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w w w.dent alnews .com Volume XX, Number II, 2013 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 Ibrahim Mantoufeh SUBSCRIPTION Micheline Assaf, Nariman Nehmeh ADVERTISING Josiane Younes PHOTOGRAPHY Albert Saykali TRANSLATION Gisèle Wakim, Marielle Khoury DIRECTOR Tony Dib ISSN 1026-261X
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12 Oral Pathology CASE REPORT
ERUPTION OF ORAL LICHEN PLANUS AFTER INTERFERON THERAPY FOR HEPATITIS C INFECTION: CASE REPORT Dr. Wafa Ali Al-Shamali
Background: The association between oral lichen planus (LP) and hepatitis C virus infection (HCV) has been discussed in several papers worldwide. The exact pathogenesis of oral LP in HCV-positive patients is still uncertain. There are several studies, which highlight the role of alpha-interferon (INF) being used for treatment of HCV- positive patients, resulting in eruption or exacerbation of oral LP. Case description: We present a case of erosive LP limited to oral cavity in a 44-year-old Egyptian man with chronic HCV infection who was treated with INF and ribavirin. Despite an extended period of treatment, there was no significant effect on the viral activity (viral load). Interestingly, following five months of termination of anti-hepatitis therapy, there was recurrence of oral LP lesions which was confirmed histopathologically. His condition improved dramatically by Protopic cream 0.1%. Conclusion: Altered immunogenicity of HCV appears to be the likely explanation, hence understanding the importance of follow-up of the patient post anti-hepatitis C therapy.
Dr. Mohamed Ahmed El-Khalawany
Dr. Rasha Matter Al-Shemmari Dr. Saqer Abdulrahman Al-Surayei
Introduction Oral lichen planus (LP) is a relatively common chronic inflammatory condition that affects the oral mucous membrane with variable clinical traits. Since the first description of oral LP associated with hepatitis C infection was reported in 1991,1 there have been several reports suggesting the association between HCV infection and oral LP.2 Many studies have showed higher prevalence (1.6-20%) of oral LP in HCV-positive patients (27). In contrast, some researchers found weak or no correlation between chronic HCV infection and LP. 8-11 A region-based correlation between HCV infection and LP has been described by some Dental News, Volume XX, Number II, 2013
researchers worldwide.12 However, the possible etiopathogenic mechanism that links the two diseases remains unclear. Immunogenic dysregulation of host infected with HCV, reaction to anti-hepatitis medications particularly alphainterferon or viral infection are considered to be the current acceptable etiopathogenic factors causing oral LP. 12-13 The clinical and histological features of oral LP associated with hepatitis C infection subjects are no different from the control patients. Although, erosive form of oral LP is common clinical phenotype noted in seropositive hepatitis C individuals, the management of oral LP in patients with or without hepatitis remains the same.
Case report A 44-year-old Egyptian male was referred from dermatology department at Farwaniya hospital to oral medicine clinic, who presented with painful and swollen ulcerated lower lip on March 2010. On examination, there was apparent swollen lower lip with central erosive areas oozing fresh blood from the eroded surfaces on light palpation, and there were white fine and coarse lace-like mucosal changes abutting the eroded lesions (fig 1). Also, there was bilateral lymphadenopathy with mobile, tender lymph nodes palpable in the submandibular triangular region. Intra-oral examination revealed ďŹ g 1
A swollen lower lip with central erosive and hemorrhagic areas.
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14 Oral Pathology LICHEN PLANUS
bilateral white and red lesions on posterior part of the buccal mucosa. These lesions had striking reticular pattern (reminiscent of LP) centered on erythematous mucosal areas. The lesion on right buccal mucosa was found rubbing against heavily restored molar tooth with amalgam (figs 2 and 3). No other lesions were seen on the rest of oral cavity mucosa. The clinical presentation of the lip
Fig 2, 3: Exhibit lichenoid changes “reticular pattern” on right (A) and left (B) buccal mucosae.
Furthermore, he is not a cigarette smoker and he does not drink alcohol. An incision biopsy of lower lip lesion revealed interface dermatitis confirming our clinical provisional diagnosis. Microscopically, the specimen exhibited orthokeratosis with prominent granular layer, intense band-like lymphohistiocytic infiltrate with plasma cell predominance and hydropic degeneration of basal cell layer with scattered Civatte bodies. ﬁg 4
Exhibit lichenoid changes “reticular pattern” on right (A) and left (B) buccal mucosae. ﬁg 3
Reveals hydropic degeneration with intense lympho-histoicytic inﬁltrates. (Hematoxylin and eosin stain at higher magniﬁcation 20X)
and oral cavity lesions were consistent with LP. On reviewing his medical history, he had been diagnosed with hepatitis due to HCV infection (genotype 4) in 2008 for which he received combined therapy of pegylated interferon-alpha (180 mcg SC, weekly for 48 weeks) and ribavirin (1000 mg PO daily for 48 weeks). The patient reported an oral soreness and burning sensation after one month of the anti-hepatitis therapy inception for the first time. The exact diagnosis of oral lesion and subsequent therapy provided by dermatology department had not been known to us. Nevertheless, oral condition was quiescent through the period of the therapy. The oral symptoms reappeared five months following discontinuation of anti-hepatitis therapy with increased severity resulting in severe pain, difficulty in eating, swallowing and speaking. In addition, he noticed progressive swelling of the lower lip with bleeding ulcers over the next 6 weeks. Besides his known medical condition, he is on insulin to manage his diabetes (type II). Dental News, Volume XX, Number II, 2013
Prominent Civatte body (*).
(Figs 4-6). The patient was treated with protopic cream 0.1% three-four times daily for 2 weeks. The lower lip status improved dramatically. ﬁg 7
Dramatic improvement of lower lip lesion after two weeks of topical tacrolimus use.
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16 Oral Pathology LICHEN PLANUS
Discussion Among viruses, human herpes viruses, human papilloma virus and hepatitis viruses have been linked with oral LP, albeit on the basis of equivocal data.12 There have been several studies, which suggest an association between LP and HCV infection.3,7 In a recent review the pooled data from all studies revealed a statically significant difference in the population of HCV seropositive subjects among LP patients when compared with the controls. Interestingly, geographic heterogeneity seems to play an important role in this LP-HCV association. As indicated by studies from the Mediterranean basin showing a significant association whereas studies from Northern Europe did not present any such association. Furthermore, in studies from countries with high prevalence such as Egypt, negative or insignificant association between HCV infection and oral LP has been reported12,14 The discrepancy may be explained by genetic differences among the population studies and this may possibly be the reason for development of LP in our patient. The exact etiopathogenesis of oral LP in HCVpositive individual is still uncertain. Nonetheless, eruption of oral LP in our case could have resulted from a lichenoid reaction to the medication used in the treatment of hepatitis C, particularly alphainterferon. This hypothesis (i.e. drug reaction) was plausible in some studies.15,20 Most of these case reports demonstrate the aggravating effect of the interferon rather than causative effect for the development of oral LP in patient with HCV infection. Besides, in our case, reappearance of severe erosive oral LP while not receiving INF therapy, suggests that it may not have played a significant role in its pathogenesis. Nonetheless, this may be viewed as it having more aggravating rather than causal effect. Therefore, it would be a good practice to screen the oral cavity of HCV-positive patients prior to initiating antiviral therapy. So, the possible eruption of oral LP can be anticipated and managed appropriately especially in those with quiescent LP. Besides INF therapy, other confounding factors appeared to have contributed to the possible initiation or aggravating already present of oral LP in our case, such as presence of amalgam on left mandibular molar and chronic rubbing of buccal mucosa. Unfortunately, we are not aware of the intraoral examination findings of the patient prior to Dental News, Volume XX, Number II, 2013
anti-hepatitis treatment. Also, there is plethora of literature suggesting role of immune dysregulation in the pathogenesis of oral LP involving the cellmediated immunity. However, viral factors, such as genotypes of HCV and HCV-RNA levels, are less important pathogenic cause.12 Why oral mucosa is most frequently affected is still unknown. Several experimental studies conducted proposing a theory of â€œcompartmentalization of mucosaâ€? that still does not give a clear explanation to this phenomenon.21,22 In HCV seropositive subjects, erosive oral LP is commonly prevalent lesion.23,24 Mega et al. 25 noted three types of OLP. He found lymphocytic inflammation deeply infiltrating lamina propria in OLP associated with a HCV infection and that could be associated with the erosive trait, as noted in our case. Management of HCV associated oral LP lesion is no different from oral LP in HCV-negative subjects. Since there is no cure different therapies are aimed primarily to ameliorate the signs and symptoms of oral LP. Although corticosteroids have been the mainstay of management, other immunosuppressant and immunomodulatory agents have also contributed significantly towards treatment of the disease.12,26,27,28 A comparative systemic review of 28 randomised controlled clinical trials of therapy for symptomatic oral LP has concluded that there is insufficient evidence to support the effectiveness of any specific treatment as being superior.26, 29 A plausible therapeutic approach should be guided by severity of the patientâ€™s condition. In our case, tacrolimus cream (0.1%) was prescribed and used three to four times daily for 2 weeks. Some studies recommend use of tacrolimus as second line of treatment especially in reluctant lesion. We preferred to use it due to severity of the lesion, which is found to be effective in other studies. 12,26 In order to prevent a flare up of the condition, we avoided use of systemic immunosuppressant therapy. Many researchers have emphasised on maintenance of good oral hygiene, relief of mechanical trauma by dental procedure or dentition itself, and discrete use of dental allergen materials (e.g. amalgam) for preventing development or irritating already existing oral LP . Up to the time of writing this case report, his oral condition is fairly controlled with topical steroids in addition to tacrolimus. Due to chronicity of LP, relapses of his oral condition did
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18 Oral Pathology LICHEN PLANUS
occur but with lesser frequency and severity. The potential for malignant transformation of OLP is still controversial. The frequency ranges from 0.4% to 6.25% with the highest rates in the erythematous and erosive lesions.30,31,32 Follow up is mandatory not only to control his oral LP but also to detect early malignant transformation.
