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18th Kuwait Dental Association International Scientific Conference


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Volume XXII, Number I, 2015


26th Saudi Dental Society International Dental Conference

AEEDC 2015

19th UAE International Dental Conference, Dubai

Dental News, Volume XXII, Number I, 2015


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Variations of Periotest Values at Different Prosthetic Implant Stages: A Pilot Study


November 19 - 22, 2014 Jumeirah Messilah Beach, KUWAIT

Dr. Elias Smaira, Dr. Mireille Rahi, Dr. Najib Abou Hamra, Dr. Danielle El Hakim

60. 18.

How to Prevent Failure of Veneered Zirconia Ceramic Dr. Ghassan Moustapha, Dr. Habib Abi Aad, Dr. Elias Smaira

KDA 2014 - 18th Kuwait Dental Association International Scientific Conference

SDA 2014 - 8th Sudanese Dental Association Conference December 2 - 4, 2014 Khortoum, SUDAN


SDS 2015 - 26th Saudi Dental Society Int’l Dental Conference January 13 - 15 Riyadh, KSA


Polyamide Resins in Removable Dentures Dr. Danielle El Hakim, Dr. Mireille Rahi, Dr. Najib Abou Hamra, Dr. Elias Smaira


AEEDC 2015 - 19th UAE International Dental Conference & Arab Dental Exhibition February 17 - 19, 2015 Dubai, UAE


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*With twice-daily brushing References.. 1. Jeandot J et al. Clinc (French) 2007; 28: 379–384. 2. Nagata T et al. J Clin Periodontol 1994; 21(3): 217–221. 3. GSK data on file. DOF Z2860473. 4. Leight RS et al. J Clin Dent 2008 19(4) 147-153. 5. Schemehorn BR et al. J Clin Dent 2011 22(1) 11-18. 6. Shellis RP et al. J Dent 2005 33(4) 313-324. 7. GSK data on file. DOF Z2860415. 8. GSK data on file. DOF Z2860435. Arenco Tower, Media City, Dubai, U.A.E. Tel: +971 4 3769555, Fax: +971 3928549 P.O.Box 23816. For full information about the product, please refer to the product pack. For reporting any adverse event/side effect related to GSK product, please contact us on Prepared: December 2014, CHSAU/CHSENO/0034/14f. We value your feedback Saudi Arabia: 8008447012 All Gulf and Near East countries: +973 16500404

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w w Volume XXII, Number I, 2015 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 Elie Hajj SUBSCRIPTION Micheline Assaf, Nariman Nehmeh ADVERTISING Josiane Younes PHOTOGRAPHY Albert Saykali TRANSLATION Gisèle Wakim, Marielle Khoury DIRECTOR Tony Dib ISSN 1026-261X

DENTAL NEWS IS A QUARTERLY MAGAZINE DISTRIBUTED MAINLY IN THE MIDDLE EAST & NORTH AFRICA IN COLLABORATION WITH THE COUNCIL OF DENTAL SOCIETIES FOR THE GCC. Statements and opinions expressed in the articles and communications herein are those of the author(s) and not necessarily those of the Editor(s) or publisher. No part of this magazine may be reproduced in any form, either electronic or mechanical, without the express written permission of the publisher.

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Dental News, Volume XXII, Number I, 2015

12 Implant Dentistry

Variations of Periotest Values at Different Prosthetic Implant Stages: A Pilot Study Abstract Dr. Elias Smaira

Periotest values seem to differ between the gingiva former, abutment placement and after single crown cementation on implants.

Material and Methods Dr. Mireille Rahi

Dr. Najib Abou Hamra

28 patients were selected and measurements were taken on 42 implants at the gingiva former level, abutment level and after single crown cementation. Mean values of all stages were then calculated and compared.


Dr. Danielle El Hakim

An increased mean value of 2.7 was noted between the gingiva former and single crown final stages.

Conclusion Positif Periotest values on implant single crown might be considered normal when the healing abutment measurements range between -3 and 0.

Introduction To evaluate the degree of osseointegration, various methods have been proposed: histology and histophotometry,1 removable torque analysis,2 pull and push through tests3 and x-ray examination.4 However, due to problems of invasiveness and inaccuracy new devices were needed. The Periotest device (Siemens AG, Bensheim, Germany) Fig.1 is an instrument specially developped for the diagnosis of periodontal diseases.5 It can also be used to assess the bone anchorage of implants6,7,8 and monitor their stability.9 The range in Preiotest速 values (PTV), shown by clinically immobile dental implants, depends on the damping characteristics of the surrounding tissues (bone in successful implants and fibrous tissues in failed implants).10 Dental News, Volume XXII, Number I, 2015

Periotest measurements give better results when measurements are made bucally during intra and interobserver tests. It is a reliable technique for the quantification of the implant stability.11 When comparing the Periotest to other systems, the Periotest is reliable on implants with a good stability and is more reliable when implants are less stable.12 A successful implant value should be inferior to zero as directed by the fabricant, but some positif measurements were collected on well anchored implants when taken at different steps of the prosthetic treatment. That is why further investigation was needed. The purpose of this study was to determine the periotest mean values of measurements for implants at 3 different restoration stages: gingiva former in place, abutment screwed on implant and single crown after cementation, in order to determine the variations of these mean values. Fig 1

Fig 1: Periotest Device

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14 Implant Dentistry Material and Methods

Fig 2

42 implants (36 Deukega, 6 Zimmer suiss plus) on 28 patients were selected for the periotest measurements: 15 in the mandibule and 27 in the maxilla. The mean age of the patients was 52.2, the youngest was 38 and the eldest 74 years old. 16 weeks after implant placement the measurements at each implant were taken, first with the gingiva former in place, then with the crown abutment (Deukega solid abutment) Fig. 2, and finally after delivery of the final single crown. The prostethis was delivered in an average of 18 weeks after implant placement. The crown abutment was fastened with a torque ratchet at 30N. The crown measurement was performed after cementation with glass ionomer luting cement (Ketac Cem 3M Espe). The periotest measurement was performed as directed by the fabricant and: 2mm above the cervical gingiva. At least two measurements were made for each implant, if measured values were divergent, the measurement was continued until two subsequent values were identical.13 This value was then noted on the data sheet. Mean values on each three groups were calculated and compared, using descriptive Fig 3

4 2 0

Gingival Former

Crown Abutment

Single Crown


High Low Close

-4 -6 -8 Fig 3: Difference between the three stages values Dental News, Volume XXII, Number I, 2015

Fig 2: Deukega Solid Abutments

statistical tests (mean and averages), in order to determine the difference between the three groups.

