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Dental News, Volume XXIV, Number II, 2017
Endodontic management of a maxillary lateral incisor with an unusual root dilaceration diagnosed with cone beam computed tomography
January 20 - 21, 2017 Hilton Metropolitan Palace Beirut, Lebanon
Dr. Mahmoud Mohammed Eid Mahgoub
The Pharmacological Management of Dental Caries Dr. Geoff Knight
LSOS 2017 Lebanese Society of Oral Surgery 7th International Convention
LOS 2017 - Lebanese Orthodontic Society 15th Annual Meeting March 24 - 25, 2017 Mövenpick Hotel & Resort Beirut, Lebanon
LSE 2017 12th international meeting for the Lebanese Society of Endodontology April 7 - 8, 2017 Hilton Beirut Habtoor Grand Sin El Fil, Beirut, Lebanon
Fluoride in dentistry: use, dosage, and possible hazards
May 4 - 6, 2017 Intercontinental Hotel Festival City, Dubai, UAE
Dr. Mounir Doumit
Comparison of the shaping ability of various nickel–titanium file systems in simulated curved canals Dr. Mothanna Alrahabi
Immediate loading of a dental implant in the esthetic zone using the CAD/CAM technique Dr. Alexandros Manolakis
Can Dentists Help Patients Quit Smoking? The Role of Cessation Medications Dr. Bo Zhang
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FDI 2017 - Annual World Dental Congress
August 29 - September 1, 2017 Madrid, SPAIN Website: www.fdiworldental.org
EDSIC 2017 Egyptian Dental Syndicate International Congress
September 13 - 15, 2017 Intercontinental City Stars, Cairo, EGYPT Website: www.edsic-eg.com
JIDC 2017 - The 25th Jordanian International Dental Conference
October 3 - 6, 2017 Landmark Hotel Amman, jORDAN Website: www.jda.org.jo
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DFCIC 2017 - The 9th Dental Facial Cosmetic Conference/Exhibition
November 3 - 4, 2017 Intercontinental Hotel, Festival city Dubai, UAE Website: www.cappmea.com
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November 21 - 23, 2017 Intercontinental City Stars Cairo, Egypt Website: www.eda-egypt.org
SDS 2017 - The 29th Saudi Dental Sociey International Dental Conference
January 9 - 11, 2018 International Convention and Exhibition Center Riyadh, KSA Website: www.sds.org.sa
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January 24 - 27, 2018 Intercontinental City Stars Cairo, Egypt Website: www.acdi2018.com
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Dental News, Volume XXIV, Number II, 2017
Endodontic management of a maxillary lateral incisor with an unusual root dilaceration diagnosed with cone beam computed tomography Dr. Mahmoud Mohammed Eid Mahgoub, Endodontic Microscope Center, Future University, Endodontic Specialist, Egypt Air Hospital firstname.lastname@example.org
Dr. Ahmed Abdel Rahman Hashem, Department of Endodontics, Faculty of Dentistry, Ain Shams University, Department of Endodontics, Faculty of Dentistry, Future University, Cairo, Egypt
Dr. Hany Mohamed Aly Ahmed, Department of Conservative Dentistry, School of Dental Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
Abstract Anterior teeth may have aberrant anatomical variations in the roots and root canals. Root di‑ laceration is an anomaly characterized by the dis‑ placement of the root of a tooth from its normal alignment with the crown which may be a con‑ sequence of injury during tooth development. This report aims to present a successful root canal treatment of a maxillary lateral incisor with unusual palatal root dilaceration (diagnosed with cone beam computed tomography) in which the access cavity was prepared from the labial aspect of the tooth to provide a straight line access to the root canal system which was instrumented using One‑ Shape rotary file system and precurved K‑files up to size 50 under copious irrigation of 2.5% NaOCl using a side‑vented irrigation tip. The canal was then obturated using the warm vertical compac‑ tion technique. Key words: Cone beam computed tomography, labial access cavity preparation, maxillary lateral incisor, root ca‑ nal treatment, root dilaceration.
Republished from the Saudi Endodontic Journal Volume 7 / Issue 1 / April 2017
A full understanding of root and root canal mor‑ phology is a fundamental prerequisite for success‑ ful root canal treatment. 1 This includes absolute awareness of landmarks associated with normal and unusual morphology encountered in daily practice. 1 Maxillary anterior teeth are well known to have a straight single root that usually encases a single root canal; nevertheless, clinicians may still face a root/root canal configuration with an aber‑ rant morphology resulting in challenges even in ac‑ cessing the root canals. 2 According to the American Association of Endo‑
Dental News, Volume XXIV, Number II, 2017
dontists glossary of endodontic terms, dilaceration is defined as a deformity characterized by displace‑ ment of the root of a tooth from its normal align‑ ment with the crown which may be a consequence of injury during tooth development. 3 Common usage has extended the term to include sharply angular or deformed roots. 3 The prevalence of dilacerated roots in the human dentition varies in different population groups which can reach up to 16%,[4‑8] and the mandibular third molars usually show the highest prevalence among other tooth types which can reach up to 30.92%. 9 With the benefit of acquiring three‑dimensional (3D) information, cone‑beam computed to‑ mographic (CBCT) imaging has been increas‑ ingly used in the endodontic treatment of anomalous teeth, especially when conven‑ tional radiographs provide limited information and further details need to be identified. 10,11 This report aims to present a successful root canal treatment of a maxillary lateral incisor with unusual palatal root dilaceration diagnosed with CBCT.
Case report A 23‑year‑old male patient was referred for root canal treatment of an anomalous maxillary left incisor tooth (#22). His medical history was non‑ contributory, and the patient denies any history of trauma. On clinical examination, the tooth #22 showed a cervical carious lesion, gingival recession, and the tooth was tender to percussion [Figure 1a]. The tooth was previously treated by the referring dentist with an access cavity sealed with a tempo‑ rary filling material. The referring dentist reported the occasion of an accidental cervical labial perfora‑ tion during an attempt to prepare an access cavity from a palatal approach. A CBCT scan (J morita, Osaka, Japan) was per‑
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14 Endodontics formed to better visualize the complexity of the root morphology. The sagittal section showed an abrupt curvature of the root starting from the coronal third palatally [Figure 1b]. The tooth was diagnosed as previously treated with symptomatic apical periodontitis. In the first visit and after rubber dam isolation, the temporary filling was removed, and a large perfo‑ ration defect was noted in the coronal third of the root. The access was irrigated with normal saline and 2.5% NaOCl, and the perforation area was sealed using a glass ionomer cement (Fuji Fast, To‑ kyo, Japan). The root was severely curved at the cervical level of the tooth to the extent that the entire crown has to be removed to have straight line access to the root canal from the lingual aspect [Figure 1b]. A calcium hydroxide paste was placed inside the ca‑ nal, and the tooth was restored with a temporary filling material (Coltosol, Coltene, USA). In the subsequent visit, the access cavity prepara‑ tion was performed through the cervical portion of the labial wall to provide a straight line access to the canal [Figure 1c]. An ultrasonic tip (ET20 , Satelec, Merignac, France) was used to ensure ad‑ equate removal of the remaining pulp tissues in the Fig. 1: (a) Preoperative photograph of the tooth #22, (b) preoperative cone beam computed tomography, (c) After initial labial access cavity preparation, (d) irrigation using a side-vented tip, (e) master Gutta-percha point (size 50 – taper 0.04), (f) vertical compaction using System B, (g) backfilling using Obtura II, (h) postoperative cone beam computed tomography
pulp chamber and horns. Gates Glidden burs size 2 and 3 (Mani, Tochigi, Japan) were used for coronal flaring, and the working length determination was performed using an electronic apex locator (Root ZX, J. Morita, Irvine, CA, USA). The canal was then instrumented using a One‑ Shape rotary file system (size #25, taper 0.06 Micro‑Mega, Besançon, France), and additional instrumentation was performed using precurved K‑files (Mani, Japan) up to size 50 under copious irrigation of 2.5% NaOCl using a side‑vented ir‑ rigation tip (Ultradent, South Jordan, Utah, USA) [Figure 1d]. The canal was obturated using the warm vertical compaction technique with the aid of System B (Kerr Endo, Orange, CA, USA), and a resin‑based sealer (Adseal, Meta, Korea) was used as the root canal sealer. The backfill was performed using thermoplasticized Gutta‑percha (Obtura II, Spar‑ tan, USA) [Figure 1e‑h]. Machtou pluggers (Maille‑ fer, Ballaigues, Switzerland) were used for vertical compaction. The access cavity was then restored with a temporary filling material (Coltosol, Coltene, USA). In the follow‑up visit, the tooth was asymp‑ tomatic, and the patient was then referred back to the referring dentist.
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Discussion Prognosis of a root‑filled tooth mainly depends on adequate debridement of the root canal system while maintaining the original root canal shape after instrumentation. 12 This report presents end‑ odontic management of a maxillary lateral incisor with an unusual palatal root dilaceration. Chohayeb13 investigated the dilaceration pattern of 480 maxillary lateral incisors and found that more than half of the samples showed a dilaceration in a distolabial direction, and palatal dilacerations of the apical third of the root apex were observed in only 10.4% of the study samples. Literature shows controversy for the etiology of root dilacerations, but mechanical trauma to the primary predecessor is the most widely contributing factor. 14, 16 However, local traumatic injury seemed unlikely to be the cause of dilacerations in this case, consider‑ ing that the patient had no history of trauma. This probably supports the fact that root dilaceration can be described as a dental anomaly and not nec‑ essarily to be a sequela of trauma. 15 Diagnosing root dilacerations before commencing root canal treatment is essential to allow proper and safe use of endodontic instruments within the confines of the curved roots. 14, 17 If the dilaceration occurs mesially or distally, it can be clearly identi‑ fied on a periapical radiograph. 14 However, when the dilaceration is toward the la‑ bial or palatal, the X‑ray beam passes through the deflected portion of the root in an approximately parallel direction, and the identification of the di‑ laceration portion can be rather difficult. Apart from being in a palatal direction, the extension of root dilaceration from the coronal portion of the root along the root apex is another interest‑ ing finding in this case, which was the main cause for the labial root perforation during access cavity preparation from a lingual approach. Failure to rec‑ ognize the multiplanar nature of the dilaceration is one of the factors that might contribute to the higher rate of unfavorable outcomes of endodon‑ tic treatment. 14 The application of CBCT in such cases can help to determine the exact position and angulation of the dilaceration. 14 A number of factors may complicate the treatment Dental News, Volume XXIV, Number II, 2017
of root dilacerations. Therefore, when attempting to perform root canal treatment procedures, the clinician must undertake great attention to avoid mishaps in teeth with significant dilacerations. 14 In the present case, the access cavity was prepared from the labial aspect of the tooth to provide a straight line access to the root canal system en‑ cased in the dilacerated root. In addition, an ul‑ trasonic tip was used to ensure adequate removal of the remaining pulp tissues in the pulp cham‑ ber and horns to prevent coronal discoloration. 18 Notably, labial access cavity preparation in anterior teeth has been described in the literature, and it is indicated in instances of teeth crowding (when the lingual/palatal surface is not accessible), exten‑ sive labial decay, and unusual shape/curvature of the root canal. 19, 20 Compromised esthetics have been considered as one shortcoming of the labial approach; 20 however, this issue can be managed properly using modern tooth‑colored restorative materials. 20 Complete biomechanical debridement of such ca‑ nals is challenging. In the present case, the One‑ Shape NiTi rotary file system was initially used followed by precurved K‑files under copious irriga‑ tion. As a general rule, dilacerated root canals are not suitable for the use of NiTi rotary files because of the severe coronal extent of the curvature that must be negotiated. 14 However, due to the large size of the canal and straight line access provided by the labial access cavity, the OneShape system was able to create a glide path for the subsequent hand files. Owing to the well‑documented antimicrobial properties of calcium hydroxide, it was used as an intracanal medicament to increase the predictabil‑ ity of the treatment. 14 The labial straight line access has also facilitated the application of warm vertical compaction technique procedures to ensure 3D obturation of the root canal system.
Conclusions Dilacerated teeth do pose a number of diagnostic and management challenges. The clinician must undertake great attention to avoid instrumenta‑ tion‑related mishaps in teeth with significant dilac‑ erations.
