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Dental News, Volume XXV, Number II, 2018


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Complete Rehabilitation of a Generalized Chronic Tooth Sensitivity and Rampant caries of a Clinical Situation Using Implant Supported Fixed Zirconia Prostheses




13eme Journées Odontologiques


LDLS 2018 Lebanese Dental Laboratories Show 10th Scientific Congress

Dr. Tony Daher


Antiplatelets & Anticoagulation Drugs: Dental Implications

April 19 - 21, 2018 St. Joseph University, Beirut - Lebanon

April 26 - 28, 2018 Hilton Metropolitan, Sin El Fil, Beirut - Lebanon

Dr. Parmanand Dhanrajani, Dr. Patrick Chung, Dr. Mark Smith, Dr. Christopher Ho



March 28 - 30, 2018 Hilton Green Plaza, Alexandria - Egypt

The FKG New Swiss Endo Academy Training Centre

A Study to Evaluate a Passive Self-Ligation Appliance Dr. Vishal Bharadwaj, Dr. Gurkeerat Singh, Dr. Sridhar Kannan, Dr. Raj Kumar Singh, Dr. Ashish Gupta, Dr. Gaurav Gupta, Dr. Abhishek Goyal


Appraisal of MTA and Biodentine in Direct Pulp Capping: a systematic review Dr. Bechir Annabi, Dr. Amir Hachicha, Dr. Sana Bagga, Dr. Chems Belkhir




Dental News, Volume XXV, Number II, 2018

Dental News, Volume XXV, Number II, 2018

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Dental News, Volume XXV, Number II, 2018



IADH 2018 The 24th International Association for Disability & Oral Health Congress

August 31 - September 2, 2018 Intercontinental Festival City Dubai, UAE

FDI 2018 World Dental Congress

September 5 - 8, 2018 Buenos Aires, ARGENTINA

IADC 2018 International Aesthetic Dental Congress

September 28 - 29, 2018 Beach Rotana Hotel Abu Dhabi, UAE

Statements and opinions expressed in the articles and communications herein are those of the author(s) and not necessarily those of the Editor(s) or publisher. No part of this magazine may be reproduced in any form, either electronic or mechanical, without the express written permission of the publisher.

BIDM 2018 - Beirut International Dental Meeting

October 4 - 6, 2018 Forum de Beirut, LEBANON

DENTAL NEWS – Sami Solh Ave., G. Younis Bldg. POB: 116-5515 Beirut, Lebanon. Tel: 961-3-30 30 48 Fax: 961-1-38 46 57 Email: Website:

Middle Eastern Carriere Symposium

November 2 - 3, 2018 Dubai, UAE

EPDA 2018 Egyptian Pediatric Dental Association

November 9 - 11, 2018 Hilton Green Plaza Alexandria, EGYPT

DFCIC 2018 Dental Facial Cosmetic Conference & Exhibition

November 9 - 10, 2018 Intercontinental Hotel Dubai, UAE

AIDC 2018 Alexandria International Dental Meeting

November 6 - 9, 2018 Alexandria, EGYPT

KDA 2018 Kuwait Dental Association Meeting

November 25 - 27, 2018 KUWAIT

EDITORIAL TEAM Alfred Naaman, Nada Naaman, Jihad Fakhoury, Dona Raad, Antoine Saadé, Lina Chamseddine, Tarek Kotob, Mohammed Rifai, Bilal Koleilat, Mohammad H. Al-Jammaz COORDINATOR Suha Nader ART DEPARTMENT Marc Salloum SUBSCRIPTION Micheline Assaf, Nariman Nehmeh ADVERTISING Josiane Younes PHOTOGRAPHY Albert Saykali TRANSLATION Gisèle Wakim DIRECTOR Tony Dib ISSN 1026-261X


This magazine is printed on FSC – certified paper. Dental News, Volume XXV, Number II, 2018

12 Prosthodontics

Complete Rehabilitation of a Generalized Chronic Tooth Sensitivity and Rampant Caries of a Clinical Situation Using Implant Supported Fixed Zirconia Prostheses Tony Daher, DDS, MSEd, FACP, FICD. Board Certified in Prosthodontics and Implant Dentistry. Co-Director, Global Dental Implant Academy.

Background and Purpose Complete-arch implant-supported restorations are widely accepted as a treatment option for completely edentulous patients and have been documented to have a success rate greater than 90%1. Many combinations of materials have been used for these types of restorations such as metal alloy-acrylic, metal alloy-composite, and metal alloy-ceramic. However, prosthesis-related complications with acrylic resin and porcelain-veneered metal frameworks are commonly reported over short and long-term periods: fracture of the acrylic resin veneer, prosthetic screw loosening/ fracture, wear and fracture of resin denture teeth, fracture of prosthesis framework, and poor gingival esthetics and architecture.2 Therefore, dentists started to look for other material options. The evolution of computer-aided design and computer-aided manufacturing (CAD/CAM) systems has allowed the introduction of an alternative restorative approach to the complete-arch implant prosthesis such as Monolithic Zirconia prosthesis.

Considering the increased use of Monolithic Zirconia in complete-mouth rehabilitations. The following case presents the clinical and laboratory protocol to fabricate a zirconia full arch prosthesis. The fabrication of a full-arch implant supported zirconia prosthesis is technique sensitive and should follow the appropriate clinical steps discussed in this case study. The clinician should do a careful patient selection and a thorough planning (location and number of implants, framework design, appropriate occlusal scheme) for a successful and predictable outcome.

Clinical Data and diagnosis A 41-year-old female patient was referred by her general dentist to our prosthodontic practice for a comprehensive treatment plan. Her chief complaints were “I have very sensitive teeth; and have mouth odor.” “My mouth always feels dry; and my dentist told me I have a lot of cavities.”

Over the past decade, Zirconia technology has had a significant impact on dentistry because of its biocompatibility, esthetics, and material strength.3

Her desires for treatment are: “I want to fix my mouth and replace the missing teeth, so I can eat and be comfortable and to look good.” The patient has been receiving sporadic dental treatments during the past 10 years. She stated that the teeth were lost due to extensive decay and gum problems resulting in abscesses requiring extractions.

The monolithic nature results in no dissimilar interfaces, and thus minimizes fracture and/ or chipping events, creates a greater bulk of material to improve the structural properties of the individual prosthesis, and enables efficient fabrication and care delivery through CAD/CAM manufacturing.4

Medical history: The patient is medically compromised. She had multiple surgery: Neck and back surgery from an accident at work, and she was disabled for a long period of time. She also had gastric bypass and was not adequately done so she was constantly vomiting. This made all her teeth eroded and became very sensitive.

Dental News, Volume XXV, Number II, 2018

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14 Prosthodontics Clinical Findings/Problem list: • Temporo-mandibular dysfunction • Partially edentulous maxilla and mandible. • Multiple defective existing restorations with recurrent decays. • Generalized tooth erosion and rampant cervical tooth decay. • Angular cheilitis. • Inadequate and poor oral hygiene with moderate plaque and calculus. • Traumatic occlusion with inadequate occlusal vertical dimension and plane of occlusion.

Clinical Decision Making and Treatment Plan After gathering all the clinical data from clinical extraoral and intraoral examination, articulated diagnostic casts using an earbow and Gothic arch tracings, and radiographs; we have presented to the patient in writing the following treatment plan in the following letter: “This letter will confirm the major elements of our conversation during your last appointment when we discussed the care we plan to provide for you.

Because you wanted a more predictable with a long outcome treatment and you have some financial constraints, the following treatments were discussed with you. 1. As you know, your advanced oral condition and the excessive severe tooth sensitivity and rampant decay mandate the removal of any questionable teeth with poor outcome to restore in a predictable manner your mouth. 2. I have presented to you with many options after tooth extraction and we have discussed the benefits of each option. You have agreed on the following option: 8 implants and fixed bridges supported by implants and this in the upper and lower jaws. Treatment Sequence: 1. Before the removal of all compromised teeth, upper and lower interim immediate prostheses to be fabricated and placed immediately after tooth removal. The reason of making these prostheses

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16 Prosthodontics before the removal of your teeth is that for better healing and esthetic reasons. (Figures 3, 4) 2. The placement of implants will depend upon the position of the final denture teeth for the achievement of optimum esthetic and function. Therefore, a CBCT radiographs is made with a radiographic template for a 3D bone evaluation. 3. Then 16 Zimmer TSVÂŽ implants are placed by our Oral and Maxillofacial surgeon in a hospital setting. 4. After implant integration and the healing is complete, the final fixed prostheses are fabricated. To get a predictable result with the final Figure 1 A, B, C, D:

restorations, it is important to fabricate provisional bridges that will be used for some time. These provisional bridges will be adjusted till the achievement of an acceptable esthetic and functional result. These will be the blue print of the final fixed prostheses. 5. Continuous care visits. This treatment we plan should have good outcome and permit to achieve good function and a pleasing smile. We anticipate that this work might be completed in 18 months. The time factor will depend greatly upon arriving at a comfortable and esthetic result with your dental restorations.�

Fig 1

A) Frontal view of the compromised dentition showing the multiple cervical caries and broken teeth. B) Occlusal view of the maxillary teeth showing acid erosion from the chronic vomit habit. C) Frontal view of the mandibular arch showing missing and compromised teeth.





D) Photo of slightly mouth opening showing the bilateral angular cheilitis and lack of visibility of the teeth that creates inadequate esthetics.

Fig 2

A Figure 2 A, B: A) The smile after the first set of provisional prostheses. B) View of the maxillary fixed provisional prosthesis and the mandibular provisional overdenture. Dental News, Volume XXV, Number II, 2018




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18 Prosthodontics Fig 3

Figure 3: Frontal view of the 16 Zimmer TSVÂŽ implants with their respective healing abutments. Figure 4 A, B, C, D, E, F.

Fig 4

A): Frontal view of the impression copings connected for the open tray impression technique. please note that 2 implants on the upper side were lost due to their non-osseointegration. Zimmer TSVÂŽ 3.5mm implant mounts were used for these impression procedure B) The modified Massad impression tray over the maxillary impression copings. C) The modified Massad dentate impression LT trays.


D) The maxillary final open tray impression using wooden Q-tip to plug the hole of these implant mounts for retrievability purposes. E) Final impressions. F) The second set of removable complete dentures used during the healing of the implants.



D Dental News, Volume XXV, Number II, 2018


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Designed to simply work better together Celtra® Duo (ZLS) blocks, Prime&Bond universal™ Adhesive, and Calibra® Ceram Cement were designed to enhance and strengthen the individual benefits each of them provides, resulting in an easy-to-use system that streamlines the restoration process. Celtra Duo (ZLS) blocks • Restoration longevity of Celtra Duo (ZLS) is ensured when used with Prime&Bond universal Adhesive and Calibra Ceram Cement • Firing is optional: choose either fire and seat or polish and seat Prime&Bond universal Adhesive • No need to use a self cure activator when used with Calibra Ceram Cement • Low film thickness to allow passive seating of the crown Calibra Ceram Cement • One-step curing when used with Prime&Bond universal Adhesive • 10-second tack cure window and 45-second gel phase ensures an easy, no-stress cleanup

22 Prosthodontics Figure 5 A, B, C:

Fig 6

A) Maxillary and mandibular record bases secured over 2 implants using 2 implant mounts with their respective Massad jaw recorders. Retruded contact jaw position (RCP) was recorded at the selected occlusal vertical dimension. The black inked lines are marking the midline and the high lip line.


B) Photo is showing from top to bottom: the earbow fork with maxillary record base; the RCP polyvinyl siloxane bite record; the final casts mounted on a Denar combi semi-adjustable articulator. C) Earbow and the Massad lip ruler measuring the low lip position.

