThe key to success in distraction osteogenesis is careful, precise, test series and practical experience, we can tions, trepanation of ZrO or for separat₂ crowns well planned surgery with care taken to preserve the vitality of provide dentists and dental technicians with the transported segment, educate and follow patients maintain high-performance diamond instruments featuring ing and ZrO to comprehensive ₂ restorations. Thanks precise vector control of the regenerating tissue. a special coating. Compared to conventional test series and practical experience, we can diamond instruments, ZR diamonds will achieve References greater substance removal and,with thanks to their provide and dental technicians 1. Block M, Chang A, Crawford C, Mandibular alveolar ridge augmentation in thedentists dog using distraction osteogenesis. J of Oral MF Surg 54; 309-314 improved service life, you can save money at the 2. Chiapasco, M, Romeo E, Vogel (2001). Vertical distraction osteogenesis of edentulous high-performance diamond instruments featuring same time. Contact your local Komet representaridges for improvement of oral implant positioning Int. J of MF Implants. 16; 43-51 3. Saulacic N, Iizuka T, Martin MS, et al (2008) Alveolar distraction osteogenesis:coating. a tive or visit to our website www.brasseler.de! a special Compared conventional systematic review. Intl Journal of Maxillofacial Implants. 37:1-7 4. Emtiaz S, Noroozi S, Caramês J, Fonseca L (2006) Alveolar vertical distraction osteodiamond instruments, ZR diamonds will achieve genesis: historical and biologic review and case presentation . International J Periodontics Restorative Dent. 26; 529-41. substance removal and, thanks to their 5. Urbani G. Alveolar distraction before implantation: a report ofgreater five cases and a review of the literature. Int J Perio Rest Dent. 2001; 21:569–579. 6. Gaggl A, Schultes G, Karcher. Distraction implants, a new possibility for augmentative improved service life, you can save money at the treatment of the edentulous atrophic mandible. Br J OMF Surg. 1999; 37:481–485. 7. Chin M, Toth B. Distraction osteogenesis in maxillofacial surgery using internal de- Contact your local Komet representasame time. vices: review of five cases. J Oral Maxillofac Surg. 1996; 54:45–53. 8. Ilizarov G. The tension stress effects on the genesis and growth of tissues. Part 1. Clin pays off www.brasseler.de! tive or visit ourQuality website Orthop Rel Res. 1989; 238:249–281. GEBR. BRASSELER GmbH & Co. KG · Germany Phone +49 (0) 5261 701-0 · www.brasseler.de
© 07/2010 · BRA/0 · 404283V2
36
Distraction Osteogenesis for Augmentation of Anterior Mandibular Segment
Class II Classification Vertical (V) Defects
ENDODONTICS
WaveOne
TM
THE SINGLE FILE RECIPROCATING SYSTEM
38
THE WaveOneTM SINGLE FILE RECIPROCATING SYSTEM
Dr Julian Webber,UK; Drs Pierre Machtou and Wilhelm Pertot, France; Drs Sergio Kuttler, Clifford Ruddle, John West, USAv
The new WaveOneTM NiTi file from DENTSPLY Maillefer is a SINGLE use, SINGLE file system to completely shape the root canal from start to finish. Shaping the root canal to a continuously tapering funnel shape not only fulfills the biological requirements for adequate irrigation to clean the root canal system of all bacteria, bacterial by-products and pulp tissue(1) but also provides the perfect shape for three dimensional obturation with gutta percha.(2,3) In most cases the technique only requires one hand file followed by one single WaveOneTM file to completely shape the canal. The specially designed NiTi files work in a similar but reverse “balanced force” action(4) using a pre programmed motor to move the files in a back and forth “reciprocal action”. The files are manufactured with M Wire technology improving strength and resistance to cyclic fatigue by up to nearly four times against other brands of rotary NiTi files.(5)
2. WaveOneTM Primary is used in the majority of canals. The tip size is ISO 25 with an apical taper of 8% that reduces towards the coronal end 3. WaveOneTM Large is used in large canals. The tip size is ISO 40 and the apical taper is 8% that reduces towards the coronal end The instruments are designed to work with a reverse cutting action. All instruments have a modified convex triangular cross section at the tip end (fig. 2) and a convex triangular cross section at the coronal end. (fig. 3) This design improves instrument flexibility overall. The tips are modified “guiding” to follow accurately canal curvature. The variable pitch flutes along the length of the instrument considerably improves safety. (fig. 4)
At present there are 3 files in the WaveOneTM single file reciprocating system available in lengths 21mm, 25mm and 31mm. (Fig 1) 1. WaveOneTM Small is used in fine canals. The tip size is ISO 21 with a continuous taper of 6%
Because there is a possibility of cross contamination associated with the inability to completely clean and sterilize endodontic instruments(9) and the possible presence of Prion in human dental pulp tissue(10) all instruments used inside root canals should be single use(11). WaveOneTM instruments are a new concept in this important standard of care as they are truly single use. The plastic colour coding in the handle deforms if sterilized preventing the file from being placed back into the handpiece. The recommendations for single use also have the added advantage of reducing instrument fatigue which is an even more important consideration with WaveOneTM files as one file is doing the job of traditionally 3 or more rotary NiTi files. The WaveOneTM motor (fig. 5) is rechargeable battery operated
Fig. 1: WaveOneTM small(yellow), Primary(red), Large(black)
Fig. 3: WaveOneTM Coronal cross section, convex triangular
There are many colleagues who for whatever reason are reluctant to use NiTi rotary instruments to prepare canals, despite the recognised advantages of flexibility, less debris extrusion and maintaining canal shape amongst other advantages(6-8). For them the use of a single reciprocating file will be very attractive both in terms of time and cost saving.