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References 1. Vertucci FJ. Root canal morphology and its relationship to endodontic procedures. Endod Topics 2005;10:3‑29 . 2. Ahmed HM, Hashem AA. Accessory roots and root canals in human anterior teeth: A review and clinical considerations. Int Endod J 2016;49:724‑36. 3. American Association of Endodontists. AAE Glossary of Endodontic Terms. 9th ed. American Association of Endodontists; 2016. Available from: http:// www.aae.org/clinical‑resources/aae‑glossary‑of‑endodontic‑terms.aspx. [Last accessed on 2016 Jun 14]. 4. Çolak H, Bayraktar Y, Hamidi MM, Tan E, Çolak T. Prevalence of root dilacerations in Central Anatolian Turkish dental patients. West Indian Med J 2012;61:635‑9. 5. Miloglu O, Cakici F, Caglayan F, Yilmaz AB, Demirkaya F. The prevalence of root dilacerations in a Turkish population. Med Oral Patol Oral Cir Bucal 2010;15:e441‑4.
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6. Udoye CI, Jafarzadeh H. Dilaceration among Nigerians: Prevalence, distribution, and its relationship with trauma. Dent Traumatol 2009;25:439‑41. 7. Afify AR, Zawawi KH. The prevalence of dental anomalies in the western region of Saudi Arabia. ISRN Dent 2012;2012:837270. 8. Vani NV, Saleh SM, Tubaigy FM, Idris AM. Prevalence of developmental dental anomalies among adult population of Jazan, Saudi Arabia. Saudi J Dent Res 2016;7:29‑33. 9. Malci A, Juki S, Brzovi V, Mileti I, Pelivan I, Ani I. Prevalence of root dilaceration in adult dental patients in Croatia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:104‑9. 10. Byun C, Kim C, Cho S, Baek SH, Kim G, Kim SG, et al. Endodontic treatment of an anomalous anterior tooth with the aid of a 3‑dimensional printed physical tooth model. J Endod 2015;41:961‑5. 11. Plakwicz P, Kapuscinska A, Kukula K, Czochrowska EM. Pulp revascularization after repositioning of impacted incisor with a dilacerated root and a detached apex.
J Endod 2015;41:974‑9.
12. Peters OA. Current challenges and concepts in the preparation of root canal systems: A review. J Endod 2004;30:559‑67. 13. Chohayeb AA. Dilaceration of permanent upper lateral incisors: Frequency, direction, and endodontic treatment implications. Oral Surg Oral Med Oral Pathol 1983;55:519‑20.
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14. Jafarzadeh H, Abbott PV. Dilaceration: Review of an endodontic challenge. J Endod 2007;33:1025‑30. 15. Hamasha AA, Al‑Khateeb T, Darwazeh A. Prevalence of dilaceration in Jordanian adults. Int Endod J 2002;35:910‑2. 16. Topouzelis N, Tsaousoglou P, Pisoka V, Zouloumis L. Dilaceration of maxillary central incisor: A literature review. Dent Traumatol 2010;26:427‑33. 17. Karabucak B, Ishii H, Kratchman SI. Conventional and surgical endodontic retreatment of a maxillary lateral incisor with unusual anatomy. Int Endod J 2008;41:524‑31. 18. Ahmed HM, Abbott PV. Discolouration potential of endodontic procedures and materials: A review. Int Endod J 2012;45:883‑97. 19. Madjar D, Kusner W, Shifman A. The labial endodontic access: A rational treatment approach in anterior teeth. J Prosthet Dent 1989;61:317‑20. 20. Logani A, Singh A, Singla M, Shah N. Labial access opening in mandibular anterior teeth – An alternative approach to success. Quintessence Int 2009;40:597‑602.
Dental News, Volume XXIV, Number II, 2017
20 Oral Pathology
The Pharmacological Management of Dental Caries Dr. Geoff Knight, general dentist, Melbourne, Australia
Every two years IDS in Cologne showcases the latest in dental technology and points to the future direction of dentistry.
About 75 per cent of the products on display this year indulged in high tech manifestations of opera‑ tive dentistry that were predicated on the ongoing progression of dental disease and tooth loss. One had to sift carefully through the manufacturers to find anyone vaguely promoting preventive care. Dental schools around the globe teach students that the preparation of a carious lesion for a res‑ toration requires removal of all infected dentine (dentine where the collagen within the tissue has been broken down and bacteria are present within the dentinal tubules) however there is a growing consensus that affected dentine (partially deminer‑ alized dentine, where the collagen matrix remains in tack and the odontogenic processes remain viable) can be reminerlized and does not require removal. However, the clinical determination be‑ tween these layers remains one of the challenges of restorative dentistry. Although every clinician has observed arrested car‑ ies amongst their patients the link between this and a tooth’s ability to heal itself under certain clinical conditions appears to have little traction within the profession. The removal of carious dentine during cavity prep‑ aration flags the dentine pulp complex as the only vital tissue within the body without a front line de‑ fence against bacterial infection. It can be argued that carious dentine is in effect an inflammatory reaction within the dentine pulp complex and pro‑ gression to arrested caries is the protective forma‑ tion of dental scar tissue, the same as skin creates scar tissue to keep invading bacteria at bay. This concept creates a pivotal shift in the man‑ Dental News, Volume XXIV, Number II, 2017
agement of dental caries, for instead of removing carious dentine, clinicians can now be seeking a medicament that assists healing within the carious dentine (similar to iodine on a wound) that will form a protective barrier against ongoing decay, ob‑ served clinically as arrested caries (dental scar tissue) As regulators are winding down the global use of dental amalgam, manufacturer’s are searching for an alternative material that provides the same level of forgiveness and predictability of service plus the biomimetic properties that prevent the onset of fur‑ ther caries as well as helping a tooth remineralize any carious tissue remaining under the restoration. Composite resin has excellent aesthetics, accept‑ able physical properties and will bond predictably to dental enamel. However polymerization shrink‑ age and the unpredictable nature of conventional dentine bonding systems creates liabilities especially on the floor of a proximal restoration extending be‑ yond the dento enamel junction. Furthermore com‑ posite resin does nothing to assist with the reminer‑ alization of caries affected dentine or enamel. Glass ionomer cements lack the aesthetics and physical properties of composite resin, however they bond chemically onto tooth structures, do not undergo polymerization shrinkage (no marginal stress) and the fluoride release protects cavo mar‑ gins from ongoing carious attack as well as fluo‑ ride penetration up to a concentration of 1 percent into carious dentine sufficient to kill bacteria to a depth of about 300 microns. This enables clinicians to leave a thin layer of carious dentine at the base of a preparation thus avoiding the dilemma of de‑ termining the demarcation between infected and affected dentine. Looking at the current state of play, an amalgam replacement material will be based more upon glass ionomer technology that that of composite
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22 Oral Pathology resin. Currently a glass ionomer, composite resin sandwich restoration combines the best of both materials and although somewhat complicated to place, offers clinicians the most satisfactory direct restorative available. Direct pharmacological intervention onto a carious lesion prior to placing a restoration is an opportu‑ nity to assist with the remineralization of carious dentine. There are a few options currently available that include ozone and Diamine Silver Fluoride (SDF) although ozone presents clinical challenges in delivery and adaption around a lesion. SDF has been used since the 70’s and shown to be an effective means of arresting caries. To date staining issues has limited its use beyond arresting caries within the primary dentition.
Dental News, Volume XXIV, Number II, 2017
The application of SDF followed by potassium io‑ dide (Riva Star: SDI Australia) has been shown to prevent stain formation and potentially increase the effectiveness of SDF alone as a caries inhibitor by depositing silver iodide salts into the dentinal tubules of carious dentine. As well as preventing staining of surrounding enamel, the application of potassium iodide reduces the caustic eschar that forms on the gingival tissues following the applica‑ tion of SDF alone. EPMA studies have shown that the fluoride ions in Riva Star penetrate through a carious lesion into the sound dentine beneath at concentrations up to 2 percent, effectively killing all the bacteria within the lesion and creating a high fluoride layer of arrested caries turning the carious dentine into a decay resis‑ tant barrier within the tooth. To maximize the effectiveness of the Riva Star is necessary to cover the treated tooth surfaces with a glass ionomer dressing for at least 1 week to enable maximum penetration into the tooth without being washed away by saliva. Riva Star has the potential for a wide range of ap‑ plications in the treatment of dental caries and as no tissue preparation is required the need for dental operative equipment is greatly reduced. In private practice Riva Star will painlessly arrest car‑ ies in the primary dentition and facilitate the resto‑ ration of asymptomatic caries in the secondary den‑ tition without staining. I is a useful adjunct for root canal treatment prior to obturation as biofilms will not form on dentine surfaces treated with Riva Star. In the public sector, where there are long waiting lists for treatment, Riva Star has profound benefits for the triage of carious lesions focusing on stop‑ ping the caries rather than restoring the teeth. A food pack is rarely the cause for attending an emer‑ gency room. Once the caries have been managed more sophisticated treatment can be provided. For emerging economies Riva Star can be applied with a minimum of equipment even if electricity is not available. This enables an important triage service for communities where high carbohydrate diets follow supposed modernization and whole populations suffer from extensive dental disease. Dentistry is at a diverging fork in its history. One group using technology to treat the ongoing prop‑ agation of caries and another focusing upon the causal factors and searching for a pharmacologi‑ cal solution based upon the medical model used to treat bacterial infections elsewhere in the body.
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24 Community Dentistry
Fluoride in dentistry: use, dosage, and possible hazards Mounir Doumit, Dr. Chir. Dent., Dr. Sc. Odont., WHO Expert in Public Health and Community Dentistry, Chairperson and Professor, Public Health Dentistry Department, and Former Dean, Lebanese University School of Dentistry, Beirut, Lebanon
Mohammad Omar Machmouchi, MD (Stomatol.), M.Sc. (Dent. Public Health) Associate Instructor, Public Health Dentistry Department, Lebanese University School of Dentistry, Beirut, Lebanon
Hicham Diab, Dental Surgeon, DU Oral Biol., DESS Preventive/Public Health Dent. Chief of Clinical Services, Public Health Dentistry Department, Lebanese University School of Dentistry, Beirut, Lebanon
Republished with permission of the Lebanese Dental Association
Abstract Fluoride (F) therapy is the delivery of fluoride to teeth, either topically or systematically, in order to protect them from dental caries. Extensive evi‑ dence proved that fluoride toothpastes and water fluoridation reduce dental caries. Fluoride and wa‑ ter fluoridation in dentistry were classified as one of the 10 most important public health measures of the 20th century. This article briefly addresses the fluoride’s issue in dentistry, its use and dosage, and possible hazards due to excess fluoride.
History In 1901, when Dr. Frederick McKay started his den‑ tal practice in Colorado Springs, USA, he noticed that many of his patients had a mysterious brown staining of their teeth, He investigated the issue for 30 years and was stunned to notice that the strangely stained or “mottled” teeth were also de‑ cay free, and he strived to determine the drinking water as the cause of this strange phenomenon. In 1931, Dr. H. Trendley Dean, a dentist working for the US Public Service, was studying the harmful effects of fluoride, and in 1950, he demonstrated that fluoride therapy, in small amounts, has obvi‑ ous large benefits with negligible side-effects re‑ sulting in an enamel staining (“mottling” of teeth), known later as “fluorosis”. At that time, Dean suggested that a water supply fluoride concentra‑ tion of about 1mg/L or 1 part per million (1ppm) (roughly equivalent to a grain of salt in a gallon of water) will be associated with substantially fewer cavities. The safety of Fluoride has been the subject of much discussion indeed; it is one of the most extensively researched health measures. What can be said is that the balance of evidence suggests that Fluoride, when properly used, offers a safe and effective route to better dental health. Dental
Dental News, Volume XXIV, Number II, 2017
and oral diseases are important public health prob‑ lems: pain, disability, and handicap resulting from them are common, and the costs of treatment are a major problem. One of the most efficient elements in prevention of dental decay is Fluoride. Fluoride reduces the incidence of dental caries and slows or reverses the progression of existing ones. Fluoride has made enormous contribution to declines in dental caries over the past 80 years. Fluorine (F) is an element of the halogen family, which also includes Chlorine, Bromine, and Iodine. It forms inorganic and organic compounds called Fluoride. Living organisms are mainly exposed to inorganic fluorides through food and water. The most rel‑ evant inorganic Fluorides are Hydrogen fluoride, Calcium fluoride, and Sodium fluoride. How does fluoride act in dental caries prevention? Three theories prevail: 1. Fluoride becomes incorporated into the hydroxy‑ apatite crystals of teeth, rendering them more resis‑ tant to acid attack. 2. Presence of saliva promotes remineralization of early carious lesions. 3. Fluoride interferes with metabolic pathways of bacteria, thus reducing acid. F can be provided either systematically (in water, salt, and milk) or locally (use of topical fluoride such as toothpaste, gel, varnish and mouth rinse). However, there are additional sources of fluoride in the environment which can occur naturally, or as result of industrial process. The US National Academy of Sciences (NAS) Insti‑ tute of Medicine has recommended an adequate intake of fluoride from all sources as 0.05 mg F/Kg body weight/day.