B C Figure 6 A, B, C: A) Frontal view of the fixed provisional implant screw retained prostheses in the mouth. B) Maxillary fixed provisional 6-implant screw retained prosthesis. C) Mandibular fixed provisional 8-implant screw retained prosthesis.


Fig 7


Figure 7: Some photos of the digital fabrication of the final Zirconia prostheses. Dental News, Volume XXV, Number II, 2018



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24 Prosthodontics Fig 8

Fig 10

Fig 11 A

Fig 12 B

Figure 8 A, B, C: A, B) Photos of the milling, heat treatment and the application of external staining and the adding of the pink porcelain. C) Final Casts and the Final Zirconia Prostheses on the Denar combi articulator. C

Figure 9 A, B: Intaglio views of both prostheses with their respective titanium bases

Fig 9

Figure 10: Different views of the patient’s smile. Figure 11 A, B, C, D: Mutually protective articulation A) Centric jaw position. B) Left working jaw position with occlusal contacts on the non-working side. C) Protrusive jaw position. D) Right working jaw position. A Dental News, Volume XXV, Number II, 2018


Figure 12: Panoramic radiograph of the final prostheses.


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26 Prosthodontics Conclusion This treatment has achieved good function and a pleasing smile. With a such of a complex comprehensive treatment plan, it is important to state to the patient the following: “Everyone has some limitations, which impact on the result. Some consideration must be given to the fact that the success rate of maxillary implants is between 90% to 95%, there are sometimes adverse reactions and surgical or restorative corrections may be required. Naturally, with the human body it is impossible to make guarantees. Nonetheless, we (the dental office) will be responsible for any work we have treated for a period of 12

months, and make any indicated modifications or adjustments for these teeth without charge. Experience has shown that this is adequate time for any latent problems to manifest. It will be important for you to keep recall appointments following our care to ensure that your mouth is maintained in a healthy manner. Excellent oral hygiene is essential and these recall appointments are not included in the initial fee.” In the end, it is worthy to state that completearch implant-supported monolithic zirconia fixed dental prostheses may be considered in these scenarios, but long-term clinical performance is still to be assessed.

Bibliography 1. Rohlin M, Nilner K, Davidson T, Gynther G, Hultin

M, Jemt T,

et al. Treatment of adult patients with edentulous arches: a systematic review. Int J Prosthodont


2. Bozini T, Petridis H, Garefis K, Garefis P. A meta-analysis of prosthodontic complication rates of implant-supported fixed dental prostheses in edentu- lous patients after an observation period of at least 5 years. Int J Oral Max- illofac Implants 2011;26:304-18. 3. Vagkopoulou T, Koutayas SO, Koidis P, Strub JR. Zirconia in dentistry: part 1. Discovering the nature of an upcoming bio- ceramic. Eur J Esthet Dent 2009;4:130-51. 4. Le M, Papia E, Larsson C. The clinical success of toothand implant- supported zirconia-based fixed dental prostheses. A systematic review. J Oral Rehabil 2015;42:467-80. 5. Abdulmajeed, A.A., Lim, K.G., Närhi, T.O., Cooper, L.F., 2016. Complete-arch implant-supported monolithic zirconia fixed dental prostheses: A systematic review. J Prosthet Dent 115, 672–677.e1. doi:10.1016/j.prosdent.2015.08.025

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28 Oral Surgery

Antiplatelets & Anticoagulation Drugs: Dental Implications Dr Parmanand Dhanrajani, BDS, MDS, MSc, MSC, FRACDS, FDSRCS, FFDRCSI Oral Surgeon

Dr Patrick Chung, Consultant anaesthetist MB BS (1st Class Hons), FANZCA

Dr Mark Smith, BDS Manager, Clinical Quality and Safety

Dr Christopher Ho, BDS, Dentist

Abstract Many patients with cardiovascular disorder, including coronary heart disease, cerebrovascular disease, atrial fibrillation and venous thromboembolic disease, take antiplatelet and/or anticoagulant drugs. Over the last five decades warfarin has been the oral anticoagulant of choice and has been considered as mainstay of treatment. However, the frequent requirement for monitoring and multiple drug and food interactions have fuelled the need for development of newer oral anticoagulants. As a direct result of this, a new generation of oral anticoagulants has been developed to treat and prevent thromboembolic disorders, the direct thrombin inhibitors and the factor Xa inhibitors. They require no monitoring; exhibit predictable pharmacokinetics, have limited food and drug interactions, and a rapid onset of action and a short half-life. However, they lack a specific reversal agent. Complementary medicines, including fish oil, garlic, ginger, green tea and glucosamine, have a weak antiplatelet effect, but this is usually not clinically significant. This paper describes the importance and implications of these drugs in the dental management.

body normally forms a blood clot. The first involves platelets, which clump, together at wound site to form a platelet plug, which slows the flow of blood through the vessel and forms a matrix. The antiplatelet drugs inhibit clumping. The next phase is coagulation when proteins in the blood interact with each other to fill in the spaces between the platelets, stabilize the clot, and make it more solid until bleeding stops. The anticoagulants drugs inhibit the activation of these proteins 3,4,5,6.


By inhibiting COX1, aspirin irreversibly blocks the formation of Thromboxane A2 in platelets producing an inhibitory effect on platelet aggregation during the lifetime of the affected platelet (7-10 days). Low dose aspirin (75mg daily) is indicated in patients at risk of myocardial infarction and ischaemic stroke, especially in those who have undergone cardiac procedures 4,7,8.

Many dental patients are taking “blood thinners” medications to prevent the formation of potentially harmful blood clots for various medical conditions involving the arterial system e.g.: stroke, heart attack and the venous system e.g. deep vein thrombosis (DVT) or pulmonary embolism (PE). However, these medications interfere with the body’s normal clotting mechanism to stop blood flow at a site of tissue injury, which is of concern to dentists for procedures that cause bleeding 1,2,3,4. There are two main processes by which the Dental News, Volume XXV, Number II, 2018

Antiplatelets: Aspirin inhibits the metabolism of arachadonic acid by irreversibly inhibiting cycloxygenase enzymes, preventing the production of prostaglandins. By inhibiting cycloxygenase 2 (COX2), aspirin prevents the production of prostaglandins responsible for mediating pain and inflammation, therefore, acting as an anti-inflammatory, antipyretic, and an analgesic. However, due to its non-specific mechanism, aspirin also inhibits cyclooxygenase 1 (COX1) which produces physiologically important prostaglandins responsible for platelet aggregation, the protective function of the stomach lining and maintains kidney function (Fig 1).

Aspirin does not usually cause significant bleeding from extraction wounds. For dentoalveolar surgery (including extractions), there is no

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30 Oral Surgery Premature discontinuation of dual antiplatelet therapy after placement of coronary stent markedly increases the risk of stent thrombosis, by 15%, which frequently leads to myocardial infarction 14. Do not stop Clopidogrel or prasugrel without expert advice. Current available information suggests that the risk of bleeding in patients undergoing invasive dental procedures (for example extraction) is low, provided that local hemostatic measures (suturing, gelatine sponge, gauze soaked 5% tranexamic acid, tranexamic mouth rinse) are used (Table 1).

Chart 1: Mechanism of action of antiplatelet agents

indication to temporarily cease prescribed regular aspirin. Patients are warned of having higher chance of bruising if aspirin is not ceased, but the risk is minor compared with the risk of embolism if aspirin is not ceased. Local measures are sufficient to achieve haemostasis, including infiltration of adrenaline containing local anaesthetic, insertion of oxidised cellulose and suturing. Clopidogrel (Plavix) and Prasugrel is antiplatelet medication used in patients following myocardial infarction, ischaemic stroke and ischaemic vascular disease. They are commonly used with aspirin to prevent stent thrombosis for up to one year after coronary stent placement. They are also used in patients who had ischaemic events despite treatment with aspirin or who cannot tolerate aspirin (Chart 1). Acute coronary syndromes are usually treated with dual antiplatelet therapy (aspirin and clopidogrel). Clopidogrel and Prasugrel irreversibly inhibits platelets aggregation and cross linking of platelets by fibrin by activating cytochrome P450 in liver. The half-life is approximately eight hours at an optimal daily dose of 75mg 9,10,11. Dental News, Volume XXV, Number II, 2018

Anticoagulants: Warfarin (a coumarin derivative) is the most widely used anticoagulant in the world. It is a vitamin K antagonist and inhibits vitamin K- dependent synthesis of clotting factors (VIII, IX, X and prothrombin II) affecting the formation of fibrin clot. These factors are synthesised in the liver in precursor form and activated by carboxylation of specific glutamic residues, which require vitamin K in its reduced form as a cofactor 6,8,12,13. In the UK it is estimated that at least 1% of the population and 8% of those over 80 are taking it regularly. It was first used in 1955 to treat American President Dwight D Eisenhower for a coronary event. It is currently used in: 1. Prevention of venous thrombosis and embolism in rheumatic heart disease and atrial fibrillation (AF) 2. Treatment and prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism (PE) 3. Stroke prophylaxis 4. AF and valvular heart disease (International Normalised Ratio) (INR target 2.5-3) 5. Mechanical heart valves (INR target 4) The maximum anticoagulant effect of warfarin takes 48 to 72 hours to develop, with an estimated duration of action of two to five days and a reported half-life of two and half days. It is important that both the patient and their medical practitioner understand how the patient’s warfarin treatment should be managed in relation to tooth extraction. It is not uncommon for patients to reduce their warfarin dose without consultation or, alternatively, to consult with their medical


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32 Oral Surgery practitioner who may unnecessarily suggest the traditional course of ceasing anticoagulants for minor surgical procedures. Owing to the risk of potentially fatal thromboembolism, cessation of warfarin therapy prior to dental treatment is not recommended. Instead, an INR should be taken 24 to 48 hours pre-operatively to establish the degree of anticoagulation.

Dental News, Volume XXV, Number II, 2018

In general, it is safe to proceed with an invasive dental procedure (including administration of local anaesthesia, periodontal or endodontic surgery and routine/surgical extractions) if the INR is less than 2.2. If the INR is greater than 2.2 to 4, the dentist should liaise with the treating physician in order to safely reduce warfarin dosage. Local measures are

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34 Oral Surgery necessary to achieve haemostasis including tranexamic acid mouthwash 15. Due to warfarin’s long half-life, a period of three to five days is required for reduction in the level of anticoagulation, as reflected in a reduce INR 14,15,16. Finally, all dentists should be cognisant of the potential interaction between warfarin and other drugs commonly used in dentistry, including azole antifungals, macrolide antibiotics, and NSAIDs (Table 1). The rationale for change: Warfarin has been the established oral anticoagulant for the last 50 years, being effective in the prevention and treatment of venous

Chart 2: Mechanism of action of warfarin and NAOCs Dental News, Volume XXV, Number II, 2018

and arterial thromboembolic disorders. However, the frequent requirement for INR monitoring, multiple drug and food interactions, unpredictable pharmacokinetics, slow onset of action and long half-life has fuelled the need for development of newer oral anticoagulants. As a direct result of this, a new generation of oral anticoagulants has been developed to treat and prevent thromboembolic disorders, direct thrombin inhibitors and the factor Xa inhibitors (Chart 2). Newer oral anticoagulants (NOACs): Recently, new oral anticoagulants have been approved for use by various drugs approval authorities around the world. One of them is dabigatran etexilate, a thrombin inhibitor and ravaroxiban (Xeralto), a factor Xa inhibitor. Dabigatran etixilate (Pradaxa) is the first of a new generation of oral anticoagulants, which are now available on the anticoagulant market. Dental surgeons in the primary care setting and those in the secondary hospital care setting will very soon be faced with decisions on the safety of surgical procedures on patients in whom these new anticoagulants are present. These are licensed for short-term primary prevention of venous thromboembolic events in adult patients who have undergone elective total hip or knee replacement surgery, while dabigatran is also licensed for prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation, plus one or more additional factors. Dabigatran is contra-indicated in patients with a prosthetic valve requiring anticoagulant treatment. As they are pharmacologically distinct from warfarin, they have different side-effect profile and have raised concern in regards to bleeding complications. Unlike warfarin, dabigatran and rivaroxiban are relatively small molecules that work as anticoagulants by targeting specific single steps of coagulation cascade 3,5,7,16,17. In addition, they are reported to have fewer drug interactions, no significant food interactions, and provide predictable anticoagulation at a specific dose, without the need of regular monitoring and alteration in dose. It is therefore incumbent on all of us to become familiar with these drugs, their indications and method of action, and in particular the management of those patients requiring invasive dental procedures, so that these patients are managed in safe manner (Table 1).