Results Table 1 and fig. 3 show the average differences and changes in the periotest measurements between the values of the placed gingiva formers, crown abutments, and recently placed single crowns. These changes amounting to -1.47 or -1.23 significantly differed from 0. The periotest value increased by 2.7 from gingiva former stage until the single crown placement.

Discussion The Periotest device has the advantage of measuring the implant stability at any stages from implant placement to crown elaboration and even many years after the crown cementation. Most of the studies determined the reliability of Periotest on implant stability with all measurements taken at the gingiva former stage only.11 German et al. conducted a study comparing the measurements of the Periotest at the 3 stages of the crown elaboration (gingiva former, abutment placement, crown cementation) using 2 different types of abutments. They found a main value increase of 3.5 between measurements taken at the gingiva former stage and at the final single crown cementation.13 To check these findings using one type of abutments instead of two was of great interest. It was obvious that Periotest measurements at the three stages were not identical and were increasing. (fig 2) The Periotest measurements on implants were made 2 mm above the cervical gingiva in order

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16 Implant Dentistry

Table 1

Crown Abutment

Gingiva Former

Single Crown

Average Change



Maximum Change



Minimum Change



Total Average Change = -2.7 Table 1 : individual differences in Periotest values

to eliminate the moment effect. In tissue level implants, this hitpoint will be almost at the same distance from the implant neck for all the implants included in this study. On average, the increased mean value of 2.7 indicates that a positive measurement does not necessarly show a failure. For example, an implant measurement on the healing abutment of -1.5 can lead on average to a +1 to +2 measurment on the single crown. If the fabricant considers zero to be the reference for success of osseointegration this number should be reconsidered when the measurements are performed on the crown itself. The increased mean value may be due to the cement layer interface and to the modulus of elasticity of the abutment screw. Periotest measurments might represent a reliable method for the assessment of the implant-bone interface. If measurements are taken after crown cementation one should take into consideration the increased mean value of 2.712-14-15

Conclusion Periotest values measured at gingiva formers increased on average by 2.7 after crown cementation. While measurements on the abutment revealed a mean increase of 1.23. Finally, positif Periotest measurements on single crown should be considered as normal when values on healing abutment are between -3 and 0. Dental News, Volume XXII, Number I, 2015

References 1. Ericsson I, Johansson CB, Bystedt H, Norton MR. A


phometric evaluation of bone to implant contact on machine-prepared and roughened titanium dental implants.

Apilot study in the dog. Oral Implant Res.1994;5:202-206. 2. Wennerberg A, Alberktson T, Anderson B, Krol JJ. A histomorphometric and removal torque study of screw shaped titanium implants with three different surface topographies. Clin.Oral Implants Res.1995;6:24-30. 3. Dhert WJ, Verheyen CC, Braak LH, De Wijn JR, Klein CP, De Groot K, Rozing PM. A finite element analysis of the push-out test: Influence of test conditions. J.Biomed.Mater.Res.1992;26:119130. 4. Meredith N. Assessment of implant stability as a prognostic determinant.Int.J.Prosthodont.1998;11:491-501. 5. Shulte W, Lukas D, Ermst E. periotest values and tooth mobility in periodontal disease: a comparative study. Quintessence Int 1990;21:289-293. 6. Huang H.M., Chiu C.L., Yeh C.Y., Lin C.T., Lin L.H., Lee S.Y. Early detection of implant healing process using resonance frequency analysis. Clin. Oral Implants Res. 2003;14:437–443. 7. Chavez H,Ortman Lf , De Franco RL, Medig J.Assessment of oral Implant mobility. J,Prosthet.Dent.1993;70:421-426. 8. Steflik DE, White SL, Parr GR et al. Clinical evaluation data from a comparative dental implant investigation in dogs. J.Oral. Impl.1993;19:199-208. 9. Teerlink J,Quirynen M, Darius P, Van Steenberghe D. Periotest:an objective clinical diagnosis of bone apposition toward implants. Int. J. Oral Maxillofac. Implants.1991;6:55-61. 10. Albrektsson T., Jacobsson M. Bone–metal interface in osseointegration. J. Prosthet. Dent. 1987;57:597–607. 11. Bilhan H, Cilingir A,Bural C,Bilmenoglu C, Sakaro O, Geckilio.The evaluation of the reliability of periotest for implant stability measurments: an in vitro study. J.Oral. Implantology.2014 mar 4(Epub a head of print). 12. Samer Al jetaily,Abdullah Al Farraj Al Dosari.Assessment of osstel and periotest system in measuring dental implant stability(in vitro study).Saudi Dental J. Jan 2011;23(1):17-21. 13. German Gomez-Roman, Dieter Lukas. Influence of the implant abutment on the periotest value: An in vivo study.Quintessence int.2001;32(10):797-799. 14. Cranin AN, DeGrado J, Kaufman M,et al. Evaluation of the Periotest as a diagnostic tool for dental implants. J Oral Implantol. 1998;24:139-146. 15. Truhlar RS, Lauciello F, Morris HF, Ochi S. The influence of bone quality on Periotest values of endosseous dental implants at stage two surgery. J Oral Maxillofac Surg 1997; 55:55-61.

