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Decision-making factors for optimized management of Root fractures in the apical third: About two clinical cases

64. Lebanese Society of

Dr. Mohamed Rafik Cherif, Dr. Maroua Garma Dr. Nabiha Douki Zbidi,

Endodontology June 21 - 22, 2018 Hilton Habtoor Grand Beirut, Lebanon

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June 22 - 23, 2018 Mövenpick Hotels & Resorts Beirut, Lebanon


A Case Report of Dental Abscess Affecting Facial Skin Dr. Amir Khalid Hassan

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Adherence to Treatment with Removable Oral Appliances: the Past and the Future Stacey Kirshenblatt, Hui Chen, Marijke Dieltjens, Benjamin Pliska, Fernanda R. Almeida


September 2018



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September 2018

Dental News


Oral Surgery Mohamed Rafik Cherif DDS & Postgraduate Student, departement of Restorative Dentistry & Endodontics, Sahloul Hospital, University of Monastir, Tunisia

Maroua Garma DDS & Postgraduate Student, departement of medical & surgery, Dental clinic, University of Monastir, Tunisia

Nabiha Douki Zbidi head of the departement of Odontology. Professor in Restorative Dentistry & Endodontics, Sahloul Hospital, University of Monastir, Tunisia

Decision-making factors for optimized management of Root fractures in the apical third: About two clinical cases Abstract Root fractures are among the most complex emergency consultation in our practice; they may involve the cervical, middle or apical third of the root. The survival prognosis of the tooth will depend on 3 types of factors referred as pre-traumatic, traumatic and treatment factors by Andreason et al. 1, 2. In this article, we focused on root fractures of

Dental News

Key words: Trauma, tooth, fracture, apical third, decision making

Introduction Root fractures are complex traumatic injury, affecting both hard dental tissues, periodontal and pulpal tissues 3, 4. This type of fracture is rare, between 0.5 to 7% of cases of trauma 3, 5, 6 and occurs most often following a violent shock during an assault, a traffic accident or during sports activities 7. Male patients between the ages of 11 and 20 years old are the most affected 6, 8. The most concerned teeth are mainly the upper central incisors (68%) and the lateral ones (27%) 3. The incidence of radicular fracture of the apical third is 34% compared to 57% in the middle third and 9% in the cervical third 6. The diagnosis may not be straight forward, as clinical signs may be similar to other types of dental trauma, the coronal fragment can be mobile or even displaced


the apical third in order to present the difficulties of their management and to propose a decision making diagram regarding the best course of treatment management, based on the best scientific evidence available and the illustration of two clinical cases.

mimicking a sub-luxation or luxation respectively. Very often the coronal fragment remains un-displaced with a slight mobility and tender to percussion mimicking a periodontal contusion. Sensitivity tests may give a negative result initially indicating a transient or permanent nerve damage 9. The diagnosis of radicular fractures of the apical third is essentially based on radiological evaluation. The fracture line is oriented obliquely in the apical-third and middle-third of the root 5 Therefore, these fractures are normally visible only when the central beam is directed in a maximum range of 15 to 20 ° of the fracture plane. Any deviation would show the fracture line as an ellipsoid 10. It is advised that in addition to the conventional periapical radiograph, two additional September 2018

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Oral Surgery

Decision-making factors for optimized management of Root fractures in the apical third

periapical radiographs should be exposed with a positive and negative angulations of 15° to fracture plane 5. Nowadays, technological advances such 3-D imaging via CBCT (Cone Beam Computed tomography), have made a significant contribution to the diagnosis and the precise localization of the root fracture line. Particularly, with 3-D image reconstruction that avoid the overlapping of anatomical structures, thus pushing the limits of conventional 2D imaging. The treatment will consist essentially in repositioning the coronal fragment when it is displaced, splinting the tooth for 2 to 4 weeks and establishing regular follow-ups schedule. The aim of this article is to expose the factors influencing the therapeutic decision-making and prognosis of radicular fractures healing of the apical third in order to put a treatment plan that can be adjusted according to the clinical situation and its evolution during follow-ups. We will review the factors that modulated our thought process in the management of two clinical cases, and finally we will present a summary diagram for decision-making based on a literature review. According to the work of Andresen et al 1, three types of factors must be taken into account before taking care of a root fracture and establishing a prognosis: (Fig 3)

1. Pre-traumatic factors • The young age of the patient and the root immaturity of the tooth, are the guarantors of a considerable blood

supply containing multi-potent stem cells, immune cells, and growth factors, which favors pulpal and hard tissue healing at the fracture line. This correlation has been widely established in previous studies 11, 12 • The periodontal status is a key factor, as periodontal pocket may cause a communication with the oral cavity exposing the fracture line to bacterial contamination and therefore the tooth is left with a poor prognosis 10. For this factor to be relevant in a root fracture of apical third, probing depth would have to exceed 6 mm.

2. Traumatic factors • The mobility and dislocation of the coronal fragment are conditioned by the severity of the trauma and are the determinant of associated periodontal trauma such as sub-luxation or luxation of the coronal fragment 13. Indeed, a study evaluating the survival prognosis of dislocated permanent teeth has shown that pulpal necrosis was observed in 15% to 55% of subluxation and extrusion cases, respectively 14. On the other hand, if the coronal fragment is not displaced there is not therapeutic interest in splint placement. • A positive response to pulp sensitivity tests with thermal stimuli during the first consultation would indicate the integrity of the neurovascular system. This sensitivity has been strongly correlated with the increased chances of pulpal healing and healing with interposition hard tissue 11.

Figure 3: Pulp and hard tissue healing factors


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September 2018


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Oral Surgery Decision-making factors for optimized management of Root fractures in the apical third: About two clinical cases

3. Treatment factors • The delay of consultation and treatment of a few hours to a few days does not seem to influence the type of healing compared to immediate management 15, 2. • Adequate repositioning: The chances of pulp healing and hard tissue interposition healing increase significantly, if repositioning of the coronary fragment is optimal for an initial displacement that does not exceed 1mm 2 • The type of splint influences significantly the type of healing pattern observed. A non-traumatic flexible splint is more in favor of pulp healing and hard tissue interposition healing than rigid splint 2. • A period of contention longer than 4 weeks has no therapeutic value. 2

Clinical cases 1st case: horizontal fracture of the apical third A 49-year-old patient, with non-contributing medical history, reported to the department of conservative dentistry and endodontics of Sahloul state hospital, Sousse, Tunisia, following a trauma on tooth #11 and #21. Clinically the two teeth were mobile and tender to percussion with a 2 mm extrusion of tooth #11, sensitivity test was negative for #11 and positive for #21, and periodontal probing was within normal depth. Also the patient presented a dysfunctional swallowing pattern. The preoperative radiograph (Fig. 1- a) showed, a simple complete and horizontal root fracture at the apical third of # 11 and a widening of the periodontal ligament space of # 21. The treatment plan was manual repositioning of the coronal fragment which was confirmed clinically by cervical margin and incisal edges alignment and radiologically by coaptation of the two fragments), followed by the placement of a semi-rigid splint for 2 weeks, removal of any occlusal interference with a diamond bur. Immediate root canal therapy (RCT) was performed on the coronal fragment (Fig. 1-b). retro alveolar Radiography Control at 6 months (Fig. 1 -c) shows a healing pattern by the interposition of a connective tissue as described by Andreason and Hjorting-Hansen 1, 11 rounding of edges at the mesial and/or distal aspects of the fracture with no radiolucency near the fracture line. Clinical signs regressed with the persistence of a slight tenderness to percussion and mobility and periodontal probing was within normal depth. Meanwhile, tooth #21 has become negative to cold testing one month later and RCT was initiated.


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September 2018

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Oral Surgery

Decision-making factors for optimized management of Root fractures in the apical third

Figure 1: A, Retro-alveolar radiography showing a horizontal root fracture in the apical third. B, postoperative retro alveolar radiograph. C, Retro-control alveolar radiograph at 6 months showing a healing pattern by the interposition of a connective tissue with rounded edges at the mesial and distal aspects of the fracture.

2nd case: Oblique root fracture of the apical third A 20 years old patient, consulting for intermittent and spontaneous pain regarding tooth # 21 with a history of trauma 5 years ago. The tooth was tender to percussion and presented a productive fistula. A preoperative retro-alveolar X-ray with a tracking gutta point (Fig. 2-A) showed a simple, oblique and complete apical root fracture at the apical third, an old filling, and radiolucency at the fracture line level and the apical fragment. The origin of the fistula was traced back to the level of the fracture line. This is a complication of the initial treatment

by interposition of a granuloma associated to pulpal necrosis of the apical fragment. Non-surgical endodontic retreatment was performed with an apexification of the coronal fragment by a plug of Biodentine ™ which filled the entire canal lumen, followed by surgical removal of the apical fragment, and thorough debridement of necrotic tissue (Fig 2-B, C). Retro alveolar Control x-ray at 18 months (Fig 2-D) showed complete bone healing. Clinically the tooth was asymptomatic and functional.

Figure 2: A, preoperative retro-alveolar radiography with a locating cone tracing the origin of the fistula to the fracture line at the apical third with bone resorption. B, surgical time; Elimination of the apical fragment and debridement of granulation tissue. C, Postoperative retro-alveolar radiography. D, Control X-ray at 18 months showing complete bone healing.