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36 Oral Surgery Dabigatran: The Food and Drug Administration (FDA), USA, first approved Dabigatran etexilate in 2010, to reduce the stroke and systemic embolization risk in patients with non-valvular atrial fibrillation, it is now also used, in EU, and Canada, for thromboembolic prophylaxis in patients who have recently undergone a total hip or knee replacement. Recent studies have shown that dabigatran, given at a fixed dose does not require monitoring and is as effective as warfarin in preventing embolic events in patients with atrial fibrillation. However, significant concerns regarding the lack of a reversal agent, and difficulty in precisely monitoring its anticoagulant effect remain 6,9,11,18,20. It is a specific, reversible, direct thrombin inhibitor that, unlike warfarin, inhibits both free and fibrin bound thrombin, so that fibrinogen cannot be converted to fibrin. Dabigatran etexilate is a pro-drug which, following oral administration is converted to its active form, dabigatran. When administered orally, the bioavailability is approximately 3-7%. It is rapidly absorbed

Dental News, Volume XXV, Number II, 2018

and is metabolised by the liver. It has a rapid onset of action with the peak plasma concentration of 0.5-4 hours. When administered twice daily, a steady state plasma concentration is reached within two or three days. The half-life elimination is 12-14 hours in healthy patients, 14-17 hours in elderly, and up to 27 hours in patients with severe renal impairment. Unlike warfarin, routine monitoring of the anticoagulants effect of dabigatran is not required. The thrombin clotting time (TT), and ecarin clotting time (ECT) are reported to be the most sensitive tests for quantifying the anticoagulant effects of dibagatran. Currently, there is no reversal agent for dibagatran. However, owing to its short half-life, discontinuation of the drug may be sufficient to resolve minor haemorrhage, with the exception of patients with renal impairment. It appears that dabigatran has few clinically significant drug and food interactions. Ketocanazole, verapamril and amiodarone may increase its anticoagulant effect, whilst rifampicin may decrease its effect. There are no clinical trials supporting specific measures in the event of haemorrhage in

38 Oral Surgery dental patients taking dabigatran. The most current information suggests that patients taking dabigatran can undergo invasive dental procedures without alteration of dose. As is the case with all other patients, irrespective of coagulation status, local haemostatic measures (absorbable gelatine or oxidized cellulose pellets, sutures, gauze soaked in 5% tranexamic acid and/or mouth wash) should be employed in events of bleeding. Owing to the risk of thromboembolism, dabigatran should never be discontinued without prior consultation with the treating physician. Dabigatran should only be recommended post-operatively once a stable clot has formed, thereby minimising the risk of bleeding. If discontinuation of anticoagulation is not safe, and extensive oral surgery procedure is required, peri-operative bridging anticoagulation with an appropriate dose of subcutaneous LMWH or unfractionated heparin is recommended (Table 2). Rivaroxaban: Rivaroxaban is an orally administered, selective, reversible, direct inhibitor of activated factor X (factor Xa), and is currently indicated for prophylaxis of venous thromboembolism (VTE) in adults after hip or knee replacement surgery. Rivaroxaban is an oxazolidinone derivative that inhibits factor Xa and interrupts both the extrinsic and intrinsic coagulation pathways, thereby inhibiting thrombin formation. It is rapidly absorbed and has a rapid onset of action of two and a half to four hours. The half-life is five to nine hours in healthy adults, and 11-13 in the elderly (due to decreased

Dental News, Volume XXV, Number II, 2018

total and renal clearance). Oral bioavailability is 80100% and the duration of effect is 10-18 hours. It is excreted in the urine (66%) and faeces (28%). Like dabigatran, routine monitoring of rivaroxaban is not required. However, in an emergency situation, measurement of the level of anticoagulation may be indicated. Anti-factor Xa assay is repotedly the most accurate measurement of the anti-coagulant effect of rivaroxaban. Approximately 1-10% of patients taking rivaroxaban experience an adverse reaction in the form of bleeding, nausea etc. Unlike warfarin, there is no specific agent to reverse the anti-coagulant effect of rivaroxaban. However, owing to its short duration of action, discontinuation of the drug should be sufficient to arrest persistent minor haemorrhage. Severe or life-threatening haemorrhage may require the use of blood product transfusion, recombinant factor VIIa, or prothrombin complex concentrate (PCC). Two-thirds of rivaroxaban is metabolised by cytochrome P450 (CYP) system, especially CYP3A4. Therefore, the concomitant use of rivaroxaban with inhibitors or inducers of CYP3A4 should be avoided which can be a risk for bleeding, including erythromycin, ketoconazole, and amiodarone. Non-steroidal and opioid analgesics should be used with caution in patients taking rivaroxaban 19,21,22. Similar to dabigatran, there are no clinical trials in the literature offering specific recommendations for the management



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of dental patients taking rivaroxaban. It is not necessary to discontinue rivaroxaban for uncomplicated extractions and other similar invasive procedures in the patients with normal renal function. Local haemostatic measures, as described previously, should be employed when necessary. For patients undergoing elective oral/maxillofacial surgery, where the bleeding risk is significant, rivaroxaben should be discontinued only after consultation with the treating physician, for at least 24 hours before surgery (Table 3).

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Oral vitamin K antagonists have, for many years been the mainstay on management for venous thromboembolism and prevention. Despite their widespread use, they are not without problem. They require regular monitoring and dose titration. In addition, they have multiple food and drug interactions. Despite this, the availability of an antidote, especially vitamin K, is somewhat reassuring. Recently, the search for a better alternative to vitamin K antagonists has resulted in the production of newer oral anticoagulants (NAOCs), direct thrombin (factor IIa) inhibitors: dabigatran (Pradaxa), and factor Xa inhibitors, namely rivaroxaban (Xeralto), aixaban (Equilis), edoxaban (Lixiana) have been used as an alternative to warfarin to treat the patients with non-valvular atrial fibrillation, and the prevention of stroke and systemic embolism 23,24. There advantages, relative to warfarin, include predictable pharmacokinetics, limited food and drug interactions, rapid onset of action and short half-life. They also require no regular monitoring or dose titration. Most current guidelines are largely based on expert opinion and pharmacologic properties of the new oral anticoagulants. Current available information suggests that the risk of bleeding in patients undergoing invasive dental procedures (for example extraction) is low, provided that local haemostatic measures (suturing, gelatine sponge, gauze soaked 5% tranexamic acid, tranexamic mouth rinse) are used and the patient has normal renal function. Indeed, the risk seems to be analogous to patients taking warfarin and with an INR of between two and three. For patients requiring multiple extractions, or oral/maxillofacial procedures, consideration must be given to discontinuation of dibagatran/rivaroxaban, with the duration determined by renal function and bleeding risk. However, dentists should not discontinue oral anti coagulants without prior consultation with the patient’s physician. If discontinuation is not feasible, due to risk of venous thromboembolism, bridging with LMWH or intravenous fractionated heparin is required. (Table 2) The most common question asked in past few years on antiplatelet and anticoagulant drugs is their influence on perioperative




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42 Oral Surgery and postoperative bleeding. These drugs are used in modern era in increasing numbers for managing thrombotic risk in our ageing populations. Frequently patients are just not taking one-blood thinner but on multiple ones so called dual or triple therapy and gets more complicated when they are on additional complimentary medications. These additional drugs may be as harmless looking as turmeric, garlic, or may be as significant as antidepressants, corticosteroids and non-steroidal anti-inflammatory drugs 23,24. The guidelines 16,17,18,19,20 so far published in literature suggests how to manage patient taking individual antiplatelet /anticoagulant drug but not elaborates how to manage patients on multiple drugs regimen with bleeding risk. Current guidelines suggest assessing each patient’s individual bleeding risk by looking at following sources:

• Patient related factors such as age, underlying medical conditions, oral health, smoking etc. • Drug related factors such as antiplatelet/ anticoagulant drugs, single or dual or multiple therapy, herbal medications, complementary drugs or antidepressants or anti-inflammatory drugs and their interactions. • Surgical procedures to be carried out such as simple forceps extraction, surgical removal of multiple teeth including pathology and degree of tissue trauma etc. Based on these factors minimal bleeding risk is managed with local measures without changing the drug regimen. The patients with multiple drug therapy and other medical conditions such as impaired renal functions etc. are best to be managed by consulting patients treating physicians or cardiologist. One should never interfere with

Flow Chart: Management of patients on anti-clotting drugs

Dental News, Volume XXV, Number II, 2018


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44 Oral Surgery patient’s drug schedule without informing or getting permission from the treating doctor (Table 3). This is the flow chart of the protocol used to manage patients taking blood thinner/anticoagulants visiting our department for the treatment (Flow chart).

Conclusion As the number of patients taking newer oral anticoagulants such as dibagatran/rivaroxaban increases, it is inevitable that dental community will encounter them in near future. It is therefore incumbent on all of us to become familiar with these drugs, their indications and mechanism of action, and in particular, the management of those patients requiring invasive dental procedures. As our experience with these medicines increases, so will our understanding of appropriate management measures. Currently, no specific protocols are available and further observational studies and randomised controlled trials are required to properly define management guidelines.

Acknowledgement This paper is dedicated in the memory of Professor Mark Jolly, Department of Oral Surgery and Oral Medicine, University of Sydney, Australia.

7. Nathwani S, Wanis C. Novel oral anticoagulants and exodontia: the evidence. British Dental Journal 2017; 222: 623-628. 8. Nathwani S, Martin K. Exodontia in dual platelet therapy: the evidence. British Dental Journal 2016; 220: 235-238. 9. Milner J, Hoffhines A. The discovery Heart Inst J 2007; 34: 179-186.

of aspirins antithrombotic effects.

10. Undas A, Brummel-Ziedines K, Mann K. Anti-thrombotic properties of aspirin and resistance to aspirin: beyond strictly platelet actions. Blood 2007; 109: 2285-2292. 11. Vane J, Botting R. The 110: 255-258.

mechanism of action of aspirin.

1. Firriolo FJ, Hupp WS Beyond

Thromb Res 2003;

12. Payne D,Hayes P,Jones C, Belham P, Naylor A, Goodall. A Combined therapy with clopidogrel and aspirin significantly increases the bleeding time through a synergistic antiplatelet action.

J Vasc Surg 2002; 35: 1204-1209.

13. Robless P, Mikhailidis D, Stansby G. Systematic review of antiplatelet therapy for the prevention of myocardial infarction, stroke or vascular death in patients with peripheral vascular disease. Br J Surg 2001; 88: 787-800. 14. Scottish Dental Clinical Effectiveness Programme. Management of dental Patients Taking Anticoagulants or Antiplatelet Drugs. 2015. Available online on (accessed September 2017). 15. Grines CL, Bonow RO, Casey DE, Gardner TJ, Lockhart PB, Moliterno DJ et al. Prevention of premature discontinuation of dual antiplatelet therapy in patients with coronary artery stents: a science advisory from American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from American College of Physicians. Circulation 2007; 115(6): 813-818. 16. Carter G, Goss AN, Lloyd J, Tocchetti R. Current concepts of the management of dental extractions for patients taking warfarin. Aust Dent J 2003;48(2): 89-96; quiz 138. 17. Expert writing group. Therapeutic Guidelines – Oral Therapeutic Guidelines Ltd. Melbourne. 2012




Dental. 2nded.