Route to successful endodontics


18 Prosthetic Dentistry

How to Prevent Failure of Veneered Zirconia Ceramic Abstract Dr. Ghassan Moustapha

Dr. Elias Smaira

Dr. Mireille Rahi

Dr. Habib Abi Aad

In spite of high zirconia mechanical strength, chipping and fracture of layering porcelains applied to zirconia frameworks continue to be a problem. The mechanical integrity and the bonding of the layering porcelain to the framework material are key factors in the successful performance of veneer/framework restorations. Another clinical problem with the use of zirconia is the difficulty in achieving suitable adhesion to resin cement. Traditional adhesive techniques used with silica based ceramics do not work effectively with zirconia. This article reviews the literature to find the favored protocol to prevent delamination between veneering materials and zirconia framework from one part; and to focus on currently available techniques for internal surface roughness and preferred approaches for zirconia cementation.

Introduction Since zirconium dioxide was introduced in dentistry as a framework material for all ceramic restorations, a particular attraction resulted to its use in prosthodontics, due to its excellent mechanical properties (flexural strength 9001200Mpa, fracture toughness 9,10 Mpa m½) and improved appearance, having a high degree of crack resistance. Due to suitable additives, e.g. yttrium oxide, the crystal lattice is stabilized in its tetragonal high temperature phase, which avoids further transformation into the monoclinic phase, occurring during the cooling process. When a fault takes place; at the beginning of a crack, zirconia grains are transformed locally from tetragonal to monoclinic form, and accompanied by an increase in volume. This procedure is described as transformation toughening.1,2 When properly veneered, it could turn out Dental News, Volume XXII, Number I, 2015

to be clinically acceptable regarding its color match and having the capability to mask dark backgrounds such as dark tooth or cast post and core.3 It has promising clinical results and high survival rate. However the mechanical complications reported were chipping of veneering ceramic, framework fracture and loss of retention. Chipping has several causes: inappropriate framework support for the layering porcelain, coefficient of thermal expansion mismatch, firing shrinkage of the ceramic and insufficient bond strength. Finally the structural characteristics of zirconia resist conventional conditioning methods usually employed for bonding traditional ceramic restorations to teeth.1,4

Tooth preparation Previously, all-ceramic restorations should be placed on a heavy-chamfer or on a shoulder preparation to ensure that it will withstand the stresses that occur in the oral environment. For zirconia, a smaller finish line can be used.5 Its classical preparation should provide 0.5mm (in case of a collar) to 1mm at the margin, 1.2 to 1.5mm at the circumferential wall, and 1.5 to 2mm at the occlusal surface for ceramic and framework thicknesses.2,6 But with the monolithic zirconia restorations, gentle preparation of only 0.5 to 1 mm are indicated.7 The finish line design does not influence the fatigue or the fracture resistance of veneered zirconia crowns. Selection of any of the finish line designs should be based on the clinical condition of the restored tooth.8

Framework design For optimal success, it is critical that the design of the substructure provides proper support and a uniform thickness of overlay porcelain.

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20 Prosthetic Dentistry The non-uniform porcelain thickness would heat at different rates which could lead to thicker porcelain areas not being fully processed.9 Therefore a uniform layer thickness between 0.7 and 1.2mm of the veneering ceramic is recommended.2 Using a CAD/CAM, porcelain support begins by applying a full anatomical contour of the crown (Fig. 1). A thickness of 1mm is removed to make space for the layered porcelain (Fig. 2). As presented in (Fig. 3) the final design of the coping leaving proper support for the porcelain. Regarding the connectors dimension, the minimum cross section requirement are 7 mm² for anterior 3 unit bridges, 9 mm² for posterior 3 units bridges or anterior 4 unit bridges and 12 mm² for posteriors 4 units bridges or cantilever bridges. The height of the connector surfaces should be as large as possible.2,6,10

Fig 1

Fig 2

Coefficient of thermal expansion The ideal coefficient of thermal expansion (CTE) between the zirconia framework and layering porcelain has not been established. The use of layering porcelain with a higher (CTE) than that of the zirconia framework results in veneer delamination and extensive micro crack formation.11 A general trend is to use a slightly lower (CTE) to generate compressive stresses in the weaker veneering ceramic; this technique is used with porcelain fused to metal. In the same manner, to prevent chipping and cracking of the layering porcelain, it is recommended to have CTEs slightly lower than or identical to those of zirconia ceramics.4,12,13

Firing of the ceramic Zirconia has the lowest thermal conductivity (2 W/ (mk) base metal 40 W/ (mk)). Consequently, zirconia requires longer duration for heat to be transferred within the material in order to insure even heat distribution in the interfacial area between the framework and the veneer, as well as the outer surfaces of the restoration even with different framework thicknesses. It also requires slowing cooling rate to prevent stresses within the porcelain, to reduce the risk of chipping or delamination, and to obtain the desired compression of the overlay porcelain.6,9

Dental News, Volume XXII, Number I, 2015

Fig 3

Bond strength between zirconia and layering porcelain To achieve best bond strength between zirconia and layering porcelain, the manufacturer’s instructions should be taken into consideration and applied as per recommended. E.max ZirCAD and VITA In-Ceram YZ don’t allow sandblasting or grinding the framework, since this can damage the surface leading to undesired phase transformation and jeopardize the bond with the layering ceramic. In case of minor correction after sintering, a thermal treatment (regeneration firing) can reverse any phase transformation.2,6 For E.max ZirCAD Zirliner must always be applied prior to the