REFERENCES 1. MOKNI M, RYBOJAD M, PUPPIN D. LICHEN PLANUS AND HEPATITIS C VIRUS. J AM ACAD DERMATOL. 1991; 24 (5 PT 1): 792. 2. NITA CHAINANI-WU, FRANCINA LOZADA-NUR, NORAH TERRAULT. HEPATITIS C VIRUS AND LICHEN PLANUS: A REVIEW. ORAL SURG ORAL MED ORAL PATHOL ORAL RADIOL ENDOD. 2004; 98 (2):171-183. 3. LC FIGUEIREDO, F CARRILHO, HF DE ANDRADE, DA MIGLIAN. ORAL DISEASES. 2002 JAN; 8 (1): 42- 6. 4. GHADERI R, MAKHMALBAF Z. SHIRAZ E-MEDICAL JOURNAL. 2007; 8(2): 72-9. 5. SANCHEZ-PEREZ J, DE CASTRO M, BUEZO GF, FERNANDEZ-HERRERA J, BORQUE MJ, GARCIA-DIEZ A. LICHEN PLANUS AND HEPATITIS C VIRUS: PREVALENCE AND CLINICAL PRESENTATION OF PATIENTS WITH LICHEN PLANUS AND HEPATITIS C VIRUS INFECTION. BR J DERMATOL. 1996 APR; 134(4):715-9. 6. THAIS DIAS TAVARES GUERREIRO, MARILIA MOURA MACHADO, THAIS HELENA PROENCA DE FREITES. ASSOCIATION BETWEEN LICHEN PLANUS AND HEPATITIS C VIRUS INFECTION: A PROSPECTIVE STUDY WITH 66 PATIENTS OF THE DERMATOLOGY DEPARTMENT OF THE HOSPITAL SANTA CASA DE MISERICORDIA DE SAO PAULO. AN BRAS DERMATOL. 2005; 80(5):475-80. 7. NIMA MAHBOOBI, FARZANEH AGA-HOSSEINI, KAMRAN BAGHERI LANKARANI. HEPATITIS C VIRUS AND LICHEN PLANUS: THE REAL ASSOCIATION. HEPAT MON. 2010; 10(3):161-4. 8. SIMON C, TUCKER AND IAN H. COULSON. LICHEN PLANUS IS NOT ASSOCIATED WITH HEPATITIS C VIRUS INFECTION IN PATIENTS FROM NORTH WEST ENGLAND. ACTA DERM VENEREOL. 1999; 79:378-9. 9. KARIN SOARES GONCALVES CUNHA, ANGELA CORREA MANSO, ABEL SILVEIRA CARDOSO, JACQUELINE BITTENCOURT ALTHOFF PAIXAO, HENRIQUE SERGIO M. COELHO, SANDRA REGINA TORRES, AND RIO DE JANEIRO. ORAL SURG ORAL MED ORAL PATHOL ORAL RADIOL ENDOD. 2005; 100:330-3. 10. YU ZHOU, LU JIANG, JIE LIU, XIN ZENG, QIAN-MING CHEN. THE PREVALENCE OF HEPATITIS C VIRUS INFECTION IN ORAL LICHEN PLANUS IN AN ETHNIC CHINESE COHORT OF 232 PATIENTS. INT J ORAL SCI. 2010; 2(2): 90-97. 11. DEL OLMO JA, PASCUAL I, BAGAN V, SERRA MA, ESCUDERO A, RODRIGUEZ F, RODRIGO JM. PREVALENCE OF HEPATITIS C VIRUS IN PATIENTS WITH LICHEN PLANUS OF THE ORAL CAVITY AND CHRONIC LIVER DISEASE. EUR J ORAL SCI. 2000 OCT; 108(5):378-2. 12. GIOVANNI LODI, CRISPIAN SCULLY, MARCO CARROZZOO, MARK GRIFFITHS, PHILIP B. SUGERMAN, AND KOBKAN THONGPRASOM. CURRENT CONTROVERSIES IN ORAL LICHEN PLANUS: REPORT OF AN INTERNATIONAL CONSENSUS MEETING. PART1. VIRAL INFECTIONS AND ETIOPATHOGENESIS. ORAL SURG ORAL MED ORAL PATHOL ORAL RADIOL ENDOD. 2005; 100:40-51. 13. A. A. AL ROBAEE AND A. A. AL ZOLIBANI, ET AL. ORAL LICHEN PLANUS AND HEPATITIS C VIRUS: IS THERE REAL ASSOCIATION? ACTA DERMATOVEN APA. 2005; 15(NO1):14-9. 14. G. LODI, M. GIULIANI, A. MAJORANA, A. SARDELLA, C. BEZ, F. DEMAROSI, A. CARRASSI, ET AL. LICHEN PLANUS AND HEPATITIS C VIRUS: A MULTICENTRE STUDY OF PATIENTS WITH ORAL LESIONS AND A SYSTEMATIC REVIEW. BRITISH JOURNAL OF DREMATOLOGY. 2004 DEC; 151 (6): 1172-81. 15. NAGAO Y, SATA M, IDE T, SUZUKI H, TANIKAWA K, ITOH K, KAMEYAMA T. DEVELOPMENT AND EXACERBATION OF ORAL LICHEN PLANUS DURING AND AFTER INTERFERON THERAPY FOR HEPATITIS C. EUR J CLIN INVEST. 1996 DEC; 26 (12): 1171-4. 16. NAGAO Y, KAWAGUCHI T, IDE T, KUMASHIRO R, SATA M. EXACERBATION OF ORAL
MASSA A, SARAIVA AM. LICHEN
C: EXACERBATION EUR J GASTROENTEROL
PLANUS AND CHRONIC HEPATITIS
OF THE LICHEN PLANUS UNDER INTERFERON-ALPHA-2A THERAPY.
HEPATOL. 1996 AUG; 8(8); 825-8. 21. CARROZZO M, QUADRI R, LATORRE P, PENTENERO M, PAGANIN S, BERTOLSSO G. MOLECULAR EVIDENCE THAT THE HEPATITIS C VIRUS REPLICATES IN THE ORAL MUCOSA. J HEPATOL. 2002;37: 364-9. 22. PILLI M, PENNA A, ZERBINI A, VESCOVI P, MANFREDI M, NEGRO F. ORAL LICHEN PLANUS PATHOGENESIS: A ROLE FOR THE HCV-SPECIFIC CELLULAR IMMUNE RESPONSE. HEPATOLOGY. 2002; 36:1446-52. 23. CARROZZO M, GRANDOLFO S, CARBONE N, COLOMBATTO P, BROCCOLETTI R, GARZINO-DEMO P, GHISETTI V. J ORAL PATHOL MED. 1996 NOV; 25(10):527-33. 24. MICHELE D, MIGNOGNA MD, LUCIO LO RUSSO, ET AL. ORAL LICHEN PLANUS: DIFFERENT CLINICAL FEATURES IN HCV-POSITIVE AND HCV-NEGATIVE PATIENTS. INT J DERMATOL. 2000 FEB. 39(2):134-9. 25. MEGA H, JIANG W, TAKAGI M. IMMUNOHISTOCHEMICAL STUDY OF ORAL LICHEN PLANUS ASSOCIATED WITH HEPATITIS C VIRUS INFECTION, ORAL LICHENOID CONTACT SENSITIVITY REACTION AND IDIOPATHIC ORAL LICHEN PLANUS. ORAL DISEASES. 2006;7(5): 296-305. 26. THONGPRASOM K, CARROZZO M, FURNESSS, LODI G. INTERVENSION FOR TREATING ORAL LICHEN PLANUS. COCHRANE DATABASE OF SYSTEMIC REVIEWS 2011, ISSUE 7. 27. N LAVANYA, P JAYANTHI, UMADEVI K RAO, K RANGANATHAN. ORAL LICHEN PLANUS: AN UPDATE ON PATHOGENESIS AND TREATMENT. J ORAL MAXILLOFAC PATHOL. 2011; 15: 127-132. 28. MAHNAZ SAHEBJAMEE, FATEMEH ARBABI-KALATI. MANAGEMENT OF ORAL LICHEN PLANUS. ARCHIVES OF IRANIAN MEDICINE. 2005; 8(4): 52-6. 29. ANALIA VEITZ KEENAN AND DEBRA FERRAIOLO. INSUFFICIENT EVIDENCE FOR EFFECTIVENESS OF ANY TREATMENT FOR ORAL LICHEN PLANUS. EVIDENCE-BASED DENTISTRY. 2011; 12: 85-86. 30. GIOVANNI LODI, CRISPIAN SCULLY, MARCO CARROZZOO, MARK GRIFFITHS, PHILIP B. SUGERMAN, AND KOBKAN THONGPRASOM. CURRENT CONTROVERSIES IN ORAL LICHEN PLANUS: REPORT OF AN INTERNATIONAL CONSENSUS MEETING. PART1. VIRAL INFECTIONS AND ETIOPATHOGENESIS. ORAL SURG ORAL MED ORAL PATHOL ORAL RADIOL ENDOD. 2005; 100:164-78. 31. ATESSA PAKFETRAT, ABBAS JAVADZADEH-BOLOURI, SAMIRA BASIR-SHABESTARI, FARNAZ FALAKI. ORAL LICHEN PLANUS: A RETROSPECTIVE STUDY OF 420 IRANIAN PATIENTS. MED ORAL PATOL ORAL CIR BUCAL. 2009 JUL; 14(7):E315-8. 32. MARIJA BOKOR-BRATIC, IVANA PICURIC. THE PREVALENCE OF PRECANCEROUS ORAL LESIONS. ORAL LICHEN PLANUS. ARCHIVE OF ONCOLOGY. 2001; 9(2):107-9.