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Methods of fluoride delivery Water fluoridation: • Life-long resistance produces the greatest caries protective ef‑ fect. • 20-40% reductions in caries over lifetime. • As of 2012, about 435 million people, worldwide, received fluo‑ ridated water at recommended level, and about 214 millions of them live in the USA. • Caries increases after fluoridation cessation. • Advantages: safe, cost-effective, consistent. Low risk of overdosage. • Disadvantages: no freedom of choice removed, requires com‑ plex infrastructure and initial capital outlay. • Dosage requirement average: 1 ppm. Fluoride Tablets and Drops: • 40-50% reduction in caries (in both adults and children). • NaF is the compound of choice. • Care required in prescribing to minimize overdosage and fluo‑ rosis. • 0.5 mg F/day in children under 4 years and 0.75 to 1 mg for older. • Advantages: effective, freedom of choice. • Disadvantages: compliance needed, consistency of delivery needed, risk of overdose. Fluoride Salt: • Effective. • Caries protective as good as fluoridation. • Dose: 250 ppm. • Advantages: effective, freedom of choice. • Disadvantages: conflict with general health messages advising reduction in salt intake. Topical fluoride: • Examples include aqueous solutions of sodium fluoride and stannous fluoride, low pH solutions such as the acidulated phosphate fluoride system. • 20-35% reduction in caries. • Used usually in school-based mouth rinsing programs. • Varnishes may be applied directly to teeth in high concentrations • Gels may applied directly to teeth, as well. • Advantages: effective in individuals at high risk for dental caries, freedom of choice. • Disadvantages: need personnel, time consuming.
Dental News, Volume XXIV, Number II, 2017
28 Community Dentistry
Local or Topical Use
Tablets and drops
Varnishes (22000 PPM)
Gels (22000 PPM)
≥ 9 years
Recommended Total Dietary Fluoride Intake
Reference Weight Kg
Adequate Intake mg/day
Tolerable upper intake mg/day
≥ 9 years
Fluoridated Toothpastes: • Simplest method of fluoride delivery. • Worldwide decline in caries (attributed to toothpastes). • Commercially available as of the late 1960s, 95% by late 70s are fluoridated pastes. • Typical concentrations used: 1000-1500 ppm of fluoride per gram of toothpaste; a lesser dose is used in children: 100-550 ppm (based on the age and the assessment of carious risk). • Advantages: easy, effective, freedom of choice.
Conclusion In a NAS September 1997 report (23rd work‑ shop), F was repeatedly regarded by speakers and panel members as an “essential nutrient”. F is obviously incorporated into mineral matrix of bones and teeth, and, without question, in‑ gestion of even milligram amounts of F during infancy and early childhood may produce the “unmistakable toxic effects of dental fluorosis” (Prof. A. W. Burgstahler, Ph.D, Chemist). Disruption of normal enamel formation is stated Dental News, Volume XXIV, Number II, 2017
(in the 1997 report) not to be “of Public Health Sig‑ nificance” if the F concentration in drinking water is below 2mg/liter (2ppm), and reports of disfigur‑ ing dental fluorosis with staining and pitting of the enamel in areas with 1-2 ppm F in drinking water were evidently overlooked. Most authors and clinicians estimate that crip‑ pling skeletal fluorosis occurs when 10-20mg of F have been ingested on a daily basis for at least 10 years: in that case, calcification of ligaments often precludes joint mobility and numerous exostosis may appear, and these effects may be associated with muscle wasting and neurological complica‑ tions due to spinal cord compression (Prof. Garry M. Whitford, Fluoride Expert, Medical College of Georgia, USA - 1996, in “The Metabolism and Toxicity of Fluoride”). Also, unexplained intermittent episodes of gastric pain and muscular weakness have been clinically linked in areas of endemic dental and skeletal fluo‑ rosis intakes as low as 2 to 5 mg/day (A. K. Sushee‑ la et al., 1992, 1993 - and Desarathy et al., 1996). In March and July 2014, Grandjean and Landrigan
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30 Community Dentistry (in “Lancet Neurology”) addressed the issue of F neurotoxicity, and some authors and experts worldwide, are presently conducting studies that aim to classify F as a neurotoxin, in order to push towards removing industrial sodium F from the world’s water supply. This trend considers F as a developmental neurotoxicant (same as manga‑ nese, chlorpyrifos, tetrachloroethylene, and others) that may cause neurodevelopmental disabilities (such as Attention Deficit Hyperactivity Disorder -ADHD-, dyslexia, etc...).
7.– 9. February Stand: 7E07
The 2013 findings by Harvard University metaanal‑ ysis (funded by the National Institutes of Health NIH, in Bethesda, Maryland, USA) concluded that children in areas with highly fluoridated water have “significantly lower” IQ scores than those who live in areas with low amounts of fluoride in their wa‑ ter supplies: this 32-page report (written by several researchers) reviewed the findings of 27 studies (published over 22 years) that suggest an inverse association between high fluoride exposure and children intelligence. Researcher’s results support the possibility of ad‑ verse effects of F exposures on children’s neuro‑ development but future research should formally evaluate dose-response relations based on individ‑ ual-level measures of exposure over time, including more precise prenatal exposure assessment and more extensive standardized measures of neu‑ robehavioral performance.
SUGGESTED READINGS • Sheiham, A. and Watt, R. G. (2000). A Systematic Review of the efficacy and safety of Fluoridation (Australian government 2007). • Essential Dental Public Health, Daly, B. Watt, R. Batchelor, P. Treasure, E. (2003). • Fluorides and Oral Health / Report of a WHO Expert Committee on Oral Health Status and Fluoride Use. Technical Reports Series - 846. World Health Organization, Geneva, 1994. • Global Consultation on oral health through fluoride. WHO collaboration with the World Dental Federation and the Interna‑ tional Association for Dental Research. November 17, 2006.
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• O’Mullane DM et al. Fluoride and oral health. Submitted to Community Dental Health. • WHO global policy for improvement of oral health - World Health Assembly 2007, by t P.E. Peterson (In Int Dent J 2008 June;58(3):115-121. • Oral Health Programme in Lebanon - Technical Assistance Provided for Development of Baseline Studies for Salt Fluoridation / Final Report on Data Collection - 2003 Lebanese Ministry of Public Health Lebanese Uiversity School of Dentistry World Health Organization M. Doumit, B. Doughan, R. Baez
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Comparison of the shaping ability of various nickel–titanium file systems in simulated curved canals Dr. Mothanna Alrahabi 1 firstname.lastname@example.org
Dr. Ayman Alkady 2
1,2 Department of Restorative Dentistry, College of Dentistry, Taibah University, Al Madinah Al Munawwarah, Saudi Arabia
Abstract Aim The aim of this study was to compare the shaping time and shaping ability of the ProTa‑ per Universal, ProTaper Next, WaveOne, and Twisted Files (TF) nickel–titanium (NiTi) systems. Materials and Methods This study was conducted using simulated root canals (n = 40). The specimens were divided into four experimental groups (n = 10 each). Each group prepared by NiTi system as follow‑ ing: ProTaper Universal, ProTaper Next, and Wa‑ veOne, the canals were injected with black ink before instrumentation, a series of photographs of each canal was saved to a computer using a set protocol. The canals were reinjected using red ink postoperatively to define their outlines, and images were taken in the same standardized manner. Photoshop software was used to super‑ impose pre‑ and post‑instrumentation images in two different layers. Each 1 mm step from the apical end was measured using ImageJ Software and evaluated by measuring the amount of re‑ moved resin. The data were analyzed using SPSS version 20.0. Significance was set at P < 0.05. Results There were significant differences (P < 0.05) in shaping time (in seconds) among the NiTi sys‑ tems where the shortest preparation time was with TF system. There were significant differ‑ ences (P < 0.05) in canal transportation values among NiTi systems. Canal transportation at D1, D2, D3, D5, and D7 was greater for the TF sys‑ tem than for the other systems (ProTaper Univer‑ sal, ProTaper Next, and WaveOne).
Dental News, Volume XXIV, Number II, 2017
The transportation with the TF System was to‑ ward the outside of the curvature, and it was greater than that with other systems at D1, D2, D5, and D7. Conclusions ProTaper Universal, ProTaper Next, and WaveOne preserved the original curvature of the canal bet‑ ter than the TF system. Keywords Nickel–titanium, ProTaper Next, ProTaper Univer‑ sal, shaping, simulated canal, WaveOne
Introduction Root canal shaping is considered an essential step in endodontic treatment. 1 According to Schilder,2 the preferred shape of the canal after mechanical shaping is a tapering funnel following the original shape and curvature of the canal, while keeping the original position of the foramen, and keep‑ ing it as small as practically possible. Tradition‑ ally, stainless steel instruments have been used to achieve these objectives. The classic method of using stainless steel instru‑ ments to shape the canal from the apical end to the coronal part does not achieve Schilder’s mechanical objectives of root canal shaping in curved canals and can cause iatrogenic dam‑ age to the original shape of the canal 3 such as straightening a curved canal, transportation, zip‑ ping, ledging, and root perforations. 4,5 Stainless steel instruments’ stiffness is considered the main cause of these procedural errors. 6 The introduction of nickel–titanium (NiTi) instruments to the endodontic field has revolutionized end‑
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odontic treatment, reducing operator fatigue and treatment time and minimizing errors associ‑ ated with the use of stainless steel instruments.1 ProTaper Universal rotary files (Dentsply Maille‑ fer, Ballaigues, Switzerland), which constitute a common NiTi rotary system, have a convex trian‑ gular cross‑sectional design and progressive ta‑ per that allows efficient movement and cutting ability to flare the canal more coronally. 7 ProTa‑ per Universal rotary files are made from a con‑ ventional superelastic NiTi wire. In previous stud‑ ies, the ProTaper Universal system showed more cracks than other rotary NiTi instruments. 8,9 Recently, several brands of NiTi instruments have been marketed to simplify root canal shaping. ProTaper Next (Dentsply Maillefer) is one of these brands with an off‑center rectangular design and progressive and regressive percent‑ age tapers on a single file, which is made from M‑Wire technology. The off‑center rectangular design of ProTaper Next minimizes contact be‑ tween the instrument and the dentin, which leads to decreased withdrawal of the instrument from the canal and reduces the risk of taper lock. 10 The novel WaveOne NiTi single‑file system (Dentsply Maillefer) is another example of new brands offered in 2011. This system is intended for use with a special reciprocating file motion. It is composed of three single‑use files: Small (ISO 21 tip and 0.06 taper) for fine canals, primary (ISO 25 tip and 0.08 taper) for most canals, and large (ISO 40 and 0.08 tapers) for large canals. 11 Files are manufactured by grinding M‑Wire NiTi alloy. Endodontic instruments made of M‑Wire are predicted to have higher strength, with wear resistance resembling conventional superelastic NiTi instruments because of M‑Wire’s unique nanocrystalline martensitic microstructure. 12 Recent improvements in NiTi systems have reduced the number of machining defects; Twisted Files (TF) (SybronEndo, Orange, CA, USA), whose use involves twisting a file blank, represent an example of these improvements. 13 TF are made by transforming basic austenite NiTi wire into the R‑phase through thermal process‑ ing through a series of heating and cooling cy‑ cles after achieving the required twisted shape. When R‑phase wire returns to the austenite Dental News, Volume XXIV, Number II, 2017
crystalline structure, it becomes superelastic when stressed. 14 The aim of this study was to compare the shaping time and shaping ability of the ProTaper Universal, ProTaper Next, WaveOne, and TF NiTi systems.