21 Prosthetic Dentistry

layering procedure in order to achieve a sound bond as well as an in depth shade effect and fluorescence. Zirliner has four shades for non shaded zirconia framework or clear for shaded framework.6 With the Lava Zirconia coping, sandblasting the outer surface is not necessary as the milling process results in an adequately rough surface to accept the overlay porcelain. Remarkably, very light sandblasting does not appear to have affected the bonding strength and appears to increase wetting of the porcelain.9 Whereas for the Cercon Degudent, it is advised to sandblast the inside and outside of the framework with alumina (110–125 μm, max 0.3 to 0.4Mpa, 45° angle).10 Applying a liner is indicated for the Cercon framework with the layered porcelain,14 but not required with the pressed porcelain.15 Aboushelib et al. evaluated in 6 papers the microtensile bond strength (MTBS) between the zirconia and the veneering ceramic.11,16,17,18,19,20 (MTBS) was chosen because shear bond strength (SBS) test may lead to undesirable stress distribution, causing cohesive failure and wrong interpretation of the data. When comparing polishing to sandblasting Cercon disc or roughening Vitablocks Mark II, no effect on the core-veneer bond strength was noted. The (MTBS) of the Cercon coreveneer would be weaker if the liner was not applied which is basically used to mask the white color of the zirconia and enhance the bond strength between the core and the veneering porcelain.11 The liner should be used with some layering veneers but not in combination with pressable veneers. The two materials have different structural composition and pressing the veneer ceramic over smooth fired liner material results in poor contact between the two materials. The pressable veneers failed mainly cohesively (within the porcelain) with no liner and interfacially (between the core and veneer) when liner is applied, whereas the layered veneers failed cohesively with liner and interfacially with no liner.16 Using the pressing technique will improve the bond strength while the esthetic outcomes are more difficult to achieve because it depends on the precolored ceramic ingots. Aboushelib et al. introduced a double-veneer technique combining layering porcelain over a previously pressed-on ceramic.17 Hence, the (MTBS) of zirconia and press on ceramic wasn’t affected by the addition of a second layer of veneering esthetic porcelain. When colored zirconia frameworks were introduced to enhance the final esthetics of the layered all-ceramic restoration, Aboushelib et al.18 found that the bond strength of colored zirconia was significantly weaker than the white Dental News, Volume XXII, Number I, 2015

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22 Prosthetic Dentistry zirconia frameworks. It was observed that the concentration of the coloring pigments (ferric oxide) was higher at the grain boundaries, which was at the expense of the concentration of the yttrium stabilizing elements.18 Furthermore, sandblasting these yellow samples decreased the bond strength in comparison to the white samples. In the other two papers, Aboushelib et al.19,20 used a new CAD/CAM veneering method to fabricate a resin replica of the esthetic ceramic seated on the zirconia framework and then processed using press on technologies. In comparison to conventional layering the CAD veneered specimens failed cohesively, while conventional layered specimens failed interfacially. Whereas Nakamura et al.21 postulated that sandblasting at a pressure 0.4 Mpa developed a strong bond to veneering porcelain compared to no sandblasting or sandblasting at a pressure of 0.2 Mpa, while using a tensile bond strength test. Yet the study didn’t include any fatigue

testing. One study 22 evaluated the influence of cyclic loading and flexural strength on zirconia after being subjected to particle abrasion with either 50 or 110µm, grinding or polished as control. It was interesting to note that the polished specimens demonstrated the least reduction in flexural strength after cyclic loading. Different surface treatment increased the amount of surface damage and the number of already available surface cracks ready to propagate. The (SBS) between zirconia and veneering ceramics wasn’t affected by thermocycling,23 however, the metal ceramic group in this study exhibited higher (SBS) than zirconia and e max group. In a recent study by means of fracture mechanics test, the toughness of zirconia veneer interface with no treatment is significantly higher than that of interfaces subjected to airborne particle abrasion.24

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24 Prosthetic Dentistry Bonding resin cement to zirconia A major weakness of dental zirconia is its inferior ability to adhere to resin cement. As zirconia has a polycrystalline structure and limited vitreous phase, neither hydrofluoric acid etching nor silanization can achieve durable zirconiaresin bonding.25 To promote micromechanical retention, sandblasting method can be used instead of acid etching, and for chemical bonding, instead of silane coupling agents, adhesive monomer could be applied.26 The surface treatment with primers or resin cement containing phosphate ester monomer such as MDP is recommended to improve the bonding to zirconia. MDP containing resin cement and airborne particle abrasion resulted in the most initial and durable bond strength after water storage and thermocycling.27,28,29 Still, it wasn’t sufficient to use MDP alone without sandblasting when subjected to thermocycling.26 Airborne particle abrasion with 50-110µm alumina particle at 0.25 Mpa is effective in roughening zirconia surface but it can create sharp crack tips and structural defects. Therefore it is recommended to reduce the pressure and use particles up to 50µm. After airborne particle abrasion (with 50 µm Al2O3 ), water storage for 150 days, and thermocycling, (37500 cycles 5˚/55˚) the MDP containing resin cement (Panavia) showed the highest tensile bond strength30 and the highest shear bond strength after sandblasting and thermocycling (10000 times).31 Tribochemical silica coating air abrades the zirconium surface with alumina particles that have been coated with silica embedding the surface with it. This results in preparing the surface for silanization and micromechanical retention, though there can be a loss in bond strength over a long term.27,29 And simple air abrasion can get the same initial bond strength.28,32 A combination between silica coating and primer application increased the bond strength between zirconia and resin cement but it wasn’t sufficient after artificial aging like water storage and thermocycling (12000 cycles 5˚/55˚) even with the MDP containing system. When testing the retentive strength (removal force along the path of insertion) of zirconia crowns cemented over extracted molars after Dental News, Volume XXII, Number I, 2015