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September 2018

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Oral Surgery Decision-making factors for optimized management of Root fractures in the apical third: About two clinical cases



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Discussion Dental trauma is a real challenge, precise diagnosis and an appropriate treatment plan with regular monitoring are key elements for a favorable prognosis. 17 In the two presented cases, we opted for decisions that we considered the most appropriate, taking into account the different factors and their influence on the final prognosis. For the first case, the coronal fragment was mobile and displaced so it was manually replaced and a flexible splint was placed to allow the healing and reorganization of the periodontal 4 According to the 2012 International Association of Dental Traumatology (IADT) recommendations 9 the cold sensitivity test on a traumatized tooth even in the event of a root fracture can be a false negative up to 3 months and should not indicate immediate endodontic treatment. The period of splinting should not exceed 2 to 3 weeks. A minimum follow-up period of one year is necessary. But in our case the age of the patient, complete root edification, the extent of coronal fragment displacement (2 mm) predicted low blood supply and therefore a low repair potential. In addition, the dysfunctional swallowing pattern (tongue taking support on the palatal side upper incisors), would have resulted in the persistence of chronic irritation of the pulp at the level of the fracture line. It is by taking into consideration these factors mentioned that the risk of necrosis was considered high and RCT of the coronal fragment was decided from the outset. The apical fragment retains its vitality in most cases thanks to the neurovascular bundle from the apex and does not require intervention. But regular monitoring is required 4, 9, 18 For the second case: • Fracture line was oblique so the apical end of the coronal fragment was oval and very large, making the reading of the working length and the fitting of gutta cone difficult. This could explain the failure of the initial endodontic treatment performed by the General practitioner who made a conventional gutta filling by cold lateral condensation. • Concerns can be raised about the conditions that RCT was carried out: asepsis conditions, use of the dam or not, irrigation protocol used and the density of the canal filling.


Dental News

September 2018

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Oral Surgery

Decision-making factors for optimized management of Root fractures in the apical third

Non-surgical endodontic retreatment was decided followed by removal of the apical fragment. The coronal fragment was treated as a non-vital immature permanent tooth. An apical barrier with a bioactive material was placed, we chose Biodentine™ (Septodont, Saint Maur des Fosses, France) which has an apical sealing ability comparable to mineal trioxide aggregate (MTA) at any apical plug thickness (19).

Also better handling proprieties than MTA as it is presented in pre-dosed capsule with 12 min setting time. In conclusion we present a diagram that sums up the decision making process in the management of fracture in apical third:

Figure 4: Decision making diagram for management of apical third root fracture


Dental News

September 2018



November 2 - 3, 2018


Oral Surgery

Decision-making factors for optimized management of Root fractures in the apical third

References 1. Andreasen JO, Andreasen FM, Mejare I, Cvek M.Healing of 400 intra-alveolar root

sors. Endod Dent Traumatol 1996; 12:129-36. 7. An-

fractures. 1. Effect of pre-injury and injury factors such as sex, age, stage of root

dreasen JO, L K Bakland ,M T Flores F M Andreasen

development, fracture type, location of fracture and severity of dislocation. Dent

L Andreasen : Traumatic Dental Injuries a manual

Traumatol. 2004 Aug;20(4):192 202.


2. Andreasen JO, Andreasen FM, Meja`re I, Cvek M. Healing of 400 intra-alveolar

8. Andreasen FM, Andreasen JO, Cvek M. Root frac-

root fractures. 2. Effect of treatment factors such as treatment delay, repositioning,

tures. In: Andreasen JO, Andreasen FM, Andreasen

splinting type and period and antibiotics. Dent Traumatol 2004; 20: 203–211

L, editors. Textbook and color atlas of traumatic

3. Von Arx T, Chappuis V, Hänni S Traumatologie des dents définitive s –3e partie:

Injuries to the teeth. Kopenhagen: Munksgaard;

traitement des fractures radiculaires. Rev Mens Suisse Odontostomatol, Vol 117:2/20

2007. p. 337-71. 9. Anthony J. DiAngelis, Jens O.

07 4. Vania Portela Dietzel Westphalen,Maria Helena de Sousa, Ulisses Xavier da

Andreasen and al International Association of Den-

Silva Neto, Luiz Fernando Fariniuk, Everdan CarneiroManagement of horizontal

tal Traumatology guidelines for the management of

root-fractured teeth: report of three cases Dental Traumatology 2008; 24: e11–e15

traumatic dental injuries: 1. Fractures and luxations

5. Y Josna Vinutha, Pavana Sandya Apical Third Horizontal Root Fractures in An-

of permanent teeth Dent Traumatol 2012;28:2-12

terior Teeth: A Review IJSS Case Reports & Reviews | February 2015 | Vol 1 | Issue 9

10. Malhotra, Neeraj & Mala, Kundabala & Acharaya,

page 61-4 6. Caliskan MK, Pehlivan Y. Prognosis of root-fractured permanent inci-

ShashiRashmi. (2011). A review of root fractures: Diagnosis, treatment and prognosis. Dental update. 38. 615-6, 619. 10.12968/denu.2011.38.9.615.) 11. Cvek M, Andreasen JO, Borum MK. Healing of 208 intraalveolar root fractures in patients aged 7–17 years. Dent Traumatol 2001; 17:53–62. 12. Andreasen FM, Andreasen JO. Resorption and mineralization processes following root fracture of permanent incisors. Endod Dent Traum 1988;4:202–14. 13. Andreasen FM: Pulpal healing after luxation injuries and root fracture in the permanent dentition, Endod DentTraumatol 5:111, 1989. 14. Andreasen FM, Vestergaard Pederson B. Prognosis of luxated permanent teeth – the development of pulp necrosis. Endod Dent Traumatol 1985; 1:207–20. 15. Andreasen JO, Andreasen FM, SkeieA, Hj)rting-Hansen E, Schwartz O. E¡ect of treatment delay upon pulp and periodontal healing of traumatic dental injuries ^ a review article. Dent Traumatol 2002; 18:116-128. 16. Andreasen JO, Hjørting-Hansen E. Intra-alveolar root fractures: radiographic and histologic study of 50 cases.J Oral Surg 1967; 25:414–26. 17. Bucher K, Neumann C, Thiering E, Hickel R, Kuhnisch J. Complications and survival rates of teeth after dental trauma over a 5-year period. Clin Oral

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Invest 2013;17:1311-1318. 18. Jacobsen I, Kerekes K. Diagnosis and treatment of pulp necrosis in permanent teeth with root fractures. Scand J Dent Res 1980;88:370–6. 19. Mehmet Bani, Elif Sungurtekin-Ekçi, and Mesut Kaltpolymerisierendes provisorisches Kronenund Brückenmaterial, Paste-Paste-System

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September 2018

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Oral Pathology Dr. Amir Khalid Hassan (BDS, MDSc) QAF, Medical Services, Doha, Qatar. Formerly assistant professor at Dental college, University of Baghdad - Iraq

A Case Report of Dental Abscess Affecting Facial Skin Introduction Dental abscess is frequently found in oral cavity 1. It is frequently related with badly treated carious tooth and poor oral hygiene. Dental caries and pulp necrosis often ended in extending the infections to alveolar bone and sometimes involving the outer layer of the face (sinus) 1-9. This facial sinus orifice cannot be distinguished easily in its origin, confusing the medical team 2-9. A fistula is an abnormal pathway between 2 anatomic spaces or a pathway that leads from an internal cavity or organ to the surface of the body. A sinus tract is an abnormal channel that originates or ends in one opening. An orofacial fistula is a pathologic communication between the cutaneous surface of the face and the oral cavity. In the literature, the terms fistulas and sinuses are often used interchangeably. Stedman’s Medical Dictionary defines a sinus as a fistula or tract leading to a suppurating cavity. Orofacial fistulas are not common, but intraoral sinus tracts due to dental infections are common. When infection or neoplasia is involved, immediate treatment is necessary. Dental infections, salivary gland lesions, neoplasms, and developmental lesions cause oral cutaneous fistulas, fistulas of the neck, and intraoral fistulas.2, 3, 5


Dental News

Chronic dental periapical infections cause the most common intraoral and extraoral fistulas. These dental periapical infections might cause chronic osteomyelitis, cellulitis, and rarly facial abscesses. Infection can spread to the skin when it is the path of least resistance then causing cutaneous fistulas. One case report 2 reviewed this occurrence from a periapical infection from the right central mandibular incisor, which drained to the patient’s chin. Because the tooth could not be restored, it was extracted, which resolved the lesion. Another case with cutaneous manifestations involved a 44-year-old woman with a draining lesion to the skin just lateral to the nasofacial sulcus. Oral antibiotics did not help treating the lesion. The patient had bad oral hygiene, and two periapical radiolucencies of the maxillary right lateral incisor and canine were observed. The teeth were extracted, which resolved the lesion. Sheehan et al emphasized on the importance of a dental examination and radiographs to rule out infection of dental origin to the cutaneous face or neck. This case study showed three cases of intra-oral abscess extending through the bone and facial skin.