Materials and methods Simulated canals This study was conducted using simulated root canals (n = 40) fabricated with clear resin blocks (Dentsply Maillefer, Ballaigues, Switzerland). The taper of the canals was 2, and they were 17 mm long (a straight coronal section of 12 mm and a curved apical section of 5 mm). The size of the canal equaled ISO file size 15#, and the curvature of the simulated root canals was 40°, based on the Schneider method of measur‑ ing curvature. 15 Photographic procedures To provide standardized photographs of each ca‑ nal, a special mold was used to position the camera (Nikon D3200, Nikon, Inc.) precisely. To improve the color contrast of photos, all canals were injected with black ink before instrumentation. In a standardized manner, a series of photographs of each canal was saved to a computer using a set protocol. The ca‑ nals were reinjected using red ink postoperatively to define their outlines, and images were taken in the same standardized manner. To reduce the margin of error, all photographs were taken by the same op‑ erator. Instrumentation The specimens were divided into four experimental groups (n = 10 each). • Group 1 was prepared using the ProTaper Universal system according to manufacturer reference guide to F2 instrument (size 25, taper 8% over the first 3 mm from apical tip) file, the instrument replaced af‑ ter preparing three canals • Group 2 was prepared using the ProTaper Next sys‑ tem according to manufacturer reference guide to × 2 (size 25, taper 6% over the first 3 mm from apical tip) file, the instrument replaced after preparing three canals • Group 3 was prepared using the WaveOne system according to manufacturer reference guide, the ca‑ nals prepared by primary single file instrument (size 25, taper 8% over the first 3 mm from apical tip) • Group 4 was prepared using the TF system accord‑
36 Endodontics ing to manufacturer instructions, the canals pre‑ pared until TF instrument (size 25, taper 6% con‑ stant taper), the instrument replaced after prepare three canals • All simulated canals were prepared by the same operator, who had more than 5 years’ experience in root canal therapy. Assessment of root canal preparation The time taken to prepare each canal was recorded including active instrumentation, instrument chang‑ es, and irrigation. Shaping efficiency was evaluated by measuring the amount of material lost at various levels (1 mm [D1], 2 mm [D2], 3 mm [D3], 5 mm [D5], and 7 mm [D7]) from the apical foramen of the root canal. Photo‑ shop (Adobe Systems, San Jose, CA, USA) was used to superimpose pre‑ and post‑instrumentation im‑ ages in two different layers. Each 1 mm step was measured using ImageJ Software (National Institute of Mental Health, Bethesda, Maryland, USA) and evaluated as follows: D (difference) = Do (outer resin removed) – Di (inner resin removed). A positive value indicated the prevalence of outer resin removal, and a negative result indicated the prevalence of inner resin removal. The closer the value was to zero, the more balanced was the prep‑ aration. Statistical analyses Statistical analyses were carried out using SPSS soft‑
ware (version 20; SPSS, Inc., Chicago, IL, USA). To evaluate the results, one‑way ANOVA and Bonfer‑ roni post hoc tests were used. Statistical significance was set at P < 0.05.
Results Shaping time evaluation There were significant differences (P < 0.05) in shaping time (in seconds) among the NiTi systems. The order of NiTi systems according to preparation time, in descending order, was as follows: ProTa‑ per Universal > TF > ProTaper Next > WaveOne. Table 1 and Figure 1 show the preparation times of each NiTi system.
Figure 1: Average shaping time (in seconds) according to nickel–titanium system
Table 1: Shaping time values (s) according to nickel-titanium
ProTaper Universal system
ProTaper Next system
WaveOne system 1
TF: Twisted Files, SD: Standard deviation
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Figure 2: Average canal transportation values according to nickel–titanium system
Canal transportation evaluation There were significant differences (P < 0.05) in canal transporta‑ tion values among NiTi systems. Canal transportation at D1, D2, D3, D5, and D7 was greater for the TF system than for the other systems (ProTaper Universal, ProTaper Next, and WaveOne). At D1, there were no significant differences (P > 0.05) in canal transpor‑ tation among ProTaper Universal, ProTaper Next, and WaveOne. At D2, there was no significant difference (P > 0.05) in canal transportation between ProTaper Universal and ProTaper Next. In addition, canal transportation with ProTaper Next was lower than that with WaveOne at D2 and D3, and canal transportation with ProTaper Universal was less than that with WaveOne at D2 and D3. Furthermore, absolute values of canal transportation with ProTaper Universal and WaveOne were lower than transportation values for ProTaper Next at D5 and D7. Table 2 shows means and standard deviation of transportation (in mm) at different apical levels. Figure 2 shows the differences in canal transportation according to NiTi system. Evaluation of canal transportation direction There were significant differences (P < 0.05) in the direction of transportation such that transportation with the TF System was toward the outside of the curvature, and it was greater than that with other systems at D1, D2, D5, and D7. ProTaper Next caused less transportation toward the outside of the canal curvature at D3 compared with the other systems. WaveOne caused less transportation toward the inside of the canal curvature at D1 compared with ProTaper Universal and ProTaper Next. ProTaper Universal caused more transportation toward the inside of the canal curvature at D2 and D7 compared with ProTaper Next and WaveOne.
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Table 2: Means and standard deviation of transportation (mm) at different apical levels
NiTi: Nickel-titanium, TF: Twisted Files
Discussion The aim of this study was to compare the shaping ability of several NiTi systems (ProTaper Universal, ProTaper Next, WaveOne, and TF) in simulated ca‑ nals. The use of simulated canals in this study al‑ lowed standardization of canal shaping evaluation 16, 17 and root canal morphology. 18, 19 The canals also supplied the same hardness and abrasion character‑ istics every time. 20 Pre‑ and post‑instrumentation studies indicate that the analysis of root canal outlines provides a stan‑ dardized study design and extremely reproducible conditions. 17, 21 In our study, there was a significant difference in preparation time among NiTi systems, where the longest time was required for the ProTaper Univer‑ sal, and the shortest for the WaveOne system. This is logical because the procedure with the ProTaper Universal required four instruments, whereas the WaveOne system is a single‑file system, and the use of a single‑file NiTi system with reciprocating mo‑ tion reduces the time of preparation in curved root canals. 17, 21 The results show that the TF rotary system caused more canal transportation than did the other NiTi systems in this study (ProTaper Universal, ProTaper Next, and WaveOne).
more difficulty negotiating a curvature and increase the risk of ledging or transportation, 25 the differenc‑ es between this study and other studies may result from differences in assessment methods and the equipment used. The reciprocating motion with WaveOne prevents instrument engagement, and that may enhance the safety of single‑file systems in curved canals.26 However, it is clear that instrumentation with sin‑ gle‑file systems is faster. 27 Furthermore, reciprocat‑ ing motion facilitates centered instrumentation more than a continuous rotating motion does, as aggres‑ sive continuous rotating motion tends toward the ex‑ ternal wall of the canal, especially in the apical third. 28 Comparisons of single‑file technique systems with the ProTaper NiTi system (continuous rotating mo‑ tion) have yielded conflicting results. Berutti et al. 17 reported that the WaveOne system facilitated cen‑ tering preparation better than the ProTaper system did, whereas Bürklein et al. 29 found no significant difference between the single‑file technique and a full NiTi file sequence technique. The shaping ability of NiTi instruments is a multifac‑ torial phenomenon that is related to the method of manufacture, 30 microstructure of the alloy, taper, cross‑sectional design, type of movement, and sys‑ tem composition.
This is consistent with the results of one other study; 22 however, in other studies, TF produced less canal transportation than did ProTaper Universal.[23,20] A recent study revealed that ProTaper and TF rotary systems could shape curved canals safely and pre‑ serve the original canal in a satisfactory way without any significant difference in shaping ability and canal transportation between them. 24 TF instruments have a triangular cross section with a constant taper. While nonlanded, ground‑fluted instruments with aggressive cutting action have
The microstructure of NiTi wire has three phases: Austenite, martensite, and the R‑phase. The strong, hard quality of NiTi alloy is present in the austenite phase, and the flexible and ductile quality are present in the martensite phase. The pro‑ gressive tapers and sharp cutting edges of ProTaper instruments are responsible for canal transportation toward the outside wall of the canal. 32 A microcomputed tomographic three‑dimensional [3D] analysis is a recent advance for evaluating root canal instrumentation. 33
Dental News, Volume XXIV, Number II, 2017
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40 Endodontics Conclusion It has recently been suggested that microcomputed tomographic 3D analysis provides clearer distinc‑ tions than photographic measurements do. Howev‑ er, evaluation of root canal instrumentation requires further studies on natural teeth to achieve accurate results. Within the limitations of the present study, the ProTaper Universal, ProTaper Next, and Wa‑ veOne systems preserved the original curvature of the canal better than the TF system did.
The results of this study revealed that ProTaper Uni‑ versal, ProTaper Next, and WaveOne preserved the original curvature of the canal better than the TF system did, with transportation toward the outside wall of the canal. ProTaper Universal, ProTaper Next, and WaveOne produced satisfactory root canal in‑ strumentation. Further studies on extracted teeth with 3D analysis are needed to obtain accurate re‑ sults.
References 1. Peters OA. Current challenges and concepts in the preparation of root canal systems: A review. J Endod 2004;30:559‑67. 2. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am 1974;18:269‑96. 3. Elizabeth M. Hand instrumentation in root canal preparation. En‑ dod Topics 2005;10:163‑7. 4. Kapalas A, Lambrianidis T. Factors associated with root ca‑ nal ledging during instrumentation. Endod Dent Traumatol 2000;16:229‑31. 5. Roda RS, Gettleman B. Nonsurgical retreatment. Pathways of the Pulp. 9th ed. St. Louis, MO: Mosby; 2006. 6. Craig RG, Mc Ilwain ED, Peyton FA. Comparison of theoretical and experimental bending and torsional moments of endodontic files and reamers.
J Dent Res 1967;46:1058‑63. 7. Bergmans L, Van Cleynenbreugel J, Beullens M, Wevers M, Van Meerbeek B, Lambrechts P. Smooth flexible versus active tapered shaft design using NiTi rotary instruments. Int Endod J 2002;35:820‑8. 8. Bier CA, Shemesh H, Tanomaru‑Filho M, Wesselink PR, Wu MK. The ability of different nickel‑titanium rotary instruments to induce dentinal damage during canal preparation. J Endod 2009;35:236‑8. 9. Ashwinkumar V, Krithikadatta J, Surendran S, Velmurugan N. Effect of reciprocating file motion on microcrack formation in root canals: An SEM study. Int Endod J 2014;47:622‑7. 10. Capar ID, Arslan H, Akcay M, Uysal B. Effects of ProTaper Universal, ProTaper Next, and HyFlex instruments on crack forma‑ tion in dentin. J Endod 2014;40:1482‑4. 11. Plotino G, Grande NM, Testarelli L, Gambarini G. Cyclic fa‑ tigue of Reciproc and WaveOne reciprocating instruments. Int Endod J 2012;45:614‑8. 12. Ye J, Gao Y. Metallurgical characterization of M‑Wire nick‑ el‑titanium shape memory alloy used for endodontic rotary instru‑ ments during low‑cycle fatigue. J Endod 2012;38:105‑7. 13. Oh SR, Chang SW, Lee Y, Gu Y, Son WJ, Lee W, et al. A com‑ parison of nickel‑titanium rotary instruments manufactured using different methods and cross‑sectional areas: Ability to resist cyclic fatigue. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:622‑8. 14. Gambarini G, Grande NM, Plotino G, Somma F, Garala M, De Luca M, et al. Fatigue resistance of engine‑driven rotary nickel‑tita‑ nium instruments produced by new manufacturing methods. J Endod 2008;34:1003‑5. 15. Schneider SW. A comparison of canal preparations in straight and curved root canals. Oral Surg Oral Med Oral Pathol 1971;32:271‑5. 16. Muñoz E, Forner L, Llena C. Influence of operator’s experience on root canal shaping ability with a rotary nickel‑titanium single‑file reciprocating motion system. J Endod 2014;40:547‑50. 17. Berutti E, Chiandussi G, Paolino DS, Scotti N, Cantatore G, Castellucci A, et al. Canal shaping with WaveOne Primary recip‑ rocating files and ProTaper system: A comparative study. J Endod 2012;38:505‑9. 18. Bürklein S, Poschmann T, Schäfer E. Shaping ability of different Dental News, Volume XXIV, Number II, 2017
nickel‑titanium systems in simulated
S‑shaped canals with and with‑ J Endod 2014;40:1231‑4. 19. Saleh AM, Vakili Gilani P, Tavanafar S, Schäfer E. Shaping ability of 4 different single‑file systems in simulated S‑shaped canals. J Endod 2015;41:548‑52. 20. Aydin C, Inan U, Gultekin M. Comparison of the shaping ability of Twisted Files with ProTaper and RevoS nickel‑titanium instruments in simulated canals. J Dent Sci 2012;7:283‑8. 21. You SY, Bae KS, Baek SH, Kum KY, Shon WJ, Lee W. Lifespan of one nickel‑titanium rotary file with reciprocating motion in curved root canals. J Endod 2010;36:1991‑4. 22. Aguiar CM, Donida FA, Câmara AC, Frazão M. Changes in root canal anatomy using three nickel‑titanium rotary system: A cone beam computed tomography analysis. Braz J Oral Sci 2013;12:307‑12. 23. Silva EJ, Tameirão MD, Belladonna FG, Neves AA, Souza EM, De‑Deus G. Quantitative transportation assessment in simulated curved canals prepared with an adaptive movement system. J Endod 2015;41:1125‑9. 24. Pagliosa A, Sousa‑Neto MD, Versiani MA, Raucci‑Neto W, Silva‑Sousa YT, Alfredo E. Computed tomography evaluation of ro‑ tary systems on the root canal transportation and centering ability. Braz Oral Res 2015;29. pii: S1806‑83242015000100240. 25. Bergmans L, Van Cleynenbreugel J, Beullens M, Wevers M, Van Meerbeek B, Lambrechts P. Progressive versus constant tapered shaft design using NiTi rotary instruments. Int Endod J 2003;36:288‑95. 26. Yared G. Canal preparation using only one Ni‑Ti rotary instru‑ ment: Preliminary observations. Int Endod J 2008;41:339‑44. 27. Paqué F, Zehnder M, De‑Deus G. Microtomography‑based comparison of reciprocating single‑file F2 ProTaper technique versus rotary full sequence. J Endod 2011;37:1394‑7. 28. Franco V, Fabiani C, Taschieri S, Malentacca A, Bortolin M, Del Fabbro M. Investigation on the shaping ability of nick‑ el‑titanium files when used with a reciprocating motion. J Endod 2011;37:1398‑401. 29. Bürklein S, Hinschitza K, Dammaschke T, Schäfer E. Shaping ability and cleaning effectiveness of two single‑file systems in severely curved root canals of extracted teeth: Reciproc and WaveOne ver‑ sus Mtwo and ProTaper. Int Endod J 2012;45:449‑61. 30. Hou X, Yahata Y, Hayashi Y, Ebihara A, Hanawa T, Suda H. Phase transformation behaviour and bending property of twisted nick‑ el‑titanium endodontic instruments. Int Endod J 2011;44:253‑8. 31. Shen Y, Zhou HM, Zheng YF, Peng B, Haapasalo M. Current out glide path.
challenges and concepts of the thermomechanical treatment of nickel‑titanium instruments.