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Bridging Continents for Global Oral Health
EROSIVE LICHEN PLANUS BY COMBINATION OF INTERFERON AND RIBAVIRIN THERAPY FOR CHRONIC HEPATITIS C. INT J MOL MED. 2005 FEB; 15(2):237-41. 17. GROSSMANN SDE M, TEIXEIRA R, DE AGUIAR MC, DO CARMO MA. EXACERBATION OF LICHEN PLANUS LESIONS DURING TREATMENT OF CHRONIC HEPATITIS C WITH PEGYLATED INTERFERON AND RIBAVIRIN. EUR J GASTROENTEROL HEPATOL. 2008 JUL; 20(7):702-6. 18. BARRECA T, CORSINI G, FRANCESCHINI R, GAMBINI C, GARIBALDI A, ROLANDI E. LICHEN PLANUS INDUCED BY INTERFERON-ALPHA-2A THERAPY FOR CHRONIC ACTIVE HEPATITIS C. EUR J GASTROENTEROL HEPATOL. 1995 APR; 7(4): 367-8. 19. PROTZER U, OCHSENDORF FR, LEOPOLDER-OCHSENDORFA, HOLTERMULLER KH. EXACERBATION OF LICHEN PLANUS DURING INTERFERON ALFA-2A THERAPY FOR CHRONIC ACTIVE HEPATITIS C. GASTROENTEROLOGY. 1993 MAR; 104(3): 903-5. 20. AREIAS J, VELHO GC, CERQUEIRA R, BARBEDO C, AMARAL B, SANCHES M,
Dental News, Volume XX, Number II, 2013
20 Aesthetic Dentistry TREATING FLUOROSIS
USING MICROABRASION AND IN-OFFICE BLEACHING TO TREAT FLUOROSIS IN PERMANENT ANTERIOR TEETH Dr. Mayada Jemâa email@example.com Pr. Sonia Zouiten
Pr. Neila Zokkar
Pr. Abdellatif Boughzala
Abstract In today’s world, there is a strong focus on perfect physical appearance. (Didier Dietsch, 2008). Different esthetic dental procedures have been developed since many patients are very dissatisfied with their appearance.3 Discolored teeth affected by fluorosis, due to the fluoridation of drinking water, are frequently seen in our population. This kind of pathology leads to the whitish, opaque, unpleasant appearance of enamel which is often visible at speaking distance. Proposed treatments, depending on fluorosis severity, range from expensive ceramic veneers to free hand bonding restorations and abrasive chemical treatments. (S.Ardu et al, 2009) Bleaching is considered before porcelain veneer placement to either eliminate the need for veneers, reduce the amount of opacifiers needed to mask discoloration, or to give the patient the option of attempting a less expensive/ invasive treatment before committing to veneers. (Van B. Haywood, 2003). The aim of this article is to describe an easy technique for managing enamel discoloration via microabrasion followed by inoffice dental bleaching.
Key words Dental fluorosis, Microabrasion, in-office bleaching
Introduction The intrinsic discoloration is incorporated into the structure of enamel or dentine and can’t be eliminated by simple prophylaxis using pumice or tooth paste.4 Dental fluorosis which is an intrinsic discoloration is defined as hypomineralization of enamel resulting from excessive ingestion of fluoride during tooth development. It is characterized by diffuse opacities on the enamel surface. These are differentiated from Dental News, Volume XX, Number II, 2013
other conditions by the characteristic bilaterally symmetric distribution of the enamel defects. (Howard E. Strassler et al. 2011). Current research suggests that superfluous amounts of fluoride cause retention of amelogenin proteins in the developing tooth structure, there by inhibiting enamel maturation. This interference results in porosities in the enamel at the time of tooth eruption. (Howard E. Strassler et al. 2011). The enamel affected by fluorosis contains higher levels of protein content than normal enamel. When normal enamel protein content ranges from 0.07 to 0.14 per cent, fluorosed enamel content ranges from 0.03 to 0.56 per cent.11 The safe level for daily fluoride intake is 0.05 to 0.07 mg F/Kg/day. Above this level, the risk of developing fluorosis due to chronic fluoride consumption will be evident.12 Dental fluorosis has been categorized under various grades as follows: (Naveen Chhabra et al. 2010). Grade 0: Normal, translucent, smooth, and glossy teeth; Grade I: White opacities, faint yellow line; Grade II: Changes as in Grade I and brown stains; Grade III: Brown line, pitting, and chipped off edges; Grade IV: Brown, black and/or loss of teeth The severity of dental fluorosis depends on when and for how long the overexposure to fluoride occurs, the individual response, weight, degree of physical activity, nutritional factors and bone growth, suggesting that similar dose of fluoride may lead to different levels of dental fluorosis. (Jenny Abanto Alvarez et al. 2009). It is very difficult to correct deeper enamel fluorosis via only Microabrasion. For this reason, a combination of different techniques such as microabrasion/inoffice bleaching is recommended to mask deeper defects since they are conservative, provide highly satisfactory results, without excessive wear of sound dental tissue. 12
22 Aesthetic Dentistry TREATING FLUOROSIS
Examination for bleaching
In Office bleaching
We should undertake a standard extra-oral and intra-oral examination.4 The initial examination and diagnosis are very important before starting the treatment. And of course they cannot be performed without the patient consulting the dentist.8 Proper examination and diagnosis, including radiographs, are needed to rule out pathology that will require completely different treatment from bleaching. (Van B. Haywood, 2003). The differential diagnosis between fluorosis and non-fluoride-induced opacities needs to establish differences between symmetrical and asymmetrical and/or discrete patterns of opaque defects. These criteria imply that all symmetrically distributed and non-discrete opaque conditions of enamel are fluorosis. (Jenny Abanto Alvarez et al. 2009). A history of eventual tooth sensitivity should be investigated.9 No bleaching procedure should be initiated without appropriate dental examination.
In-office vital tooth bleaching has been used for many years in dentistry and is known to be a reliable technique for quickly lightening discolored teeth. (Ruta Zekonis et al. 2003). For this technique, we use higher concentration of hydrogen peroxide (35%) than we can use at-home bleaching and for this reason, the bleaching agent will penetrate the tooth more rapidly with in-office bleaching.14 In general, the in-office bleaching procedure for vital teeth involves several necessary and important steps: (M. S. Gutmann and J. L. Gutmann, 2001) UÊ*>ViÊ>ÊÀÕLLiÀÊ`>ÊÀÊÕÃiÊ>Ê} ÌVÕÀi`Ê«>ÌÊ dam along with a petroleum jelly to protect the gingival tissues. UÊ /iiÌ Ê >ÞÊ ÀÊ >ÞÊ ÌÊ LiÊ iÌV i`Ê «ÀÀÊ ÌÊ placement of the bleaching agent. A gel or liquid bleaching agent, usually 35% hydrogen peroxide, is then applied to the enamel surface. If the liquid form is used, gauze squares saturated with the bleaching agent are placed on the facial surfaces. Allow the bleaching agent to remain on the teeth for 20-30 minutes. Apply a heat source, usually a visible light curing lamp or a laser, to accelerate the chemical reaction UÊ Ê ÌÊ ÕÃiÊ V>Ê >iÃÌ iÃ>Ê `ÕÀ}Ê Li>V }Ê and monitor patient discomfort to avoid tissue burns or excess heat build-up in the pulp. Analgesics, such as ibuprofen, acetaminophen, or aspirin, may be recommended for the first 24 hours if any tooth sensitivity is noted. UÊ ÌÊ Ì iÊ i`Ê vÊ Ì iÊ «ÀVi`ÕÀiÊ Ì iÊ iÝViÃÃÊ bleaching agent should be removed with water before removing the rubber dam. Different studies reveal that, 2-6 visits with about 45 minutes application per time in-office bleaching are necessary to obtain acceptable results.14 We also should take into account the possible appearance of tooth sensitivity that is why we must wait at least one week between visits.14 The use of bleaching light may lead to the augmentation of pulpal temperature which depends on the exposure time and the light source.9 In addition to that, tooth sensitivity and pulpal irritation may be higher with the use of bleaching light or even heat application.9,15 One of the most safety advantages of the in-office dental bleaching is that it is under dentist’s control.16 The disadvantages are: the cost which can be considered as expensive for some patients, the
Microabrasion Microabrasion is a procedure developed by Dr. Theodore Croll6 helping in removing superficial stains related to discrete or moderate fluorosis.1 It is composed of a mixture of hydrochloric acid and pumice that is rubbed onto the surface of the tooth repetitively until the outer layers of the enamel containing the stains are abraded away. The stains in the outer layers of enamel can be removed, leaving a smooth, glassy enamel surface.6 It is recommended to use a rubber dam so as to protect the gums from the acid. After that, the pumice-acid slurry is then applied to the teeth and rubbed with a very slow speed rubber cup. After a few layers of enamel are removed, the slurry is rinsed with water and the result is evaluated. This process is repeated until the stain is gone or the process must be stopped for other reasons such as enamel getting too thin or tooth getting sensitive.6 At the end, it is recommended to bath teeth with a fluoride gel so as to reduce eventual postoperative sensitivity.6 This technique is simple to perform and the depth of enamel removed in 10 applications is approximately 100 μm. (0.1 mm.).4 Microabrasion is a time-proven technique that is safe and effective for the atraumatic removal of superficial enamel defects. (HO Heymann, 1997). Dental News, Volume XX, Number II, 2013
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24 Aesthetic Dentistry TREATING FLUOROSIS
duration of the treatment and the unpredictable results.16 Some dangerous features may be the post-treatment sensitivity, the increasing temperature of the pulp and eventual discomfort concerning the gingival barrier.16
Case reports Case N°1 A 30-year old male patient with complaints of dissatisfaction about the discolored teeth (Figure 1) came to the department of conservative dentistry. Patient gave history of discoloration from his childhood. No other relevant medical history was reported by the patient. His oral hygiene was good. Diagnosis: Dental fluorosis (Grade III: Brown line, pitting, and chipped off edges) Treatment plan: Microabrasion followed by inoffice dental bleaching.
childhood. Good oral hygiene. Diagnosis: Dental fluorosis (Grade III: Brown line, pitting, and chipped off edges) Treatment proposed was Microabrasion followed by in-office dental bleaching. ﬁg 5
Fig 5: Labial view showing the severely discolored maxillary incisors. ﬁg 6
Fig1: Initial view of a patient’s teeth affected by ﬂuorosis ﬁg 2
Fig 6: Microabrasion procedure ( Placement of the gingival barrier + application of the micro abrasion gel on the surface of the enamel of the upper anterior teeth for stain removal + the gel was rubbed with a slow speed rubber cup + the teeth was rinsed off and air dried Examination) ﬁg 7
Fig 2: Light curing rubber dam application and Microabrasion with Opalustre ® ﬁg 3
Fig 3: After 2 visits (of Microabrasion procedure) ﬁg 4
Fig 7: Intra-oral view of the maxillary incisors after two Treatments (4 visits): Microabrasion and in-ofﬁce tooth whitening (Hydrogen Peroxide 35%) ﬁg 8
Fig 4: Final view of the clinical case after the end of the In-ofﬁce bleaching (with Hydrogen Peroxide 35%) in 3 visits
Case N°2: A 47-year old female patient was unsatisfied with the discolored upper front teeth (Figure 5) came to the department of conservative dentistry. Patient gave history of discoloration since her Dental News, Volume XX, Number II, 2013
Fig 8: Post-treatment view illustrating the improved aesthetics following tooth whitening, microabrasion and restoration with resin composite of the two central incisors.