September 2018




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Oral Pathology

A Case Report of Dental Abscess Affecting Facial Skin

Case 1 A 20-year-old Yemeni patient visited many doctors only when the abscess came out from her face. Drainage and curettage has been performed by General Physicians as well as laser cauterization by Dermatologist. Lately, it was suspected that it might be of dental origin. The patient was referred to Dental Department. Root canal treatment on upper right first molar has initially been done 3 years ago (2010) but it is not completed. Therefore, she suffered from chronic periapical abscess in which intrapulpal drainage has been made with antibiotics for several times and left open with no further treatment. During the examination it was noticed that the abscess extended to the face and was drained through infraorbital skin area. (pic 1) Radiographical examination were done by orthopantogram and periapical parallel technique inserting the gutta percha cone inside the facial orifice of the sinus andtrackFig. 1

Figure 1: The facial lesion showing the pus and then the irrigation solution coming out of the facial lesion

Fig. 3A

Figures 3A, 3B: After 3 months


Dental News

ing the origin of it. These revealed the presence of this abscess and its relation to the suspected tooth. A case has been discussed fully to the patient, as well as the poor prognosis of the tooth treatment. Full root canal therapy preparation and obturation using protaper system was done through three visits of 10 days interval and under antibiotic coverage of Doxycycline capsule 150 mg twice a day orally systematically. The same antibiotic tablets (3 tabs) were crashed into a chlorohexidine mouthwash and used as irrigant for the root canals along the procedures. (pic 2) The case has been observed for three months (pic 3, 4), six months (pic 5) and one year without any complaints. The tooth is finally restored with a ceramic crown. The outer scar of the sinus was treated by laser and it is nearly disappeared.

Fig. 2

Figure 2: Endodontic treatment

Fig. 3B

Fig. 4

Figure 4: After 3 months

Fig. 5

Figure 5: After 6 months September 2018










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Oral Pathology

A Case Report of Dental Abscess Affecting Facial Skin

Case 2 A 22-year-old Pakistani female patient was complaining of recurrent excised skin infection at the neck with purulent discharge from the corner of the mandible. She went to medical physicians many times and ended by surgical excision of the granulation tissue at the neck with many courses of antibiotic with no use.

the outer neck skin lesion revealing that its origin is related to the root of lower left 6 (LL 6) which is found badly carious, infected and poor prognosis(PIC 6,7&8). The same method of treatment in case 1 was followed. The skin lesion has subsided and disappeared, leaving a light scar (pic 9-14).

She attended the facility of Qatar Armed Forces where she was referred to Dental Department for consultation. Full oral examination was carried out, x-ray views using an old technique of inserting gutta percha cone inside

Evaluation for the case were made for one, three months, six months and a year with progressive success. The patient refused to do laser treatment to remove the scar as lesion become shallow and not recognizable.

Fig. 6 Fig. 8

Figure 6: Pre-operative OPG showing LL 6 with active and extended periapical lesion

Fig. 7A

Fig. 7C

Figure 8: The finished treated tooth

Fig. 9

Fig. 7B

Fig. 7D

Figure 9: The tooth when oburated. Figures 7 (A, B, C, D): Photograph showing the clinical features of the facial lesion and the oral status of the affected tooth.


Dental News

September 2018


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Oral Pathology

A Case Report of Dental Abscess Affecting Facial Skin

Case 3 A Pakistani female (62 years old) patient had been referred from dermatology clinic suffering from discharging nodule on the right lower nasiolabial fold since more than two months. She took many courses of antibiotics and surface lozenges with no benefits. Patient is diabetic as well as hypertensive and controlled medically. Oral and dental examination was carried using clinical and radiological investigations, she was wearing a complete fixed prostheses from molar to molar. A (GP) point inserted inside the facial nodule shows clearly that the nodule is related to the apical abscess of the RCF routine.

Fig. 10

Figure 10: The case after 3 months

Fig. 13A

Work was made through the prostheses to clear the pathological tissue. It was shown during the irrigation procedure of RCF , the solution comes out of the nodule sinus. fucidine cream to cover the facial sinus. Irrigation was made by Doxicycline capsule solved in 500 ml of Saline. The patient kept monitoring and irrigated every week, for 3 weeks, the facial sinus completely closed, the radioapacity of the periapical area of the specified tooth reduced to minimum, and obturation is done by Gutta Perchas as routine. The patient followed up to after 2 -3 months until successful healing of facial sinus.

Fig. 11

Fig. 12

Figure 11: The case after 6 months

Figure 12: The case after 12 months

Fig. 13B

Figure 13 (A, B): Clinical appearance and orthopantogram for the case. Note the irregation fluid coming out of the lesion.


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September 2018


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Oral Pathology

Fig. 14A

A Case Report of Dental Abscess Affecting Facial Skin

Fig. 14B

Fig. 14C

Figure 14 (A-C): The endo treat finished.

Fig. 15A

Fig. 15B

Figure 15 (A, B): The case finished, followup after 21 days (a) 1 month and (b) 2 months.

Conclusion Some neck or face lesion might confused the physicians in its origin especially if it is dentally involved. A good teamwork treatment is essential to discover such as lesion and even in the treatment to finalize the case properly by cosmetic dermatological treatment using


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lazer. The importance of irrigation solution with broad spectrum antibiotic such as doxycycline with chlroheidine mouthwash is equal to proper root canal preparation in the success of treatment of such extensive periapical lesions.

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Oral Pathology A Case Report of Dental Abscess Affecting Facial Skin

References 1. Neville, Brad W. [et al.] (1st ed., 1995). Oral and Maxillofacial Pathology. Saunders. pp. 104–5. 2. Cantatore JL, Klein PA, Lieblich LM. Cutaneous dental sinus tract, a common misdiagnosis: a case report and review of the literature. Cutis. Nov 2002;70(5):264-7. [Medline]. 3. Sheehan DJ, Potter BJ, Davis LS. Cutaneous draining sinus tract of odontogenic origin: unusual presentation of a challenging diagnosis. South Med J. Feb 2005;98(2):250-2. [Medline]. 4. Gound TG, Maixner D. Nonsurgical management of a dilacerated maxillary lateral incisor with type III dens invaginatus: a case report. J Endod. Jun 2004;30(6):448-51. [Medline]. 5. Nallapati S. Clinical management of a maxillary lateral incisor with vital pulp and type 3 dens invaginatus: a case report. J Endod. Oct 2004;30(10):726-31. 6. Steffen H, Splieth C. Conventional treatment of dens invaginatus in maxillary lateral incisor with sinus tract: one year follow-up. J Endod. Feb 2005;31(2):130-3. [Medline]. 7. Sert S, Bayrl G. Taurodontism in six molars: a case report. J Endod. Aug 2004;30(8):601-2. [Medline]. 8. Yasui H, Yamaguchi M, Ichimiya M, Yoshikawa Y, Hamamoto Y, Muto M. A case of cutaneous odontogenic sinus. J Dermatol. Oct 2005;32(10):852-5. [Medline]. 9. Gonçalves M, Pinto Oliveira D, Oliveira Oya E, Gonçalves A. Garre’s osteomyelitis associated with a fistula: a case report. J Clin Pediatr Dent. 2002;26(3):311-3. [Medline]. 10. Gerhards F, Büttner R, Jänicke S. [Aberrant salivary gland tissue in differential diagnosis of branchiogenic neck cyst]. HNO. Jun 2001;49(6):476-8. [Medline].


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September 2018

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Oral Verruciform Xanthoma A case report A 49 years old male patient presented to the oral surgery clinic with a history of a plaque like lesion on the right ventral aspect of the tongue. It was of 2 to 3 years duration, yellowish-grey, well demarcated, slightly raised and demonstrated a verrucous surface with no evidence of ulceration (Fig 1). He was medically fit and a non-smoker. Extra-oral examination was non-significant. A clinical diagnosis of idiopathic leukoplakia was made and option of biopsy was discussed. The patient consented for biopsy and the lesion was excised completely under local anaesthetic. Post-operative phase was uneventful. I have reviewed him during 12 months follow-up with no signs of any recurrence. Histological examination revealed mucosal verrucous hyperplasia with parakeratosis and collections of foamy histiocytes in the subepithelial stromal papillae (Fig 2).

These are highlighted in a CD68 histiocytic marker immunoperoxidase stain, confirming the diagnosis of oral verruciform xanthoma (Fig 3). No fungal elements were seen in PAS-stained sections. The features are not those of Fordyce spots. There is no epithelial dysplasia or evidence of malignancy. The differential diagnosis is important as it can clinically resemble malignancy. Differentials include verrucous carcinoma, squamous cell carcinoma, squamous papilloma, verruca vulgaris, condyloma and leukoplakia. The verrucous architecture and exophytic nature of this lesion could mimic malignancy clinically and therefore biopsy becomes mandatory. A reassuring clinical feature is that the lesions tend to be soft on palpation, unlike a malignant process which is firm. The presence of foamy cells is characteristic of VX, which tend to accumulate in between rete ridges in the connective tissue.

Fig. 1

Figure 1: Clinical photograph showing yellowish grey slightly raised well-demarcated area.


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September 2018


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Figure 3: Immunostain photomicrograph X 100 showing foamy cell can be seen darkly stained in the stromal papillae.

Acknowledgments The assistance of Associate Professor Hedley Coleman, Senior Staff Specialist, Tissue Pathology & Diagnostic Oncology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead NSW 2145, Australia, and Dr Peter Cropley, Anatomical Pathologist, Laverty Pathology, 60 Waterloo Road, North Ryde NSW 2113, Australia, in establishing the pathological diagnosis is acknowledged.





1. Byakodi S, Kumar B, Patil S, Shinde S. Verruciform xanthoma of the tongue. Natl J Maxillofacial Surg 2017; 8: 78-80. 2. Harris L, Staines K, Pring M. Oral verruciform xanthoma BMJ Case Rep 2015; doi: 10.1136/bcr-2014-209216.


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September 2018

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Orthodontics Stacey Kirshenblatt, DDS, MS, FRCD(C) Private practice, Toronto, ON.

Hui Chen, DDS, MS, PhD Clinical assistant professor, faculty of dentistry, University of British Columbia, Vancouver, BC.

Marijke Dieltjens, MBS, PhD Associate researcher Faculty of medicine, Antwerp University, Belgium.