18. Dubois V, Dincq S, Douxfils J et al. Perioperative management of patients on direct oral anticoagulants. Thromb J 2017:15; 14. https://thrombosisjournal. warfarin: the new generation of oral antico-

Oral Surg

19. Keeling D, Campbell Tait R, Watson H. Peri-operative management of anticoagulation and antiplatelet therapy. Br J Haematology 2016; 175: 602-613.

2. Rybak I, Ehle M, Buckley L, Fanikos J. Efficacy and safety of novel anticoagulants compared with established agents. Ther Adv Haematol. 2011; 2(3): 175-195.

20. Spyropoulos AC, Al-Badri A, Sherwood MW, Douketis JD. Periprocedural management of patients receiving a vitamin K antagonist or a direct oral anticoagulant requiring an elective procedure or surgery. J Thromb Haemost 2016; 14: 875-85.

3. Mekaj YH, Mekaj AY, Duci SB, Miftari EI. New Oral Anticoagulants: their advantages and disadvantages compated with vitamin K antagonists in the prevention and treatment of patients with thromboembolic events. Therapeutic and Clinical Risk Management 2015; 11: 967-977.

21. National Blood Authority. Preoperative bleeding risk assessment and intervention resource: quick reference guide. / documents/preop-bleed-risk-assessment-resource.pdf. Accessed 08/09/17

4. Wang C-Z, Moss J, Yuan C-S. Commonly used dietary supplements on coagulation function during surgery. Medicines (Basel) 2015; 2(3): 157–185.

22. Heidbuchel H, Verhamme P, Alings M et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015 Oct;17(10):1467-507

agulants and their implications for the management of dental patients.

Oral Med Oral Pathol Oral Radiol 2012; 113(4): 431-441.

5. Brieger D. Anticoagulation: A GP primer Family Physician 2015; 43(5): 253-259.

on new anticoagulants.


6. Patel JP, Woolcombe SA, Patel RK, Obisesan O, Roberts LN, Bryant C, and Arya R. Managing direct oral anticoagulants in patients undergoing dentoalveolar surgery. British Dental Journal 2017; 222: 245-249.

Dental News, Volume XXV, Number II, 2018

23. Australian Medicines Handbook. Accessed via Australian Medicines Handbook Pty Ltd. Last updated July 2017. 24. The Perioperative Use of Natural Medicines. Natural Medicines TRC 2017 Therapeutic Research Center. Last updated Sep 2017.




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46 Orthodontics

A Retrospective Study to Evaluate the Intra-Arch Dimensional Changes in Moderate Crowding Cases Treated Non Extraction with a Passive Self-Ligation Appliance Vishal Bharadwaj Post Graduate Student

Gurkeerat Singh Professor and HO

Sridhar Kannan Professor and HOD, Department of Orthodontics and Dentofacial Orthopedics, Manav Rachna Dental College, Faridabad, Haryana, India

Ashish Gupta Professor,

Gaurav Gupta Reader

Abhishek Goyal Reader

Raj Kumar Singh Assistant Professor

Department of Orthodontics and Dentofacial Orthopedics, Sudha Rustagi College of Dental Sciences and Research, Faridabad, Haryana, India

Abstract Background: Non-extraction treatment protocols are better accepted by patients as well as clinicians. Among the techniques and mechanics with the potential to facilitate non-extraction treatment includes headgears, fixed sagittal correctors, transverse expansion screws and self-ligating systems. Objectives: To evaluate the intra-arch dimensional changes in moderate crowding cases, treated non-extraction with a passive self-ligating (Damon 3MX) appliance using digitized models and lateral cephalograms. Methods: A total of 20 patients (age group of 15 - 18 years) who had undergone non extraction orthodontic treatment with the Damon 3MX appliance were selected. All the pre-treatment and post-treatment dental stone models of maxillary and mandibular arches were scanned using 3D digital scanner (Maestro 3D, Greatlakes, USA) and were converted into digital models. Various pa-rameters undertaken were measured digitally on the computer in millimetres. Cephalometric tracings of pre and post treatment cephalograms were performed using digital cephalometrics (Nemo Ceph, version 6.0, Spain). Statistical analysis was performed using t-test. Results: More transverse expansion was observed in the region of 1st and 2nd premolars as compared to the inter-canine and inter molar region in maxillary and mandibular arch. However a decrease in arch depth was observed in maxillary arch but arch depth of mandibular arch was found to be increased. There was

Dental News, Volume XXV, Number II, 2018

significant increase in anterior proclination in both maxillary and mandibular arches. Conclusions: Passive self-ligating system causes a significant increase in transverse width in both maxillary and mandibular dental arches. Keywords: Passive Self Ligation Brackets, Arch Width, Digitisation, Non-Extraction

Background Irregularly placed front teeth is one of the most frequently encountered chief complaint in day to day or-thodontic practice. The etiology for which may be tooth size-arch length deficiency 1-4. This condition can be treated, either by reducing tooth size and/or by increasing arch width and/or arch depth 5-7. In other words, Orthodontists can gain space by expanding the arch antero-posteriorly or transversely along with other conventional means, depending on the treatment plan. Non-extraction treatment protocols are better accepted by patients as well as clinicians. Among the techniques and mechanics with the potential to facilitate nonextraction treatment includes headgears, fixed sagittal correctors, transverse expansion screws and self-ligating systems. Although each of these approaches necessitates an increase in arch length to facilitate alignment without extraction, it has been purported that passive self-ligating brackets can induce specific, uniquely stable arch dimensional changes when used with thermal-loy archwires 8. Self-ligating brackets (SLB) are not new in orthodontics. They were introduced to the specialty nearly a century ago, with the Russell

EXPODENTAL MEETING 2018 The expected success of a growing event

The last Expodental Meeting in Rimini was a real success, confirming that this event is the only meeting hub for the dental industry, distribution and professionals in Italy; a melting pot of ideas, business opportunities and scientific training. This year 350 dental companies from all over the world exhibited in Rimini, and almost 20.000 distributors, buyers, dentists, dental technicians, hygienists and dental assistants visited the trade-show, with a 11% increase over the 2017 edition. Expodental Meeting reflects a more than vital sector: the Italian dental field confirms to be a world leader, with a strong industry that is very appreciated throughout the world, and a growing internal market with increasing investments by Italian dental practices and dental technicians’ laboratories. 350 forward-looking dental companies had great expectations for this event and decided to show their latest innovations at Rimini Fiera, with a large commitment in terms of wonderful booths, strong promotion of the event, organization of workshops and leisure activities. Our Exhibitors gave a very important contribution to the success of this year edition.

Bringing together a wide range of professional associations, scientific organizations and universities in a single cultural program, Expodental Meeting represented a unique opportunity of scientific updating for the Italian oral care professionals: 12 training rooms with more than 40 clinical and extra-clinical events, ECM courses, more than 100 high-level international speakers and 25 workshops by the Exhibitors. Thanks to the EXPO3D project, besides the display of materials, equipment and technologies used within the digital workflow, a conference room was entirely focused on digital technologies, including events by dental associations and scientific lectures by academic experts. This year Expodental Meeting confirmed its international vocation, attracting a large number of foreign buyers and professionals. The 11,5% of the total visitors (more than twice compared to last year) came from abroad. Thanks to the cooperation with ICE/ITA (Italian Trade Agency) more than 80 foreign delegates from 24 Countries met the Italian Companies in almost 1.500 b2b meetings, with an increase of 21% over the past edition. Save the date for the next Expodental Meeting, from 16th to 18th of May 2019.

48 Orthodontics Lock 9 edgewise attachment being described in 1935. The Damon SL bracket 10 were introduced in 1996 and have been modified over the years. In the past two decades, there has been an increase in the manufacturing and release of self-ligating brackets with active or passive ligation modes. The basic advantage of these brackets involves the elimination of certain utilities or materials such as elastomeric modules along with the process or tools associated with their application. This is supposed to bring about several favorable features to the treatment including, the elimination of potential crosscontamination with elastic ligatures, consistently full engagement without the undesirable force relaxation of elastomeric modules, reduced risk for enamel decalcification from the elimination of the retentive site for plaque accumulation, reduced friction in sliding mechanics, and assumed lowmagnitude forces resulting in fewer side effects 11.

Objectives The Objective was to retrospectively evaluate the intra-arch dimensional changes in moderate crowding cases, treated non-extraction with a passive self-ligating (Damon 3MX) appliance by assessing the pre treatment and post treatment digitized models and lateral cephalograms. The study was formulated as a double blind study.

Methods A total of 20 patients between the age group of 15 - 18 years who had undergone non extraction orthodontic treatment with the Damon 3MX (Ormco, San Diego, Calif) appliance were selected. Patients with a full complement of teeth up to erupted second permanent molars with moderate crowding in the maxillary and/or mandibular arch, with skeletal Class I jaw base relation treated with non-extraction treatment plan were included in the study. Orthodontically retreated cases, congenital absence of teeth, aberration in tooth size/shape were excluded. Only those pretreatment and post treatment mod-els and lateral cephalograms were selected for scanning which met all the inclusion and exclusion criteria as well who were treated according to the passive self ligation philosophy as well with the standard wire sequencing. The following arch wire sequencing were used: Dental News, Volume XXV, Number II, 2018

0.013” / 0.014” Copper Nickel-Titanium (Cu Ni-Ti) was in place for 2 - 4 months Followed by 0.016” x 0.016” Cu Ni-Ti for a minimum pe-riod of 2 months or a 0.014” x 0.025” Cu Ni-Ti for a minimum period of 2 months 0.016” x 0.025” Cu Ni-Ti for minimum of 2 months 0.017” x 0.025” SS, 0.019” x 0.025” Titanium Molybdenum alloy (TMA) finishing wire for minimum period of 2 months All the pre-treatment and post-treatment dental stone models of maxillary and mandibular arches were scanned using 3D digital scanner (Maestro 3D, Great lakes, USA) and converted into digital models which could be examined in all the 3 planes of space. Parameters undertaken for study were measured digitally on the computer in millimeters which included Inter-canine width (C) of maxilla and mandible, Inter-1st pre-molar width (PM1) of maxilla and mandible, Inter-2nd pre-molar width (PM2) of maxilla and mandible, Inter-molar width (M1) of maxilla and mandible, Arch depth of maxilla and mandible, Maxillary incisor inclination and Mandibular incisor inclination (Figures 1 - 4). Inter-canine width: Measurements were made from the cusp tips of the right and left canine. Inter-first premolar width: Measurements were made between the buccal cusp tips of right and left first premolars. Inter second premolar width: Measurements were made between the buccal cusp tips of right and left second premolars. Inter first molar width: Measurements were made between the mesio-buccal cusp tips of right and left first molars. Arch Depth First line is drawn connecting the central fossa of first molars on the right and left sides. A second line was drawn perpendicular to the first, bisecting the contact point between the central incisors. Cephalometric tracings were performed using digital cephalometrics (Nemo Ceph, version 6.0, Spain). Pre-treatment and post-treatment readings of each patient were evaluated from the software and pre treatment and post treatment superimposition was also carried out.