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26 Aesthetic Dentistry TREATING FLUOROSIS
Fig 9: sensitivity occurred and we stopped it with the use of Flor Opal ® gel ﬁg 10
Fig 10: After 14 months ﬁg 11
Fig 11: Before ﬁg 12
Fig 12: After
Discussion Due to the recent increase in dental fluorosis, extensive research has been performed to understand the aetiology and pathogenesis of this systemic disease. (S. Ardu et al. 2009) The aetiology is well established and based on the excessive consumption of fluoride during specific critical ages.7 Browne indicated that this critical period is 15 to 24 months of age for males and 21 to 30 months of age for females.18 Bleaching may represent a conservative first approach for many cosmetic conditions. (Kevin J. Donly et al. 2002) Conservative treatment options such as microabrasion and/or tooth whitening can produce dramatic improvements in brown and yellow discoloration, providing a satisfactory interim result before more invasive procedures are considered, if necessary.(F Ng et al. 2007) The microabrasion procedure is considered as safe Dental News, Volume XX, Number II, 2013
and simple. It allows us to obtain excellent results when treating superficial enamel stains.19 It does not require the use of anesthesia that is why dentist can have a better relationship with patients.20 The Opalustre™ microabrasion slurry (Ultradent Products Inc, Utah, USA) is composed of 6.6% hydrochloric acid and silicon carbide microparticles.11 According to (F Ng et al. 2007), the Hydrogen peroxide (HP) is an oxidizing agent which breaks down into free radicals that will combine to create oxygen and water. And that the HP oxidizes, carboxylates and lightens chromophores, particularly within the dentine. Most current in-office whitening systems are based on HP solutions of 25 to 35 per cent. Higher peroxide concentrations also have been shown to be effective in tooth whitening; however, these are professionally supervised to a greater extent. (Kevin J. Donly et al. 2002) The higher concentrations of peroxide lead to faster rate of bleaching, but added to that a possible higher incidence of dental sensibility.8 While the higher concentrations may reach the end point sooner, they also “overshoot” the color and have a greater relapse, and a longer time for the color to become stable. (Van B. Haywood, 2003) One of the common adverses of vital bleaching is dental sensitivity because the peroxide can penetrate the enamel, dentine and even the pulp chamber.11 Other side effects such as irreversible pulpitis and pulp necrosis can occur with the uses of 35% of hydrogen peroxide.3 When the concentration of PH increase, the degree of penetration in dental structure will increase, also we can note a greater penetration in hypomineralized enamel.11 The patient in the second case reported sensitivity with the in-office whitening system containing 35% of HP that is why we opted for desensitizing gel Flor Opal ®. This may have been because of the relatively higher concentration of HP used (35%). According to (HO Heymann, 1997), we must wait a minimum of one week after bleaching procedure before placing any resin-bonded restoration on tooth structure because the strength of resin bonds to freshly bleached enamel and dentine are reduced. A study of (Christian Hannig et al. 2006) showed that bleaching procedure has an impact not only on surface micro-hardness of composites but also for deeper layers of adhesive filling materials. Bleaching
28 Aesthetic Dentistry TREATING FLUOROSIS
versus Porcelain veneers? Dentists should make a choice for their patients between teeth whitening or veneers. If there is any regression in whitening after esthetic translucent veneers are placed, the teeth can be relightened from the lingual. (Van B. Haywood, 2003). In cases when teeth bleaching didn’t produce the expected result, the patient is confident since the most conservative options have been attempted first, and that porcelain veneers are the best option they have for an esthetic smile.8 We shouldn’t also ignore the minor cost of bleaching compared with the expensive cost of dental veneers that is why the bleaching procedure is usually the first choice for patients to retrieve better smile.8
Conclusion This combined approach (Micro abrasion and in office bleaching) may be considered an interesting alternative to more invasive prosthetic techniques such as ceramic veneers. In addition to that, this minimal invasive technique allows acceptable aesthetic results and even a possible cost reduction for these patients.
REFERENCES 1. OPTIMIZING
SMILE COMPOSITION AND ESTHETICS WITH RESIN COMPOSITES AND OTHERS
DIDIER DIETSCH, DMD, PHD THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY, VOLUME3, NUMBER1,SPRING 2008 2. VIABLE APPROACH TO MANAGE SUPERFICIAL ENAMEL DISCOLORATION NAVEEN CHHABRA AND KIRAN P. SINGBAL CLIN DENT. 2010 OCT-DEC; 1(4): 284– 287. 3. SOME CURRENT PERSPECTIVES ON TOOTH BLEACHING AND MANAGEMENT OF TOOTH STAINS PR. M. S. GUTMANN - PR. J. L. GUTMANN DENTAL NEWS, VOLUME VIII, NUMBER III, 2001 4. TREATMENT OF INTRINSIC DISCOLORATION IN PERMANENT ANTERIOR TEETH IN CHILDREN AND ADOLESCENTS ALYSON WRAY AND RICHARD WELBURY. INTERNATIONAL JOURNAL OF PAEDIATRIC DENTISTRY VOLUME 11, ISSUE 4, JULY 2001, PAGES: 309–315 5. MANAGEMENT OF FLUOROSIS USING MACRO- AND MICROABRASION HOWARD E. STRASSLER, DMD; AUTUMN GRIFFIN, DDS; AND MARGRIT MAGGIO, DMD DENTALCETODAY.COM 6. HTTP://WWW.DENTALARTANDSCIENCE.COM/MICROABRASION/MICROABRASION.HTM 7. A COMBINED CHEMO-MECHANICAL APPROACH FOR AESTHETIC MANAGEMENT OF SUCONSERVATIVE ESTHETIC PROCEDURES
PERFICIAL ENAMEL DEFECTS
S. ARDU, N. BENBACHIR, M. STAVRIDAKIS,D. DIETSCHI, I. KREJCI AND A. FEILZER BRITISH DENTAL JOURNAL VOLUME 206 NO. 4 FEB 28 2009 205 8. FREQUENTLY ASKED QUESTIONS ABOUT BLEACHING VAN B. HAYWOOD, DMD COMPENDIUM / APRIL 2003 VOL. 24, NO. 4A 9. TOOTH WHITENING/BLEACHING: TREATMENT CONSIDERATIONS FOR DENTISTS AND THEIR PATIENTS ADA COUNCIL ON SCIENTIFIC AFFAIRS SEPTEMBER 2009 (REVISED NOVEMBER 2010) 2009 AMERICAN DENTAL ASSOCIATION. 10. NONRESTORATIVE TREATMENT OF DISCOLORED TEETH:REPORTS FROM AN INTERNATIONAL SYMPOSIUM HO HEYMANN JADA 1997;128(6):710-711 11. AESTHETIC MANAGEMENT OF SEVERELY FLUOROSED INCISORS IN AN ADOLESCENT FEMALE F NG, DJ MANTON AUSTRALIAN DENTAL JOURNAL 2007;52:3. 12. DENTAL FLUOROSIS: EXPOSURE, PREVENTION AND MANAGEMENT JENNY ABANTO ALVAREZ , KARLA MAYRA P. C. REZENDE , SUSANA MARÍA SALAZAR MAROCHO , FABIANA B. T. ALVES ,PAULA CELIBERTI , ANA LIDIA CIAMPONI MED ORAL PATOL ORAL CIR BUCAL. 2009 FEB 1;14 (2):E103-7.
Dental News, Volume XX, Number II, 2013
13. CLINICAL EVALUATION OF IN-OFFICE AND AT-HOME BLEACHING TREATMENTS RUTA ZEKONIS, BRUCE A MATIS ,MICHAEL A COCHRAN, SALAH E AL SHETRI, GEORGE J ECKERT, TIMOTHY J CARLSON, OPERATIVE DENTISTRY, 2003, 28-2, 114-121 14. A COMPARISON OF AT-HOME AND IN-OFFICE BLEACHING VAN B. HAYWOOD DENTISTRY TODAY 2000:19(4):44-53 15. EXTERNAL BLEACHING THERAPY WITH ACTIVATION BY HEAT, LIGHT OR LASER—A SYSTEMATIC REVIEW. BUCHALLA W, ATTIN T. DENT MATER 2007;23:586-96. 16. HISTORY, SAFETY, AND EFFECTIVENESS OF CURRENT BLEACHING TECHNIQUES AND A PLICATIONS OF THE NIGHTGUARD VITAL BLEACHING TECHNIQUE VAN B. HAYWOOD QUINTESSENCE INT 1992;23:471 488. 17. EFFECT OF BLEACHING ON SUBSURFACE MICRO-HARDNESS OF COMPOSITE AND A POLYACID MODIFIED COMPOSITE CHRISTIAN HANNIG, SEBASTIAN DUONG, KLAUS BECKER, EDGAR BRUNNER, ELKE KAHLER, THOMAS ATTIN 2006 ACADEMY OF DENTAL MATERIALS. PUBLISHED BY ELSEVIER LTD. 18. FLUORIDE METABOLISM AND FLUOROSIS. BROWNE D, WHELTON H, O’MULLANE D. J DENT 2005; 33: 177-186 19. ASSOCIATION OF MINIMALLY INVASIVE PROCEDURES FOR THE REHABILITATION OF DISCOLORED PERMANENT TEETH. CLINICAL CASE REPORT MAIRA ATHAIDE, LEONARDO MUNIZ MAGAZINE FGMNEWS – EDITION 2- OCTOBER 2009 20. MICROABRASION OF TOOTH4.4 WITH WHITENESS RM ENRICO COGO, PIETRO SIBILLA, ROBERTO TURRINI MAGAZINE FGMNEWS – EDITION 2OCTOBER 2009
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30 Restorative Dentistry Case report
THE IMPORTANCE OF THE CONTACT POINT IN CLASS II RESTORATIONS Dr. Marco Calabrese email@example.com
Clinical case Class II restorations using composite resins present a number of technical problems, including the creation of a tight interproximal contact points. A tight proximal contact will balance the mesial and distal forces and prevent food impaction. For a while now, the use of preformed matrices and separator rings, in combination with wedges, has made it possible to obtain good restorations with satisfactory morphology. An even more efficient system has recently been introduced, which combines preformed matrices, innovatively designed wedges, and nickel-titanium rings providing optimum separation that remains consistent over time. This clinical case demonstrates the procedure for conservative restoration of teeth 15 and 14 using this innovative system. The radiograph (Figure 1) shows that the patient has a distal carious lesion of 14 and a mesial lesion of 15 (Figure 2). After isolating the operative field with a rubber dam (Figure 3), the cavity on 14 is prepared (Figures 4 and 5) ďŹ g 1
Fig 1: Distal carious lesion of 14 and mesial lesion of 15. Dental News, Volume XX, Number II, 2013
Fig 2: Occlusal view. Fig 3
Fig 3: Isolating the operative ďŹ eld with a rubber dam . Fig 4
Fig 4: Accessing the carious lesion .