Benjamin Pliska, DDS, MS, FRCD(C) Assistant professor, faculty of dentistry, University of British Columbia, Vancouver, BC.

Adherence to Treatment with Removable Oral Appliances: the Past and the Future Abstract Oral appliances (OAs) are frequently used in orthodontics and for the treatment of obstructive sleep apnea. Because OAs can be inserted and removed by patients themselves, the patient’s cooperation is a major component of effective treatment. In this review, we provide an overview of factors studied in the past that affect adherence to OA use in orthodontics and dental sleep medicine. We also describe future directions in adherence and the use of objective microsensor technology to measure adherence in these patients.

Introduction Because removable oral appliances (OAs) can be inserted and removed by patients themselves, their cooperation and adherence to therapy are necessary to achieve success. 1,2

Removable OAs, such as headgear, removable retainers and functional appliances, are used in orthodontics to correct malocclusions. In the field of sleep medicine, removable OAs are increasingly used as an option in the treatment of patients with obstructive sleep apnea (OSA).

Republished with permission from the Journal of the Canadian Dental Association

The gold standard for the treatment of moderate to severe OSA is continuous positive airway pressure (CPAP); however, adherence to this

Fernanda R. Almeida, DDS, MSc, PhD Associate professor, faculty of dentistry, University of British Columbia, Vancouver, BC.


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treatment has been found to be limited. 3-5 Removable OAs, which reduce upper airway collapse by advancing the mandible, have emerged as a non-invasive treatment option for patients with OSA. These devices are similar in design to functional appliances used commonly for growth modification in orthodontics. They can be inserted and removed by patients, thus, placing responsibility on the patient to follow a prescribed wear schedule. To date, many scientific publications have addressed the issue of adherence to treatment in orthodontics and dental sleep medicine to determine how to improve and monitor patient compliance.3,6-16 However, there is controversy over the factors that might predict adherence, mainly because, in the absence of objective monitors, information has been limited to self-reported use, which is often false or overestimated. 17 Recently, objective compliance monitoring for removable OAs has become available. 18,19 In this article, we present an overview of the factors that affect adherence to treatment in both orthodontics and sleep medicine. In addition, we review the use of objective microsensor technology to measure adherence in patients using removable OAs. 17 September 2018

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Adherence to Treatment with Removable Oral Appliances: the Past and the Future

Determinants of Adherence Factors that are thought to be related to patient compliance and cooperation during therapy with removable OAs in orthodontics and dental sleep medicine include gender, age, socioeconomic status, psychosocial aspects, patient’s family and partner and the interaction between the dentist or physician and the patient. 15,20 This multifaceted system leads to complex interactions in which each individual component as well as the interplay of factors should be studied. 15, 16

Gender Patient gender is a factor commonly cited as a predictor of adherence to orthodontic treatment. Some reports suggest better adherence among female compared with male patients. 21-24 Girls tend to take a more responsible attitude toward orthodontic therapy as they mature earlier than boys. 23 On the other hand, more recent reports have failed to show gender as a significant factor in predicting adherence. 6,22,25-30 Previous findings relied on subjective measures of adherence, such as orthodontists’ judgement, which may be more a reflection of social and gender stereotypes than a valid correlation. 6 Studies using objective measures of adherence during orthodontic treatment, such as electronic sensors, have found no difference in overall wear time between genders. 6,25,29,30 Although many studies in orthodontics have examined these issues, the correlation between gender and adherence has not been thoroughly assessed in OA treatment for OSA. However, long-term discontinuation of this therapy has not been found to be different between genders. 31, 32

Age Age is also often considered to be an influential factor in adherence to orthodontic therapy. 33 Although some studies have found greater cooperation among younger patients (< 12 years), 6,7,9,28,34-37 others have found no difference. 7,22,25-27,30,38 The variation in reports on the effect of age on adherence may be confounded by variations in children’s individual psychological maturation. Teenage years are often associat-ed with decreased parental influences and cooperation. 7,36,37 Orthodontic studies focus on children, whereas OA therapy for OSA is mainly studied in adults. Although discontinuation of long-term OA therapy by OSA patients has not been found to be dependent on age, the effect of age on OA adherence has yet to be explored in this population. 31,32


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Socioeconomic Status The potential influence of a patient’s socioeconomic status on adherence has been addressed and debated in the literature. Patients with higher socioeconomic status have been shown to be more cooperative orthodontic patients. 7,21 A possible explanation is that higher socioeconomic groups perceive dentofacial appearance to be highly important for social and occupational success. 22,39 On the other hand, another study reported greater adherence among patients from lower middle-class families compared with upper-class families.40 This may be attributed to a greater need for social acceptance, higher social aspiration, better child–parent relationships and greater emphasis on value for money seen in these socioeconomic groups. Some studies also report no difference in patient adherence based on socioeconomic status. 22,38 In sleep medicine, patients with lower socioeconomic status are less likely to accept and commence CPAP therapy. 15,41 Sleeping with a spouse or partner has been found to increase adherence as the partner may provide feedback regarding elimination of symptoms, such as snoring, which may increase CPAP use. 42 Although these factors may be similar in OA therapy, this has not been assessed.

Psychosocial Aspects Considerable attention has been devoted to the examination of personality characteristics as a method to predict patients’ adherence to orthodontic treatment. 1,2,6,22,25,36,43-46 In general, cooperative patients are characterized as enthu-siastic, energetic, outgoing, self-controlled, responsible and hard working. 33 These patients tend to have better grades and show less deviant behaviour in school. 39 In contrast, uncooperative patients are described as hard headed, independent, temperamental, impatient, individualistic and intolerant of prolonged effort. 33 Based on these findings, a patient’s performance in school may serve as a useful tool in determining adherence. However, children who are of below-average intelligence do not necessarily show poor adherence. 39 Studies showing no correlation between person-ality questionnaires and adherence stated that treatment adherence and orthodontic cooperation is not reflective of a simple, single, monotonous dimension of cooperation, but rather a complex and interactive reaction. 25,22,44,46,47 The use of psychological instruments 44,45 to predict adherence has been shown to be useful, but these tools are not used in clinical practice. September 2018


Adherence to Treatment with Removable Oral Appliances: the Past and the Future

In sleep medicine, OSA patients who display significantly more hypochondriasis and psychopathic deviation, presents a potentially higher rate of discontinuation and lower compli-ance. More specifically, OSA patients with a so-called type D (“distressed”) personality, defined as a combination of negative affectivity and social inhibition, 48,49 show a signifi-cantly higher discontinuation rate for both CPAP and OA therapy. 50,53

Measurement of Adherence There are several approaches to measuring adherence. In orthodontics, the most common method relies on clinicians’ judgement. Typical clinical methods for estimating wear time of devices, such as headgear and removable OAs, include evaluation of patients’ oral hygiene, condition of the appliance, such as a worn-looking neck strap, mobility of molars, ease of patient use and missing or being late for scheduled orthodontic appointments. 21 Unfortunately, these methods are unreliable. For example, adolescent patients brought to the orthodontist’s office by a parent or guardian reflect the punctuality of the parent, not the patient. 2,6,28,52,53 As well, clinicians’ judgement is often influenced by therapeu-tic outcome. This is problematic because it assumes there is a direct link between the clinical outcome and the patient’s adherence to treatment, which is not necessarily the case. 53 Another way to monitor adherence is through patients’ self-reports: interviews, questionnaires or log records. However,thiscanleadtofalseoroverestimatedcompliance, largely because patients wish to appear more compliant than they actually are. 8,29 The best way to assess compliance is by objective measures. Investigators have attempted to provide timers and micro-sensors to record accurate details of patient compliance, and the technology used in manufacturing these microsensors has been improving over many years.

Extraoral Compliance Timers In 1974, Northcutt 10 described the first extraoral orthodontic headgear with a timing mechanism to measure wear. It worked by simultaneously turning on 2 switches triggered by the pull of the strap and pressure on the back of the neck while the headgear is worn. 10,54,55 Banks et al. 56 found that the Northcutt timer was easily circumvented by the patient placing heavy objects on the pressure switch to activate the timer without actually wearing the headgear.


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In 1991, Cureton et al. 57 described a micro-electronic approach to measuring compliance using a small ladies’ quartz calendar watch with an accuracy level of 99.9% over 20 days of testing. A limitation of such an external headgear timer is that it is bulky and diminishes patient comfort when it is placed in a neck strap. 58 The patient can also circumvent it by just stretching the band and, thereby, falsifying the wear data.52,59 In addition, many of these devices give only a cumulative overall measure of wear time and provide the orthodontist with intermittent headgear wear information and no easily accessible feedback to patients. 6,53,59,60

Intraoral Compliance Timers The ability to monitor intraoral appliance adherence is even more challenging because of the damaging effects of saliva. One of the first methods used was controlled-release glass discs 60 composed of phosphates, borates and trace elements. A disc was fitted onto the surface of an orthodontic appliance and would dissolve in saline solution indicating wear. Problems with this method included disc separation from the appliance because of poor adhesion, surface grinding of the discs leading to fragmentation and dissolving of discs at different rates. 60 More recently, a compliance indicator was introduced for aligner therapy. A food dye (erioglaucine disodium salt) is embedded in the OA and dissolves from the polymer when exposed to oral fluid. 61,62 The clinician and the patient can evaluate 5 potential colour changes (from dark blue to clear) to obtain a graphic representation of wear time and have instant feedback on adherence. However, the rating on a 5-point scale involves subjective judgement and, thus, does not yield an objective wear time. In addition, the results can be easily falsified by patients, as the dye will fade in various aqueous solutions, for example, when left in the mouth while drinking, stored in water, cleaned with tablets containing oxidizing agents or cleaned in a dishwasher. A large variation in degree of fading was found among patients who strictly adhered to the prescribed wear times. 57 In 1990, Sahm et al. 11,63 created a reed-switch, which was embedded into a bionator functional appliance and was activated by a magnet system bonded to the lingual surface of the mandibular first permanent molar. The main problem noted with this device was its bulkiness and patient discomfort. September 2018