Dental News, Volume XVIII, Number III, 2011
Fig. 2: WaveOneTM Apical cross section, modified convex triangular
Fig. 4: WaveOneTM variable pitch flute increases safety
Simplicity is the real innovation
•
Only one sterile NiTi instrument per root canal in most cases
•
Decreases the global shaping time by up to 40%*
•
Reciprocating technology respecting the root canal anatomy
•
Single use as new standard of care *data on file
www.dentsplymea.com
ENDODONTICS use WaveOneTM Primary 3. If a 20 hand file or larger goes to length use WaveOneTM Large
Single File Shaping
40
THE WaveOneTM SINGLE FILE RECIPROCATING SYSTEM
Fig. 5: WaveOneTM motor and 6:1 reducing handpiece
with a 6:1 reducing handpiece. The pre programmed motor is preset for the angles of reciprocation and speed for WaveOneTM instruments. The counterclockwise (CCW) movement is greater than the clockwise (CW) movement. CCW movement advances the instrument engaging and cutting the dentine. CW movement disengages the instrument from the dentine before it has a chance to (taper) lock into the canal. Three reciprocating v gradually advances in the canal with little apical pressure required. All brands of NiTi files can be used with the WaveOneTM motor as it has additional functions for continuous rotation. However as WaveOneTM files have their own unique reverse design, they can ONLY be used with the WaveOneTM motor with its reverse reciprocating function. The WaveOneTM technique involves the following stages 1. Straightline access – accepted protocol 2. WaveOneTM file selection 3. Single file shaping 4. Copious irrigation with 5% NaOCl and EDTA before, during and after single file shaping
WaveOneTM File Selection and Clinical Procedure (fig.6, 7, 8) Whilst a good preoperative periapical radiograph will give an indication of what to expect before the canal is prepared (size of canal, length of canal, number of canals, degree and severity of curvature) only the first hand file into the canal will aid in the selection of the Wave One file as follows 1. If a 10 K File is very resistant to movement use WaveOneTM Small 2. If a 10K file easily moves to length easily, is loose or very loose,
1. Take hand file into canal and watch wind to resistance or approximately 2/3 canal length 2. Use appropriate WaveOneTM file to the same length. 3. Irrigate copiously 4. Take hand file to length and confirm with an apex locator and radiograph 5. Take WaveOneTM to length 6. Confirm foramen diameter with hand file the same size as WaveOneTM file. If snug preparation is complete 7. If foramen diameter larger than WaveOneTM file consider the next larger WaveOneTM file 8. The majority of cases will be completed with WaveOneTM Primary
Guidelines for Use 1. Use WaveOneTM files with a progressive up and down movement no more than 3-4 times. Little force is required 2. Remove file regularly, wipe clean, irrigate and continue 3. If file does not progress confirm patent canal and consider going to a smaller WaveOneTM file 4. Whilst glide path management is minimal with WaveOneTM shaping files some practitioners will be more comfortable if the glide path is first secured with PathFilesTM (DENTSPLY Maillefer) 5. In severely curved canals complete apical preparation by hand if reproducible glide path is not possible 6. WaveOneTM files can be used to relocate the canal orifice and expand coronal shape. Even in a reciprocating motion use them with a “brushing” action short of length to achieve this 7. Never work in a dry canal and constantly irrigate with NaOCl and later EDTA 8. As preparation time is short activate the irrigating solutions to enhance their effect. The EndoActivator® (DENTSPLY Maillefer) is ideal for this (Fig.9)(12)
WaveOneTM Obturating Solutions Obturation of the root canal system is the final part of the endodontic procedure. The WaveOneTM system includes matching paper points, gutta percha points and Thermafil® style WaveOneTM obturators. (fig. 10-12)
Fig. 6-8: . WaveOneTM Small, Primary and Large files with their respective file selection and clinical procedural flow chart Dental News, Volume XVIII, Number III, 2011
Fig. 9: EndoActivator irrigation device
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ENDODONTICS
Fig. 10: Calamus Dual Obturation unit
Fig. 11: WaveOneTM matching paper points
The matching gutta percha points can be used in conjunction with the DENTSPLY Maillefer Calamus速 Dual Obturation System (fig.13) as seen in the following cases
42
THE WaveOneTM SINGLE FILE RECIPROCATING SYSTEM
Case I - (Fig 14 a-c) Tooth 36 presented with symptoms of irreversible pulpitis and early apical periodontitis. Initial radiographic assessment showed four narrow and curved canals. Access was made and all canals were worked to length with 10 K-file. WaveOneTM Primary (25 .08) was selected and length was reconfirmed with 10 K-File. The WaveOneTM Primary file was worked to length in all 4 canals. Obturation was done with Warm Vertical Condensation (WVC) using Calamus Dual
Fig. 12: WaveOneTM matching gutta percha points
Fig. 13: WaveOneTM matching Thermafil style obturators
Case III - (Fig 16 a-c) Tooth 17 presented with radiographic evidence of apical periodontitis and was non vital. The canals were hardly visible on the preoperative X-ray. Primary consideration would have been WaveOneTM Small (21.06). In all canals the 8 K-File moved to length easily. The 10 K-File also moves to length but was tight. WaveOneTM Primary (25 .08) was selected and taken to approx three quarters of the length. Recapitulation was achieved with 10 K-File to length. The WaveOneTM Primary (25 .08) was taken to length in all canals and the Canals were then obturated with WVC
Fig. 16 a-c: Pre op radiograph 17 with canals hardly visible(a). Post op radiographs: Canals were shaped with a WaveOneTM Primary and filled with gutta percha with WVC(b&c) Fig. 14 a-c: Pre op radiograph of 36 showing narrow and curved canals(a). Post op radiographs: Canals were shaped with a WaveOneTM Primary and filled with gutta percha with WVC (b&c)
Case II - (Fig 15 a-c) Tooth 16 had symptoms of acute pulpitis with temporary filling covering exposure distally. Severe curvature of MB canals and apically in distal seen radiographically. K-Files 8 and 10 were taken to length in all canals. A WaveOneTM Primary (25 .08) was selected. Length was confirmed with a 10 K-File. The WaveOneTM Primary file was taken to length in all canals. Obturation was done with WVC using Calamus速 Dual
Fig. 15 a-c: Pre op radiograph of 16 showing severely curved MB and DB canals(a). Post op radiographs: Canals were shaped with a WaveOneTM Primary file and filled with gutta percha with WVC(b&c) Dental News, Volume XVIII, Number III, 2011
Case IV - (Fig 17 a-c) Tooth 16 presented with radiographic evidence of asymptomatic apical periodontitis. The canals were hardly visible on the preoperative X-ray. The MB canal was severely curved, and the distobuccal (DB) and palatal were not visible. A 10 K-file moved to length easily in the MB and DB canals. In the palatal canal, 10 and 15 K-files moved to length easily. A WaveOneTM Primary (25.08) was selected for all canals. Lengths were confirmed and the canals were shaped to length with WaveOneTM files.