airborne particle abrasion (with 50 µm Al2O3)33 or silica coating34 and thermocycling (5000 cycles 5˚/55˚), minor difference was detected between various resin cement self adhesive cement and resin modified glass ionomer cement. In comparison to other resin cements, MDP monomer resulted in the highest (MTBS) values with zirconia and produced higher bond strength than two phosphate monomers (RelyX UniCem, and Multilink) while microshear test failed to detect such difference.35 (MTBS) is recommended to test the adhesive bonding effectiveness and the interfacial material property as its result is comparable to the micro tensile fatigue resistance which is more laborintensive and time consuming to do.36 The (MTBS) of the MDP containing resin cement is higher than self adhesive or conventional resinous cement, independently of the surface treatment (sandblasting or silica coating).37,38 Rely X unicem had lower bond strength value but like Panavia wasn’t affected by the water aging38 or thermocycling (10000 times)31 and both cement demonstrated satisfactory performance in media with different pH.39 With RelyX Unicem, air abrasion at 0.25Mpa is recommended to contribute to a durable bond yet it can initiate surface defect. The combination of low pressure air abrasion (0.05 Mpa) and MDP containing primer is useful to achieve durable bond after 37500 thermocycling.40 On a shear bond strength test, the better bond were obtained by dual-polymerizing (Panavia, Variolink II) cements than auto polymerizing (Rely X and Multilink) resins. The better bond is associated with sand¬blasting or silica coating and an adhesive containing MDP.41 Some primers mix MDP with another molecule like Monobond plus (phosphate monomer with silane (MPS) 42 or Z-prime plus (organophosphate and carboxylic acid monomers) 43 they also showed high bond strength same as the use of a phosphonic acid monomer (6-MHPA).44 Different alternative methods to treat zirconia surfaces have been evaluated to produce reliable long term adhesion. The most innovative was introduced by Aboushelib et al.45,46 and tested to (MTBS). This method was named selective infiltration etching (SIE). They applied a low temperature molting glass on selected zirconia



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26 Prosthetic Dentistry surfaces which is submitted to a heat-induced maturation by 2 short thermal cycles 650-750˚C which resulted in stressing the grain boundary region and infiltration of the glass materials. Then the glass is removed by hydrofluoric acid solution, leaving porosities for the resin cement. The (SIE) specimens bounded with Panavia had the highest bond strength (49.8 Mpa) in comparison with airborne particle abrasion that bonded with the same cement (33.4 Mpa) or with Rely X (23.3Mpa). Contrarily to other cement with selective infiltration etching the MDP containing cement conserved their bond strength after one month of water storage. MPS also produced greater bond strength, but the use of silanes with SIE didn’t aid in producing a hydrolytically stable bond.47

transformation from the tetragonal phase to the more stable monoclinic phase in the absence of any mechanical stresses. This phenomenon decreases the physical properties of the material. Moreover, leaving the zirconia framework without ceramic veneering would expose this framework to salivary environment increasing the potential of plaque retention and reducing resistance to low temperature degradation and service life.1

A large range of mechanical, chemical or both approaches have tried to modify the zirconia surface and improve resin bonding. Nano structured alumina coating48 consists of precipitating aluminum hydroxide originating from alumina nitride powder with subsequent thermal treatment. It can improve the bond strength compared to air abrasion pretreatment. Another technique is the Chloro silane combined with vapor phase allows pretreatment that deposits a silica like layer used to increase adhesion with traditional silane and bonding technique.49 In addition, Hot etching acidic solution (HCl and FeCl3 (100˚C))also increases the surface roughness, enabling optimal bond to resin cement.50 Likewise the application of a glass-ceramic/glaze containing a major lithium disilicate phase subsequently treated with hydrofluoric acid and silane might also be useful in improving the bond strength of zirconia to resin cements.51 Furthermore, laser application that removes particles through ablation process by micro explosions and vaporization, inducing phase transformation. Yet its durable bond strength is contradictory.52,53,54,55 One more is the treatment of zirconia with plasma, which reduces the contact angle, and increases the surface wettability which may also improve its bond strength.56

- The framework design should provide a uniform layer thickness of the veneering ceramic.

Finally, a subject that’s worth studying is the aging of zirconia or low temperature degradation. It consists of a spontaneous slow Dental News, Volume XXII, Number I, 2015

Conclusion According to the reviewed literature it is possible to prevent failure of veneered zirconia ceramics, and to conclude that: - Smaller finish line can be used with zirconia.

- It is better to have identical CTE or slightly lower between veneering ceramics and zirconia. - Veneering ceramics need longer firing time and slower cooling rate. - Further treatment or sandblasting of the external surface before veneering, doesn’t seem to increase the bond strength, yet it can damage the surface and jeopardize the bond with layering ceramic. - The liner is beneficial for colored zirconia using the layered technique, but not necessary for the pressed on technique. - The use of MDP containing resin cement on airabraded zirconia crown with 50 microns alumina particles at low pressure can be recommended as most retentive luting method. Likewise, the selective infiltration etching (SIE) method with MDP is a reliable and promising method for establishing a strong and durable bond. Many sophisticated techniques are developed to increase this bonding, but simple methods are also applicable like glass-ceramic glaze.