Upper Incisor Inclination U1 to SN plane angle: It is the inferior inside angle formed between the long axis of the upper incisor and Sella-nasion plane. U1 to Palatal plane angle: It is the inferior inside angle formed between the long axis of the upper incisors and palatal plane (formed by line joining the anterior nasal spine and posterior nasal spine) U1 to N-A (Angular): It is the angle formed by the intersection of the long axis of the upper central incisors and the line joining the nasion to point A. Lower Incisor Inclination L1 to Mandibular plane angle: It is the angle formed by the intersection of the long axis of the lower incisor with the mandibular plane. It indicates the inclination of the lower incisors. L1 to Occlusal plane angle: It is the inferior inside angle formed by the intersection of the long axis of the lower incisor with the occlusal plane.

Figure 1: Scanned Digital Image of Pretreatment and Post Treatment Archwidth of Maxillary Arch

Figure 2: Scanned Digital Image of Pretreatment and Post Treatment Arch Depth of Maxillary Arch

Figure 3: Scanned Digital Image of Pretreatment and Post Treatment Arch Width of Mandibular Arch

Figure 4: Scanned Digital Image of Pretreatment and Post Treatment Arch Depth of Mandibular Arch

This angle is read as a positive or negative deviation from the right angle. L1 to N-B (Angular): It is the angle formed by the intersection of the long axis of the lower central incisors and the line joining the nasion to point B.

Results All the pretreatment and post treatment measurement of scanned digital models and the measurement obtained from the scanned cephalograms were subjected to statistical analysis using software SPSS (statistical package for social sciences) version 21.0 and Epi-info version 3.0 and Paired t-test was applied to see the statistical significance - It was used for comparison of 2 mean values obtained from a same group or a pair of values obtained from the same sample. The P-value was taken significant when less than 0.05 (P < 0.05) and Confidence interval of 95% was taken. The following results were obtained after the statistical analysis:

Discussions Self ligation appliances regained popularity since the early nineties because of the certain advantages which were claimed such as: increased patient comfort, better oral hygiene, increased patient cooperation, less chairtime, shorter treatment time, greater patient acceptance, expansion, and less dental extractions 10, 12, 13. Self ligation appliances achieved significant amount of expansion with no apical root resorption and with increase in buccal bone thickness. Self ligation appliance also offer precise control of tooth during translation, reduce overall anchorage demands, rapid alignment and more certain space closure. Alleviating dental crowding without extractions requires an increase in arch perimeter or interproximal reductions to attain good teeth alignment 14. In the absence of distalization, the changes in arch dimensions involve transverse expansion and increased proclination of teeth.

Table 1: Descriptive Statistics of Pre-Treatment and Post Treatment Arch Width and Arch Depth Values Are Shown (mm)a

52 Orthodontics Table 2: Descriptive Statistics of Pre-Treatment and Post Treatment Upper Incisor and Lower Incisor Inclination Values Are Shown (Degrees)a

Passive self-ligation treatment philosophy 10 is based on providing optimum force levels for orthodontic tooth movement which should be just high enough to stimulate cellular activity without completely occluding the blood vessels in the PDL. Light continuous forces will produce continuous, frontal resorption and will not overpower the periodontal and orofacial musculature, and will prevent proclination of anteriors and causes more expansion in the transverse direction. Photoelastic model showed lower stress in periodontal tissue with self-ligating appliance as compared to conventional bracket system.15 Intra arch dimensional changes in both maxillary and mandibular arches in moderate crowding cases treated non-extraction with a passive self ligation appliance (Damon 3MX) were analyzed using digitized models and digital cephalograms. This study showed an increase in maxillary inter-canine width, inter 1st premolar width, inter 2nd premolar width and inter molar arch width (Table 1). More transverse expansion was observed in the region of 1st and 2nd premolars as compared to the inter-canine and inter molar region. More expansion in the premolars region can be because of lip bumper effect which minimizes the pro-clination of anterior teeth and allow more expansion in posterior region. Previous study also showed majority of transverse changes in the premolar areas in both upper and lower arches, with less expansion in the canine and molar region 16, 17. While assessing maxillary arch depth, the study showed (Table 1) a decrease in arch depth which can be because of more of transverse expansion, which created space and helped in unraveling of crowding in upper anteriors and less proclination. OverlapDental News, Volume XXV, Number II, 2018

ping because of crowding in anteriors was reduced with minimal proclination. Because of lateral expansion and derotation in posterior segment, some amount of mesial movement of molars could also have occurred, to improve molar relation. The inclination of upper incisors was evaluated using U1 to N-A (Angular), U1 to palatal plane angle and U1 to SN plane angle (Table 2). Results showed an increase in proclination which was statistically signiďŹ cant. Similar studies done in past also showed signiďŹ cant amount of arch expansion in the maxillary arch 8. In the mandibular arch also an increase in mandibular intercanine width, inter 1st premolar width, inter 2nd premolar width and inter molar arch width was observed (Table 1) similar to maxillary arch. Study also showed an increase in the mandibular arch depth (Table 1). Change in inclination of lower incisors was evaluated using L1 to N-B (Angular) values, L1 to mandibular plane angle and L1 to occlusal plane angle (Table 2). Results showed increase in proclination which was statistically signiďŹ cant. Insufficient interproximal reduction can be one of the cause of increased proclination of lower anteriors and increase in arch depth in mandibular arch. Results of the study also showed more increase in the mandibular intercanine and interpremolar widths as compared to the inter molar width with increase in arch depth and increase in proclination. Previous studies showed transverse expansion and incisor proclination, and more expansion in the inter molar region 11, 18

Conclusions Study showed increase in inter-canine width, inter 1st premolar width, inter 2nd premolar width and inter molar width in both maxillary and mandibular arches, with more expansion in premolar area. Arch depth was found to be decreased in upper arch it was found to be increased in lower arch however the passive self-ligation appliance can be used as a valuable tool because it minimizes the proclination which could have been produced during unravelling of crowding in both the arches without the space which have been gained with passive self ligation appliance by posterior expansion. Limitations of Study Present study had the limitations of small sample size of twenty patients and retrospective in nature. As retrospective studies are always subject to various types of bias because of the lack of randomization. Hence, the results obtained from the current study should be further strengthened using a larger sample size and preferably us-ing a prospective study model.

1. Brunelle JA, Bhat M, Lipton JA. Prevalence and distribution of selected occlusal characteristics in the US population, 1988-1991. J Dent Res. 1996;75 Spec No:706–13. doi: 10.1177/002203459607502S10. [PubMed: 8594094]. 2. Infante PF. An






relations in preschool children.

J Dent Res. 1975;54(4):723–7. 10.1177/00220345750540040501. [PubMed: 1057556].


3. Kerosuo H. Occlusion in the primary and early mixed dentitions in a group of Tanzanian and Finnish children. ASDC J Dent Child. 1990;57(4):293–8. [PubMed: 2373787]. 4. Gabris K, Marton S, Madlena M. Prevalence of malocclusions in Hungarian adolescents. Eur J Orthod. 2006;28(5):467–70. doi: 10.1093/ejo/cjl027. [PubMed: 16923783]. 5. Damon D. Treatment of the face with biocompatible orthodontics. In: Graber TM, Vanarsdall Jr RL, Vig KWL, editors. Orthodontics: current principles and techniques. 4th ed. Philadelphia: Elsevier; 2005. p. 753–831. 6. Yu YL, Tang GH, Gong FF, Chen LL, Qian YF. [A comparison of rapid palatal expansion and Damon appliance on non-extraction correction of dental crowding]. Shanghai Kou Qiang Yi Xue. 2008;17(3):237–42. [PubMed: 18661061]. 7. McNally MR, Spary DJ, Rock WP. A comparing







randomized controlled




J Orthod. 2005;32(1):29–35. 10.1179/146531205225020769. [PubMed: 15784941]. correction

10. Damon DH. The Damon low-friction bracket: a biologically compatible straight-wire system. J Clin Orthod. 1998;32(11):670–80. [PubMed: 10388398]. 11. Pandis N, Polychronopoulou A, Eliades T. Self-ligating vs conventional brackets in the treatment of mandibular crowding: a prospective clinical trial of treatment duration and dental effects. Am J Orthod Dentofacial Orthop. 2007;132(2):208–15. doi: 10.1016/j.ajodo.2006.01.030. [PubMed: 17693371]. 12. Fleming PS, DiBiase AT, Lee RT. Self-ligating 2008;42(11):641–51. [PubMed: 19075378].

appliances: evolution or revolution?.

J Clin Orthod.

13. Rinchuse DJ, Miles PG. Self-ligating brackets: present and future. Am J Orthod Dentofacial Orthop. 2007;132(2):216–22. doi: 10.1016/j.ajodo.2006.06.018. [PubMed: 17693372]. 14. Weinberg M, Sadowsky C. Resolution of mandibular arch crowding in growing patients with Class I malocclusions treated nonextraction. Am J Orthod Dentofacial Orthop. 1996;110(4):359–64. doi: 10.1016/S0889-5406(96)70035-5. [PubMed: 8876484]. 15. Sobral GC, Vedovello Filho M, Degan VV, Santamaria MJ. Photoelastic analysis of stress generated by wires when conventional and self-ligating brackets are used: a pilot study. Dental Press J Orthod. 2014;19(5):74–8. doi: 10.1590/2176-9451.19.5.074-078.oar. [PubMed: 25715719]. 16. Maltagliati LA, Myiahira YI, Fattori L, Filho LC, Cardoso M. Transversal changes in dental arches from non-extraction treatment with self ligating brackets. Dental Press J Orthod. 2013;18(3):39–45. doi: 10.1590/S2176-94512013000300008. [PubMed: 24094010]. 17. Lineberger MB, Franchi L, Cevidanes LH, Huanca Ghislanzoni LT, Mc- Namara JJ. Three-dimensional digital cast analysis of the effects produced by a passive self-ligating system. Eur J Orthod. 2016;38(6):609–14. doi: 10.1093/ejo/cjv089. [PubMed: 26843516]. 18. Fleming PS, DiBiase AT, Sarri G, Lee RT. Comparison of mandibular arch changes during alignmentandleveling with 2 preadjusted edgewise appliances. Am J Orthod Dentofacial Orthop. 2009;136(3):340–7. doi: 10.1016/j.ajodo.2007.08.030. [PubMed: 19732667].



9. Stolzenberg J. The Russell attachment and its improved advantages. Int J Orthod Dent Dent Child. 1935;21(9):837–40. doi: 10.1016/s0097- 0522(35)90368-9.

the doi:

8. Fleming PS, Lee RT, Marinho V, Johal A. Comparison of maxillary arch dimensional changes with passive and active self-ligation and conventional brackets in the permanent dentition: a multicenter, randomized controlled trial. Am J Orthod Dentofacial Orthop. 2013;144(2):185–93. doi: 10.1016/j.ajodo.2013.03.012. [PubMed: 23910199].

54 Endodontics

Appraisal of MTA and Biodentine in Direct Pulp Capping: a systematic review Dr. Bechir Annabi, Associate Professor of Endodontics

Dr. Amir Hachicha, Private clinician

Dr. Sana Bagga, Professor of Endodontics

Dr. Chems Belkhir, Professor of Endodontics

Department of Endodontics, Faculty of Dentistry, Laboratory of Dento-Facial, Biological and Clinical Approach, University of Monastir - Tunisia

Abstract Introduction New materials have appeared to replace calcium hydroxide such as the calcium silicate-based materials i.e. Mineral Trioxide Aggregate (MTA) and Biodentine®. Both materials have shown improved sealing properties and greater ability to stimulate reparative dentin formation compared with Ca(OH)2. The aim of this study is to assess the clinical outcomes of two direct pulp-capping products: Biodentine® and MTA. Methods A systematic literature search was conducted up to November 2017. A structured search using two Boolean equations and the keywords “dental pulp capping”, “Mineral trioxide aggregate”, “tricalcium silicate”, “direct pulp capping”, “Biodentine” was performed. Initially, 14 potentially relevant articles were identified. After removal of duplicates and screening by title, abstract, and full text when necessary, five studies were included. Three studies were randomised controlled trials and two studies were controlled trials. Results All the studies showed that The Biodentine® gave clinical, radiological and histological outcomes similar to those observed during the direct pulp capping with MTA. The pulp vitality was conserved and no periapical image was noted. The formation of Dentin Bridge of good quality preventing any bacterial infiltration and promoting the closure of the breach was observed. Conclusions No clear evidence to identify the superiority of

Dental News, Volume XXV, Number II, 2018

Biodentine® over MTA was found. However, the Biodentine® can be an excellent alternative to the MTA in the framework of direct pulp capping. It presents some advantages easy to handle, can be used as a provisional coronal obturation, timesaving and better cost effectiveness.