Fig. 17 a-c: Pre operative radiograph17 with canals barely visible and 15 with a quite large canal(a). Post op radiographs: 17 canals were shaped with WaveOneTM Primary file. 15 was shaped with WaveOneTM Large file. All canals were filled with gutta percha with WVC(b&c)
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ENDODONTICS In tooth 15 a large single canal was clearly visible. 20 and 25 K-files went to length and a WaveOneTM Large file (40:08) was selected. Canal length was confirmed and the WaveOneTM Large file was used to shape the canal.
Advantages of the WaveOneTM file reciprocating system 1. Only one NiTi instrument per root canal and in most cases per tooth 2. Lower cost 3. Less instrument separation due to the unique reciprocating movement that will prevent and/or delay the instrument advancing from plastic deformation to its plastic limit. 4. Decreases global shaping time allowing the clinician to spend more time cleaning the root canal system with enhanced irrigation techniques 5. Eliminates procedural errors by using a single instrument rather than using multiple files 6. A new standard of care eliminating the possibility of Prion contamination owing to single use 7. Easy to learn 8. Easy to teach
The Nova Southeastern University College of Dental Medicine in the USA is conducting research into WaveOneTM. The following areas of research, amongst others, are being investigated using micro-focus CT scanning technology, which provides remarkable insight into: 1. Canal centring ability of WaveOneTM (13) (Fig 18a-c) 2. Remaining canal wall thickness after instrumentation with WaveOneTM(14) 3. Final shape versus initial shape of the canal with WaveOneTM(15)
Other areas of research are flexibility(17), fatigue(18) and debris extrusion(19) To date, the results of these studies suggest that WaveOneTM single reciprocating files are comparable in performance to all the major leading brands of NiTi files that operate in continuous rotation.
Conclusion The WaveOneTM system is an exciting new concept in the preparation of the root canal. Whilst current teaching advocates the use of multiples NiTi files of different diameter and taper to gradually enlarge the root canal, only one WaveOneTM single shaping file is required to prepare the canal to an adequate size and taper, even in narrow and curved canals. However, along with this, there must be a caveat. WaveOneTM files only shape the canal, extremely quickly in many instances, but they do not clean the root canal. It is the duty of teachers, clinicians and manufacturers to emphasise the role and importance of irrigation as a major determinant of endodontic success. Once it is fully appreciated that shaping and cleaning the root canal system are irrevocably intertwined, then endodontics will be easier for all and available to all and WaveOneTM will truly become the root canal preparation instrument of the future. This article originally appeared in roots_international magazine of endodontology Vol. 7, Issue 1/2011. It is published with permission by Oemus Media AG. Š 2011 Oemus Media AG. References available on www.dentalnews.com
44
THE WaveOneTM SINGLE FILE RECIPROCATING SYSTEM
WaveOneTM research
4. Canal wall cleanliness with WaveOneTM(16) (Fig 19a-c)
Fig. 18 a-c: Micro focus CT scan at coronal level (a), mid-root level (b) and apical level (c) of the mesial canals of the lower first molar demonstrates the excellent centring and shaping ability of WaveOneTM Primary file
Fig. 19 a-c: A SEM representative sample at coronal level (a), mid-root level (b) and apical level (c) of the canal wall, showing excellent cleanliness and open dentinal tubules after shaping with a WaveOneTM Primary file and assisted irrigation with the EndoActivator Dental News, Volume XVIII, Number III, 2011
ENDODONTICS
When to decide to remove an Endodontically treated tooth? Dr. Yaser Al Asousi , BDS, MS, FRCDC - email: dr.alasousi@gmail.com Head of the Endodontic Department, Al Farwaniya Specialized Dental Center, Kuwait
Abstract
46
When to decide to remove an Endodontically treated tooth?
Failure in endodontic treatment is considered as one of the main reason for removal of teeth. Other endodontic treatment options like retreatment, peri apical surgery should be given due consideration before deciding on removing a failed root canal treated tooth. The article discusses the need for proper treatment planning, review and the need to opt for other endodontic procedures with the help of a case which had failed after primary endodontic therapy.