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28 Prosthetic Dentistry

References 1. Zarone F, Russo S, Sorrentino R. From porcelain-fused-to-metal to zirconia: Clinical and experimental considerations. Dent Mater. 2011 Jan; 27(1):83-96. 2. VITA In-Ceram® YZ Working Instructions .2011 Nov. 3. Aboushelib MN, Dozic A, Liem JK. Influence of framework color and layering technique on the final color of zirconia veneered restorations. Quintessence Int. 2010 May; 41(5):e84-9. 4. Komine F,StrubJ, Matsumura H. Bonding between layering materials and zirconia frameworks. Japanese Dental Science Review (2012) 48, 153—161. 5. Akesson J, Sundh A, Sjögren G.Fracture resistance of all-ceramic crowns placed on a preparation with a slice-formed finishing line. J Oral Rehabil. 2009 Jul; 36(7):516-23. 6. IPS e.max®ZirCAD Instructions for use .Ivoclar Vivadent technical 2010 Feb. 7. Zenostar dental restorations from Wieland. The clear monolithic line in dental technology.2013 Apr. 8. Aboushelib M. Fatigue and Fracture Resistance of Zirconia Crowns Prepared with Different Finish Line Designs. J Prosthodont. 2012 Jan; 21(1):227. 9. EspertiseTM Scientific Facts. Zirconia-supported Ceramic Restorations: Uncovering the Mysteries. 3M ESPE 2009 10. CAD/CAM Cercon®. Product description and instructions for use, Cercon® base/Cercon® ht. Degudent 2011 Dec. 11. Aboushelib M, Jager N, Kleverlaan C, Feilzer A. Microtensile bond strength of different components of core veneered all-ceramic restorations. Dent Mater. 2005 Oct; 21(10):984-91. 12. Aboushelib M, Feilzer A, JagerN,Kleverlaan C. Prestresses in Bilayered All-Ceramic Restorations. J Biomed Mater Res Part B: Appl Biomater 87B: 139–145, 2008. 13. Saito A, Komine F, Blatz M, Matsumura H. A comparison of bond strength of layered veneering porcelains to zirconia and metal. J Prosthet Dent 2010; 104:247-257. 14. Cercon Ceram kiss. Product description and processing manual for Cercon Ceram kiss veneering ceramics. Degudent 2009 Nov. 15. Cercon Ceram press. Product description and instructions for Cercon Ceram press. Press-on porcelain- Degudent 2006 Sep. 16. Aboushelib M, Kleverlaan C, Feilzer A. Microtensile bond strength of different components of core veneered all-ceramic restorations Part II: Zirconia veneering ceramics. Dent 2006 Sep; 22(9):857-63. 17. Aboushelib MN, Kleverlaan CJ, Feilzer AJ. Microtensile bond strength of different components of core veneered all-ceramic restorations. Part 3: double veneer technique. J Prosthodont. 2008 Jan; 17(1):9-13. 18. Aboushelib M, Kleverlaan C, Feilzer A. Effect of Zirconia Type on Its Bond Strength with Different Veneer Ceramics. J Prosthodont. 2008 Jul; 17(5):401-8. 19. Aboushelib MN, de Kler M, Van der Zel JM, Feilzer AJ. Microtensile bond strength and impact energy of fracture of CAD-veneered zirconia restorations. J Prosthodont. 2009 Apr; 18(3):211-6. 20. Aboushelib MN, de Kler M, van der Zel JM, Feilzer AJ. Effect of veneering method on the fracture and bond strength of bilayered zirconia restorations. Int J Prosthodont 2008; 21:237-240. 21. Nakamura T, Wakabayashi K, Zaima C, Nishida H, Kinuta S, Yatani H. Tensile bond strength between tooth-colored porcelain and sandblasted zirconia framework. J Prosthodont Res 2009; 53:116-119. 22. Aboushelib M. Long Term Fatigue Behavior of Zirconia Based Dental Ceramics. Materials 2010, 3, 2975-2985. 23. Guess P, Kuliˇs A, Witkowski S, Wolkewitz M, Zhang Y, Strub J. Shear bond strengths between different zirconia cores and veneering ceramics and their susceptibility to thermocycling. Dent Mater. 2008 Nov; 24(11):1556-

67. 24. Wang G, Zhang S, Bian C, Kong H.Effect of zirconia surface treatment on zirconia/veneer interfacial toughness evaluated by fracture mechanics method. J Dent. 2014 Jul; 42(7):808-15. 25. Lee T, Ahn J, Shim J, Han C, Kim S. Influence of cement thickness on resinzirconia microtensile bond strength. J Adv Prosthodont 2011; 3:119-25. 26. Yun J, Ha S, Lee J, Kim S. Effect of sandblasting and various metal primers on the shear bond strength of resin cement to Y-TZP ceramic. Dent Mater. 2010 Jul; 26(7):650-8. 27. Qeblawi D, Muñoz C, Brewer J, Monaco E. The effect of zirconia surface treatment on flexural strength and shear bond strength to a resin cement. J Prosthet Dent 2010; 103:210-220). 28. Mattiello R, Coelho T, Insaurralde E, Coelho A, Terra G, Kasuya A, Dental News, Volume XXII, Number I, 2015