J Endod 2013;39:163‑72. 32. Schäfer E, Vlassis M. Comparative investigation of two rotary nickel‑titanium instruments: ProTaper versus RaCe. Part 1. Shaping ability in simulated curved canals. Int Endod J 2004;37:229‑38. 33. Aminsobhani M, Ghorbanzadeh A, Dehghan S, Niasar AN, Kharazifard MJ. A comparison of canal preparations by Mtwo and RaCe rotary files using full sequence versus one rotary file tech‑ niques; a cone‑beam computed tomography analysis. Saudi Endod J 2014;4:70‑6.
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42 Implant Dentistry
Immediate loading of a dental implant in the esthetic zone using the CAD/CAM technique Dr. Alexandros Manolakis email@example.com
The female patient presented in the dental office with the chief complaint of a fractured maxillary lateral incisor (Fig.01). The patient was in good general health, taking no regular medication. She was not a regular smoker. The horizontal tooth fracture happened due to se‑ vere decay under the old PFM crown (Fig.03). The periapical radiograph revealed no periradicular pathology (Fig.02). The tooth was deemed unre‑ storable. Fig 1
FIg. 1: Initial situation. Fig 2
FIg. 3: Initial situation.
The proposed treatment plan consisted of ex‑ tracting the root (#22) and placing an immedi‑ ate implant. If sufficient primary stability could be reached, the implant would be loaded immedi‑ ately. After application of local anaesthesia, the root was extracted in a minimally traumatical way without raising a flap (Fig.04). The labial wall of the alveo‑ lar bone was assessed with a periodontal probe. No buccal fenestration or dehiscence could be de‑ tected. Fig 4
FIg. 4: Extraktion socket. Fig 5
FIg. 2: Initial periapical radiograph. Dental News, Volume XXIV, Number II, 2017
FIg. 5: Implant placed in the correct 3D position.
After careful implant bed preparation, an immediate implant was placed (Bredent Medical Narrow-SKY 3,5x11mm) (Fig.05). The implant was positioned slightly palatal, according to current literature recommendations, and the void in the buccal area be‑ tween bone and implant was filled with a xenograft (Botiss Cera‑ bone). The implant shoulder was placed 3mm apical to the labial gingival margin of the extracted root. Implant insertion depth was assessed in accordance to the neighbouring teeth as well. The implant was inserted with a torque of 40Ncm, thus allowing an immediate provisionalization. A scan-abutment was secured into the implant and subsequently scanned using an intraoral scanner (Planmeca PlanScan) (Fig.06).
The shape of the titanium-abutment to be used for the restoration was stored in the implant library of the CAD software (Fig.08). First the subgingival part of the restoration was designed, achiev‑ ing a custom emergence profile that resembles the original tooth and is slightly narrower (Fig.09). Fig 9
FIg. 9: Design of the subgingival part of the crown.
Further on the actual crown was designed. After taking into ac‑ count occlusal and approximal contacts, as well as tooth morphol‑ ogy and aesthetics, the shape of the crown was finalised. At the end the subgingival and the supragingival parts were merged into one final object (Fig.10, 11).
FIg. 6: Scan-Abutment inserted into implant.
The resulting STL file was imported into a CAD software (Planmeca PlanCAD Premium), in order to design the new crown. A screwre‑ tained crownabutment would be the favoured type of restoration. Initially implant position was indexed in the CAD software by matching the scan-abutment geometry (Fig.07).
The crownabutment was milled at the chairside milling unit (Plan‑ meca PlanMill 40) out of an acrylic block (Ivoclar TelioCAD) (Fig.12). The acrylic crownabutment was cemented extraoral on the tita‑ nium abutment (Bredent Medical Uni.fit CAD) resulting in a screwretained restoration (Fig.13). Fig 8
FIg. 7: Matching of scan-abutment geometry in the CAD software. FIg. 8: Geometry of titanium abutment. FIg. 10: Merge of supragingival and subgingival parts of the crown. Buccal view. FIg. 11: Merge of supragingival and subgingival parts of the crown. Approximal view.
44 Implant Dentistry Fig 12
After 3 months of uneventful healing, the soft tis‑ sue profile was optimal and treatment could be continued with manufacturing of the final restora‑ tion (Fig.16, 17, 18). Fig 16
FIg. 12: Milled restoration and titanium abutment. Fig 13
FIg. 13: Extraoral cementation and one-piece crownabutment.
The restoration could be delivered 45 Minutes af‑ ter implant placement (Fig.14,15). This protocol provided a short treatment time and reduced postoperative discomfort.
FIg. 16: Periapical radiograph 3 months after surgery. Fig 17
FIg. 17: Clinical situation 3 months after surgery. FIg. 14: Insertion of the restoration.
FIg. 15: Restoration in-situ 45 Minutes after extraction and implant placement.
Dental News, Volume XXIV, Number II, 2017
FIg. 18: Clinical situation 3 months after surgery.
46 Community Dentistry
Can Dentists Help Patients Quit Smoking? The Role of Cessation Medications Dr. Bo Zhang, PhD Research officer, Ontario Tobacco Research Unit, University of Toronto, Toronto. Michael.Chaiton@ utoronto.ca
Dr. Susan J. Bondy, PhD Associate professor, Epidemiology Division, Dalla Lana School of Public Health, University of Toronto. Principal investigator of the Ontario Tobacco Research Unit, Toronto.
Ms. Lori M. Diemert, MSc Research of cer, Ontario Tobacco Research Unit, University of Toronto, Toronto.
Dr. Michael Chaiton, PhD Assistant professor, Epidemiology Division, Dalla Lana School of Public Health, University of Toronto. Scientist at the Ontario Tobacco Research Unit, Toronto.
Abstract Background Clinical trials show the efficacy of dentists’ counseling in smoking cessation. However, little is known about the effectiveness of such advice in the general population of smokers. Objective To examine the association between dentists’ advice, use of cessation medications and quit‑ ting behaviours in the general population of adult smokers in Ontario, Canada. Methods Data were from the Ontario Tobacco Survey panel study, which followed people who were smokers in July 2005 semi-annually for up to 3 years until June 2011. Baseline smokers, who were seen by a dentist during the study, were included in the analysis (n = 2714 with 7549 observations). Logistic regression analysis with generalized estimating equations was used to examine associations among dentists’ advice, use of cessation medications and quitting out‑ comes (quit attempts and short-term quitting ≥ 30 days). Results Those who received dentists’ advice were more addicted to tobacco, compared with those who did not receive dentists’ advice (self-perceived addiction to tobacco: 96% vs. 89%, p < 0.001). Dentists’ advice alone was not associated with making an attempt to quit smoking or shortterm quitting. However, receiving dentists’ ad‑ vice in conjunction with cessation medications was associated with a higher likelihood of quit attempts (adjusted odds ratio [OR] 9.85, 95%
Dental News, Volume XXIV, Number II, 2017
confidence interval [CI] 7.77–12.47) and shortterm quitting (adjusted OR 3.19, 95% CI 2.20– 4.62), compared with not receiving dentists’ ad‑ vice and not using cessation medications. Conclusion: Dentists play an important role in smoking ces‑ sation, because they can encourage patients to stop smoking and promote success by advising patients to use cessation medications.
Introduction The health consequences and economic cost of tobacco use are extensive.1 By helping their pa‑ tients quit smoking, health professionals play a key role in enhancing their health and well-being, and clinical guidelines have been developed to facilitate evidence-based clinical care in smok‑ ing cessation.2,3 The dental team, in particular, is fundamental to cessation. Because tobacco use has a significant impact on oral health (smokers have a greater risk of oral cancers, periodontitis and other oral diseases), dental professionals are uniquely qualified to conduct smoking-cessa‑ tion interventions.4 Smoking is a risk factor for the destruction of hard and soft tissue around natural teeth.1 Smoking affects inflammation, promotes the growth of periodontal pathogens and reduces gingival blood flow.1 Dentists, dental hygienists and other professionals have been on the front lines of tobacco control for many de‑ cades, and most dental practitioners have long believed that counseling is an important part of their practice.5 Advice from and intervention by dental profes‑ sionals has also been shown to be effective, and
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48 Community Dentistry at least 14 high-quality clinical trials have shown that dental professionals have helped tobacco users to quit.6 Dating from 2001, the Canadian Dental Asso‑ ciation’s official position is that it encourages “the eradication of the use of tobacco products. Studies indicate that dental counselling is effec‑ tive in influencing patients to quit using tobacco. The Canadian Dental Association urges dentists to inquire about their patients’ tobacco use and provide advice and encouragement to those in‑ terested in quitting.”7 In 2012, the Ontario Tobacco Research Unit conducted a survey of 1966 dental health pro‑ fessionals in Ontario.8 It found that dental pro‑ fessionals, particularly dental hygienists, were enthusiastic about smoking cessation, and over 50% reported providing services of some sort at least some of the time, including advice to quit and warning of the dangers of smoking. Never‑ theless, substantial barriers to providing smoking
cessation services remain. Only 21% of respon‑ dents had received formal training in providing such services, and 29% were not at all confident in their knowledge and skills in this area. Lack of interest by patients and fear of alienation of pa‑ tients are regarded as key barriers.8 Although the efficacy of smoking cessation ad‑ vice from dental professionals in clinical settings is well known, information about its effectiveness in the general population of smokers in Ontario and Canada is limited. In this study, we exam‑ ine the characteristics of smokers who received smoking cessation advice from dentists and the impact of that advice in a representative cohort of Ontario adult smokers.
Methods Data Source We used data from the Ontario Tobacco Survey (OTS). The OTS longitudinal panel is a populationbased telephone survey of Ontario adult smokers (≥ 18 years of age) who were recruited and fol‑ lowed every 6 months for up to 3 years (maxi‑
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Dental News, Volume XXIV, Number II, 2017
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50 Community Dentistry mum of 7 interviews: baseline and 6 follow-up interviews) between 2005 and 2011.9 Current smokers were eligible for inclusion in this analysis if they had smoked at least 100 cigarettes in their lifetime; smoked daily or occa‑ sionally in the past 30 days at the time of the in‑ terview; and were seen by a dentist at least once during the study. Overall, 2714 eligible smokers had been seen by a dentist at least once dur‑ ing the study. On average, each eligible smoker contributed 2.8 observations over the 3 years of follow up, resulting in 7549 observations for analysis. Measures Dentists’ advice was measured as a positive re‑ sponse to the survey question “Did the dentist advise you to quit or reduce smoking” among those who reported that they had seen a dentist in the past 6 months. Use of cessation medica‑ tions was measured as a positive response to the survey question “In the past 6 months, did you use… to help you quit or reduce smoking, or stay smoke free?” This question was asked for each form of nicotine replacement therapy (NRT), including nicotine gum, patches, inhaler, nasal spray and lozenges, as well as bupropion and varenicline. The outcome of 1 or more quit
attempts was measured as a report “trying to quit smoking completely” by a respondent dur‑ ing the follow-up period. Short-term quitting was measured as self-reported “not smoking for at least 1 month” at any follow-up interview. Analysis We conducted bivariate analyses using either a X2 test for categorical variables or a t test for continuous variables to examine the relation between sociodemographic characteristics or smoking-related variables and dentists’ advice. Each eligible smoker contributed 1 data point, i.e., if a smoker was given advice 3 times during the 3-year follow up, he or she was included in the “receiving advice” group as 1 record; those who were seen by a dentist but never received advice were classified as “not receiving advice.” To examine the association among dentists’ advice, cessation medications and quitting out‑ comes, while controlling for confounding factors, we used logistic regression through generalized estimating equations (GEEs) with exchangeable correlation matrix, which take into account cor‑ related error terms for repeated measures within individuals. Odds ratios and 95% confidence in‑ tervals were reported. All analyses were conduct‑ ed using SAS v.9.3, and all p values were 2-sided.