Introduction Fortunately, the changes when the microscope, microinstruments, ultrasonic tips, and more biologically acceptable root-end filling materials were introduced in the last decade. The concurrent development of better techniques has resulted in greater understanding of the apical anatomy, greater treatment success and a more favorable patient response(1). With the advent of implants and popularity of implants among patients and dentists, removal of failed endodontically treated teeth is on the rise without giving proper consideration of the treatment options available. The decision to extract an endodontically treated tooth should be taken only after due diligence and exploring all other possibilities to save the tooth(2-7). Failure of an endodontic treatment can occur due to various factors including operator inefficiency, operational mishaps, missed canals, incomplete sterilization of the root canal system, improper post endodontic restorations, fracture of tooth and poor oral hygiene. The decision to remove an endodontically treated tooth must be taken by an Endodontist or with consultation with an Endodontist after assessing the patient clinically and exploring all possibilities to save the natural tooth. To substantiate this, a case report is presented where all endodontic treatment possibilities were explored.
with symptoms on endodontically treated mandibular right central incisor, that warranted further dental intervention. The patient had undergone Endodontic treatment six years ago and had a resin restoration which sealed the access cavity. On clinical examination, soft tissue swelling was observed. A buccal sinus stoma was present between the mandibular central incisors at 1cm below gingival margin. There was slight gingival recession, pain on percussion, no mobility and there was no evidence of crown or root fracture. Radiographic examination with Intra Oral Peri Apical (IOPA) radiograph (Fig.1) showed peri radicular radiolucency of 6 X 8 mm in size and inadequate obturation and generalized alveolar bone loss.
Treatment plan Detailed treatment plan was made and explained to the patient. Endodontic re-intervention was decided taking into consideration the clinical symptoms and radiographic findings. Retreatment will be performed as initial stage and after periodic evaluation, surgical intervention can be opted if signs and symptoms do not improve satisfactorily. The patient was taken in to confidence and informed consent was sought.
Retreatment Phase
A 64 year old male patient reported to the endodontic facility
The previous Gutta Percha was completely removed and access was established to full working length. Endodontic retreatment was performed using Pro Taper rotary system in two visits. 5.25% Sodium hypochlorite, 17% EDTA Solution and Glyde Path were used during the retreatment phase and Calcium Hydroxide was used as intra canal medicament between appointments. Retreatment was completed after symptoms subsided and the canal was completely dry. Intracanal cleaning, shaping and obturation were performed under operating microscope. Post operative IOPA (Fig. 2) showed complete obturation of the pulp space and patient was scheduled for 6 and 12 months post operative review.
Fig. 1
Fig. 3
Case Report
Dental News, Volume XVIII, Number III, 2011
Fig. 2
Fig. 4
ENDODONTICS
48
When to decide to remove an Endodontically treated tooth?
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Follow Up Phase
Discussion
Follow up review is important in any treatment plan and should be given due importance. On 6 months postoperative review, patient was asymptomatic although no radiographic changes were evident. At 12 months review intraoral fistula was noted buccally (Fig. 3) and radiographic examination revealed increase of peri apical radiolucency (Fig. 4). Based on the signs and symptoms, it was noted that the retreatment had not succeeded completely and decision was made to intervene surgically. Patient was intimated the need for surgical intervention and was motivated enough to save the tooth.
With the emergence of improved instruments and devices, endodontic treatment gives excellent and predictable results if treated following all endodontic principles. Treatment failures can occur as in any other treatment modality due to various factors. A failed endodontic treatment should not be considered as the end game in our objective of saving a tooth from extraction. Although implant dentistry has developed and evolved much in recent years, a natural teeth is still the best option available for the patient as long as it can play the aesthetic and functional role assigned to it. Every available endodontic treatment options should be explored before deciding to remove a tooth with failed endodontic treatment and the patient should be given the choice to make the informed decision (8-13). In the present case, the primary nonsurgical endodontic treatment failed du e to improper cleaning, shaping and the inability of the clinician to reach and fill the apical one third satisfactorily. Instead of opting for removal, the patient was informed, educated and motivated to save the tooth and all possible outcomes including peri apical surgery and removal was explained. All endodontic procedures warrant regular follow up review and especially if it is a retreatment. The case discussed here was regularly followed up and decision to intervene surgically was taken as and when required without waiting too long. If the case was not followed properly, it would have ended up in greater bone loss and mobility leading to removal of the tooth. Surgical intervention is needed in very few cases were a true cyst has developed following a pulpal pathosis. Majority of the cases with peri apical pathology heals with a complete cleaning, shaping and obturation of the root canal space.(14-16) Use of Surgical Microscope for better visibility, ultrasonic tips for accurate root end preparation and Mineral Trioxide Aggregate (MTA) as root end filling material, greatly enhances the ability to heal a large bony lesion. Clinical reviews showed very good response to the surgical treatment(1).
Surgical Phase After completing all pre surgical examinations and precautions, modern microsurgical technique was performed using Carl Zeiss microscope and retro grade filling with Mineral Trioxide Aggregate ( MTA ). Intra sulcular incision with 15 C blade was made extending from tooth number 32 to 43 and two vertical release incision made distal to tooth number 32 and mesial to tooth number 43. Rectangular full thickness flap was raised and cortical bone fenestration (Fig. 5 ) in relation to tooth 41 was identified. Tissue at the site of the lesion appeared to be encapsulated and it was excised as a unilocular lesion and was sent for biopsy and the result was periapical true cyst . (Fig. 6) Osteotomy with saline irrigation was done with Number 6 round bur, and 3 mm of root tip was resected with Lindemann bur. Bleeding was controlled using two epi pellets under pressure for 2 minutes at the bone crypt. Using ultrasonic tip, 3 mm retrograde cavity preparation was made and filled with MTA. After review radiograph, (Fig. 7) the flap was repositioned and massaged with wet gauze and was sutured with 8 interrupted sutures using 5.0 silk. Post-surgical instructions were given. Patient tolerated the procedure well and suture removal was done 5 days later.