Adherence to Treatment with Removable Oral Appliances: the Past and the Future

More recently, temperature sensitive microsensors have been used to objectively measure orthodontic OA use. These microsensors record temperature changes, assuming a difference between room and intraoral temperature. Schott and Göz 64 assessed the accuracy of 2 tempera-ture-sensitive microsensors: the Smart Retainer (discontinued production) and the TheraMon microsensor (IFT Handels und Entwicklungsgesellschaft GmbH, Handelsagentur Gschladt, Hargelsberg, Austria) using in vitro testing in a programmable water bath. They reported that the TheraMon microsensor is more accurate, with the Smart Retainer overestimating wear time by 1 h. However, the water bath was programmed to room temperature and oral temperature while not taking into account the time it takes for the water bath to heat or cool. A year later, in vivo testing of the microsensor was conducted by Schott and Göz58 on patients fitted with upper and lower active plates, functional appliances or retention devices. However, they provide only 1 case report of a patient wearing an upper appliance and no statistical analysis of the accuracy of the device. In 2013, Schott et al. 30 published a study examining the adherence rate of patients fitted with retainers or functional appliances during the retention phase of their orthodontic treatment. Although patients were instructed to wear the appliances at least 8 h/day, the median wear time was 7 h/day. The report stated that adherence rates were influenced by age, sex and place of treatment, but these differences were not statistically significant. Using the TheraMon microsensor, Pauls et al. 29 found that orthodontic patients tended to overestimate their OA use by an average of 2.7 h/day. Informing and confronting the patients with their objectively measured OA use led to a more accurate subjective estimation, with an average overestimation of only 0.7 h/day. The first report on intraoral recording of OA compliance during treatment for OSA was published by Lowe et al.65 This ceramic monitor had a memory system and temperature sensor that would monitor wear time based on temperature measured above 31°C. Several problems with this device were reported, including the damaging effect of saliva, heat intolerance of the electronic components and energy consumption over a long period. 65


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Vanderveken et al. 18 were the first to assess the safety and feasibility of the TheraMon microsensor in vivo in dental sleep medicine. In their 3-month prospective clinical trial, they demonstrated that this compliance monitor could be used safely. No adverse effects, including oral burns, lesions or detachment of the microsensor were reported by the participants. Only 1 of 51 sensors was disqualified in this study because of technical problems. Recently, long-term results with the TheraMon microsensor in dental sleep medicine showed relatively high objective OA use on 1-year follow-up. 66 To our knowledge, 3 microsensors that can be integrated into removable OAs for OSA are currently available commercially. These sensors differ in terms of data-recording interval, longevity, form of readout signals, size, weight, storage capacity and availability of a patient station, which permits patients to monitor their own adherence and upload their data remotely. Kirshenblatt et al.67 tested the accuracy of these thermosensitive microsensors in vitro using a water bath (34–37°C) to simulate OA wear time. The TheraMon microsensor was accurate during both short and long durations of simulated OA wear, whereas the AIR AID SLEEP sensor (AIR AID GmbH & Co. KG, Frankfurt, Germany) significantly underestimated OA use during short durations by 3.67 ± 9.34 min./ day, (mean and standard deviation) and the DentiTrac microsensor (Braebon Medical Corporation, Kanata, Canada) overestimated OA use during both short and long durations by 8.34 ± 3.62 min./day and 3.53 ± 2.42 min./day, respectively. However, these under- and overestimations were considered not clinically relevant.

Discussion Adherence to a prescribed treatment modality is of utmost importance in ensuring successful therapy. Lack of adherence can reduce the effectiveness of the best treatment plan and the most promising treatment mecha-nisms.5 This literature review shows that several factors have been thought to affect adherence in the fields of both orthodontics and dental sleep medicine. Studies indicating that adherence may be influenced by gender, age, psychosocial and socioeconomic factors have found wide variation among individuals. 1,25 Other factors may also be found to be important, such as cultural background and severity of

September 2018


Adherence to Treatment with Removable Oral Appliances: the Past and the Future

malocclusion/disease. Although the studies have tried to pinpoint which factors are determinants of patient adherence, this review shows that, in reality, it is difficult and challenging for clinicians to predict which patients will be cooperative. This can be explained by the fact that human behaviour is multifactorial and includes complex interactions in which each individual component, as well as the interplay of factors, should be studied. 15

different treatment modalities, such as CPAP therapy, surgery and oral appliances. For example, in the literature, CPAP therapy and oral appliances have been comparable in terms of mean disease alleviation. 18,71 It has been suggested that the greater efficacy of CPAP therapy is being offset by inferior CPAP adherence compared with OA adherence, possibly resulting in equal effectiveness. 72,73

Another important finding is that patients’ adherence significantly increases when there is some objective feedback or when they are aware of being monitored objectively. 10,34,68,69 Because patients are more motivated to change their behaviour when they know it is being monitored, there is a strong need for and interest in an objective compliance monitor for OA therapy in both orthodontics and dental sleep medicine. The use of such monitors alone may improve adherence.

In orthodontics, objective microsensors will increase the strength of evidence from studies comparing various appliances and retainer designs. Future studies using these monitors may also help identify the most appropriate wear pattern clinicians should be prescribing for the most effective treatment results.

However, the use of such devices is not part of routine daily clinical practice. A major problem with these monitors for removable OAs is accuracy. Besides the technical and functional factors, additional requirements must be met to achieve a high level of product acceptance by patients and health care professionals. Compliance monitors must be safe and small without altering the dimensions of the OA or affecting patients’ comfort; read-outs and monitoring must be easy and fast; and the sensors’ unit price must be reasonable. 70 Microsensors that have recently become available can assist with monitoring patient adherence to orthodontics treatment and OA therapy for patients diagnosed with OSA.19 Such microsensors will give clinicians a better understanding of their patients and will allow them to tailor appointment schedules to best meet patients’ individual treatment needs. These microsensors can be used as a tool to motivate patients. In addition, the availability of objective compliance data will eliminate inconsistencies in patients’ subjective reports if the data prove to be accurate.

Conclusion Removable OAs are frequently used in both orthodontics and the treatment of OSA. Many of the appliances used in orthodontic practice rely on patients wearing the devices as prescribed. Adherence is of utmost importance in ensuring successful treatment. This literature review shows that, although several factors have been thought to affect adherence, human behaviour is complex and open to multifactorial influences. Therefore, there is a strong need for and interest in objective adherence monitors for OA therapy. The availability of such monitors will allow clinicians to track patient adherence, motivate patients and improve research that compares treatment outcomes.

References 1. Gross AM, Samson G, Dlerkes M. Patient cooperation in treatment with removable appliances: a model of patient noncompliance with treatment implications. Am J Orthod. 1985;87(5):392-7. 2. Mehra T, Nanda RS, Sinha PK. Orthodontists’ assessment and management of patient compliance. Angle Orthod. 1998;68(2):115-22. 3. Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE. A systematic review of CPAP adherence across age groups:

Furthermore, it is difficult to compare tolerance to various OA devices based on subjective compliance data without proof that patients are actually wearing them. In the field of sleep medicine, objective monitoring will allow for calculation of mean disease alleviation, which depends on both efficacy and compliance for therapeutic effectiveness. 18 Calculation of real therapeutic effectiveness allows for comparison of


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September 2018



Adherence to Treatment with Removable Oral Appliances: the Past and the Future

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Dental News

September 2018

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Med. 2013;188(9):1162

Orthodontics John Lannon Special projects editor, Orthotown

Embracing ‘Sagittal-First’ Treatment The Carriere Motion 3D Appliance: Revolutionizing Class II and Class III Corrections

Q&A Dr. Luis Carrière Dr. Luis Carrière, who invented the Carriere Self-Ligating Bracket and the Carriere Motion 3D Appliance, lectures internationally on these products as well as other topics. Carrière is a member of the editorial review board for the American Journal of Orthodontics and Dentofacial Orthopedics and an invited professor at several orthodontic departments throughout the world. He maintains a private practice in Barcelona.


Dental News

What features of the Motion 3D Appliance make it so effective?

times for mixed dentition in adolescents and adults.

LC: Its sleek, noninvasive design has allowed it to revolutionize Class II and Class III correction. The appliance attaches to only three teeth, so it’s comfortable and discreet, while it also allows for the use of the progressive “sagittal first” philosophy to correct the AP at the beginning of treatment, when patients are most compliant. It delivers a gentler, more natural force for tooth movement, controlling the movement of the tooth and providing crucial corrections to the bite and tooth alignment, in preparation for treatment with fixed orthodontic appliances such as braces or clear aligners. The appliance provides shorter treatment

How does the appliance fit into Henry Schein Orthodontics’ tenet of airway-friendly orthodontics? LC: The appliance, based on the action of the human hip ball/socket joint, repositions the mandible forward as a unit for those patients who need it, and controls it with built-in stops for direct molar movement to the ideal position. This prevents over-rotations and unwanted tipping and can be an effective means of increasing a patient’s airway. It’s been astounding and exciting to watch the progression of airway-friendly orthoSeptember 2018



edition 1010th thedition Dental Facial CosmeticConference Conference & & Exhibition Dental Facial Cosmetic Exhibition A



-2 008 0







-2 008 0

09-10November November 2018 2018 09-10 InterContinental Hotel, Dubai Festival City, Dubai, UAE

InterContinental Hotel, Dubai Festival City, Dubai, UAE

Conference Programme

Conference Programme




in the DR. CHRISTIAN AdvancedMAKARY Piezosurgery Simple and Reliable PROF. Periodontics ANDREA CARLOS SABROSA Implant Era... Techniques: A clinical DR. Procedures in Modern MOMBELLI, SWITZERLAND LEBANON BRAZIL and Scientific Rationale Restorative Dentistry

Periodontics in the Implant Era...