Favarão I, Gonçalves L, and Fonseca R. A Review of Surface Treatment Methods to Improve the Adhesive Cementation of Zirconia-Based Ceramics. ISRN Biomaterials, vol. 2013, Article ID 185376, 10 pages, 2013. 29. Thompson J, Stoner B, Piascik J, Smith R. Adhesion/cementation to zirconia and other non-silicate ceramics: Where are we now? Dent Mater. 2011 Jan; 27(1):71-82. 30. Wolfart M, Lehmann F, Wolfart S, Kern M. Durability of the resin bond strength to zirconia ceramic after using different surface conditioning methods. Dent Mater. 2007 Jan; 23(1):45-50. 31. Lüthy H, Loeffel O, Hammerle C. Effect of thermocycling on bond strength of luting cements to zirconia ceramic. Dent Mater. 2006 Feb; 22(2):195-200. 32. Chen L and Suh B. Bonding of Resin Materials to All-Ceramics: A Review. Curr. Res. Dent 2012, 3: 7-17. 33. Palacios R, Johnson G, Phillips K, Raigrodski. Retention of zirconium oxide ceramic crowns with three types of cement. J Prosthet Dent 2006; 96:104-14. 34. Ernst CP, Cohnen U, Stender E, Willershausen B. In vitro retentive strength of zirconium oxide ceramic crowns using different luting agents. J Prosthet Dent. 2005 Jun; 93(6):551-8. 35. Mirmohammadi H, Aboushelib M, Salameh Z, Feilzer A, Kleverlaan C. Innovations in bonding to zirconia based ceramics: Part III. Phosphate monomer resin cements. Dent Mater. 2010 Aug; 26(8):786-92 36. Poitevin A, Munck J, Cardoso M, Mine A, Peumans M, Lambrechts P, Meerbeek B. Dynamic versus static bond-strength testing of adhesiveInterfaces. Dent Mater. 2010 Nov; 26(11):1068-76. 37. Oyagüe R, Monticellib F, Toledano M, Osorio E, Ferrari M, Osorio R. Influence of surface treatments and resin cement selection on bonding to denselysintered zirconium-oxide ceramic. Dent Mater. 2009 Feb; 25(2):172-9. 38. Oyagüe R, Monticelli F, Toledano M, Osorio E, Ferrari M, Osorio R. Effect of water aging on microtensile bond strength of dual-cured resin cements to pre-treated sintered zirconium-oxide ceramics. Dent Mater. 2009 Mar; 25(3):392-9. 39. Geramipanah F, Majidpour M, Sadighpour L, Fard MJ. Effect of Artificial Saliva and pH on Shear Bond Strength of Resin Cements to Zirconia-Based Ceramic. Eur J Prosthodont Restor Dent. 2013 Mar; 21(1):5-8. 40. Yang B, Barloi A, Kern M. Influence of air-abrasion on zirconia ceramic bonding using an adhesive composite resin. Dent Mater. 2010 Jan; 26(1):4450. 41. Román-Rodríguez J, Fons-Font A, Amigó-Borrás V, Granell-Ruiz M, Busquets-Mataix D, Panadero R, Solá-Ruiz M. Bond strength of selected composite resin-cements to zirconium-oxide ceramic. Med Oral Patol Oral Cir Bucal. 2013 Jan 1; 18 (1):e115-23. 42. Obradovic-Djuricic K, Medic V, Dodic S, Gavrilov D, Antonijevic D, Zrilic M. Dilemmas in Zirconia Bonding: A Review. SrpArhCelokLek. 2013 May-Jun; 141(5-6):395-401. 43. Magne P, Paranhos M, Burnett Jr. L. New zirconia primer improves bond strength of resin-based Cements. Dent Mater. 2010 Apr; 26(4):345-52. 44. Kitayama S, NikaidoT, Takahashi R, Zhu L, Ikeda M,Foxton R, Sadr A, Tagami J. Effect of primer treatment on bonding of resin cements to zirconia ceramic. Dent Mater. 2010 May; 26(5):426-32. 45. Aboushelib M, Kleverlaan C, Feilzer A. Selective infiltration-etching technique for a strong and durable bond of resin cements to zirconia-based materials. J Prosthet Dent 2007; 98:379-388. 46. Aboushelib M, Matinlinna J, Salameh Z, Ounsi H. Innovations in bonding to zirconia-based materials: Part I. Dent Mater. 2008 Sep; 24(9):1268-72. 47. Aboushelib M, Mirmohamadi H, Matinlinna J, Kukk E, Ounsi H, Salameh Z. Innovations in bonding to zirconia-based materials. Part II: Focusing on chemical interactions. Dent Mater. 2009 Aug; 25(8):989-93. 48. Jevnikar P, Krnel K, Kocjan A, Funduk N, KosmačT. The effect of nanostructured alumina coating on resin-bond strength to zirconia ceramics. Dent Mater. 2010 Jul; 26(7):688-96. 49. Piascik JR ,Swift EJ, Thompson JY, Grego S, Stoner BR .Surface modification for enhanced silanation of zirconia ceramics. DentMater.2009 Sep;25(9)1116–1121. 50. Casucci A, Mazzitelli C, Monticelli F, Toledano M, Osorio R, Osorio E, Papacchini F, Ferrari M. Morphological analysis of three zirconium oxide ceramics: Effect of surface treatments. Dent Mater. 2010 Aug; 26(8):75160. 51. Ntala P, Chen X, Niggli J, Cattell M. Development and testing of multiphase glazes for adhesive bonding to zirconia substrates. J Dent. 2010 Oct; 38(10):773-81. 52. Foxton RM, Cavalcanti AN, Nakajima M, Pilecki P, Sherriff M, Melo L, Watson TF. Durability of resin cement bond to aluminium oxide and zirconia ceramics after air abrasion and laser treatment. J Prosthodont. 2011 Feb; 20(2):84-92.

Maintain your patients’ confidence and satisfaction with their dentures by helping them overcome daily social, emotional and physical challenges. Help your patients eat, speak and smile with confidence with the CoregaŽ denture care regime. Arenco Tower, Media City, Dubai, U.A.E. Tel: +971 4 3769555, Fax: +971 3928549 P.O.Box 23816. For full information about the product, please refer to the product pack. For reporting any Adverse Event/Side Effect related to GSK product please contact us on Date of preparation: June 2014, CHSAU/CHPLD/0008/14b We value your feedback Saudi Arabia: 8008447012 All Gulf and Near East countries: +973 16500404

18 30 Prosthetic Dentistry

Polyamide Resins in Removable Dentures Abstract Dr. Danielle El Hakim

Dr. Mireille Rahi,

Dr. Najib Abou Hamra,

Dr. Elias Smaira

Thermoplastic resins have been used in dentistry for over 50 years. In the meantime, their use has spread due to their superior characteristics, and the interest in polyamide based materials (nylon) have increased. Their ongoing development has yielded new classes of more and more advanced materials and technologies, which make possible new applications for thermoplastic resins in the future. The dentists have to meet growing demands for prosthetic rehabilitation due to population aging and higher requirements on the quality of life. In this article we will talk about physical, mechanical and thermal properties of polyamide materials, surface roughness, flexibility and absence of monomer in comparison with PPMA, and the various applications of polyamide resins in removable dentures.

porosity, high water retention, volume variations and irritating effect of the residual monomer. Researches have attempted to improve the mechanical properties of PMMA denture bases by reinforcement with fiber glass or carbon, (Fig.1,2) and also by chemical modification.7 Development of alternative materials such as thermoplastic resins has also been reported in the literature.2,8 Fig 1