Review Phase Patient was reviewed periodically and clinical progress was noted. In 8 months post surgical review, intra orally there was no swelling, no sinus tract, slight gingival recession, no periodontal pockets, no mobility. Peri Apical radiograph showed radiographic evidence of bone healing (Fig. 8). The patient was recalled four years post operatively and radiograph showed excellent healing and clinically the tooth is sound and functional (Fig. 9). Dental News, Volume XVIII, Number III, 2011
Conclusion Proper diagnosis, treatment planning and involving the patient in the decision making process, help the clinician to deliver the best results even when the prognosis is guarded. Removal of teeth should be the last resort and all efforts should be made to save the natural teeth. References available on www.dentalnews.com
ENDODONTICS References
When to decide to remove an Endodontically treated tooth?
1. Modern endodontic surgery concepts and practice: a review. Kim S, Kratchman S. J Endod. 2006 Jul;32(7):601-23 2. Rubinstein RA, Kim S. Short-term observation of the results of endodontic surgery with the use of a surgical operation microscope and Super-EBA as root-end filling material. J Endod 1999: 25: 43–48. 3. Rubinstein RA, Kim S. Long-term follow-up of cases considered healed on year after apical microsurgery. J Endod 1999: 28: 378–383. 4. Zuolo ML, Ferreira MOF, Gutmann JL. Prognosis in periradicular surgery: a clinical prospective study. Int Endod J 2000: 33: 91–98. 5. Testori T, Capelli M, Milani S, Weinstein RL. Success and failure in periradicular surgery: a longitudinal retrospective analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999: 87: 493–498. 6. Chong BS, Pitt Ford TR, Hudson MB. A prospective clinical study of mineral trioxide aggregate and IRM when used as root-end filling materials in endodontic surgery. Int Endod J 2003: 36: 520–526. 7. Maddalone M, Gagliani M. Periapical endodontic surgery: a 3-year followup study. Int Endod J 2003: 36: 193–198. 8. Rose LF,Weisgold AS.Teeth or implants: a 1990’sdilemma. Compend Contin Educ Dent 1996: 17: 1151–1159. 9. Trope M. Implant or root canal therapy-an endodontist’s view. J Esthet
Dental News, Volume XVIII, Number III, 2011
Restor Dent 2005: 17: 139–140. 10. Ruskin JD,Morton D, Karayazgan B, Amir J. Failed root canals: the case for extraction and immediate implant placement. J Oral Maxillofac Surg 2005: 63: 829–831. 11. Moiseiwitsch J. Do dental implants tool the end of endodontics? Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002: 93: 633–634. 12. Heffernan M, Martin W, Morton D. Prognosis of endodontically treated teeth? Quintessence Int 2003: 7: 558–561. 13. O’Neal RB, Butler BL. Restoration or implant placement: a growing treatment planning quandary. Periodontol. 2000 2002: 30: 111–122. 14. Danin J, Stromberg T, Forzgren H, Linder LE, Ramskold LO. Clinical management of nonhealing periradicular pathosis: surgery versus endodontic retreatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996: 8: 213–217. 15. Kvist T, Reit C. Results of endodontic re-treatment: a randomized clinical study comparing surgical and nonsurgical procedures. J Endod 1999: 25: 814–817. 16. Siqueira JF Jr. Aetiology of root canal failure: why well treated can fail. Int Endod J 2001: 34: 1–10.
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Getting to the root of the problem.
راعي هذا اإلحتفال سعادة رئيس اجلامعة اللبنانية الدكتور زهير شكر يقولها معكم وعاليا ً إننا مهما تضاعفت األثقال ،وتعاظمت األوزار ،فلن نرضخ لليأس واإلستسالم. يحتضن أهل كلية طب األسنان من أفراد الهيئة التعليمية واإلدارية والطالب قسما ً مقدسا ً بأن تظل وتبقى هذه الكلية وف ّي ًة لدورها ،أمينة لرسالتها ،حريصة على موقعها ،مثابرة على طاقاتها وتطوير امكانياتها، ال تتراجع أمام عثرة ،وال تتخاذل عند كبوة ،وال تهادن في انتزاع حق ،كما إنها ال حتجم عن بذل اجلهد والواجب. حضرات الدكاترة احملاضرين العرب واألجانب، ال يخفى عليكم أنه وإن أضفت الطبيعة على لبنان موقعا ً استراتيجيا ً وجغرافيا ً وطقسا ً ساحريا ً إال أنها يتضح سر اهتمامنا كلبنانيني مبواردنا البشرية وتنميتها ووجودكم بخلت عليه باملوارد الطبيعية ،ومن هنا ّ هنا يكمن في تبادل اخلبرات واملعرفة بيننا. احلضور الكرمي ،إن املستوى العلمي ألية مؤسسة جامعية يقاس وفقا ً ألربع ركائن أساسية تشكل العمود الفقري لهذه املؤسسة وعنيت بذلك: -1الهيئة التعليمية ودرجة تأهيلها -2البرامج التعليمية ومستواها كمّ ا َ ونوعا ً -4البحث العلمي ومدى تطوره -3التجهيزات التقنّية وحداثتها نرى أنه حق وواجب علينا أن نقف ونتساءل بصدق وبعد سبع وعشرين عاما ً على تأسيس الكلية أين نحن من كل هذه املقاييس. اجلواب على الركن األول :إن أفراد الهيئة التعليمية هم من النخبة تخرجوا من كبرى اجلامعات واملعاهد حيث نالوا أعلى الدرجات العلمية .عملوا بإخالص وأعطوا دون حساب فكان لهم الدور األساسي واملميز في إجناح مسيرة الكلية. عن الركن الثاني :إن البرامج التعليمية النظريّة والتطبيقّ ية السريريّة وما قبل السريرية التي تعتمد أساسا لها فهي أحدث ما يدرس في جامعات العالم ،تأتي وليدة دراسات عميقة تخضع ملراجعة دورية ولضوابط عديدة ودقيقة .آخر اجنازاتنا والدة حديثة لبرامج اختصاصات املاجستير في علوم طب األسنان. عن الركن الثالث :إن التجهيزات الفنية التي تسلمتها كليتنا وتستعمل يوميا ً ،هي من أحدث ما صنع وأهميتها ال تخفي على أحد بالنسبة إلى كلية تطبيقية ككلية طب األسنان. عن الركن الرابع :إن إمياننا العميق بأهمية البحث العلمي ودوره األساسي في تطوير العملية التعليمية واكتناز املعرفة ومبردوده اإليجابي على كل الصعد قادنا إلى السعي احلثيث لتأمني األرضية الصاحلة لهذا البحث وإعطائه زخما ً ودفعا ً جديدين .وقد جتسد طموحنا هذا في مطلع هذه السنة بأبحاث مشتركة مع املعهد العالي للدكتوراه في العلوم والتكنولوجيا Ecole Doctoraleواجمللس الوطني للبحوث العلمية البروفسور منير ضوميط CNRSفي مجال زرع األسنان والتركيبات الثابتة .