Advanced Piezosurgery Techniques: A clinical and Scientific Rationale


Coming soon

Aesthetic Dentistry and DR. RAMAN S AULAKH Clear Aligner Therapy UK

Aesthetic Dentistry and Clear Aligner Therapy


Management of Anterior DR. MATTHEW HOLYOAK Tooth Trauma UK

Management of Anterior Tooth Trauma




Advances in Composite Restoration DR. RICCARDO AMMANNATO, ITALY

All About Esthetic Composite Restoration -DR. Direct and RAHM Indirect SYLVIA Procedures GERMANY

Influence of Vertical Dimension on Facial Aesthetics PROF. PAUL TIPTON UK


Guided Bone Coming soon Regeneration in Simple and Complex Ridge PROF. CRISTIAN DINU DR. DAVIS THOMAS Augmentation ROMANIA USA

Guided Bone Regeneration in Simple and Complex Ridge Augmentation NEW

Simple and Reliable Procedures in Modern Restorative Dentistry


Advances in Composite Restoration

All About Esthetic Composite Restoration - Direct and Indirect Procedures

Influence of Vertical Dimension on Facial Aesthetics





The Face and Tooth Integration in Modern Dentistry. New Insights

DSD Concept in Integration with Facial Analysis

The Biomimetic Smile Makeover – Conserving and Strengthening Tooth Structure while Transforming a Smile DR. MARC LAZARE USA

Digital Occlusion and Neuromuscular Paradigm



The Face and Tooth

DSD Concept in

The Biomimetic Smile


Digital Occlusion and

Integration in Modern with Facial – Conserving Neuromuscular Target Group: Dentists,Integration Dental Team, DentalMakeover Students, Dental Industry, Dental Hygienists Dentistry. New Insights Analysis and Strengthening Paradigm Accreditation: 14 CE Credits | Est.Tooth DHAStructure 12 CME | Est. HAAD 12 CME while Transforming a Smile

Tel: +971 4 347 6747 | Mob: +971 50 2793711 | E: Target Group: Dentists, W: Dental Team, Dental Students, Dental Industry, Dental Hygienists Accreditation: 14 CE Credits | Est. DHA 12 CME | Est. HAAD 12 CME


Embracing ‘Sagittal-First’ Treatment

dontics in our industry. Orthodontists everywhere are realizing how they’re able to provide patients with more than just beautiful smiles—they also can provide the opportunity for patients to live healthier, happier lives, which is a strong aspect of HSO’s culture.

How does the appliance time?

shorten treatment

LC: Class II or Class III correction takes place at the beginning of the orthodontic treatment, when there are no competing forces in the mouth caused by brackets or other appliances. This is also when the patient is the most

motivated and compliance is at its highest. Treating to the Class I platform is made simple and usually completed in three to four months. Each Motion 3D Appliance addresses its intended sagittal dimension to reduce the need for extractions or surgery, and also helps reposition the jaws in better relation to one another, balancing the relationship between the nose, upper and lower lips, and chin for facial harmony. Both are biomimetic in function and consist of a small single-part design. This offers patients considerable freedom of movement for significantly greater comfort than traditional AP correctors.

Changing the patient experience for the better

Q&A Dr. John Graham Dr. John Graham is an innovator and educator who lectures internationally to both doctors and orthodontic staff on orthodontic treatment philosophies. He holds faculty appointments at the University of the Pacific Arthur A. Dugoni School of Dentistry and the University of Rochester Eastman Institute for Oral Health. Graham sits on the editorial board for Orthotown and is a contributing editor for the Journal of Clinical Orthodontics and a reviewer for Orthodontics: The Art and Practice of Dentofacial Enhancement. He lives in Salt Lake City.

The Carriere Motion 3D Appliance fits into the HSO tenets of airway-friendly orthodontics, shorter treatment times and the “sagittalfirst” philosophy. Explain how it’s used in your practice, and the results you’ve seen. JG: The “sagittal-first” philosophy using the Motion 3D Appliance is a real paradigm shift in the way orthodontists treat patients. It helps me reduce patient treatment times—sometimes by up to one year. It’s so rewarding to offer this treatment concept because I no longer receive hesitation from patients, especially adults, about moving forward with treatment. I get to explain that they won’t be making a commitment to wearing braces for two years—most likely, it will be around a year or less.

How do the appliances work with clear aligner therapy? JG: The orthodontist and the patient don’t have to make


Dental News

a decision between braces or aligners before the patient starts treatment—we can think about it while the AP is being corrected. This new treatment method allows me to treat more cases with clear aligners. The Motion 3D Appliance allows me to easily turn complex Class II patients into Class I patients; previously, a complex case would not be suitable for aligner treatment. Also, using the appliance allows you to empower patients to be compliant. As you watch them through the AP correction, you can see if they’re a good fit for aligners.

How did you get your staff on board with this shift? JG: For an orthodontist to succeed with any new treatment philosophy, you need to have buy-in from your staff. The great thing for me when I introduced the “sagittal-first” concept to my staff is that it made total September 2018

sense to them that the heaviest lifting we do in ortho, which is generally the AP correction, should take place at the beginning of treatment, rather than after the patient has already been in braces for a year or longer.


With the “sagittal-first” philosophy, I am able to achieve AP correction on average in just three months! AP correction used to take a year and at the end of treatment, when no patient was interested in being compliant anymore. Also, because the Motion 3D Appliance is so discreet, patients don’t think of themselves in treatment even though they are.

JG: I’m able to confidently tell my patients that their treatment time should take a year or less.

You’re able to get patients to commit to being cooperative at the beginning of treatment, when they are excited about the impact braces will make on their lives.

Which benefits does the Motion 3D Appliance offer that haven’t previously experienced?

Going Straight to the Source Henry Schein Orthodontics’ mission is to provide stateof-the-art orthodontic products and innovative clinical solutions that enable its customers to offer exceptional patient care while expanding the scope and profitability of their practices. The company continues to grow as a global orthodontic solutions provider by not only providing high-quality products but also going beyond the typical supplier/client relationship, instead cultivating partnerships with its customers so they can deliver positive patient outcomes and maintain healthy, successful businesses.

For more than 40 years, Henry Schein Orthodontics has manufactured most of its products in the United States, including at its 65,000-square-foot corporate building in north San Diego. Among its offerings is the Carriere System, which incorporates the latest advances in orthodontic technology with gentle forces that work with natural physiology to correct a bite at the beginning of treatment. By utilizing the Carriere Motion 3D appliances in the beginning stages and then transitioning into Carriere SLX Self-Ligating Brackets to complete treatment, the total time in treatment is greatly reduced when compared with other traditional approaches.

HSO’s wide array of orthodontic offerings include brackets and bands, intraoral appliances, elastomerics, archwires and temporary anchorage devices. Other solutions include innovative orthodontic products and progressive continuing education opportunities to help fuel the growth and success of orthodontic practices in more than 75 countries.

“Shifting to the Carriere Motion 3D Appliance has been one of the most significant treatment advances I have implemented during the past five years,” says Ron Maddox, a San Dimas, California-based orthodontist. “I’ve been able to reduce the overall treatment time and significantly reduce the time that my patients are in braces.”

Advertorial Dr. Andres Baltzer Basel, Switzerland

Figure 1A and 1B: A core buildup and acrown were used to restore the root-treated tooth 12; the partially damaged toot 11 was restored with a veneer. VITABLOCS Mark II was used in both cases. Perfect matching of shades could have hardly been accomplished with different materials. Complex fabrication processes and temporary restorations were avoided thanks tochairside treatment in a single appointment.


Dental News

VITABLOCS: All-Rounders for Single Tooth Restorations CAD/CAM supported restoration of single teeth using the fine-structure feldspar ceramic VITABLOCS Mark II and the polychromatic, layered VITABLOCS TriLuxe and TriLuxe forte variations (VITA Zahnfabrik) has become established in numerous dentist practices worldwide.

When using the overpressing technique andwhen fabricating sintered crowns, each unit requires much more time and higher manufacturing costs. The VITABLOCS Mark II ceramic enables fully anatomical restorations and reduced structures, which can be individualized later on.

The clinical procedure has been tested and proven over many years. The success of this all-round ceramic material in the area of single tooth restorations is based on the combination of numerous advantageous properties, which, among others, include profitability, esthetics and flexibility. In the following, some clinical cases are used to demonstrate these advantages.


Profitability Compared to other types of dental restorations, such as reduced and veneered substructures, fully anatomically designed, mono-ceramic CAD/CAM restorations ensure high profitability.

Since the feldspar ceramic blocks VITABLOCS Mark II, TriLuxe and TriLuxe forte are suitable for all single tooth restorations (table 1), they ensure perfect combination and harmony of materials, which is desired for esthetic reasons.

Fig. 1A

Fig. 1B

In cases of a crown restoration on a tooth and a veneer on an adjacent tooth, it is not possible to achieve an identical visual appearance using different materials. In such cases a material should be selected which can be used for both indications (fig. 1a and 1b).