Introduction Direct pulp capping is a treatment for exposed vital pulp involving the placement of a dental material over the exposed area to facilitate both the formation of protective barrier and the maintenance of vital pulp. Clinical pulp conditions related to patient symptoms are to be considered before the direct pulp capping material placement. Pulp capping could be performed on a tooth with normal pulp or reversible pulpitis. Percussion, palpation, and periodontal probing test results should be within normal limits. The radiograph should show normal apical tissue. The pulp exposure site should be less than 1 mm in diameter and stopping pulpal hemorrhage should be prerequisite before direct pulp capping material placement 7. Direct pulp capping using calcium hydroxide-based agent has been a standard therapy for years. To address its shortcomings, new materials have appeared to replace calcium hydroxide such as the calcium silicate based materials i.e. Mineral Trioxide Aggregate (MTA) and Biodentine®. Both materials have shown improved sealing properties and greater ability to stimulate reparative dentin formation compared with Ca(OH)2. The aim of this systematic review was to assess the clinical outcomes of two direct pulp-capping products: Biodentine® and MTA.

56 Endodontics Material and Methods Research question was: has Biodentine better clinical and histological outcomes than MTA in direct pulp capping of immature and mature permanent teeth? This research question was formulated using PICO format: • P: the patient population was children and adults having either immature or mature permanent teeth requiring direct pulp capping • I: the intervention was direct pulp capping using Biodentine • C: the comparator was MTA. • O: the main outcomes were formation of Dentin Bridge and conservation of pulp vitality. Search strategy The research was conducted on MEDLINE via PubMed using different combinations of Medical Subject Headings (MeSH) terms and free text words. The keywords used were “dental pulp capping”, “Mineral trioxide aggregate”, “tricalcium silicate”, “direct pulp capping”, “Biodentine”. Only “dental pulp capping”, Mineral trioxide aggregate” and “tricalcium silicate” were MeSH words. Two Boolean equations were formulated without using filters: (Equation 1): “Dental pulp capping”[MeSH] AND “tricalcium silicate”[supplementary concept] AND

“Mineral Trioxide Aggregate” [supplementary concept]. (Equation 2): “Direct pulp capping” AND “Biodentine” AND “Mineral Trioxide Aggregate”. Selection criteria All types of clinical studies addressing the research question were included. Human teeth both immature and with closed apex were also included. Another inclusion criterion was the post-operative follow-up, which must be of at least six months. In vitro studies, animal studies and studies not dealing with direct pulp capping were excluded. Selection process The selection of the studies was performed in three steps: first, the title of the studies was considered, eliminating obviously irrelevant articles. Then, the abstracts were screened after the first selection eliminating articles not meeting the inclusion criteria. Finally were excluded the articles whose abstracts were not available or incomplete by reading the integral article. (Figure1). In addition, bibliographies of all relevant articles selected were hand-searched for additional studies. Three reviewers (AMB, BC, HA) assessed and selected the studies based on specified inclusion criteria and extracted the data onto a pre-designed reading grid, independently.

Figure 1: Article selection flow chart for the systematic review according to PRISMA guidelines. Dental News, Volume XXV, Number II, 2018

Results Excluded Articles The first formula resulted in nine articles on November 15th 2017. Seven articles were excluded: five articles were in vitro studies and two articles were not available. (Table1). The second formula resulted in five articles on November 15th 2017. Two articles were excluded (in vitro studies). (Table1). Selected articles A total of five articles were selected since they meet the aims of our study. Two of these articles were found with the first research and three with the second research formula. (Table 2). The articles selected were two controlled trials and three randomized controlled trials. Data of articles The two studies of Nowicka. 11, 12 dealt with focused on third molars of patients aged between 19 and 32 years. The pulp exposure was voluntary. The work of Nowicka, Lipski et al. 11 was interested in the direct pulp capping with Biodentine and MTA. The work of Nowicka; Wilk et al. 12 compared the direct pulp

capping of four groups: MTA, Biodentine® calcium hydroxide and a universal adhesive (Single Bond Universal® (SBU), Filtek Ultimate® 3M). For these two studies 11, 12, a clinical follow-up of six weeks was performed then the teeth were extracted and their pulps studied histologically. Nowicka and Wilk studied the formation of the dentin bridge with the CBCT before achieving the histological examination. MTA and Biodentine® gave similar clinical (conservation of the pulp vitality) and histological (closure of the pulp breach by formation of the dentin Bridge) results. The study of Katge 6 interested the first permanent molars of patients between the ages of 7 and 9. The pulp exposure was conducted during the curettage of decay. The direct pulp capping was carried out with MTA and Biodentine®. Clinical and radiological follow-ups were made 6 and 12 months later. The two products gave similar clinical (conservation of the pulp vitality) and radiological (no radiolucency or periodontal widening) results. The study of Brizula 1 interested permanent molars of patients between the age of 7 and 16. The pulp exposure was conducted during the curettage of decay. The direct pulp capping was



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carried out with MTA, Biodentine® and calcium hydroxide. Clinical and radiological follow-ups were made to 3, 6, and 12 months later. After 3 months, a failure was found in the calcium hydroxide group. After 6 months, another failure was found in the calcium hydroxide group and four in the group of the MTA and one year later, one more failure in the calcium hydroxide group. The statistical results did not show significant differences between MTA and Biodentine®. The study of Hedge 5 interested permanent molars of patients aged between 18 and 40. The pulp exposure was conducted during the curettage of decay. The direct pulp capping was carried out with MTA, Biodentine®. Clinical and radiological follow-ups were made within 3 weeks, 3 months and 6 months. Three patients (two of the Group Biodentine®, one of the Group MTA) presented spontaneous pain and the teeth were endodontically treated. Six months and a year later, the clinical and radiological results were similar for the two groups and for the rest of the teeth: conservation of the pulp vitality, absence of radiolucencies and formation of a dentin bridge.

Discussion To date, few clinical studies have addressed direct pulp capping with Biodentine®, the same for the studies comparing MTA and Biodentine® as agents of direct pulp capping. The two research formulas used for this study gave different results. The first formula using Mesh words found two clinical and histological studies. The second formula using the direct search on PubMed found three most recent articles, which were clinical studies on decayed teeth. The studies of Katge 6, Brizula 1 and Hedge 5 were clinical and radiological studies. The conservation of the pulp vitality was considered clinically positive if the teeth responded positively to the electrical test of sensitivity with absence of periapical radiolucencies radiologically.




The study of Katge 6 reported 100% success. Six months after the treatment, the number of teeth showing the formation of Dentin Bridge was more important in the MTA group than in the group Biodentine® but the difference was not significant. Twelve months after the direct pulp capping, the number of teeth “showing the formation of Dentin Bridge was more important in the Biodentine® group than in the group MTA but the difference was not significant. The authors concluded that the two materials allowed the conservation of the pulp vitality and the closure of the breach. The study of Brizula 1 showed a success rate of 100% with the Biodentine to 3, 6, and 12 months later. The MTA Group showed three cases of failure only after 6 months of treatment. The results between these two groups were not statistically

significant. The authors concluded that MTA and Biodentine® constituted an alternative to the calcium hydroxide for the direct pulp capping. The study of Hedge 5 showed a rate of success to six months with the groups MTA and Biodentine of 91.7% and 83.3% respectively. One year after treatment two teeth of the MTA Group and two teeth of the Biodentine® group showed the formation of a bridge dentin. The authors concluded that MTA and Biodentine® were reliable direct pulp-capping agents. The two studies of Nowicka, Lipski et al. 11 and Nowicka, Wilk et al. 12 were clinical studies followed by histological examinations. The conservation of the pulp vitality was considered positive clinically if the teeth responded positively to the electrical test of sensitivity with absence of periapical reaction (after 6 weeks of observation). According to these two studies, all teeth that underwent direct pulp capping with the Biodentine and the MTA kept their pulp vitality. According to Nowicka, Lipski et al. 11, the formation of a dentin bridge after direct pulp capping was considered a sign of pulp healing and not a reaction to a pulp irritation. This study showed that histologically speaking, dentinal Bridges were formed directly under the two capping materials: Biodentine and MTA. No important inflammatory sign was observed. A layer of well-organized odontoblasts and odontoblasts-like constituted these dentinal bridges, the dentinal tubules were well distinguished but had different orientations. This layer formed the reparative dentin, which enabled the closure of the pulp breach. This can be explained by the physico-chemical properties of the MTA and the Biodentine®, which induced the secretion of the growth factor ß1 by the pulp cells essential to the formation of the dentin bridge. In the study of Nowicka, Wilk et al. 12, optical microscopy made it possible compare the formation of dentin bridge between four groups: the formation of the dentin bridge was low at the group level SBU compared to the other groups. The thickness of this bridge was lower in the group SBU compared to the groups MTA, Biodentine and Ca(OH)2. Under high magnification, the structure of the hard tissues formed was more dense and compact in groups MTA and Biodentine compared to the groups Ca(OH)2 and SBU which presented porosities and tunnels. The CBCT imaging demonstrated to show the formation of dentinal bridges in groups MTA and Biodentine® at a rate higher than the other two groups (Ca(OH)2 and adhesive). The average and the maximum volume of the dentin bridge formed at the level of the Group Biodentine® was higher compared to averages and maxima of volume of other groups. The MTA present a better minimum threshold of volume of Dentin Bridge formed by report to other products used. The study of Hedge showed that,

radioactively; the dentinal bridges formed by the Biodentine® were thicker than those formed by the MTA. According to these two studies 11, 12, the quality of the dentin bridge observed for the teeth that underwent direct pulp capping with Biodentine and MTA was due to the superior efficiency of silicate of calcium products (MTA and Biodentine) through the recruitment of stem cells of the pulp; these cells regulate the expression of the transcription factors as Runx2, which were involved in the process of molecular dentinogenesis. The stimulation of cell proliferation and differentiation can be linked to calcium silicate itself, which is one of the main components of the MTA and Biodentine®. According to Nowicka, Wilk et al. 12, an increase in the activity of alkaline phosphatases and the regulation of odontoblastic differentiation markers was noted for the MTA and the Biodentine®. According to Nowicka 11, Hedge 5, and Katge 6, the response of the pulp following a direct pulp capping was related to the presence or the absence of a bacterial infiltration. In fact, the microorganisms interfere with the response to pulp products of capping. The bacteria stimulate the pulp inflammation and reduce the surface of formation of the dentin bridge 11. The pulp vitality after an exposure was not linked to the bioactive property of the capping product but rather to its ability to protect the pulp of a bacterial infiltration 11. According to Nowicka, Wilk and al. 12, the porosities present in the dentin bridge facilitated the bacterial infiltration of the pulp, their study showed that the teeth treated with MTA and Biodentine® presented dentinal bridges more homogeneous and more dense compared to Ca(OH)2. The authors concluded that MTA and Biodentine® presented a best antibacterial barrier through the formation of dentinal bridges of best qualities. Some studies 3, 9 confirmed these data. The pulp healing following a pulp exposure depends essentially on the ability of the capping product in preventing the bacterial infiltration; this capacity is considered as the first criterion for the choice of the product for pulp capping. Other factors play an important role in the success of the direct pulp capping i.e. the vascularization of the pulp, the severity of the inflammation, the possibility of the hemostasis, disinfection of the exposed site, the size of the pulp breach and the biocompatibility of the material used. The immature permanent teeth have a direct pulp capping success rate more important than the mature permanent teeth. The two Nowicka studies interested healthy mature teeth that of Katge 6 decayed immature teeth and those of Brizula 1 (average age 11.3) and of Hedge 5 decayed mature teeth.