32 Restorative Dentistry Case report
through which the mesial lesion on 15 can be reached (Figure 6) and the tooth is restored (Figure 7). The Palodent® Plus matrix is then placed on tooth 14, with simultaneous placement of a wedge and ring (Figure 8). The unique design of the nickel-titanium ring means that the matrix fits perfectly around the tooth (Figure 9). Next comes the bonding phase; DETREY® Conditioner 36 (36% phosphoric acid) is applied first (Figure 10), followed by XPBond® adhesive (wet bonding method). The cavity is then partially filled with SDR® – Smart Dentin Replacement (Figure 11); after waiting a few seconds for the products to self-level perfectly inside the cavity, it is polymerised. The distal wall is created with Ceram.X®mono+ composite, shade A2 (Figure 12). The matrix is removed, leaving minimal amounts of excess material to be removed (Figure 13). The restoration is then completed using Ceram X®mono+ composite, and finished (Figure 14).
Fig 5: Finished cavity on 14.
Fig 6: Mesial lesion on 15.
Fig 7: Final restoration of 15.
Fig 8: Fitting the Palodent® Plus matrix to tooth 14, placement of wedge and ring .
Fig 9: Excellent adaptation of the matrix around 14 thanks to the ring design with Vshaped tines that accommodate the wedge perfectly .
Fig 10: Bonding phase: applying conditioner (DETREY® Conditioner 36). Fig 11
Fig 11: Partial ﬁlling of the cavity with SDR® - Smart Dentin Replacement. Fig 12
Fig 12: Creating the distal wall with CeramX®mono+ composite Dental News, Volume XX, Number II, 2013
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Fig 14: Final restoration of tooth 14, perfect interproximal contacts and bite check.
Conclusion Composite restorations performed using techniques designed for amalgams (round matrices) do not create the correct anatomical contours. However, with the use of Palodent® Plus sectional matrices it is now possible to create a proximal contact that is elliptical in the buccolingual direction about 1 mm apical to the height of the marginal ridge. The interdental papilla fills the space apical to this contact and prevents lateral food impaction. The Palodent® Plus system makes it possible to create a good tooth contour adjacent to the papilla, which is necessary to reproduce the original shape. The use of the innovative DENTSPLY sectional matrix in Class II restorations allows the dentist to produce more predictable and morphologically correct restorations.
Dental News, Volume XX, Number II, 2013
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36 Orthodontics Case report
MAINTAINING MISSING CENTRAL SPACE USING TAD Dr. Faraj A. Sedeqi email@example.com
Dental News, Volume XX, Number II, 2013
Abstract Typically developmental anomalies are not uncommon in orthodontic cases. One of the most common contributor to malocclusion is hypodontia. Maxillary lateral incisors are known to be some of the most common congenital missing teeth. This introduces an imbalance to the maxillary and mandibular dental arch length.1 Treatment for the replacement of the missing tooth depends on a number of factors, such as arch length, the number of missing teeth, patient profile and smile line. Treatment options are either to close the space by positioning the adjacent tooth into the missing tooth site, close it with a fixed bridge2 or an implant supported crown. Treatment plans for patients with missing maxillary incisors have traditionally included either space closure or space opening for future restoration. The most common objectives to orthodontic space closure are that the treatment outcome may not look â€œnaturalâ€?, making retention questionable, also making the functional occlusion compromised. Clinicians in general prefer to create space for the missing lateral incisor with single-tooth implants or resinbonded bridges.3-12 Implants are becoming the treatment of choice for replacing missing teeth. One disadvantage with implants is that they should not be placed until all residual growth has subsided. That, however, means for most orthodontics patients who are adolescent, have to wait 4-6 years until the appropriate age of 18 for the implants. Maintaining the space for a long time can be challenging especially with teenagers if their cooperation and the retainer wear is compromised. Gradually with time the bone at the missing tooth site remodels thereby making it thin and may not support or be wide enough for the Implant.13 TAD or
mini screws are commonly used in orthodontic cases for anchorage ; they are relatively cheap and have proved their success in supporting tooth movement. Orthodontic management of a congenital missing upper lateral incisor is the subject of this case report. The primary orthodontic consideration was to maintain the space for the Implant and maintain bone integrity where a TAD with an acrylic prosthetic tooth was placed as a space maintainer.
Treatment Objectives Ideally, the treatment objectives for the final restoration of the missing tooth would be commenced only after there is a downward incline towards to any residual remaining growth.14 However, achievement of this objective would lead to further bone loss, thereby making it unsuitable for either an implant or a fixed bridge prosthesis at the suitable age. Therefore to preserve the bone height and thickness a temporary anchorage implant was thought of. The alternative method to reestablish normal alveolar process is by tooth transplantation which can inherent a potential for bone induction as indicated by B.U. Zachrisson et al.15
Treatment Procedure The clinical patient is a 14 year old female with congenitally missing left central incisor, generalized spacing on the upper anterior with a midline shift to the left. On examination she presented a straight profile and a Class I molar relation. After the alignment and the midlines were coincided with the space opened up, the braces were removed and spaces were maintained using removable retainers (fig. 1,2). In order to avoid collapsing of the arch and
38 Orthodontics A Clinical Report
Fig: 1 Space created for the TAD
Prosthetic tooth placed ﬁrmly over the TAD Fig 2
Fig: 2 Occlusal view (mirror image) space created for the TAD
Occlusal Radiograph showing the TAD in place Fig 3
Fig: 3 TAD in place
further degradation of the bone height, a TAD with an acrylic tooth was shaped and trimmed accordingly to preserve the present conditions (fig. 3,4,5). As the radiographs showed that there was enough bone thickness; the roots were diverged and it had sufficient bone shelf in the edentulous area. An 8 mm screw of IMTEC® was placed parallel to the adjacent roots in alignment with the adjacent teeth. The head was placed and checked for clearance from the lower incisors. The acrylic tooth was trimmed and checked for occlusal interferences. Wax was placed in between to check for the approximate fit prior to placing it firmly with composite (fig. 4,5).
Treatment results After the 3 months’ through the retention period, the TAD was placed. The radiographs showed fairly good response without any occlusal interference from the lower anteriors. There weren’t any significant loosening, infection or damage to the underlying structures (fig. 6,7). The shape and color of the prosthetic tooth had a significant matching to the adjacent teeth. This helped in avoiding a collapse of the facial fullness and her profile. Thus improving her smile and gaining her confidence drastically (fig. 5,8,9). Fig 7
Fig: 4 Occlusal view (mirror image) - TAD in place with the prosthetic tooth placed over it to check for interference Dental News, Volume XX, Number II, 2013
Radiograph showing the TAD in place
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40 Prosthodontic Dentistry A Clinical Report
Facial photograph prior to TAD placement Fig 9
Facial photograph after ﬁrmly ﬁxing the prosthetic tooth to the TAD
Conclusion Treatment of congenitally missing anterior teeth by the use of TAD is fairly a new idea which has little supporting literature. Our idea and our credit goes to Dr. John Graham for his concept on bone preservation using TAD, which was presented in the AAO annual meet 2009. ® 3M IMTEC corporation
REFERENCES 1. MCNEILL, R.W.; JOONDEPH, D.R.:CONGENITALLY ABSENT MAXILLARY LATERAL INCISORS: TREATMENT PLANNING CONSIDERATION, ANGLE ORTHOD.43:24–29,1973. 2. TURPIN, D.L.:TREATMENT OF MISSING LATERAL INCISORS, AM. J. ORTHOD. DENTOFACIAL ORTHOP.125:129, 2004. 3. ROSA, M.; ZACHRISSON, B.U.:INTEGRATING ESTHETIC DENTISTRY AND SPACE CLOSURE IN PATIENTS WITH MISSING MAXILLARY LATERAL INCISORS, J. CLIN. ORTHOD. 35:221– 234,2001. 4. CARLSON, H.: SUGGESTED TREATMENT FOR MISSING INCISOR CASES, ANGLE ORTHOD. 22:205-216,1952. 5. ASHER, C.;LEWIS, D.H.: THE INTEGRATION OF ORTHODONTIC AND RESTORATIVE PROCEDURES IN CASES WITH MISSING MAXILLARY INCISORS. BR. DENT. J. 160(7):241-245, 1986. 6. TUVERSON, D.L.: ORTHODONTIC TREATMENT USING CANINES IN PLACE OF MISSING MAXILLARY LATERAL INCISORS. AM. J. ORTHOD.58:109-127, 1970. 7. MC NEIL, R.W.;JOONDEPH, D.R: CONGENITALLY ABSENT MAXILLARY LATERAL INCISORS: TREATMENT PLANNING CONSIDERATIONS. ANGLE ORTHOD.43: 24-29, 1973. 8. ZACHRISSON, B.U.;MJOR, I.A.: REMODELLING OF TEETH BY GRINDING. AM. J. ORTHOD. 68: 545-553, 1975. 9. SENTY, E.L.:THE MAXILLARY CUSPID AND MISSING LATERAL INCISORS: ESTHETICS AND OCCLUSION. ANGLE ORTHOD.46:365-371, 1976. 10. ZACHRISSON, B.U.: IMPROVING ORTHODONTIC RESULTS IN CASES WITH MAXILLARY INCISORS MISSING. AM. J. ORTHOD.73:274-289, 1978. 11. BALSHI, T.J.: OSSEOINTEGRATION AND ORTHODONTICS: MODERN TREATMENT FOR CONGENITALLY MISSING TEETH. INT. J. PERIODONT. RESTOR. DENT.13:499-505, 1993. 12. SABRI, R.: MANAGEMENT OF MISSING MAXILLARY LATERAL INCISORS. J. AMER. DENT. ASSOC.130:80-84, 1999. 13. IKUYA, M.;YOICHI, T.; EISHIN, W.; HIROHIKO, S.; TADAHIKO, I.: INFLUENCE OF CORTICAL BONE THICKNESS AND IMPLANT LENGTH ON IMPLANT STABILITY AT THE TIME OF SURGERY – CLINICAL, PROSPECTIVE, BIOMECHANICAL AND IMAGING STUDY, BONE. 37: 776-780, DECEMBER 2005. 14. ZACHRISSON, B.U.: LETTERS TO THE EDITOR; SINGLE IMPLANTS—OPTIMAL THERAPY FOR MISSING LATERAL INCISORS?.AM. J. ORTHOD.126(6):A13-A15, 2004. 15. EWA, M.C.;ARILD, S.;BJØRN, A.;ZACHRISSON, B.U.: AUTOTRANSPLANTATION OF PREMOLARS TO REPLACE MAXILLARY INCISORS: A COMPARISON WITH NATURAL INCISORS. AM. J. ORTHOD.118: 592-600,2000.