Pr. Mounir Doumit, Dean of the Dental School
Pictures from the inauguration of the exhibition floor
Drs. Marwan Saadeh, Ziad Noujeim, Radhouane Dallel, Tony Dib
Drs. Mona Ghousoub, Mounir Doumit, Robert Garcia, Dr. Mireille Guibert
MORE PICTURES Dr. Mohamed Rifai, President of the organizing committee
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internal tri-channel connection with or without platform shifting for unrivalled tactile feel and the strong sealed conical connection with built-in platform shifting. After 45 years as a dental innovator we have the experience to bring you future-proof and reliable technologies for effective patient treatment. Their smile, your skill, our solutions.
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Visit nobelbiocare.com/nobelreplace Š Nobel Biocare Services AG, 2011. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. 1 Source: Millennium Research Group. 2 Dental Product Shopper voted NobelReplace Tapered Best Product 2011. www.dentalproductshopper.com/nobelreplac
pictures from the exhibition floor
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Picture with President General Michel Suleiman at the presidential palace in Baabda
Dear colleagues and friends, The Lebanese University, School of Dentistry has the pleasure to announce its 12th International Meeting entitled â&#x20AC;&#x153;Challenges in Dentistryâ&#x20AC;? from June first till June fourth 2011. Needless to say that this is a major event, it involves dentists and professionals from all over the world, from the Arab Countries (Egypt, Jordan and Morocco), The United States of America, Canada, Turkey and Europe (Switzerland, United Kingdom, Denmark, Germany, Italy, and France). 37 international speakers will participate in this event discussing the latest technologies and findings in all dental specialties. When planning this event, we faced different challenges: Challenges in organizing the lectures, challenges in connecting and committing with international speakers, and challenges in selecting the appropriate topics to be discussed. Nevertheless we organize 6 pre-congress courses, 130 lectures with more than 100 speakers, out of which 37 international ones, 54 local speakers and 14 lectures given by our residents, who have really proved competence and professionalism. We highly recommend you to attend the young podium session on Saturday at 9:00. In addition to that, hands on sessions and live surgery will be transmitted. Our challenge as well is to present the State-of-the-Art in Dentistry including the latest research in all fields for general practitioners and dental specialists, as well as to establish strong bonds with international practitioners all over the world. Last but not least, let me thank all the members of the scientific committee for all their effort, the organizing committee for making this dream true, our administration employees for their perseverance and determination, and the dean for his confidence in our team and, of course, you for being part of the success of this meeting. Chairperson of the Scientific committee Ass. Pr. Elie Maalouf
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Dr. Michael Dieter focused on the clinical treatment sequence
To welcome its 5th Anniversary this year, CAD/CAM & Computerized Dentistry Int’l Conference embarked on a brand new journey. The organizers, CAPP and Emirates Dental Society achieve for the 5th time great record of attendance and established a reputation as the industry’s leading international conference. The Address Dubai Marina Hotel hosts 726 participants in the very elegant atmosphere. Technology is changing the world of dentistry. In an increasingly inter-linked global environment. New threats and challenges have created an urgent need for new responses. Nowhere is this more true than in the area of education and training where technology is bringing new advantages and opportunities. “A quick glance at the last IDS in Koln, Germany shows not only the extraordinary improvements to computerized technology, but the extraordinary improvements to this technology, but the vast number of manufacturers that are joining the market as well” Dr. M Silwadi Bringing together leading experts and practitioners, the conference proved an excellent opportunity for networking and sharing experiences in the application of technology throughout the learning cycle - from primary and secondary education through to professional development and lifelong learning. The 6th edition of the CAD/CAM & Computerized Dentistry Int’l Conference will take place on 3-4 May 2012.
Dr. Faysal Succaria, Dr. Steven Morgano, Dr. Khalil Al Ali
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Dr. Dobrina Mollova offering a souvenir trophy for the 5th edition of the CAD/CAM & Computerized Dentistry Conference to Dr. Aisha Sultan
Mr. Jamal El Hajj president of the Lebanese Dental Laboratories Association offering a trophy to Dr. Mollova
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Compothixo : Improved Quality Restorations
Kerr is proud to announce the launch of a new product inspired by you: Compothixo!