September 2018


94th Annual session

NO PRE-REGISTRATION FEE Meeting Dates: November 23-28


Exhibit Dates: November 25-28





The Largest And Most Popular Dental Meeting/ Exhibition/Congress In The United States

Greater New York Dental Meeting™

200 West 41st Street - Ste. 800 / New York, NY 10036 USA Tel: (212) 398-6922 / Fax: (212) 398-6934 E-mail: / Website:


VITABLOCS: All-rounders for Single Tooth Restorations

Preparation and cementation Today “smooth” designs without stress-causing edges and corners are recommended for the preparation of all-ceramic restorations 1. More and more dentists prefer the round diamond instrument instead of the classic fissure bur. Adhesive cementation of the restorations is mandatory to achieve permanent resistance to stress comparable to zirconium oxide crowns fixed with glass ionomer cement 2, 3, 4. In cases of epigingival (not subgingival) preparation margins, drying, intraoral scanning and final cementation can be completed without any major problems. Since the silicate ceramic provides an excellent chameleon, the preparation margin can no longer be seen after adhesive cementation, grinding and polishing of the restoration. In cases of deeper preparation margins, surgical lengthening of the clinical crown is recommended. Subgingival margins are difficult to control so that – in many cases – a supragingival position is obtained due to periodontal recession. Naturally, there are also situations in which subgingival preparations margins are required.

Such cases, however, can also be treated with a chairside or semi-chairside sandwich crown (VITA YZ + VITABLOCS Mark II) prepared in a single appointment.

Range VITABLOCS Mark II blocks are available in ten VITA SYSTEM 3D-MASTER and in three VITA classical A1-D4 shades. In addition to the monochromatic VITABLOCS Mark II, there are also the polychromatic block types VITABLOCS TriLuxe and TriLuxe forte with three and four harmoniously matched shade layers. VITABLOCS TriLuxe can be used to fabricate restorations which simulate the higher cervical chroma and the increased incisal transparency of natural teeth (fig. 2). Treatment can be completed chairside in a single appointment. Time-consuming and complex subsequent thermal treatment and staining are not required. Glaze firing to achieve characteristic shade effects can, but does not need to be, carried out.

Table 1: The entire range of single tooth ceramic restorations is covered with the fine-structure feldspar ceramic of VITABLOCS Mark II, TriLuxe and TriLuxe forte. Depending on the requirements, the restorations can be fabricated chairside, semi-chairside and labside. Subsequent thermal treatment is not required; glaze firing can be carried out. The ceramic exhibits excellent processing characteristics and problems of chipping have hardly been reported.


Dental News

September 2018

Fig. 2

2. The result, which features esthetic and natural shade, shape and surface structure, was achieved by reworking in the dental laboratory and subsequent glaze firing performed chairside. Digital shade measurement confirms the good visual impression of the restoration made from VITABLOCS TriLuxe (fig. 4a - 4c). Fig. 4A

Fig. 2: When using VITABLOCS TriLuxe and TriLuxe forte, the restoration can be placed individually in the polychromatic block using the milling preview.

Clinical examples Not highly demanding cases but examples of daily routine work are listed below for documentation purposes. The examples given are limited to anterior restorations. 1. Tooth 21 was simply restored with VITABLOCS TriLuxe and manual polishing was carried out subsequently. In this case, less emphasis needs to be put on the esthetic appearance. The target was to fabricate a favorably priced restoration for the patient (fig. 3a, 3b.)

Fig. 4B

Fig. 3A

Fig. 3B Fig. 4C

Fig. 3a and 3b: Efficient solution: manually polished crown made from VITABLOCS Mark II.

Fig. 4a to 4c: A perfect shade and surface structure were achieved.


VITABLOCS: All-rounders for Single Tooth Restorations

3. Light colors (Tetric Color, Ivoclar Vivadent) were applied to the severely discolored, prepared teeth to add the desired color depth (see also contrast photo) to the translucent ceramic (VITABLOCS TriLuxe) with a basic shade of 2M2. Perfect imitation of the shades of adjacent teeth is achieved by the slightly yellowish color of the cervical areas - obtained with glaze material (fig. 5a to 5f). Fig. 5A

Fig. 5D

Fig. 5B

Fig. 5E

Fig. 5C

Fig. 5F

Fig. 5a to 5f: The crowns made from VITABLOCS TriLuxe exhibit natural color depth and are harmoniously integrated into the dentition. The restorations were fabricated and fitted in a single appointment in a way to ensure high profitability.


Dental News

September 2018



The feldspar ceramic VITABLOCS from VITA Zahnfabrik is an all-round ceramic since it is suitable for all types of single tooth restorations. With more than 16 million restorations, the material has proven its clinical suitability all over the world. The fine structure features an abrasion behavior identical to that of natural enamel. Thanks to the homogeneous type of structure, the VITABLOCS ceramic can be easily polished and milled in a way to reduce tool wear. The high translucency of the ceramic ensures perfect integration into the residual tooth substance.

1. Arnetzl, G.; Arnetzl, V.: Präparation für vollkeramische Restaurationen. Universitätsklinik für Zahn-, Mund- und Kieferheilkunde, Graz (2008). 2. Frankenberger, R.: Adhäsivtechnik 2009 – Neuigkeiten, Tipps und Trends. In: Quintessenz, 60(4); 415-423 (2009). 3. Hämmerle C. et al.: Dentale Keramiken, Aktuelle Schwerpunkte für die Klinik. Universität Zürich, (2005). 4. Zahran, M.; El-Mowafy, O.; Tam, L. et al.: Fracture Strength and Fatigue Resistance of All-Ceramic Molar Crowns Manufactured with CAD/CAM Technology. In: J Prosthodont., Mar 17 (2008).

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Lebanese Society of Endodontology June 21 - 22, 2018 Hilton Habtoor Grand Beirut, Lebanon

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Picture from the opening ceremony The main goal of this event is to honor the Lebanese Endodontists who trusted their dreams and excelled in the Endodontic field. Each one of these Lebanese Endodontists Members of LSE left his fingerprint in the progress of endodontics whether in the Concepts, Techniques, instruments, materials or devices. The start of this legacy in Lebanon and the region was with one of the fathers of endodontics Prof. Elie Maalouf, the main Founder of our Society, Following Professor Ghassan Yared inventor of Reciprocs and Reciprocation coming from Canada. Dr. Philippe Sleiman, inventor of SP pluggers Hu-Friedy, cryotherapy technique in RCT, sequence of irrigation, apiectomy, coinventor of TF instrument and has a book about ultrasonics. Prof. Walid Nehme, one of the team developing 2 Shape and one flair from MicroMega. Prof. Roger Rebeiz leader in the field of education and developing instruments. Prof. Rebeiz is founder of Dental College Past President of LSE. Prof. Issam Khalil Past President LSE developer of MMTA and BioMM a new bioceramic Material. Prof. Edmond Koyess Past President LSE involved in education since 30 years and actual director of post-grad program at the Lebanese University. Prof. Rola Abiad vice Dean of BAU and also involved in Endodontic Education and worked on Laser Doppler flow meter. Prof. Charbel Allam pioneer in the endodontic surgery field and developer of surgical techniques and instruments. Dr Allam is a reference to all endodontists in this field. Prof. Edgard Jabbour leader in the world of endo surgery and in extraction and direct implantation in case of failed root canal treatment and also in complex cases of bone grafting . Dear all, you have been exemplary for the coming endo generations with your devotion, knowledge, expertise and the way of teaching and in transmitting the bug of endo which leads to an incurable disease! We at the LSE, have also trusted our dreams and each year we try to challenge ourselves and upgrade our event, as we have one main goal ahead of us which is to deliver to our endodontic and dental community the best of knowledge and science through lectures, workshops, exhibition and Live Demos.

Dr Edward Rizk,

President of the Lebanese Society of Endodontology 64

Dental News

Welcome again to our rich event, Enjoy!

Edward Rizk President, Lebanese Society of Endodontology September 2018



Two files to shape

Safety Proprietary Heat Treatment process

Quality of cleaning Usability

Increases flexibility Minimizes the risk of instrument fracture

Clinical case

Shaping using 2Shape: TS1 & TS2. Dr. Jean-Philippe Mallet, France



5-12 rue du Tunnel - 25006 Besançon Cedex - France -

Pr Roger Rbeiz receiving his trophy from Dr Marc Kaloustian

Pr Ghassan Yared receiving his trophy from LSE president Dr Edward Rizk

Dr Filippo Santarcangelo talking about the anatomically guided shaping

Pr Philippe Sleiman talking about the role of irrigation in Endo

L to R: Dr Edward Rizk, Pr Joseph Sader, Pr Hrant Kaloustian, Dr Marc Kaloustian Drs: Edgard Jabbour, Edmond Koyess, Carla Z Moubarak

Photo from the Exhibition 66

Dental News

September 2018

Dr Carla Zgheib Moubarak, Pr Stephen Niemczyk

L to R, Drs: Marc Habib, Tony Harb, Hareth AbdelSater, Walid Nehme, Carla Zgheib, Edward Rizk, Ghada Bassil, Alexandre Mulhauser

L to R: Walid Nehme, Laurent Bataillard, Ghada Bassil, Omar Bahgat

Drs Elie Rouphael, Salim Kassis, Charbel Allam

Photo with a group of the audience with the LSE board members

Lebanese Orthodontic Society 16th Annual Meeting

With Tunisian Association of Research & Studies in Orthodontics June 22 - 23, 2018 Mรถvenpick Hotels & Resorts Beirut, Lebanon

of the

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Picture from the opening ceremony 16th Lebanese Orthodontic Society Annual Meeting Ladies and Gentlemen, It gives me great pleasure to extend to you all a very warm welcome on behalf of the Lebanese Orthodontic Society Board and committees to this joint Tunisian-Lebanese Scientific Meeting between the Tunisian Association of Research and Studies in Orthodontics and the Lebanese Orthodontic Society which happens to concur with the 16th Annual Meeting of the Lebanese Orthodontic Society. It was a real privilege to organize and launch this congress with our colleagues from Tunisia, country where Phoenician immigrants who then came to be Lebanese Ancestors, founded Carthage in the 12th Century BC. Thus, this empathy could have been generated from these shared ancestors. I would like to recognize the hard work of all previous Lebanese Orthodontic Society Presidents and all committees and individuals for their precious contributions to establish a solid base on which we will continue to build in order to achieve all the aforementioned goals.