Dental News, Volume XX, Number II, 2013
42 General Dentistry Scican
STEAM AS THE PREFERRED TABLETOP STERILIZING AGENT, AND THE RAGING CONTROVERSY BETWEEN THE “B” AND “S” APPROACHES
Table top sterilizers in a clinical setting have been around since the time of Louis Pasteur. The beginnings of preservation and sterilization techniques go back to ancient years. Aristotle recommended to Alexander the Great, his troops should boil water before they drank it. The beneficial effect of passing surgical instruments through flame was well known to ancient civilizations. Heat as a preservative method in medical industry was introduced in 1809 by Nicholas Appert, with his method of sealing vegetables and fruits in glass jars and then heating them. Louis Pasteur recommended to French vintners heating the new wine at 55°C in the absence of air in order to avoid serious problems. Later he noticed that moist heat was more effective than dry heat. The proposition of sterilization (1879) was simple enough: an integrated chamber with burners located at the bottom, and a serpentine connection to an adjacent water tank that would deliver a fixed amount of distilled water to the chamber at the outset of each cycle…the autoclave was developed. An autoclave is a device used to sterilize equipment and supplies by subjecting them to high pressure saturated steam at set temperature for a set time depending on the size of the load and the contents. The name comes from Greek auto - ultimately meaning self, and Latin clavis meaning key — a self-locking device. Dental News, Volume XX, Number II, 2013
Under this 19th century theory, the burners would then bring the temperature up to 121°C, the internationally accepted minimum for sterility to take place, and the resulting steam would permeate every corner, nook and cranny within and annihilate any pathogenic or non-pathogenic organism in this enclosed environment. A brilliant idea indeed that has been with us since the 1880s and that allowed for the notion of sterile instruments at or in the vicinity of clinical pointof-use to be actively pursued by the pioneers of microbiology. In order to understand the implications of cross contamination, and because of the forgetful nature of the human brain, it would be prudent to review basic definitions. Sterilization (when applied to the eradication of microorganisms): The total annihilation of pathogenic and non-pathogenic organisms in any given environment rendering a product free of viable microorganisms.* Disinfection: The reduction in numbers of pathogenic and nonpathogenic organisms in any given environment that may or may not be detrimental to human health.** As we can see, the first (sterilization) is an absolute as there are no degrees of sterility inherent to the definition, whereas the second (disinfection) is not an absolute, and we can thus speak of low, medium, and high levels of disinfection. This indicates that in the proposition “total annihilation” the key word is “total.” And here we begin to understand why steam has made it as the predominant sterilizing agent. A word on steam: It is commonly accepted that the ideal sterilization process is one that can be used between patient procedures; one that does not damage or corrode heat-sensitive instruments; one that is inexpensive; and one that consistently
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44 General Dentistry Scican
penetrates narrow orifices, channels, and the lumen of instruments of certain complexity. All of the above makes pressurized steam the perfect candidate for the job as it is cost-effective, presents with no environmental concerns, and it proves to be highly pervasive. An important concept to remember regarding steam is that the increase in temperature from boiling point to 134°C is instant, and that the temperature of moist heat can be raised by increasing chamber pressure, with the accepted formula as follows: 121°C sustained for thirty minutes will bring about sterility, but if we are able to increase the temperature to 132°C, we may decrease the time of exposure down to four minutes with the same result, that is, sterility. The main objection to the traditional approach of steam in an integrated chamber was exposed in 1989 by Professor Fodder, who demonstrated that leaving 5 percent or more of air in the chamber effectively prevents a true claim of sterility. The rationale behind this is that steam tends to spread out in layers, and because steam is lighter than air, all air must vacate the chamber in order to avoid the formation of airpockets, into which steam could not penetrate. Obviously, without such penetration sterilization could not happen and would be particularly absent within the hollow of instruments. So, it is established then that air removal is a condition sine qua non for sterility to occur. Effective air removal was achieved in 1990 with the advent of STATIM®, a revolutionary design that moved away from the integrated chamber approach to the removable cassette-based chamber, where sterile instruments can be aseptically transported right to the point of use. This is air removal by positive pressure pulse displacement (dynamic air removal), where a steam generator injects pressurized steam into the chamber. Saturated steam*** now forces the air out through a valve, with the remainder of the air being removed by opening this valve at intervals. The effect is the creation of positive pressure pulses.
EN13060 EN13060 is the European Standard for small steam sterilizers, i.e. steam sterilizers whose chamber volume does not exceed 60 litres. As a longstanding, active member of the working group responsible for this standard, SciCan is intimately familiar with the requirements of EN13060+A2 Dental News, Volume XX, Number II, 2013
2010 This European Standard specifies the performance requirements and test methods for small steam sterilizers and sterilization cycles which are used for medical and dental purposes or for materials that are likely to come into contact with blood or body fluids. This Standard is intended for sterilizer manufacturers and is also used and referenced by many non-European health/regulatory authorities and sterilizer users. At the heart of this Standard is the definition of the types of approved cycles: B, S, and N, as is defined in the beginning of EN13060**** : B cycle – The sterilization of all wrapped or nonwrapped solid, hollow load products type A and porous products as represented by the test loads in the standard S cycle – The sterilization of products as specified by the manufacturer of the sterilizer N cycle – The sterilization of non-wrapped solid products. B-cycles use a vacuum pump to create a vacuum that ensures air removal before the chamber is pressurized with steam. The process is known as fractionated vacuum (negative pressure) and, relative to gravity displacement cycles, allows for better steam penetration through the entire load, but it must be tested daily for adequate air removal by using an approved process challenge device. S-cycles can use a variety of technologies to ensure air removal before the chamber is pressurized with steam. The STATIM Cassette Autoclave, as stated above, uses positive pressure pulse displacement
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46 General Dentistry Scican
(dynamic air removal). S-cycles do not require daily air removal testing. In accordance with EN13060:2004+A2 2010 Section 7.1, STATIM sterilizers are tested on a microbiological basis and have proven to consistently achieve a sterility assurance level of 10-6 (or a 6-log reduction in microorganisms) for a variety of loads (solid, hollow, hinged, etc.). Furthermore, as required by Section 7.2 and 7.3, STATIMs 2000S and 5000S have passed Type testing, and each unit shipped has successfully undergone Works testing (the results of the Works test are provided with each unit). N-cycles do not use multiple steam purges during the preparation phase of the cycle that would ensure air was removed from cavities of instruments such as found in dental handpieces. Here the trapping of air is a real concern and the formation of air pockets a possibility and therefore N-cycles, similar to gravity displacement cycles are only adequate for solid instruments.
Microbiological Testing Because STATIMs are S-cycle machines, they are very likely the sterilizers that have the most microbiological test data to prove their efficacy in destroying microorganisms, especially in medical and dental environments, while other autoclave manufactures (B-cycles) rely on EN867-5:2001 approved PCDs (process challenge device) to claim load processing. STATIM users can therefore have the utmost assurance in the sterilization efficacy of the STATIMs. They have been microbiologically tested and proven to successfully and effectively sterilize a variety of instruments. A PCD is a mechanical device which simulates the worst case of conditions for attainment of the specified sterilization conditions within the items to be sterilized as defined by EN867-5:2001, definition 3.2. The device is constructed so that a biological or non-biological indicator system can be placed within the device in the position which it is most difficult for the sterilizing agent to reach. The design of the process challenge device depends on the nature of the goods to be sterilized and the sterilization procedure. The performance of the STATIM autoclaves have been validated via microbiological testing, conducted by a well respected researcher and leader in the field of infection control. To regularly Dental News, Volume XX, Number II, 2013
validate the STATIMs and ensure they continue to attain the specified sterilization conditions, the STATIM Process Challenge Device (PCD) has been designed in order to demonstrate that the sterilization parameters required and validated during microbiological testing have indeed been obtained. This device tests the unit and ensures that the mechanical components and software controls are functioning correctly and match those of the units tested during microbiological testing. In sum, the removal of the air***** from the chamber prior to the commencement of “killing” time is the fundamental consideration in selecting the best autoclave for any clinical practice. The methodology through which this removal is achieved is of secondary importance. The fact remains, in spite of the opinions of manufacturers, advocates, partisans and others, that both the S and the B cycles expel the air from the sterilization chamber to such an extent where sterilization of hollow instruments (such as dental handpieces) can be attained. Where the removal of air through positive pressure (STATIM) establishes its dominance is in the reduced duration of the cycle, aspect this rightly coveted by most professionals, since the instrument turnaround time could be as short as 10 minutes. This is achieved as a result of having the technological capability of injecting steam at will, and of creating conditions of sterility (temperature and pressure) through a chamber whose walls are extremely thin. In mechanical terms, the effect of this approach is a gentler sterilization process for your expensive instruments.