Compothixo represents a unique generation composite placement and modelling instrument suitable for all classes of restorations. New Compothixo technology enhances the thixotropic properties of composites by only changing its viscosity, without altering the chemical and mechanical characteristics of the material.
Compothixo stays for: • Better wettability • Superior adaptation of composite to cavity walls • Reduction of air bubbles • Precise application • Layer thickness control • Improved sculptability • Reduced stickiness
Compothixo is indicated for: • Modelling of composite • Occlusal modelling, fissures and removal of excess • Layer application technique • Bulk technique in small cavities • Direct veneering Compothixo – Our Vibrations Never Felt so GOOD! www.kerrdental.eu
PRODUCT NEWS
Mectron Piezosurgery® touch Mectron launched the very first generation of PIEZOSURGERY® in 2001, in a time where talking about piezoelectric bone surgery was revolutionary and pioneering at the same time! At IDS 2011, Mectron presented the last generation of PIEZOSURGERY® , with the main aim to consolidate his philosophy of “clinician orientated” unit. Highest attention has been paid to the user interface, in order to make the controls even more intuitive: an exclusive black glass touch screen allows to select in no time the correct bone quality and the irrigation flow rate – and here you go!
New inserts will be available for Mectron PIEZOSURGERY®: from tips dedicated to mini dental implants to new applications in prosthesis related to the finishing of the cervical margin in crown preparations. www.mectron.com
The new Mectron PIEZOSURGERY® touch is characterized by a new handpiece with a 360 degrees rotating LED which enables the user to switch the light on or off directly from the keyboard, or to select the “auto” mode to activate automatically the LED when the foot pedal is pressed.
ULTRADENT Dental units. Made in Germany PRODUCT NEWS
knowledge should be updated to all Educational Dental Schools & institutes in the region, monitoring the performance of all partners to assist them achieving the best. Supporting the dental Schools, Education centers, institutes, Students & post grad in the whole region in the term of training , education and special packages to equipe the most up dated German technology in its premises. www.ultradent.de
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ULTRADENT has epitomized German ingenuity ever since the company was established. Many of the Munich-based dental manufacturer’s ideas have set new standards. The customeroriented development and use of innovative technologies have always been the most important success factor. A new head office in the Brunnthal/Munich industrial park provides the logistical means to meet all requirements that may be placed on dental specialists now and in the future. The german dental manufacturer had again be presenting many new products and enhancements at IDS 2011. On March 2011, ULTRADENT has appointed Mr. Mohamed Murad as a Regional Manager for Middle East & Africa. The first event joined was IDS 2011, it was an excellent opportunity to meet all dealers from Middle East region and select new partners for ULTRADENT. His role to achieve ULTRADENT goals and objectives in the region, in addition to improve the customer relation, education and after sales training, taken in the consideration the service and
Dental News, Volume XVIII, Number III, 2011
UNIVERSITY OF SHARJAH & EMIRATES MEDICAL ASSOCIATION
3rd SHARJAH DENTAL COLLEGE
& 16th EMA INTERNATIONAL DENTAL CONFERENCE
Clinical Excellence in Dentistry: Current Concepts and Controversies
7th – 9th of December 2011
The conference will be revisiting holistic quality care in dentistry by exploring their solutions based on global best practices, with emphasis on evidence-based clinical practices. Conference topics: Esthetic Dentistry Implantology Pediatric Dentistry Periodontology Endodontics Laser Dentistry Oral Medicine and Special Needs Dentistry
Pre conference workshops: Dental Implantology Laser Dentistry Cosmetic Dentistry Emergency in Dental Practice
Poster Presentation and Dental Research Competition: The conference welcomes research posters from students, scientists and dentists across all disciplines of basic and clinical sciences. The research competition will run in two categories: •The Young Dental Scientist Award •The Dental Student Award Kindly send your structured abstract of not more than 300 words to the conference secretariat. Who should attend? Dental practitioners from the public and private sectors, academicians, dental leaders and administrators, dental hygienist, technologist, nurses and students.
For further information: Emirates Medical Association. Dubai, United Arab Emirates. PO Box 6600 Tel: +971-4-3377377 Fax: +971-4-3344082 / 3355083 E-mail: dental@ema.ae www.ema.ae, www.sharjah.ac.ae
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Image plate technology by Dürr Dental - “Made in Germany” quality is recommended
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Brilliant diagnostics and handling like that of analogue film - with these features, Dürr Dental’s VistaScan systems have established the great reputation of dental image plate technology. Recent studies even indicate that such systems are more conclusive than sensors. And according to users of the new VistaScan Mini Plus, even the speed difference for image availability is practically zero.
DENTAL LED LIGHT
A member of the VistaScan family, the VistaScan Mini Plus is suitable for use as an everyday system for intraoral X-rays and as a chair-side device for surgeries with several treatment rooms. The VistaScan Perio Plus can be used as a central solution for intraoral imaging in large surgeries, since it is able to automatically scan in up to eight image plates in a single step. So dentists who need a system that enables complete X-ray diagnostics including panorama and ceph imaging are extremely well justified in choosing the VistaScan Plus. As a leading supplier of image plate technology, Dürr Dental offers a range of different systems, including the right system for general dentists, endodontic and implant technology specialists, and orthodontists. www.duerr.de
creartcom.it
THE OTHERS...JUST BULBS
www.gcomm-online.com Authorized exclusive dealer in Lebanon:
Services Rapides Beyrouth rapiserv@cyberia.net.lb
New Planmeca ProMax 3D ProFace system enables safer and faster facial surgeries The Planmeca ProMax 3D ProFace unit acquires patient’s facial 3D photo in a radiation-free process giving the medical or dental professional opportunity to plan operations and document the follow-up images. Planmeca is first to introduce an integrated 3D unit producing a realistic 3D face photo in addition to traditional digital maxillofacial radiography. One single scan generates both a 3D photo and a CBVT volume. Alternatively, the 3D photo can be acquired separately in a completely radiation-free process: the lasers scan the facial geometry and the digital cameras capture the colour texture of the face. The 3D photo visualises soft tissue in relation to dentin and facial bones, providing an effective follow-up tool for maxillofacial operations. As Planmeca ProMax 3D ProFace acquires both a CBVT image and a 3D photo in single scan, the patient position, facial expression, and muscle position remain unchanged, resulting in perfectly compatible images. Careful preoperative planning, where the medical professional can study the facial anatomy thoroughly using Planmeca Romexis software, facilitates a detailed operation and enhances the aesthetic results.