Note: SD = standard deviation. * Receiving any advice to quit or reduce smoking from a dentist during the course of the study. † Including nicotine replacement therapy, bupropion and varenicline. ‡ Including physicians, pharmacists and nurses.
Table 1: Differences in baseline characteristics of smokers receiving and not receiving dentists’ advice to quit smoking during follow up, according to the Ontario Tobacco Survey, 2005–2011. Dental News, Volume XXIV, Number II, 2017
52 Community Dentistry Results Smokers who received advice were more likely to be male, less educated and in poorer health; to have a higher perceived addiction to tobacco; to smoke daily and more cigarettes per day; to use cessation medications; and to receive advice to quit from other health professionals, but less likely to have home smoking restrictions, com‑ pared with those who did not receive advice (Ta‑ ble 1). Thus, smokers who received advice were more addicted to tobacco than those who did not receive advice. In Table 1, each smoker only contributed one data point.
Rates of quit attempts and short-term quitting were higher among those who did not receive dentists’ advice, compared with those who did (Table 2, Model 1). Rates of quitting were also higher among those who received advice from a dentist and used ces‑ sation medications and those who used medica‑ tions alone compared with those who received dentists’ advice alone and those who did not receive dentists’ advice and did not use medica‑ tions (Table 2, Model 2).
Note: CI = confidence interval, OR = odds ratio. *Percentages were estimated based on multiple observations per individual. † In Model 1, adjusted for baseline variables of age, gender and education and time-varying variables of selfperceived health, self-perceived addiction, daily smoking, cigarettes smoked per day, number of lifetime quit attempts, home smoking restrictions, advice to quit from other health professionals and use of cessation medications. In Model 2, adjusted for the same variables as in Model 1, except for medications.
Table 2: The association between dentists’ advice, use of cessation medications and quitting smoking, based on the Ontario Tobacco Survey, 2005–2011.
Adjusted logistic regression analysis using the GEE method showed that receiving dentists’ ad‑ vice was not associated with quit attempts (ad‑ justed OR 1.07, 95% CI 0.92–1.25) and was not associated with short-term quitting (adjusted OR 0.78, 95% CI 0.60–1.01) compared with not re‑ ceiving dentists’ advice (Table 2, Model 1). Dental News, Volume XXIV, Number II, 2017
Compared with not receiving dentists’ advice and not using cessation medications during fol‑ low up, receiving dentists’ advice alone was not associated with quit attempts (adjusted OR 1.01, 95% CI 0.83–1.22) or short-term quitting (ad‑ justed OR 0.78, 95% CI 0.56–1.08). Those who received dentists’ advice and used
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54 Community Dentistry cessation medications during follow up had a higher likelihood of quit attempts (adjusted OR 9.85, 95% CI 7.77–12.47) and a higher likeli‑ hood of short-term quitting (adjusted OR 3.19, 95% CI 2.20–4.62) (Table 2, Model 2). Using medications alone was also associated with a higher likelihood of quit attempts and short-term quitting (Table 2, Model 2). There was no difference in quitting outcomes be‑ tween those receiving both dentists’ advice and cessation medications and those who used ces‑ sation medications alone. Those who received dentists’ advice were more likely to use cessation medications compared with those who did not receive dentists’ advice (19.4% vs. 17.3%, p < 0.05; data not shown). In Table 2, each smoker might contribute multiple data points.
to be male, less educated, in poorer health and more addicted to tobacco smoking, i.e., Ontario dentists are providing advice to people who are more affected by their tobacco use. Thus, these patients will receive the greatest benefit from quitting smoking, but they are also the most challenging group to treat.
Our results have 2 major implications for prac‑ tice. First, dentists should ensure that their advice reaches a broader audience, including patients who are lighter smokers, less addicted or have not yet fully developed nicotine dependence. Dental advice has been shown in clinical studies to be just as effective in this population, and this will help increase the absolute number of quit at‑ tempts driven by dental professional advice.
In the general population of Ontario, a substan‑ tial number of smokers (nearly 54%) received advice to quit or reduce smoking from a den‑ tist. This suggests that dental advice is a key component of the smoking cessation system. In this study, we found that dentists’ advice, when given in conjunction with smoking cessation medications, was effective in encouraging quit attempts and promoting successful smoking cessation. The efficacy of smoking cessation services provided by dental health professionals is well established in the literature. Randomized con‑ trolled trials indicate that routine smoking ces‑ sation counseling by dental health professionals has resulted in twice as many patients success‑ fully quitting smoking cigarettes compared with control groups (16.9% vs. 7.7%10 and 13.3% vs. 5.3%11). Most trials in dental settings report a quit rate comparable to that achieved by physi‑ cians.6 However, in this representative population of smokers, those who did not use smoking cessa‑ tion medications did not appear to be helped by receiving dentists’ advice alone. Given the con‑ sistent findings of the efficacy of smoking ces‑ sation, this is likely primarily a reflection of the substantial differences between smokers who received advice and those who did not. Those who received dentists’ advice were more likely Dental News, Volume XXIV, Number II, 2017
Although many variables, including those re‑ lated to tobacco addiction (such as daily smok‑ ing, number of cigarettes smoked per day and self-perceived addiction) were controlled for, un‑ measured or unmeasurable variables (e.g., men‑ tal health issues and genetic differences) might contribute to the null association between receiv‑ ing dentists’ advice and quitting outcomes in our study.
Second, to the extent appropriate, advice or in‑ formation about health effects should be given in conjunction with evidence-based treatments that increase the likelihood of successful smok‑ ing cessation for patients. These treatments include pharmaceutical aids, such as nicotine patch and gum, buproprion and varenicline. Without dentists’ advice, some smokers in this study would not have used cessation medica‑ tions or would not have used medications ap‑ propriately to achieve the optimal outcome. Studies have shown that most smokers in the general population do not use cessation medica‑ tions when trying to quit, and, those who use them, do so for less than the recommended period.12,13 Dentists should provide quit advice to their smoking patients and encourage these patients to use cessation medications as recom‑ mended for success. The Canadian Smoking Cessation Clinical Prac‑ tice Guideline should be used to ensure that evidence-based practices are adopted and imple‑ mented by dentists across Ontario.3
Conclusion In this study, we found that dentists’ advice in conjunction with smoking cessation medications can encourage smokers to make quit attempts and can promote successful smoking cessation. The dental office can be an important source of smoking cessation pharmacotherapy, and more emphasis on this role is needed. Patients’ increased awareness that den‑ tal professionals may be a smoking cessation resource, and dentists’ increased confidence in providing pharmacotherapy can help patients quit smoking and improve their oral health. Dental practitioners have a credible and important role in pro‑ viding smoking cessation services.14
References 1.The health consequences of smoking — 50 years of progress: a report of the Sur‑ geon General. Rockville, Md: United States Department of Health and Human Services; 2014.. Accessed April 25, 2016. 2. Fiore MC, Jaén CR, Baker TB, Bailey WC, Benowitz NL, Curry SJ, et al. Treating tobacco use and dependence: 2008 update. Clinical practice guideline. Rockville, Md: United States Department of Health and Human Services; 2008. 3. Canadian Action Network for the Advancement, Dissemination and Adoption of Practice-informed Tobacco Treatment (CAN-ADAPTT). Canadian smoking cessation clinical practice guideline. Toronto: Centre for Addiction and Mental Health; 2011. 4. Sandhu HS. A practical guide Assoc. 2001;67(3):153-7.
to tobacco cessation in dental of ces.
5. Gerbert B, Coates T, Zahnd E, Richard RJ, Cummings SR. Dentists sation counselors. J Am Dent Assoc. 1989;118(1):29-32. 6. Carr AB, Ebbert JO. Interventions for tobacco cessation chrane Database Syst Rev 2012;1: CD005084.pub3.
J Can Dent
as smoking ces‑
in the dental setting.
7. Brothwell DJ. Should the use of smoking cessation products be promoted of ces? An evidence-based report. J Can Dent Assoc. 2001;67(3):149-55.
8. Babayan A, Dubray J, Haji F, Schwartz R. Provision of smoking cessation by Ontario dental health professionals. Toronto: Ontario Tobacco Research Unit; 2012. Avail‑ able from: 9. Diemert LM, Bondy SJ, Victor JC, Cohen JE, Brown KS, Ferrence R, et al. Ef cient screening of current smoking status in recruitment of smokers for population-based research. Nicotine Tob Res. 2008;10(11):1663-7. 10. Cohen SJ, Stookey GK, Katz BP, Drook CA, Christen AG. Helping smokers quit: a randomized controlled trial with private practice dentists. J Am Dent Assoc. 1989;118(1):41-5. 11. Macgregor ID. Ef cacy of dental health smoking. Br Dent J. 1996;180(8):292-6.
advice as an aid to reducing cigarette
12. Paul CL, Walsh RA, Girgis A. Nicotine replacement therapy products over the counter: real-life use in the Australian community. Aust N Z J Public Health. 2003;27(5):491-5. 13. Zhang B, Cohen JE, Bondy SJ, Selby P. Duration of nicotine replacement therapy use and smoking cessation: a population-based longitudinal study. Am J Epidemiol. 2015;181(7):513-20. 14. Jannat-Khah DP, McNeely J, Pereyra MR, Parish C, Pollack HA, Ostroff J, et al. Dentists’ self-perceived role in offering tobacco cessation services: results from a nationally representative survey, United States, 2010–2011. Prev Chronic Dis. 2014;11:E196.
Use of a new camera with interchangeable lenses in the practice
Three clever heads assist with caries diagnosis by Dr. Jens-Christian Hanf, Illingen - Germany 1986-1992: studied dentistry at the Eberhard-Karls University in Tübingen 1992-1993: assistant physician in Schwäbisch Gmünd From 1993 to now: working in the group dental practice Illingen/Enzkreis Since 2008: certified to DIN EN ISO 9001-2008 Various periods abroad for studying, including 3 months in Brazil, UCLA Los Angeles.
FIg. 1: Initial clinical situation: Intraoral image showing discolouration on tooth 15. Fig. 2: The infrared image indicates suspicion of approximal caries. Fig. 3: X-ray image for comparison purposes: It confirms the diagnosis of approximal caries on tooth 15. Fig. 4: Intraoperative monitoring immediately after opening: The false colour image taken with the fluorescence interchangeable lens makes it easier to distinguish between the carious region on tooth 15 (red) and the healthy tooth enamel (green). Fig. 5: Intraoperative monitoring: The carious regions have been completely removed. Fig. 6: Intraoral image at the end of treatment: The definitive filling on tooth 15.
It is easy to summarise what it is that makes the VistaCam iX HD camera that was introduced to support caries diagnostics so exceptional: With just one interface, it offers three diagnostic capabilities. The following description of a patient case shows how this comes into play in the practice. We have already been using digital camera sys‑ tems in our practice since 2003. At the time, we found that it was usually not possible to explain the findings from caries diagnostics to patients in a meaningful way with the aid of X-ray images alone – they were too abstract and too far removed from the normal types of image that people see. At the same time, explaining treatments to patients has become more and more important over the years, not least because of changing legislative require‑ ments (German Patientenrechtegesetz, the law in‑ troduced to improve the rights of patients in Ger‑ many). But, as dentists, we also come up against certain limits when using X-ray images in caries di‑ agnostics. They do not always enable us to reliably spot small surface lesions or small to medium-sized approximal lesions. In recent years, conventional intraoral imaging techniques have been supplemented with two new technologies that provide us with additional options: fluorescence imaging and, just recently, infrared imaging. All three functions are com‑ bined in the new VistaCam iX HD (Dürr Dental, Bietigheim-Bissingen). As a dentist, you work here with three interchangeable lenses – with the result that the complementary image information can be combined for an improved diagnostic outcome in each specific case. Reliable diagnosis – complete excavation The patient presented in the practice with occlusal discolouration on tooth 15 (Fig. 1). In order to in‑ vestigate further, we took an infrared image (Proxi interchangeable head). The opaquely brightened area in the distal region prompted a suspicion of caries (Fig. 2). An X-ray image taken for comparison purposes confirmed this suspicion (Fig. 3).