* Definitions of sterility in the medical literature vary in composition depending on the source, but the definition given here encompasses general consensus. ** Definitions of disinfection in the medical literature vary in composition depending on the source, but the definition given here encompasses general consensus. *** EN 13060 2004+A2 2010, § 3.34 **** EN 13060 2004+A2 2010, Table 1 ***** EN 13060 2004+A2 2010, § 3.3
48 Esthetic Dentistry VITA
VITA ENAMIC THE FIRST HYBRID DENTAL CERAMIC IN THE WORLD WITH A DUAL-NETWORK STRUCTURE In January 2013, a new generation of materials for chairside treatment using CAD/CAM technology were made available. The future of chairside CAD/CAM restoration is VITA ENAMIC (Fig. 1). A Fig. 1: With its dual-network structure, the VITA ENAMIC hybrid ceramic represents a new class of materials.
are within the same range as those for silicate ceramics. And at 30 GPa, the material also offers a modulus of elasticity comparable to that of human dentin. Up until now, no dental restoration material has matched this “natural” elastic range. The result is unusually high stability as demonstrated by internal and external studies. Thanks to the elasticity provided by the integrated polymer network, VITA ENAMIC absorbs the applied load, achieving the best results (approx. 2890 Newtons, see Fig. 2) in a fracture load study ﬁg 2
composite material that is unique worldwide in combining the benefits of conventional ceramic and composite materials. Both scientific studies and initial clinical experience confirm that with the VITA ENAMIC hybrid ceramic, a new dimension in stability, reliability, precision and cost-efficiency can be achieved.
Material concept With the development of VITA ENAMIC, a whole new approach has been adopted, creating a hybrid ceramic comprised of a dominant ceramic network reinforced by a polymer network structure. With both networks fully integrated with one another, VITA ENAMIC offers considerable benefits for patients and for practice and laboratory use – from a lower tendency towards brittle fracture than pure ceramics, through to greater abrasion resistance than composite materials.
Findings of materials science With flexural strength values of approximately 150-160 MPa, the results for VITA ENAMIC Dental News, Volume XX, Number II, 2013
Fig. 2: In this test setup, VITA ENAMIC demonstrates the highest fracture load of approx. 2890 Newtons and the lowest standard deviation. Source: Internal study, VITA R&D
of any of the materials tested. This result also correlates with the study results published by Dr. Petra Güß of the clinic for oral and maxillofacial surgery at the University of Freiburg. Here it was found that when a dynamic load is applied in a chewing simulator, VITA ENAMIC crowns demonstrate a 100 % survival rate, both for walls of normal and of reduced thickness (Fig. 3). As a measure of the reliability of a material, the Weibull modulus indicates the benefits of VITA ENAMIC particularly effectively. An internal study conducted by the VITA Research & Development
VITA ENAMIC ® creates a new deﬁnition for resistance
The ﬁrst hybrid ceramic with dual network structure for unsurpassed absorption of masticatory forces
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50 Esthetic Dentistry VITA
Fig. 3: The survival rate of VITA ENAMIC crowns with walls of normal and reduced thickness is 100%. Source: University of Freiburg, Dr. Güß
that in the same way as silicate ceramics, VITA ENAMIC also facilitates superior-quality etching using hydrofluoric acid gel. This is an important factor in ensuring permanent and tight contact adhesion between the restoration and the tooth substance.
department shows that at a value of 20, the Weibull modulus for the VITA ENAMIC hybrid ceramic is more than double that of comparable materials for the fabrication of monolithic singletooth restorations (Fig. 4). Fig. 4: Of the materials examined in this test, VITA ENAMIC offered the greatest reliability. The Weibull modulus is 20. Source: Internal study, VITA R&D
Fig. 5: VITA ENAMIC exhibits high edge stability even in areas with thin margins. Top view: 30° wedges: left: VITA ENAMIC, right: e.max CAD
In practical application, the superior properties of the new hybrid ceramic make it ideally suited to crown restorations in areas with high occlusal load, and facilitate reduced wall thickness for minimally-invasive restorations. They also enable greater precision, improved edge stability and, as a result, finer, more accurate milling results than previously possible using conventional CAD/CAM ceramics. SEM images illustrate the difference compared to conventional ceramics (Fig. 5).
At the same time, the innovative composite material can also be milled more cost-effectively than comparable CAD/CAM materials – the milling times for VITA ENAMIC restorations are the shortest both in normal and in fast milling mode, while also ensuring a longer service life for diamond milling tools. It is also important to note Dental News, Volume XX, Number II, 2013
VITA ENAMIC will be available initially in block size EM-14 (12 x 14 x 18 mm), as well as in the shades 0M1, 1M1, 1M2, 2M2 and 3M2, and in two degrees of translucency. The hybrid ceramic can be processed in the usual manner using the CEREC and inLab MC XL systems, for example. Software version V4.0 or higher is prerequisite. For easy, efficient pre-polishing and high-gloss polishing of VITA ENAMIC restorations that is gentle on the material, a special polishing set is provided (Fig. 6).
Fig. 6: These instruments, which have been developed especially with VITA ENAMIC in mind, allow superior, plaque-resistant surface results to be achieved.
The VITA ENAMIC STAINS KIT, which contains six stains as well as accessories (Fig. 7), can be used for characterization. The stains are bonded to the restoration as part of a polymerization process. Surface sealing can be performed using the chemical glaze material VITA ENAMIC GLAZE, which increases the durability and brilliance of the shade in the oral environment. Processing could not be easier – simply condition the surface of the
52 Esthetic Dentistry VITA
GC Fuji IX GP EXTRA from GC Improved Fast-Setting Packable Glass Ionomer Restorative now available in powder-liquid delivery
Fig. 7: Simply apply the VITA ENAMIC stains to the restoration and polymerize – that’s all that’s required to quickly characterize the shade of VITA ENAMIC restorations.
restoration, mix and apply the shades, perform intermediate polymerization, apply chemical glaze and complete final polymerization. Firing is not required.
Summary Thanks to the dual ceramic-polymer network, the new VITA ENAMIC composite combines the benefits of ceramic and composite materials in one outstanding product, providing a quantum leap in the development of CAD/CAM materials. It is approved for single-tooth restorations such as inlays, onlays, veneers and crowns, and is also distinguished not least by the superior comfort it offers to patients, thanks to material properties similar to those of natural dentition.
Dental News, Volume XX, Number II, 2013
With Fuji IX GP Extra in powder-liquid, GC, the glass ionomer world leader, is providing the most advanced GI technology to Powder Liquid users. Actually, advances in glass technology have resulted in the development of GC Fuji IX GP EXTRA, a high strength glass ionomer cement with a new generation of glass ﬁller which gives the restorations a very high translucency that changes little over time. The result is natural aesthetics never before achievable with conventional glass ionomer. GC special glass ﬁller used in GC Fuji IX GP EXTRA releases three times more ﬂuoride than conventional glass ionomers so it provides even better protection against caries. The comfortable working time combined with a fast setting time mean you can start ﬁnishing and polishing just two and a half minutes after mixing. The indications of Fuji IX GP Extra are for permanent and temporary teeth. It can be used for Class I and II restorations in children’s teeth, non-load-bearing Class I and II restorations in adult teeth, Class V and root surface restorations, core build-up and for use with a composite or an inlay in the immediate or delayed sandwich technique. Find out more about Fuji IX GP Extra powder-liquid at www.gceurope.com
Oman International Dental Conference
February 27-28, 2013 Al Bustan Hotel, Muscat, Sultanate of Oman
More Pictures Available On www.facebook.com/dentalnews1
On behalf of the whole team of the “Oman International Dental Conference 2013”, I would like to extend my warm welcome to all of you participating in this rich scientific event, which is intended to be held regularly every two years. It is also my great honor on this occasion to express my heartfelt thanks to all of those who spared their valuable time, to those who came up with new ideas and especially to those who made this conference a reality. We welcome you all in Oman so we can experience together the rich culture, the history and the hospitality of the Sultanate. Dr. Jasim Al Saidi Chairman of the Organizing committee
DR. JASIM AL SAIDI
MINISTER DR. AHMED AL SAIDI CUTTING THE RIBBON OF THE EXHIBITS
DR. LOUIS HARDAN LECTURING ON ESTHETICS
MINISTER DR. AHMED AL SAIDI IN THE MIDST OF THE GUESTS AT THE OPENING CEREMONY Dental News, Volume XX, Number II, 2013
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Tornado – the new generation of compressors from Dürr Dental Dürr Dental, the inventor of oil-free dental compressors, presents an unbelievably quiet and powerful compressor for dentistry in the form of the new “Made in Germany“ Tornado. ▪ Oil-free, dry, and hygienic ▪ One of the quietest of its kind ▪ Dust- and Sandresistant ▪ Antibacterial inner tank coating ▪ Low-maintenance thanks to membrane-drying unit Duerr Dental Middle East, P.O.Box: 87355, Al Ain - U.A.E., Mobile: +971 (0) 50 - 550 84 12, Fax: +971 (0) 3 767 - 5615, email: email@example.com
58 March 12-16, 2013 Koelnmesse, Cologne, Germany
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IDS 2013 SETS NEW RECORDS
125,000 VISITORS FROM 149 COUNTRIES & 2,058 SUPPLIERS FROM 56 COUNTRIES
Dental News, Volume XX, Number II, 2013
MASTER DENTAL TECHNICIANS AND DENTISTS, WILL HAVE TO WORK TOGETHER MORE CLOSELY IN THE FUTURE
Dental News, Volume XX, Number II, 2013