www.dentalnews.com
Volume XVIII, Number III, 2011
77
“This new product clearly demonstrates our groundbreaking R&D and best practices in imaging. Planmeca provides the most advanced tools – 3D imaging units and software – for visualising patient anatomy making treatment planning and follow-up for orthodontic, maxillofacial and aesthetic surgeries more precise, faster and safer,” explains Ms Helianna Puhlin-Nurminen, Vice President of Digital Imaging at Planmeca Oy. helianna.puhlin@planmeca.com
Dental News, Volume XVIII, Number III, 2011 DENTAL NEWS, VOLUME XVIII, NUMBER II, 2011
The UNIVERSAL self-curing luting composite with light-curing option
MULTILINK SPEED 速
The FAST self-adhesive, self-curing resin cement with light-curing option
The first
ivadent.com
n | Liechtenstein | Tel.: +423 / 235 35 35 | Fax: +423 / 235 33 60
polychromatic
press ingot
Ivoclar Vivadent presents a new, innovative ingot for the press technology: IPS e.max Press Multi. With this ingot, highly esthetic restorations showing a lifelike shade transition can be achieved in just one press cycle. IPS e.max Press Multi is the first polychromatic ingot for the press technology. It is suitable for the fabrication of highly esthetic monolithic anterior and posterior crowns and veneers which show a lifelike shade transition from the dentin to the incisal. Time-consuming layering is a thing of the past if this ingot is used to fabricate restorations. As a result, this ingot meets exacting demands with regard to both esthetics and efficiency. In two steps to the completed restoration An innovative, patented processing technique from Ivoclar Vivadent is used to produce Multi restorations. The restorations are efficiently pressed using new accessory components and an EP 3000 or EP 5000 press furnace featuring intuitive operation. The final esthetic properties are achieved with the coordinated products IPS e.max Ceram Shades, Essences and Glaze in a concluding characterization and glaze firing cycle.
Lithium disilicate-based material
Like the proven IPS e.max Press ingots, the IPS e.max Press Multi ingots consist of lithium disilicate glass-ceramic exhibiting a flexural strength of 400 MPa. The lithium disilicate glass-ceramic provides for the desired fit, shape and function of the restorations. www.ivoclarvivadent.com
Compothixo
TM
Improved Quality Restorations
Smart Vibrations Compothixo™ is a unique generation in composite placing and modelling instrument suitable for all class restorations. The new Compothixo™ technology optimizes the thixotropic properties of composites by changing viscosity only, without altering the chemical and mechanical characteristics of the material.
• Better wettability • Superior adaptation of composite to cavity walls • Reduction of air bubbles • Precise application • Layer thickness control • Improved sculptability • Reduced stickiness
KerrHawe SA P.O. Box 272 6934 Bioggio Switzerland
Freephone: 00800 41 05 05 05 Fax: ++41 91 610 05 14 www.kerrdental.eu
Your practice is our inspiration.™
new
Redefining the science of dentine hypersensitivity Now there’s a major advance to help you meet the challenge of dentine hypersensitivity Announcing the arrival of Sensodyne® Repair & Protect, which brings the unique potential of NovaMin® calcium phosphate technology to a daily fluoride toothpaste. NovaMin® builds a reparative hydroxyapatite-like layer over exposed dentine and within the tubules1-5 to continually help protect your patients against the pain of dentine hypersensitivity6-8
Welcome to the new science of Sensodyne Repair & Protect
Specialist in dentine hypersensitivity management References: 1. Burwell A et al. J Clin Dent 2010; 21(Spec Iss): 66–71. 2. LaTorre G, Greenspan DC. J Clin Dent 2010; in press. 3. Efflant SE et al. J Mater Sci Mater Med 2002; 26(6):557−565. 4. Clark AE et al. J Dent Res 2002; 81 (Spec Iss A): 2182. 5. GSK data on file. 6. Du MQ et al. Am J Dent 2008; 21(4): 210−214. 7. Pradeep AR et al. J Periodontol 2010; 81(8): 1167−1113. 8. Salian S et al. J Clin Dent 2010; in press. SENSODYNE® and the rings device are registered trademarks of the GlaxoSmithKline group of companies. Prepared November 2010. Z-10-175.
“THAT’S ALL I NEED!” Galip Gürel, Dentist, Turkey.
Many different indications and many different materials to choose from – this scenario is a thing of the past. The IPS e.max system allows you to solve all your all-ceramic cases, from thin veneers to 12-unit bridges. Dental professionals all over the world are delighted.
amic all cer need u all yo
www.ivoclarvivadent.com Ivoclar Vivadent AG Bendererstr. 2 | FL-9494 Schaan | Principality of Liechtenstein | Tel.: +423 / 235 35 35 | Fax: +423 / 235 33 60