Dr Mona Sayegh Ghossoub president of the LOS

And now I declare opened the Lebanese-Tunisian congress which coincides with the 16th Annual Meeting of the Lebanese Orthodontic Society.

Dr. Mona Sayegh Ghossoub President of the Lebanese Orthodontic Society

Dr Adel Ben Amor president of the Tunisian Association of research in Orthodontics 68

Dental News

Exchange of trophies between the Lebanese Society of Orthodontics and the Tunisian Society September 2018












Featuring Six Hands-On Workshops


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Dr Joseph Ghoubril,

president of the scientific committee

L to R Drs: Adel Ben Amor, Saad Nafaa, Fadi Gaith, Chafic Tabbara

Dr Roy Sabri lecturing about management of dental trauma

Dr Naji Abou Chebl talking about

the rotation of the occlusal plane

Dr Gilberto Sammartino receiving the certificate from Dr Adel Ben Amor Dr Mohamed Salah Khalfi receiving the certificate from Dr Mona Sayegh

Dr Bachar Reda receiving the certificate from Dr Zouhair Skaf and Antoine Darazi 70

Dental News

September 2018

Pr Dirk Wichmann explaining lingual orthodontics

Mรถvenpick Beirut June 22 - 23

LOS 2018

Dr Samir Tobji talking about the dynamics of the brackets

Dr Fayez Saleh lecturing about

the correction of the gummy smiles

Trophy Distribution to Dr. Josephine Bouery

T Trophy Distribution to Dr. Rhea Souaid

Trophy Distribution to Dr. Carla Daou Trophy Distribution to Dr. Corine Samaha

Trophy Distribution to Dr. Ghandour

Trophy Distribution to Pr. Amine El Zoghby

Exhbition Floor

LOS 2018

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Byblos Dental Association 25th Summer Dental Meeting June 23, 2018 Eddésands Hotel & Resort Jbeil, Lebanon

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L to R: Dr. Elie Rouphael, Prof. Carlos Khairallah, Dr. Martin Bakhos (LABD), Prof. Toni Zeinoun Under the patronage of the Lebanese Dental Association represented by its president Prof. Carlos Khairallah, the Byblos Dental Association (BDA) and the Lebanese Association of Dentists graduated from Belgian Universities (LADB) held their 25th Summer Dental Meeting on Saturday June 23, 2018 At é Byblos Hall - Eddésands Hotel & Resort - Jbeil.

Dr. Ziad Salameh

Photo from the Audience

Dr. Elie Rouphael, Dean Essam Osman, Dean Joseph Makhzoumi September 2018

Photo taken during the Lunch

Dr. Rawad Samarani Dental News


Lebanese Society of Pediatric Dentistry Silver Jubilee’s Convention June 26, 2018 The Key ApartHotel Beirut, Lebanon

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Photo of Past and Actual Board Committee Members of the Lebanese Society with the Founder Prof. Elia Sfeir and Past Presidents The Lebanese Society of Pediatric Dentistry celebrated its silver jubilee within a convention with Hachem Dental Care’s exclusive sponsorship at the Key Aparthotel on the 26th of June, 2018. This scientific meeting was in collaboration with the department of pediatric dentistry at the Lebanese University, Saint Joseph University and Beirut Arab University. Hachem Dental Care introduced their Kiddy Caps Crowns product during this convention with the creator and developer Mr Mattias Finzelberg from Germany.

“ We reached today a highly professional level of scientific meetings with the Lebanese Society’s conventions year after year since 1992. Every past president increased the standard of communication between all pedodontists and even among other societies abroad. We will follow that pathway for the three years to come and work hard for an optimal level and make sure that we will be chapters in other professional societies to make us more scientifically exposed. ”

Dr. Bechara Al Asmar, Elected President, LSPD

Prof. Samia Abou Jaoudeh, Past President 74

Dental News

Dr. Bechara Al Asmar President, Lebanese Society of Pediatric Dentistry

Prof. Maha Daou, Speaker

Prof. Cherine Badr, Speaker (Rep. Dean Osman) September 2018

Mr. Mattias Finzelberg, Creator & Developper of Kiddy-Caps

Prof. Elia Sfeir, Speaker

L-R: President Prof. Roula Dib, Dean Prof. Tony Zeinoun, Profs: Nada Mchaileh, Amine El Zoghbi, Mona Nahas, Jean-Claude Abou Chedid

Dr. Hassan Bacho, Speaker

L-R: Mr. Joseph Nader, Mr. Chawki Hachem, Mr. Mattias Finzelberg, Profs: Tony zeinoun, Amine El Zoghbi, Samia Abou Jaoudeh, Dr. Michel Salameh

Prof. Samia Abou Jaoudeh, Prof. Amine El Zoghbi (Rep. Pres. LDA), Dr. Bechara Al Asmar

Prof. Nada Mchaileh (Rep. Dean Makhzoumi), Dr. Toni Dib, Prof. Samia Abou Jaoudeh

Prof. Mona Nahas, Dr. George Abi Hatem, Dr. Hitaf Nasseh 76

Dental News

September 2018

L-R: Dr. Maya Ayoub, Prof. Nada Chedid, Prof. Roula Dib, Dr. Hitaf Nasseh

The Key Beirut June 26

L-R: Dr. Claire Hachem, Dr. Camille Samneh, Prof. Jean-Claude Abou Chedid, Prof. Marlene Khoury, Dr. Michel Salameh

Dr. Sandra Dagher (Vice President LSPD), Dr. Guitta Abi Nasr (General Secretary LSPD)

LSPD 2018

Prof. Riad Bacho, Prof. Balsam Soubra, Dr. Mohamad Ezzeddine

Hachem Dental Care Team with Mr. Mattias Finzelberg

L-R: Dr. Camille Samneh, Professors: Nada Mchaileh, Roula Dib (President LDA North), Samia Abou Jaoudeh, Amine El Zoghbi, Dean Tony Zeinoun, Drs: Guitta Abi Nasr, Mohammad Ezzeddine, Sandra Dagher, Prof. Jean-Claude Abou Chedid, Dr. Michel Salameh

Product News

Osstell Adds Next Level in Implant Stability Measurement Instruments Osstell, the developer of the ISQ diagnostic technology (Implant Stability Quotient), now presents the next leap in the evolution of implant diagnostic instrumentation: The Osstell BeaconTM, an innovative and highly intuitive tool designed to guide implant treatments for more predictable results. Osstell’s patented technology allow clinicians working with implants to make decisions based on reliable and objective stability values when determining the course of treatment for each patient. The procedure can be used to measure primary implant stability, observe osseointegration based on secondary stability readings and determine the best possible time for loading the implant, thereby helping to prevent failures, shortening healing time and ensuring high quality.


Dental News

The dental implant market has changed over the past few years. There are now more dentists with less experience within implantology and a generation shift with different expectations is coming. Clinicians are facing more complex decisions as there is an increase in patients with risk factors as well as increasing demands for shorter treatment times. Digital planning and workflows are redefining protocols and techniques. There is thus a need for objective tools to increase efficiency, and to guide and optimize the implant treatment for both complex and more straight-forward cases, making ISQ diagnostics a necessary and objective key value to help improve outcomes and quality.

September 2018

“We have listened to our users who need advanced technology in the form of an easy-to-use and intuitive complete product concept for the Osstell approach. Accordingly, we have developed a complement to the more comprehensive Osstell IDx to meet the needs from both large University clinics and small private practices. For clinicians that are new to this method and technology, the feedback from the color coding, which essentially is an extract of all the scientific data that the Osstell ISQ scale is based on, will provide a guide as to when to load the implant.” - Stefan Horn, VP Product Development, Osstell.

In the industry today, there is a lot of talk about connectivity, Internet of Things and big data. With this comes a strong need to, not only capturing the data, but also to be able to provide context to the numbers, to turn it into something useful and insightful. That’s why we are continuously focusing on enhancing connectivity and Osstell Connect, our online service where you can analyze your data and get relevant insights of your implant treatment performance.

“Osstell’s innovative and patented technology allow dentists around the world to make dental implant treatments even safer and more predictable, and thereby helping clinicians improve patient confidence and comfort. We always aim to serve our customers and users with even better products and services as well as helping them to provide best practice services to their customers – the patients. Patients’ well-being is always the top priority.

We believe this will only become more and more valuable for the clinicians.”, continued Mr. Horn. Both the Osstell Beacon and the Osstell IDx give you access to Osstell Connect.

With this – the Osstell Beacon – being newest addition we take another important major step towards making our technology, products and our approach even more accessible”, says Mr Jonas Ehinger, CEO of Osstell.

From 14 - 17 November 2018

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