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The 17th Kuwait Dental Association Conference April 13-15, 2013 Radisson Blu Hotel, Kuwait
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DR. IBRAHIM TAQI HEAD OF THE
TROPHY TO DR. MOHAMAD
TROPHY TO DR. AZIM
DR. ELIE MAALOUF
TROPHY TO DR. FADIA
TROPHY TO DR. AISHA
DR. DOMINIKI CHATZOPOULO
DR. TONI DIB
THE KUWAIT DENTAL ASSOCIATION BOARD MEMBERS AND THE ORGANIZING COMMITTEES GROUP PICTURE
PHOTO OF THE LEBANESE DELEGATION WITH THE ORGANIZERS DURING THE CLOSING CEREMONY
The #1 patient-requested professional whitening system* is now better than ever. New Philips Zoom offers advanced light technology that gives you more control and your patients even greater results. And with a worldwide public awareness campaign to drive patients to you and new programs to help you easily integrate Philips Zoom WhiteSpeed light-activated whitening into your practice, you’ll have the answer to the confident, beautiful smile your patients are asking for. Ask about the new Philips Zoom WhiteSpeed today. Visit philipsoralhealthcare.com. For more information, contact your local sales representative or call +971 50 643 1707. *In the United States. Philips is a registered trademark of Koninklijke Philips Electronics N.V. ©2012 Discus Dental, LLC. All rights reserved. To be dispensed by or on the order of a dental professional only. ADV-3545ARA 101912
EGYPT Elsafaa Tel: 2 (0) 10 1466997
JORDAN Al Ghad Medical Supplies Tel: +962 6 552 6358
KUWAIT Alpha Medical Co. Tel: +965 2247 8611
LEBANON G. Tamer Holding Tel: 961 1 694000
MOROCCO Ortho-Rama +21 2 22862086
SAUDI ARABIA Bashir Shakib Al Jabri & Co. Tel: +966 26700430
TUNISIA MSI Tel: +216 73 449 401
UNITED ARAB EMIRATES Al Hayat Pharmaceuticals Tel: +971 6 5592 481
Intâ€™l Quintessence Dental Arab Congress April 24-26, 2013 Riyadh, KSA
More Pictures Available On www.facebook.com/dentalnews1
PROF. ABDULLAH AL SHAMMERY THE RECTOR OF THE RIYADH COLLEGES OF DENTISTRY AND PHARMACY
PRESIDENT TAWFIK AHMAD KHOJA RECEIVING THE TROPHY FROM PROF. ABDULLAH AL SHAMMERY
DR. ESAM TASHKANDI GIVING THE TROPHY TO DR. ANDREA RICCI
TROPHY TO DR. FEDERICO FERRARIS FROM ITALY
The Second International Quintessence Dental Arab Congress jointly organized by the Riyadh Colleges of Dentistry and Pharmacy (RCsDP) and the Quintessence International Publishing Group and the 8th Riyadh International Dentistry Meeting (RIDM) closed on 26 April 2013. The meeting was held at the Al Faisaliah Hotel in Riyadh City and covered eleven scientific papers presented by internationally known dental experts and authors of dental books from Switzerland, Italy, Germany and Great Britain. The program also included a short ceremony for the GCC Preventive Dental Program. President Tawfik Ahmad Khoja, President of the Executive Board of the Health Ministers Council for GCC was on hand to officiate at this ceremony.
THE GCC HEALTH MINISTERS WERE AWARDED PLAQUES AND TOKENS OF APPRECIATION AS A FITTING CAP TO THE CEREMONY
LEFT TO RIGHT DRS. MASSIRONI, RASPERINI, RICCI, FERRARIS
PICTURES FROM THE EXHIBITION FLOOR
OptiBondâ„˘ XTR Unmatched power for all your direct and indirect restorations.
Clear, long resin tags with penetration into lateral dentin tubule branches (2,000x).
OptiBond XTR XTR Self-Etch, Self-Etch,Light-Cure Light-Cure Universal Adhesive. Adhesive. Univesal $ Extraordinary performance for long-lasting restorations. $ Minimizes post-operative sensitivity, maximizes patient comfort. $ A true universal adhesive. $ #Enables use with all cements, core build-up materials and substrates. For more information visit: !!! "
KerrHawe SA P.O. Box 268 6934 Bioggio Switzerland Freephone: 00800 41 05 05 05 Fax: ++41 91 610 05 14 www.kerrdental.eu
Your practice is our inspiration.â„˘
SlimCollection Hu-Friedy’s SlimCollection, which consists in a full line of sleek new orthodondic instruments that feature smaller, thinner, lighter working ends for more maneuverability. Slim collection consists in eight new instruments, which guarantee the orthodontist a more efficient and precise working method. The pliers, tweezers and cutters of the new product line are considerably narrower, thinner and lighter than conventional products to greatly improve intraoral adaptation, flexibility and view. The result: More maneuverability, more patient confort and time savings for doctor and patient. For more information www.hufriedy.eu
AngleFix Concept Prosthetic Restorations on angled tioLogic© Implants The AngleFix concept provides the tioLogic© implant system with yet another indication it enables edentulous patients to be treated with immediate restorations such as screw retained bridges or a bar constructions in the maxilla or mandible. It consists of various fully compatible prosthetic components, which enable the tioLogic© implants to be inserted at an angle, in order to avoid augmentation in the posterior region and enable anatomically critical areas to be treated with care. The prosthetic supporting surface is displaced in a distal direction, the prosthesis is additionally supported and the local bone substance is put to best possible use. The AngleFix abutments are available for the implant lines S, M and L in straight (0°) and angled at 18° and 32°. The angled abutments can be positioned exactly using the integrated PentaStop®. The design of the abutments is such, that implant axis deviations of up to 44° to one another are possible. There are closure screws, impression copings, laboratory analogs and acrylic and titanium copings available for the extended prosthetic restoration. There are two angle aids available in 18° and 32° for the exact alignment of the implants. Alternatively, the implant axis can also be determined using the navigation system tioLogic© pOsition and the drilling template made with this. If you should have any questions, the Dentaurum Implants Hotline is available with experienced implantologists and dental technicians to give assistance. For more information www.dentaurum-implants.de
The Next Generation of the Endo Gold Standard PROTAPER NEXT is the newest innovation to the DENTSPLY Maillefer PROTAPER system, which has been the gold standard in endodontics for many years. It is still based on the PROTAPER philosophy, including a single file sequence for all clinical cases, variable tapers for optimised crown-down technique and commonly approved apical finishing diameters. PROTAPER NEXT has an off-centred rectangular cross section, providing a snake-like “swaggering” movement of the file in the root canal. The DENTSPLY proprietary M-WIRE NiTi provides improved flexibility to the file as well as greater resistance to cyclic fatigue. As a result, PROTAPER NEXT covers more difficult clinical cases, improves safety and also shortens the shaping time. For more information www.dentsplymea.com Dental News, Volume XX, Number II, 2013
Exomed™ From our R&D department a new company has been created, Medesy Engineering, whose unique mission is to develop new materials and new products. Exomed™ is the extraordinary result of Medesy Engineering, Exomed™is an instrument which allows the extraction of teeth and roots with minimal trauma. Among the most important advantages: - The periodontal and alveolar tissues remain fully undamaged after the extraction, the neighbouring tissues are practically intact after the operation - No need of forceps and root elevators, nor to perform a luxation and syndesmotomy before extraction! - The implant insertions are possible even immediately after the extraction: the alveolar sites have no lacerations - The patient will recover from the extraction in a much shorter time. - The extraction of roots is really easier and faster … THE MORE YOU KNOW IT, THE MORE YOU USE IT! SIMPLE & REVOLUTIONARY. EXOMED™, SIMPLY NO STRESS. For more information www.exomed.it
NEW! Cavex Bite&White Ready 2 Use ‘pre-ﬁlled whitening trays’ The Cavex Bite&White Ready 2 Use professional home whitening system is a fast, safe and above all very simple whitening system for use at home. Just open the packaging, place the pre-filled tray in your mouth and enjoy the result after an hour. Mere child’s play! The highly viscous Cavex Bite&White Ready 2 Use whitening gel contains 6% hydrogen peroxide (partly as carbamide peroxide), a sustainable and active combination of effective whitening substances with a proven reputation worldwide as an effective whitening agent. Adding potassium nitrate avoids sensitivity. The unique ‹one-size-fits-all› Dryflex® whitening tray is made of a special type of plastic which the mouth tolerates well. Thanks to its 95% compatibility, the whitening tray is suited to almost everyone. Cavex Bite&White Ready 2 Use complies totally with new European legislation for teeth whitening agents. For more information www.biteandwhite.eu
VITA ENAMIC the ﬁrst hybrid dental ceramic in the world VITA Zahnfabrik have created a new generation in ceramic materials: VITA ENAMIC is the first hybrid dental ceramic in the world with a dual-network structure that combines the best of what ceramic and composite materials have to offer. The CAD/ CAM blocks are not only suitable for fabricating conventional inlays, onlays, veneers and crowns for anterior and posterior applications, but they can also be used for minimally-invasive restorations such as non-prep veneers and for restorations in areas where space is limited. For more information www.vita-zahnfabrik.com Dental News, Volume XX, Number II, 2013
SHIFTING THE WAY YOU THINK ABOUT ORTHODONTICS. The Carriere® Distalizer™ Appliance
Carriere Self-Ligating Bracket
* Typical case: Patient 16 years Start of treatment, prior to placement of Carriere Distalizer Appliance 5.10.10
Class II to Class I achieved, and Carriere Distalizer Appliance treatment completed 8.30.10
Total orthodontic treatment completed 3.7.12
Turn Complex Class II into Simple Class I Cases With its non-invasive design, the Carriere Distalizer Appliance corrects Class II malocclusion at the beginning of treatment, prior to bracket placement when patient motivation is highest. Call us today at 888.851.0533 or visit us online at OrthoOrganizers.com.
Carriere Ortho 3D A FREE App. for iPads, iPhones, and Android tablets and phones
* Images courtesy of Dr. Clark Colville. © 2012 Ortho Organizers, Inc. All rights reserved.