60 Endodontics According to Nowicka 11, 12, when the pulp is healthy, the results obtained are assigned exclusively to the materials used. The intensity of the response on pulp of healthy Teeth remains lower than that observed on the decayed teeth. The work of Katge 6 showed a 100% clinical and radiographic success for the MTA and the Biodentine® The only shortcoming of this study 6 is the size of the sample. It concluded that these two materials contribute significantly to maintaining the pulp vitality when direct pulp capping was indicated correctly. The study of Brizula 1 using a sample more important than Katge 6 found a 100% clinical and radiological success rate only with the Group of Biodentine®. The Group MTA presented 13.64% of failure. The study of Hedge 5 conducted with patients older than that of Brizula 1 showed a rate of success more important with MTA that with Biodentine®.

References 1. Brizuela C , Ormeno A, Cabrera C, Cabezas R, Silva CL, Ramirez V, Mercadi M. Direct Pulp Capping with Calcium Hydroxide, Mineral Trioxide Aggregate, and Biodentine in Permanent Young Teeth with Caries: A Randomized Clinical Trial. J Endod. 2017; 43:1776-80. 2. Camilleri J. Hydration characteristics of Biodentine and Theracal used as pulp capping materials. Dent Mater 2014; 30(7):709-15. 3. Cox CF, Keall CL, Keall HJ, Ostro E, Bergenholtz G. Biocompatibility of surface-sealed dental materials against exposed pulps. J Prosthet Dent 1987; 57(1):1-8. 4. De Rossi A, Silva LA, Gatón-Hernández P. Comparison of pulpal responses to pulpotomy and pulp capping with biodentine and mineral trioxide aggregate in dogs. J endod

2014; 40(9):1362-9.

5. Hedge S, Sowmya B, Mayhew S, Bhandi SH; Nagaraja S, Dinesh K. Clinical evaluation of mineral trioxide aggregate and biodentine as direct pulp capping agents in carious teeth. J Conserv Dent. 2017; 20: 91-95. 6. Katge FA, Patil DP. Comparative Analysis of 2 Calcium Silicate–based Cements (Biodentine and Mineral Trioxide Aggregate) as Direct Pulp-capping Agent in Young Permanent Molars: A Split Mouth Study. J Endod 2017;43: 507-13. 7. Komabayashi T, Zhu Q, Eberhart R, Imai Y. Current status of direct pulp-capping materials for permanent teeth. Den Mat J 2016; 35(1): 1–12.

According to Nowicka 11, 12, Brizula 1 and Katge 6, Biodentine® requires a simpler manipulation than the MTA and a shorter setting time. The price of these two materials is higher than the calcium hydroxide. However, the MTA is slightly more expensive than the Biodentine 12.

8. Mouawad S, Artine S, Hajjar P, McConnell R, Fahd JC, Sabbagh J. Frequently asked questions in direct pulp capping of permanent teeth. Dent Update. 2014; 41(4):298-300, 302-4.

Authors’ conclusions

10. Natale LC, Rodrigues MC, Xavier TA, Simões A, de Souza DN, Braga RR. Ion release and mechanical properties

No clear evidence was found to identify the superiority of Biodentine® over MTA. However, Biodentine® can be an excellent alternative to MTA in the framework of direct pulp capping. It presents some advantages i.e. easy to handle, can be used as a provisional coronal obturation, timesaving and has better cost effectiveness. However, this systematic review shows low number of studies concerning this subject, which can be explained by the relatively high price of MTA and Biodentine® compared to calcium hydroxide, and the difficulties encountered in carrying out studies in vivo. Other randomized clinical studies are needed to approve the results of this systematic review.

Acknowledgements The authors deny any conflicts of interest related to this systematic review. Dental News, Volume XXV, Number II, 2018

9. Murray PE, Windsor LJ, Smyth TW, Hafez AA, Cox CF. analysis of pulpal reactions to restorative procedures, materials, pulp capping, and future therapies. Crit Rev Oral Biol Med 2002; 13 (6):509-20.

of calcium silicate and calcium hydroxide materials used for pulp capping. Int Endod J. 2015; 48(1):89-94.

11. Nowicka A, Lipski M, Parafiniuk M. Response of Human Dental Pulp Capped with Biodentine and Mineral Trioxide Aggregate. J Endod 2013; 39(6): 743-7. 12. Nowicka A, Wilk G, Lipski M, Ko1ecki J, BuczkowskaRadlinska J. Tomographic Evaluation of Reparative Dentin Formation after Direct Pulp Capping with Ca OH) 2, MTA, Biodentine, and Dentin Bonding System in Human Teeth.J Endod 2015; 41: 1234-40. 13. Özyürek T, Demiryürek EÖ. Comparison of the antimicrobial activity of direct pulp-capping materials: Mineral trioxide aggregate-Angelus and Biodentine. J Conserv Dent 2016; 19(6):569-72. 14. Rada RE.New options for restoring a deep carious lesion. Dent Today. 2013; 32(3):102, 104-5. 15. Shayegan A, Jurysta C, Atash R, Petein M, Abbeele AV. Biodentine used as a pulp-capping agent in primary pig teeth. Pediatr Dent. 2012; 34: 202–8. 16. Stefanova VP, Tomov GT, Tsanova STs. Morphological Study Of Border Area Of Pulp-Capping Materials And Er:YAG Laser Prepared Hard Dental Surface. Folia Med 2015; 57(1): 49-55. 17. Strassler HE, Levin R. Vital pulp therapy with capping. Dent Today 2012; 31(11):98, 100, 102-3.




March 28 - 30, 2018 Hilton Green Plaza Alexandria, Egypt

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April 19 - 21, 2018 St. Joseph University - Faculty of Dentistry Beirut, Lebanon

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Photo of the head of departments of the Dental School of the St Joseph university during the opening ceremony around the vice rector and the Dean La Faculté de Médecine Dentaire de l’Université Saint-Joseph de Beyrouth fête cette année le 98ème anniversaire de son existence. Je voudrais aujourd’hui rendre hommage aux Pères Jésuites qui l’ont fondée et construite, puis à ceux qui l’ont développée et assuré sa pérennité. Edward Young, poète et philosophe britannique, écrivait en 1742 : « La science n’est rien dans l’ombre ensevelie : en la communiquant, l’esprit se multiplie ». Plus de 2 siècles et demi plus tard, cette pensée reste toujours d’actualité. Les Journées Odontologiques sont à leur 13ème édition. Elles ont toujours eu lieu au mois de Juin au sein du magnifique Campus des Sciences Médicales à la rue de Damas. Cette année, exceptionnellement, en raison du mois de Ramadan et des élections législatives d’une part, et des travaux d’édification de la nouvelle faculté de Médecine de l’autre, nous avons dû avancer

Prof. Joseph Makhzoumi, Dean of the Dental School

la date de la tenue du congrès et hélas, changer d’adresse. Ce rendez-vous bisannuel vise à diffuser les dernières percées scientifiques et découvertes dans le domaine de la médecine dentaire. Cette rencontre est aussi un moment d’échanges extraordinaires ; une occasion pour créer une synergie entre les chercheurs étrangers et Libanais, afin d’approfondir leurs connaissances et de partager leurs expériences respectives. Il confirme leur engagement à œuvrer collectivement à l’amélioration de la santé bucco-dentaire des individus. Cette année, les étudiants de la FMD tiennent un stand dans lequel ils exposent leurs inventions, fruits de recherches approfondies. Notre faculté investira de manière stratégique dans l’implémentation de la culture de l’innovation biomédicale. Ainsi, nous introduirons dans le cursus de l’enseignement, dès l’année prochaine, de nouvelles unités qui motiveront les étudiants à adapter leurs acquis à des réalisations innovantes et créatives dans le domaine dentaire. Nous sommes heureux de voir cette année que les Journées Odontologiques réunissent

R. P. Michel Scheuer, vice recteur Universite St Joseph

des doyens Arabes et des conférenciers venant de France, de Belgique, d’Italie, du Canada, d’Irlande, de Grèce, d’Egypte, de Bulgarie et des Etats-Unis… auxquels vont s’associer des intervenants des 3 facultés dentaires du Liban. Qu’il me soit permis d’adresser un salut cordial au Pr Tony Zeinoun, Doyen de l’Université Libanaise, ainsi qu’au Pr Issam Osman, Doyen de l’Université Arabe de Beyrouth. L’appui que vous avez manifesté révèle que le dialogue et la coopération entre les universités au Liban sont une réalité et une nécessité qu’il conviendrait d’approfondir davantage en dehors de toute interférence politique, religieuse et communautaire. Je terminerai par les paroles de Denis Robert, de l’Ordre des dentistes du Québec : « La mise en place d’une restauration directe en bouche est l’acte médical pratiqué sur l’être humain le plus fréquent au monde. Il vaut la peine d’en parler ». Je vous souhaite à tous un excellent congrès.

DrDental . Ghassan Yared , president News, Volume XXV, Number II, 2018 organizing committee

Prof. Joseph Makhzoumi, Doyen de la Faculté de Medecine Dentaire

L to R; Prof. Nada Mchaileh, Edy Nehme, R.P. Michel Scheuer cutting the ribbon of the exhibition, Prof. Joseph Makhzoumi

Drs: Karim Kabbara, Rola Khalaf, Antoine Khoury

JO 2018

Drs: Gabriel Menassa, Ghassan Farjallah, Joseph Makhzoumi

Opening Ceremony

Dr. Carole Yared on behalf of the LSP offering the “main d’or” trophies to Pr. Joseph Makhzoumi and Khaldoun ElRifai

Drs: Cynthia El Khoury, Ronald Younes, Ghassan Yared, Pierre El Khoury, Tony Zeinoun, Carole Yared, Joseph Makhzoumi, Michel Scheuer, Essam Osman

Drs: Khaldoun ElRifai, Joseph Makhzoumi, Tony Zeinoun, receiving trophies from the Lebanese society of prosthodontics represented by Pierre Khoury, Carole Yared

To Prof. Nouhad Rizk

JO 2018

To Prof. Philip Souaid

Trophy Distribution

To Prof. Andre Sacy




Dental News, Number II, 2018 o Volume rof XXV,hassan arjallah

To Prof. Joseph Sader

To Prof. Habib Chemaly

To Prof. Gaby jabbour

To Prof. Hani Khoury

To Prof. Hrant Kaloustian

JO 2018

To Prof. Elie Maalouf

Trophy Distribution

To Prof. Roger Rebeiz

To Prof. Philip Hajj

To Prof. Fares Abou Obeid

Deans of the arab universities: Tarek Mahmoud, Magid amine, Tarek Abbas, Essam Osman, Joseph Makhzoumi, Tony Zeinoun, Antoine Khoury, Raad Hilmi

JO 2018 Exhibition Floor

Dental News, Volume XXV, Number II, 2018

LDLS 2018 Lebanese Dental Laboratories Show 10th Scientific Congress


April 26 - 28, 2018 Hilton Metropolitan Sin El Fil, Beirut - Lebanon

More Pictures Available On

Fadi Hanna, Jamal el Hage (president OPDL) H.E. Melhem Riachi, Elie Sabbagh Cutting the ribbon of the scientific exhibit