Dental News, Volume XXIV, Number II, 2017
With the aid of the infrared image, we were able explain to the patient the need for treatment on tooth 15 (removal of caries and restoration with composite). During the treatment, we took ad‑ vantage of the possibility for intraoperative caries monitoring (Proof interchangeable head). Immediately after opening up, carious (red) areas could be seen in the approximal region (= caries, Fig. 4). The number 1.8 next to it indicates a deep caries lesion in the tooth enamel. The defect was surrounded by healthy tooth enamel (green). The control image we took after caries excavation doc‑ umented complete removal of the affected tooth structure (Fig. 5). We recorded the clinical situation at the end of treatment in an intraoral image, just like the “before” image (CAM interchangeable head, Fig. 6). The occlusal discolouration on tooth 15 that was conspicuous at the start turned out to not require treatment and was removed with simple polishing.
Conclusions for caries diagnostics In order to take full advantage of the opportunities offered by the three interchangeable lenses, it is important to understand how the different types of information complement each other to pro‑ duce a better overall picture. When detecting caries already at an early stage, fluorescence images help on occlusal and smooth sur‑ faces, while infrared images make approximal caries visible. X-ray images are thus no longer needed at all in many cases, which is appreciated by many patients. “No radiation exposure” – for most patients, that is definitely a positive. Fluorescence images help during the caries excavation. In the past, we did this with dyes, which meant that we had to wait for them to soak in – this was simply not an option that we felt was ideal. With fluorescence imaging, we feel more confident now particu‑ larly when working close to nerves, and we can forensically and perfectly document the removal of remaining caries.
A wide range of diagnostic possibilities Diagnosis of approximal caries with the aid of infrared images, in‑ traoperative caries monitoring with the fluorescence false colour image, patient information via the intraoral image – this patient case highlights a whole range of possibilities offered by the new interchangeable head camera. However, the possible fields of ap‑ plication go beyond even this. For example, fluorescence images can be used to detect occlusal caries and smooth-surface caries. In cases where the dentist is in doubt (“is treatment required or not?”), follow-up monitoring can be performed. This avoids unnecessary treatments. Based on our experience, with the aid of the false colour image it is particularly easy to explain to patients why a certain treatment is necessary. Pa‑ tients generally don’t understand the black infrared image at first glance, but with the aid of verbal explanations and comparisons with the intraoral image on the monitor – as was done in the case described – this type of image can also be understood. Patients have the greatest difficulties interpreting an X-ray image. However, based on an infrared image we can at least explain to the patient why we need to take one in individual cases. While initial caries lesions in the approximal region can often be seen more eas‑ ily in an X-ray image (e.g. thanks to the typical triangular shape), identification can be a lot more difficult in the case of deeper caries that extends into the dentine or if there are fillings or inlays. The reason for this is that dentine appears opaque, just like carious le‑ sions, and composites block the infrared radiation.
From a purely practical point of view, the fact that three different diagnostic capabilities are combined in a single camera with in‑ terchangeable heads simplifies our workload in a way that cannot be underestimated. I need less space and do not have to reach for different devices that are on the left, on the right or behind me – instead, I have everything right in my hand with the compact “diagnostic camera for everything” for as long as I need it, and otherwise it is ready to use in its storage location.
Prophylaxis also more successful Beyond the diagnostic capabilities for caries, it is also possible to vi‑ sualize plaque and calculus with the fluorescence interchangeable head. This helps our prophylaxis team a great deal when it comes to explaining diagnosis and treatment plans to patients. Patients who have never experienced proper, professional prophy‑ laxis quickly understand how important it is. And sceptics are con‑ vinced by the comparison of “before” and “after” images. They can readily see that plaque has been removed that was missed by their normal teeth cleaning routine at home. Once the benefits have been seen, these patients are much more likely to attend their recall appointments afterwards.
LSOS 2017 Lebanese Society of Oral Surgery 7th International Convention
January 20 - 21, 2017 Hilton Metropolitan Palace Beirut, Lebanon
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Picture from the Opening Ceremony at the Hilton Metropolitan Palace Beirut
Dr. Ronald Younes, president of the Lebanese Society of Oral Surgery Dear colleagues, friends, and invited speakers, On behalf of the Lebanese Society of Oral Surgery Board and members, I would like to warmly and cordially welcome all of you, lecturers, attendees, guests, and industry partners to our 7th International Convention that will gather all of us for 2 interactive days of scientific interaction. Following the resounding success of the 6 previous conventions, we hope that this one will exceed your expectations. Indeed, the latest cutting edge challenges in oral and implant surgery will be extensively addressed and discussed. Different solutions will be proposed through 5 “first-class” international speakers, coming from different European countries using different approaches that will highlight the latest updates in the different fields of oral surgery. Under the theme “Challenges & Solutions”, we are most confident that the 7th LSOS meeting will once again reflect the quality and innovation of a rich and multidirectional scientific program. It will provide the opportunity to discuss and share with your peers the latest advances in hard and soft tissue augmentation, keeping in mind the ultimate goal leading to an optimal esthetic rehabilitation. Dental News, Volume XXIV, Number II, 2017
Dr. Carlos Khairallah, President of the Lebanese Dental Association A focused exhibition with 20 sponsors will run concomitantly in addition to hands-on workshop and seminar provided by our invited speakers. One thing you can be sure of dear colleagues, is that our Society is open to all oral surgery tendencies and trends ,to all implant systems , to all innovative techniques ,and to all surgical dentists and oral surgeons worldwide, with no exception. Our ultimate goal is to address to our members all contemporary horizons and trends in oral surgery and implant dentistry ,so they can freely chose and adopt, certainly in accordance with evidence-based dentistry . On behalf of all the Society board members, I promise you that we will continue pursuing our goals, which are yours, in order to lead us to better achievements in the future of Oral and Dental Implant surgery. Finally, I would like to thank all of you all for your active participation and sincere support, making this event so successful and fruitful, ENJOY the MEETING!! Dr. Ronald Younes President of the Lebanese Society of Oral Surgery
Picture from the Audience
Dr. Stavros Pelekanos addressing perio prosthetic approach of Implants
Dean Essam Osman, Dean Nada Naaman, Deam Toni Zeinoun, Pr. Antoine Khoury
Dr. Daniele Botticelli lecturing on Sinus Floor Elevation
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Come visit us! Dental News, Volume XXIV, Number II, 2017
FKG Dentaire SA www.fkg.ch
Madrid, Spain 29 August - 1 September 2017
Bringing the World together to improve oral health
LOS 2017 Lebanese Orthodontic Society 15th Annual Meeting
March 24 - 25, 2017 Mรถvenpick Hotel & Resort Beirut, Lebanon
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Photo from the opening ceremony at the Movenpick hotel, Beirut
Dr. Fadi Dahboul, president of the Lebanese Orthodontic Society
Dental News, Volume XXIV, Number II, 2017
Left to Right: Drs. Fadi Dahboul, Mehdi Chahrour, Hussein ElAli, Ali Fahs, Fadi Ghaith
Dr. Donald Ferguson, Dr. Raffaele Spena, Dr. Silvia Allegrini evaluating the poster presentations
Pr. Ibrahim Nasseh talking about CBCT input for Orthodontists
Dr. Zouhair Skaf lecturing about microimplants in the treatment plan
Pr. Joseph Ghafari; bridging the gap between goals and outcomes
DDental r. ENews, lie A mm talking Volume XXIV, Numberabout II, 2017 challenges in Orthodontics
Dr. Donald Ferguson describing Periodontally accelerated Orthodontics
Dr. Silvia Allegrini explaining about Class II timing
Left to Right: Drs. Chafic Tabbara, Riyad Battikhi, Alaa AbouKhalaf, Fadi Dahboul
Dr. Pamela Genno from the AUB
Dr. Joseph Ghoubril, Dr. Ramzi Haddad
Dr. Raghid Chkeiban from the LU
Dr. Joe Helou for the best poster research
Dr. Mohamad Chalhoub from BAU receiving the literature review award
12th international meeting for the Lebanese Society of Endodontology
April 7 - 8, 2017 Hilton Beirut Habtoor Grand Sin El Fil, Beirut, Lebanon
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Picture of The Audience during the Opening Ceremony
Dr. Edward Rizk, President of the Lebanese Society of Endodontics
Pr. Carlos Khairallah, president Lebanese Dental Association
Pr. Giuseppe Cantatore from la Sapienza University
Dr. Marc Kaloustian, scientific chairman of the LSE
Dear Colleagues, It is my pleasure to welcome you all Endolovers to this Special 12th International Congress of the Lebanese Society Of Endodontology under the patronage of the President of the Lebanese Dental Association, Prof. Carlos Khairallah. And as you must have seen on our programme, our speakers are actually endostars! We would like to welcome Pr. Giuseppe Cantatore, Pr. Filippo Cardinali, Dr Gianluca Plotino, Dr Oscar Von Stetten, and Dr. Fabio Gorni.This year I start with “Where there is no VISION there is no HOPE” George Washington Carver The true vision of our society is to always deliver the Best to the Endo community in terms of science and clinical expertise, in the hope to reach the high level of your expectations. 1- This vision originates from years and years of experience of the Lebanese society of endodontolgy that actually dates back to the early 90’s and this event will be our 12th international Congress. Dental News, Volume XXIV, Number II, 2017
2- This vision is coupled with a homogenous Active Board scientifically and socially. 3- And this vision would not have seen the light without the support of the Sponsors who believe in the LSE. thank you FKG with Tamer Holding Zeiss and intermedic , Dentsply Sirona and pharmacol, MM and dentaltech, VDW and DMS. And last but not least I would like to thank the endolovers that have proved to be faithful to our society all through the years. This year we opted for Microscopy and its role in the success of the root canal therapy, because “you can only treat what you can see”. In order to have this shift from a possibility to a reality, we have planned lectures, trainings and live demos… Dr. Edward Rizk President of the Lebanese Society of Endodontics
L to R: Drs. Ibrahim Husseiny, Fadl Khaled, Joseph Chaer, Roula Abiad, Carlos Khairallah, Edward Rizk, Rahil Douaihy, Tony Zeinoun, Paul Nahas
Ghada Haddad, Gianluca Plotino, Oscar von Stetten, Ali Razouki, Tony Dib, Alexandre Mulhauser
Live Transmission by Dr. Fabio Gorni of Microscopic Endodontics
L to R: Drs. Marc Kaloustian, Edward Rizk, Tony Kamel, Hrant Kaloustian, Fadl Khaled, Cynthia Kamel, Agop Lozoyan
Dr. Oscar von Stetten Conducting Workshop on Microscope in Endo
L to R: Drs. Omar Bahgat, Roula Abiad, Filippo Cardinali, Tony Dib
CAD/CAM 2017 68
12th CAD/CAM & Digital Dentistry Conference
May 5 - 6, 2017 Intercontinental Hotel Festival City, Dubai, UAE
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Picture from the attendants
Intra oral scanning at the 3Shape booth Advances in digital dentistry are bringing substantial changes in today’s dental offices. The partnership between dental laboratories and dental offices is built on a foundation of computer assisted design and the growing trend of digital impressions - oral scanning. Additionally, CAD/CAM systems in dental offices and dental labs are becoming standard equipment.
Computer aided design at the Ivoclar Vivadent booth The main purpose of this dental event was to examine the concept of digital dentistry, its advantages and limitation, and make statements and observations on specific areas of digital dentistry based on research, direct personal experience, and communication with dental manufacturers and clinicians worldwide.