H.E Melhem Riachi representing the President of the republic Michel Aoun

Jamal El Hage, Dental News, Volume XXV,D Number II, 2018 president Lebanese ental Laboratory Association

9 12 4

22nd Annual Meeting





International Congress of Mediterranean

Societies of Pediatric Dentistry

International Congress of Arab

Society of Pediatric Dentistry International Congress of Egyptian

Pediatric Dentistry Association

9-11 November


Hilton Alexandria

Green Plaza

President of the Congress

Prof. Aly Sharaf Vice President

Prof. Fatma Abdel Moniem Congress General Secretary

Prof. Amr Abd El-Aziz

Half Scientific Day Sponsored by AAPD

Different Societies .. Different Needs

Photo from the Opening Ceremony

Fouad Awada, Alain Sakr, Tarek ElHindi

Jamal El Hage, Amine Hassounah, Rohny Khoury

LDLS 2018

Fadi Amhaz, Elie Sabbagh, George Sayegh, Emad Lahoud, Elie Rizk

Jamal El Hage, Bill Marais, Rohny Khoury

DentalA News, Volume II, 2018, Kamal Kheiry, Rohny Khoury, Fadi Amhaz, Tarek Hindi, Mazen ElHouly Maher bboud , EXXV, lieNumber Sabbagh

Dr. Tony Dib, Imad Lahoud, Director Maya Nohra, George Sayegh

Mr. Elie Sabbagh, president scientific committee

Fouad Awada, President Jamal El Hajj, Ihsan Hamadeh

LDLS 2018 P E hotos from the


Ayham Farah at Ivoclar Vivadent booth

sit down with


Director, Professional Relations & Scientific Affairs, Philips Oral Healthcare Dr Maha, I want to ask the general question that all of the dentist will ask, how do power toothbrushes compare with manual toothbrushes in plaque removal? In general, there are a lot of recommendations out there talking about power being better than manual, we have the European federation of Periodontology recommending public-health-wise that power is better, then when the questions comes which Power, that’s where we Philips are proud that we just published 5 new studies last year in the “Journal of Clinical Dentistry”. This is the big news for Philips. So we published randomized control trials comparing Sonicare versus manual. The first two studies, we saw DiamondClean® FlexCare® with significantly 10 times better plaque removal versus manual toothbrush. And then we did a meta analysis, that included 18 studies with 1870 subjects, and again Sonicare power brushes were significantly better in plaque removal and gingival health than manual toothbrushes. We know from our randomized controlled trials that power brushes are better than manual and this is called evidence-based approach. That’s why we want dental professionals to feel safe, and recommend something that’s based on evidence.

Manual tooth brushing is the first step into oral health Education. Do you think one day the mechanical tooth brushing will become mainstream in the future? I believe so, because I think in different countries it’s still in different stages, so if you go to the US and Europe for example, it’s more established to use power toothbrush and you see that our penetration in the market is much higher, so power toothbrushes are more common between the general public, but I think maybe in other countries they are still picking up.

How is Philips supporting the FDI oral health care campaigns? Philips is a health tech company, focusing on delivering innovations across from prevention, diagnosis, home care, and treatment. We have equipment like ultrasound… So that’s where Philips is focusing on a holistic approach, and that’s why I am proud to be part of Philips because it’s not just Sonicare, it’s part of something much bigger to help a holistic approach of Oral health. I remember meeting the FDI three years ago, and that’s where the whole thing started when I met with Emmanuel and talked about what synergies are there, Philips has a goal to improve the lives of people with meaningful innovations, and for that to happen you have to increase awareness, people don’t know about the oral-systemic relationship for example, taking care of your teeth is not just your mouth and helping you smile but also the overall health, so that’s when we thought we had the same vision, let’s work together in increasing public awareness, and the World Oral Health Day is focusing on oral-systemic relation. That’s where we thought it was the perfect fit, so let’s team up and if you go together with FDI and Philips you can reach broader audience, we are activating their tools through social media, doing iniatives like smile initiaves. We do different initiatives around the world, and that’s our way of contributing back with dental professionals, working with them and working with patients to increase awareness.

Good job. Thank you very much. Dental News, News, Volume Volume XXV, XXV, Number Number II,II, 2018 2018 Dental












Featuring Six Hands-On Workshops


For more information, please contact :


6 - 8 DEC E MB E R For hotels, visa and other registration information, please contact: +971 50 879 9035


The New Swiss Endo Academy Training Centre FKG Dentaire is proud to announce the opening of its new Training Centre in Dubai. FKG Dentaire SA (La Chaux-de-Fonds, Switzerland), leader in innovation and production of hightech rotary Ni-Ti systems, is highly committed in worldwide Continuing Education for dentists.

This Centre exhibits the latest generation of highend equipment (operating microscopes, phantom heads,...) and offers a real simulation laboratory, allowing general dentists and specialists, to enhance their clinical experience while exposed to the latest endodontics Ni-Ti systems, more particularly to 3D Ni-Ti treatments range: the XP-EndoÂŽ sequence.

After having set up its Training Centre in 2014 (Swiss Endo Academy), based at the company’s headquarters, FKG Dentaire is proud to announce a new Continuing Education Centre, located at its representative office, FKG Dentaire DMCC (Dubai, UAE).

The centre of the Swiss Endo Academy in Dubai has been inaugurated on February 5, just before the AEEDC congress, in the presence of the top management of the mother-company and the entire IMEA team of FKG Dentaire.

Training table and center view

Lecture room with high definition projector

Training table with 24 seats, monitors, FKG training kits, Endo motor and Apex Locator, Labomed Microscopes, Phantom Heads, Surgery LED lights, Dental Stools Dental News, Volume XXV, Number II, 2018

Olivia MULHAUSER (Office Manager & Sales Assistant – IMEA) and Alexandre MULHAUSER (Middle East, Africa and India Director)

Training set up with FKG Rooter S (Endo Motor), S-Apex (Apex Locator), Training kit and obturation devices

Alexandre Mulhauser (Middle East, Africa and India Director) with Thierry Rouillet (General Manager, FKG Dentaire)

FKG Dentaire DMCC United Arab Emirates

Swiss Tower | Cluster Y | Office 1502 | PO Box 450280 Jumeirah Lake Towers | Dubai

Website: Email: Facebook page: Phone: +4971 445 222 40


Tetric CAD enhances Ivoclar Vivadent’s block portfolio The successful Tetric composite family is growing: the new Tetric CAD composite blocks are now available. They round out Ivoclar Vivadent’s broad portfolio of blocks. The introduction of Tetric CAD enables dental practices to use materials from Ivoclar Vivadent for all of their digital restorations. Tetric CAD is an esthetic composite block designed for the efficient production of indirect single-unit restorations. The new block is based on the proven Tetric technology and adds a new option to the range of direct restorative treatments covered by the Tetric Evo-Line. Due to the pronounced chameleon effect of the material, restorations made of Tetric CAD optically blend into the existing tooth structure to generate a natural esthetic integration. Conveniently efficient and easy The block is straightforward to use and efficient to process. It allows restorations to be milled and polished quickly and then seated using an adhesive technique. In this way, dentists quickly achieve an esthetic result. The new blocks are therefore especially suited for treatments in a single session.

Sensible addition to portfolio Tetric CAD complements the Tetric family and completes the broad portfolio of CAD/CAM blocks provided by Ivoclar Vivadent. The portfolio now covers a wide spectrum of indications, ranging from temporary restorations made of PMMA materials to permanent restorations made of ceramic, zirconia or composite. Designed for several systems The new composite blocks are available in an MT and HT level of translucency, in five and four shades and in sizes I12 and C14. They can be processed with PrograMill (Ivoclar Vivadent), CEREC/inLab (Dentsply Sirona) or PlanMill (Planmeca) systems. website:

Faster, safer, and more efficient endodontic treatment with SICAT Endo SICAT Endo is the first and only fully integrated and complete 3D solution for the diagnosis and planning of endodontic treatment that also supports clinical implementation with surgical guides. Using the software, all root canals can be easily identified in 3D, and the working length and depth of the access cavity can be determined precisely. Even heavily curved and calcified canals can be diagnosed easily. This process considerably improves the endodontic workflow for practitioners. The user-friendly software has diagnostic advantages for optimal treatment planning - efficient, reliable, with predictable outcomes. The combination of high-resolution intraoral 2D X-ray images and the depth information from 3D X-ray data facilitates diagnostics considerably. Thanks to the simultaneous navigation in 2D and 3D, dentists are easily oriented in all dimensions and can concentrate on the root canal to be diagnosed. Dental News, Volume XXV, Number II, 2018

SICAT Endo is optimized for 2D and 3D X-ray units and CEREC by Dentsply Sirona. The software is fully integrated in Sidexis 4 with 3D data from Galileos and Orthophos SL units combined with 2D data; including Schick33 and Schick Elite sensors. No export and manual import of data are required. The integration of optical impressions allows the occlusal surface to be visualized precisely, thus optimizing planning for the access cavity and the exact determination of the working lengths. website:

Ormco team participates in the Saudi Orthodontic Society annual conference & exhibition As part of Ormco marketing and educational strategy in the Middle East and to continue our focus and strong presence in the Saudi Orthodontic Market, Ormco team have participated for the second consequence year with their own booth in the Saudi Orthodontic Society annual conference & exhibition which took part in Riyadh from the 23rd -25th of March 2018.

The booth design was very simple and showed the original taste of Ormco, which attracted a very good traffic during the 3 days. At the end, we can say it was such a wonderful and successful event.


Towards a simpler root canal treatment On the occasion of the AEEDC international dental congress in the Middle East and one year after the launch of 2Shape, a sequence with two instruments, MICRO-MEGA presents One Curve, an all-in-one NiTi shaping instrument for single use featuring the brand-new heat-treatment C.Wire and a direct access to the apex. In combination with the patented instrument design, the C.Wire technology – the DNA of One Curve – determines the instrument’s major features: One Curve is intelligent, efficient and conservative. Intelligent: The use of only one single-use file with direct access to the apex reduces the preparation time and eliminates any risk of cross contamination. Efficient: the heat-after treatment C.Wire provides the NiTi with shape memory properties and makes it more flexible while improving its resistance to fracture. One Curve is pre-bendable and keeps the flection in order to eliminate constraints in the root canal. Conservative: In association with the continuous rotation movement, the instrument design guarantees a perfectly centered trajectory as well as excellent cutting efficiency and upward removal of debris.

The advantages • Gain in time and optimal safety • Treatment of all root canals, even the most curved ones • Respect of the root canal trajectory and apical foramen website:


“First ever Biological Bulk Fill” Pediatrics


For vital pulp therapy, bulk-filling the cavity with Biodentine™ makes your procedure better, easier and faster: • Pulp healing promotion: proven biocompatibility and bioactivity • Reduced risk of failure: strong sealing properties • Only one material to fill the cavity from the pulp to the top • Similar mechanical behavior as natural dentin: ideal for bulk filling The final enamel restoration will be placed within 6 months.

Innovative by nature

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The complete implant workflow – easiness with one software

Taking an implant plan to actual surgery is now easier than ever! From imaging to implant planning and guide design, all workflow steps can be controlled and completed in the Planmeca RomexisÂŽ software. Find more info and your local dealer!

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Tetric N-Line ÂŽ

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Ivoclar Vivadent AG Dental News, Volume XXV, Number II, 2018 Bendererstr. 2 | 9494 Schaan | Liechtenstein | Tel. +423 235 35 35 | Fax +423 235 33 60