Additionally, this conference is a path breaking opportuThe 12th edition of the CAD/CAM & Digital Dentistry Con- nity for professionals to exhibit their paramount research ference, organized by CAPP took place on 05-06 May 2017 work through Poster Presentations at the Intercontinental Hotel Festival City in Dubai. It covered all the current trends in digital dentistry and also gave dental professionals more insights into the latest CAD/CAM systems. 12th CAD/CAM & Digital Dentistry Conference/Exhibition Features: The dental conference programme was designed by dentists • Educational sessions with industry experts for dentists, sharing the dental knowledge and insights that • Dental Technician International Meeting (DTIM) dental professionals need. The conference programme pro- • Poster Presentations vided the latest thinking in dentistry, delivered by some of • Pre and post hands-on courses with industry experts the best speakers in the business. Dental News, Volume XXIV, Number II, 2017
To Dr. Fayez AL Khalayleh representing the Jordan Dental Association
To the GSK team
To Mr. Dariush Vazvan from Planmeca
To Dr. Ibrahim Soubt from Ivoclar Vivadent
To Dr. Mazen Canon from the MAC company
To Mr. Dietmar Goldmann from Coltene
Volume XXIV, Number TDental o DrNews, . Amr Adel from II,D2017 entsply Sirona
To Mr. Martin Serck from Carestream
Dr. Roberto Turrini lecturing on Digital Treatment Planning in All-Ceramic Rehabilitations
Dr. Julian Conejo talking on Material Selection for Esthetic Ceramics
Dr. Alexandros Manolakis, Digital Implant Workflow - From Guided Surgery to CAD/CAM Prosthetic Rehabilitations
Dr. Çağdaş Kışlaoğlu lecturing on Minimal Invasive Smart Smile Design
Demonstration at the Cerec CAD/CAM for dental office
Scientific Congress and Exhibition Organised by The Antonine University
May 5-6, 2017
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Palais Des Congrès - Dbayeh, Lebanon
Opening ceremony at the Palais des Congès, Dbayeh, Lebanon
Mr. Nabil Asmar, Director of Dental Laboratory Technology
Rector P. Germanos delivering the trophy to the President of the LU Pr. Fouad Ayoub
Father Germanos Germanos Rector of the Antonine University
I want to express my deepest thanks and gratitude for your presence at the opening ceremony of the Antonine University’s Scientific Congress and Exhibition 2017. Your attendance today is a great pleasure, as this congress became a necessity to spread cutting-edge technology and leading modern science in our field of activity, offering us daily stateof-the-art technological means and most important scientific methods to facilitate our work and develop it to provide better health, feelings and happiness to patients. We highlight at the beginning the remarkable and perceptible progress achieved by the Dental Laboratory Technology Department of the Faculty of Public Health at the Université Antonine, which constitute a qualitative leap in order to keep abreast of the fast development of technology and provide it in a distinctive and effective way to students and graduates. We also point out that more than seven years ago, the Dental laboratory Department was the first to add the CAD/CAM technology in the undergraduate program. Today, we are pioneers in this field, well acquainted with all its aspects, in order to keep abreast of scientific developments.A Postgraduate program was added, and it provides a specialty program that includes Implantology, Photography, Zirconia, Ceramics and metal-free bridges. In my previous speeches, I spoke about the dangers surrounding our profession, stating that technology is more like a whale swallowing manual skills to make the laboratory work equivalent and acceptable in medical and aesthetics terms. As you may notice, nowadays the concept of aesthetics has become common and unified: we see that most of women’s lips are now similar, even faces would have become almost similar due to the technological advances in plastic surgery.... This frenzy reached teeth in the dental world. These lathes programmed owing to the progress of technology produce standard teeth without spirit deprived of the natural and aesthetics values that only human beings can infuse into them. The large quantity produced by these advanced lathes in a short time requires greater technical skill, taste and vitality by those using these machines and equipment. Quantity is now prevailing over the quality and the specialists in this field should treat these matters accurately, sensitively and in a creative manner for a promising future of our dear profession. This is the message of the Université Antonine, a quintessential scientific and humanitarian mission, and according to this vision, and this orientation we move forward. Mr. Nabil Asmar Director of Dental Laboratory Technology Dental News, Volume XXIV, Number II, 2017
Dirk Galle from Belgium lecturing about the evolving Lab Technologies
Nondas Vlachopoulos lecturing about the Art behind the Design
Ricardo Soares from Portugal exposing a new world of personalized Dentures
Jean Pierre Casu at the Ivoclar booth after his lecture on Zirconia
Demonstration of the Trios scanner at the 3Shape booth by Georgio Haddad
Ihsan Hamadeh demonstration of the Initial ceramics by GC
The Latest DentsplySirona Milling machines and solutions at the Richa booth
Mr. Nabil Asmar, Dr. Pierre Khoury, Pr. Toni Zeinoun, Dr. Joseph Chaer, Mr. Jamal Hajj, Pr. Carina Mhanna, Rev. P. Germanos Germanos, Pr. Fouad Ayoub, Mr. Riad Haddad
Dr. Rawad Samarani, Mr. Lamberto Villani, Dr. Najib AbouHamra, Dr. Simone Vaccari
Photo from the Renfert Booth
Survey: Protective varnish saves time Cervitec F â&#x20AC;&#x201C; fluoridation and germ control in one step
In a recent survey, dentists and their teams were asked to test and comment on the new protective varnish Cervitec F. A total of 279 questionnaires were received from the surveyees and evaluated. The results show that Cervitec F is well liked. More than 80 per cent of the test participants reported that they were generally satisfied with, or even very satisifed with the properties of the varnish system. They were pleased with the esthetics of Cervitec F as well as with its wide range of applications, delivery form, fluoride and chlorhexidine concentration and its taste.
Highly recommended Eighty per cent of the people questioned would recommend using the protective varnish after professional tooth cleaning. More than half of the respondents would recommend using the product during the orthodontic treatment of high-risk patients or patients with motor impairments. They furthermore indicated that they use Cervitec F in individuals with root caries, implants or erupting teeth and as a general caries prevention measure. According to the survey participants, a significant advantage of this combination product is the fact that it saves time. website: www.ivoclarvivadent.com Dental News, Volume XXIV, Number II, 2017
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A-dec Introduces New LED Light: Accurate. Economical. Reliable. Designed specifically for dentists who want the clarity and accuracy of A-dec’s premium, award-winning lights in a simple, economical version, the new A-dec 300 LED brings doctors an economically priced light, without sacrificing the optical fidelity or quality and durability customers expect with the A-dec brand. In the surgery, a clean, white light that replicates trueto-life tones with a balanced color spectrum is key to a dentist’s ability to properly diagnose. The A-dec LED consistently produces 5,000 Kelvins and a high color rendering index (CRI) of 94 to flood the oral cavity with light. It also features “stadium lighting” that diminishes shadowing, and a soft, feathered edge that reduces eye fatigue. Comfort is further enhanced with the quiet, passive cooling design that keeps the light, dental staff and patient cool. The A-dec 300 LED also consumes 80-90% less power and is more than 20% brighter than halogen lights, with a life expectancy of 40,000 hours—all without ever having to change a bulb.
ergonomics and illumination, while being backed by the market leading A-dec 5-year warranty,” says Simon Baxter, Director International Sales, EMEA (Europe, the Middle East and Africa).
“We are very excited to be able to offer the award-winning technology of A-dec LED lighting to a wider range of customers “Customers can now benefit from the exceptional innovations worldwide.” of A-dec lighting throughout our complete product range, allowing us to support more dentists in achieving their best results. The new A-dec 300 LED light combines outstanding website: www.a-dec.com
Olivier Schiller, patron de Septodont, remporte le trophée d’industriel de l’année en France Fondée en 1932 par la famille Schiller, l’entreprise Septodont, basée à Paris est implantée dans plus de 150 pays, est aujourd’hui le leader mondial du marché de l’anesthésie dentaire. De ses unités de production en sortent 500 millions par an selon une technologie laser qui permet un remplissage plus précis, pour éviter les bulles d’air par exemple. Olivier Schiller, ingénieur, diplômé d’HEC, troisième de la lignée Schiller à diriger l’affaire, a impulsé une nouvelle stratégie qui consiste d’abord à développer des produits thérapeutiques innovants, alors que l’entreprise redéploie 6 à 7 % de son chiffre d’affaires en R & D. Cette stratégie lui a valu avec grand mérite le trophée d’industriel de l’année (catégorie Entreprise de Taille Intermédiaire). Septodont qui emploie 1 500 salariés dans le monde, a réalisé un chiffre d’affaires de plus de 250 millions d’euros en 2015. Son activité devait encore croître de 7 ou 8 % en 2016.
website: www.septodont.com Dental News, Volume XXIV, Number II, 2017
Beyond Accelerator The Polus® Advanced Whitening Accelerator is a next-generation upgrade to the award winning Polus® series of whitening accelerators. The hallmark feature remains a combination halogen/LED light source (LightBridge™) with over 200,000 fiber optics set in place to clean and bring the full power of the light source to the front of the accelerator head for maximum acceleration of the gel. A new ultrasound feature helps make stains easier to target with the gel and light acceleration. The high-end features continue with passive air ionizer, intuitive color TUI panel and audible call button that can give periodic updates on the remaining time for treatment. The BEYOND® II Whitening Accelerator is a reinvented version of the best-selling Beyond Power Whitening system, allowing the whitening process to become more simple and affordable. The innovation is three fold: an augmented high-intensity LED light output for premium teeth whitening, passive air ionizer and secondary attachment that provides two-person simultaneous whitening capability. The unit is also smaller and more mobile compared with previous versions. Now available in white, silver and blue. website: www.beyonddent.com
NEW PIEZOSURGERY® INSERTS FOR SINUS LIFT BY LATERAL APPROACH After 15 years, Mectron re-defines the sinus lift technique by lateral approach launching on the market 5 new PIEZOSURGERY® inserts developed in collaboration with Professor Tomaso Vercellotti, Italy. Thanks to the new inserts shapes, the revisited protocol makes the technique even safer, minimizing the risk of membrane perforation.
• The new SLC insert allows to perform the osteoplasty of the sinus vestibular wall with maximum safety and unparalleled intraoperative control; • The new high-efficiency SLO-H insert permits to execute the osteotomy procedures with the maximum safety • The new thin SLS membrane separator is more efficient in comparison with the old generation “elephant paw shape”. • The new elevators SLE1 and SLE2, the first one to start the sinus membrane elevation from the sinus floor and the second one to finalize the sinus membrane elevation from the palatal wall, are featured by a sharp terminal part allowing to cut Sharpey’s fibers from the endosteum with the maximum safety, protecting it thanks to the convexity of the tips. The precision and the maximum evidence-based safety guaranteed by these piezoelectric inserts make this kit a wonderful addition to the surgical armamentarium for to both novice and expert surgeons. The inserts will be available separately as well as in a Kit with all five inserts dedicated to sinus lift by lateral approach. website: www.mectron.com
MICRO-MEGA is pleased to announce the launch of its new instrumental sequence for the endodontic treatment. This new sequence is composed of two shaping instruments in continuous rotation – TS1 and TS2 – which include our latest innovations. 2Shape has been heat-treated using the T.Wire method which improves the instruments’ flexibility and provides the practitioner with added comfort. Experience an outstanding negotiation of curvatures with the 2Shape instruments which return to their initial form after each use.
2Shape integrates the latest generation of MICROMEGA® cross-sections with 3 cutting edges: the perfect combination of efficiency and debris removal. Advantages • A new efficient asymmetrical cross-section • T.Wire for improved safety and flexibility website: www.micro-mega.com
Essentia from GC Open the door to simplification Aesthetics brought back to the essentials Thanks to its innovative shade concept, the Essentia composite system achieves top-notch results with only those seven shades. Developed over four years together with GC Europe’s Restorative Advisory Board, the product and its new approach to layering has now been proven over two years in clinical practice. The natural aging process of human teeth is the foundation for this innovative shade system: while younger teeth are whiter and more opaque, older teeth are more translucent and chromatic. This is where Essentia comes in with its unique combination of three dentin and two enamel shades. Depending on the combination chosen, young, adult or senior teeth can be easily replicated. Four modifiers ensure that even special cases are covered. Essentia offers a mono-shade solution for posterior restorations with its Universal Shade, to achieve aesthetic results in a simple way. The addition of GC Essentia HiFlo and GC Essentia LoFlo to this pioneering system creates a complete, easy solution for the posterior region, for with these two new products Essentia now offers three strong options for all posterior restorations. As all viscosities have excellent physical properties and are indicated for all cavity classes, the clinician can choose his preferred consistency based purely on the requirements of each particular case. The highly flowable Essentia HiFlo shows Dental News, Volume XXIV, Number II, 2017
an impressive radiopacity and is easily applied in narrow cavities and undercuts. Essentia LoFlo is characterised by its injectable viscosity and thixotropic properties, which make it a perfect choice for cervical lesions. The Universal Shade of Essentia has a packable, non-sticky consistency that will, for instance, be optimal for building proximal walls. All three products feature high strength and wear resistance, guaranteeing long-lasting results, even for occlusal fillings. The Essentia Universal Shade also has an outstanding blending effect, which ensures flawless integration with natural tooth tissues. Because they have the same shade, the different viscosities can also be combined easily within one clinical case – for instance Essentia HiFlo as a liner for an optimal adaptation, followed by a full restoration with Essentia Universal paste. Essentia from GC is the perfect proof that outstanding aesthetics can be combined with brilliant simplicity. website: www.gceurope.com
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