Introduction Polymethylmethacrylate (PMMA) resin has been a commonly used denture base biomaterial since 1937. The properties of favorable working characteristics, ease of manipulation, ability to repair, aesthetic appearance, low cost, acceptability by most of the patients, stability in the oral environment, and accurate fit have contributed to the success of this material.1-4 They are synthetically obtained materials that can be modeled, packed or injected into molds during an initial plastic phase, which solidify through a chemical reaction-polymerisation.5 Its mechanical feature, however, is far from the ideal because it has weak flexural and impact strength and low fatigue resistance. These often lead to denture failure during chewing or when it is dropped.3 Denture fractures is one of the most common clinical problems.6 Other disadvantages of PMMA resin are increased Dental News, Volume XXII, Number I, 2015

Fig 1: Glass fiber reinforcement Fig 2

Fig 2: Carbon fiber reinforcement

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32 Prosthetic Dentistry Thermoplastic resins may be repeatedly softened by heating and hardened by cooling without undergoing a chemical change. They may be considered as being composed of bundles of chainlike molecules (called polymers) of many different lengths and molecular weights. They can be classified as thermoplastic acetal, thermoplastic polycarbonates, thermoplastic acrylic and thermoplastic nylon (polyamides).9 However, the desired denture base material has not been developed yet.3 Thermoplastic polyamide (nylon), synthesized by the condensation reaction between a diamine and a dibasic acid,1,10 was first studied as a denture base biomaterial in the 1950s. The early form of polyamides displayed several problems, such as high water absorption, discoloration tendency, surface roughness, bacterial contamination, and difficulty in polishing.1,11 It was especially used in exceptional cases like repeated denture fracture and for patients with tissue allergies against acrylic denture base or denture fractures.3 In recent years, polyamide has been attracting attention as a denture base biomaterial due to the advantages of: favorable aesthetic outcome, reflect the color of gingival tissue beneath due to highlight transparency, they have high quality esthetic properties; toxicological safety to patients allergic to conventional metals and resin monomers; higher elasticity than conventional heat-polymerizing resins; high physical strength, flexible and strong structure; heat resistance and chemical resistance, low water absorption and solubility, low porosity.1,9,10,12,13,14 The polyamide resins could be injection-molded, the advantages of using this system lay in the fact that the resin is delivered in a cartridge, thus excluding mixture errors with long-term shape stability, reduces contraction, and gives mechanical resistance to aging.14,15 Some disadvantages of polyamide are also described, mainly the lack of chemical bonding between the base and the acrylic teeth, thus the need for mechanical retention (Fig. 3), and the difficulty in repairing and relining the denture.2,10,14,16

Dental News, Volume XXII, Number I, 2015

Fig 3

Fig 3: Mechanical retention between polyamide denture base and acrylic teeth.

Physical, Mechanical and Thermal Properties of Polyamide Resins in Comparison with PPMA Nylon is a crystalline polymer whereas polymethylmethacrylate is amorphous.1 This results in lack of solubility in solvents, high heat resistance, and high strength coupled with more ductility.9 Polyamide molecules contain hydrogen bonding, which increases the melting point of the polyamide.1 The outstanding features of the nylons are their toughness, low density, abrasion resistance, higher melting point and resistance to chemical attack. The flexibility coupled with its strength, enables it to resist all normal attempts to fracture.9 The main advantage of nylon lies in exceptional mechanical properties of resistance to shock and repeated stressing, it has higher fatigue resistance compared to PMMA. Polyamide denture bases are strong and light. Nylon has higher abrasion resistance, elastic memory, creep resistance and is conductive to cyclic stress.9 The polyamide denture base resins have lower flexural strength at the proportional limit

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34 Prosthetic Dentistry and low elastic modulus12 along with good fracture resistance.9 Though nylon has superior mechanical properties than any other non-metallic base yet there are some serious limitations such as processing difficulties and dimensional changes. Nylon is hygroscopic; its moisture content varies slowly with the surrounding conditions. On immersion in water the material swells, i.e. there is linear expansion. Processing the denture base materials produced unequal deformation in different dimensions (anterior-posterior and cross-arch). The magnitude of this dimensional change depends on the conditions of molding, shape of the mould, and direction in which it is measured.9 Nylon has low coefficient of linear expansion and galvanic conductance.9 Less sorption and solubility of thermoplastic polyamide nylon resin would extremely decrease porosity of the denture base and thus promote hygiene maintenance.13

alteration of the denture prosthesis bearing area, adaptation of the denture base, careful planning of the path of insertion and the use of resilient lining material. An alternative denture prosthesis design in which optimal flange height and thickness can be achieved is by using flexible denture basematerial. Polyamide denture base materials are more flexible than the commonly used PMMA.2,13 The flexibility of nylon varies greatly depending on the type of molding powder used, temperature of injection, pressure of injection.9 With thermoplastic materials, the clasps are made of the same material as the denture base (Fig. 4), when using superflexible polyamide, we used ready-made clasps, in the case of using medium-low flexibility polyamide. When manufacturing polyamidic dentures, the support elements blend in with the rest of the denture, as they are made of the same material.17 Fig 4

Surface Roughness of Polyamide Resins in Comparison with PPMA Surface roughness is an important factor, which affects the clinical life of materials and resistance to plaque formation. Surface roughness is related to the abrasion of materials. Rough denture surface makes accumulation of microorganisms easier and a higher level of biofilm formation occurs compared to smooth surfaces. Rough surfaces also affect staining resistance, health of oral tissue, comfort of the patient, aesthetics and retention of the dentures directly or indirectly.14 Polyamide denture base material when polished with conventional laboratory technique became more than 7 times smoother whereas processed PMMA when polished became more than 20 times smoother using the same polishing technique. However the surface roughness of polyamide is well within the accepted norm of 0.2 Îźm Ra. Polyamide produces a clinically acceptable smoothness after conventional polishing.2

Flexibility Unilateral or bilateral undercuts are frequently encountered and may complicate successful fabrication of denture prosthesis. Management of these situations conventionally includes Dental News, Volume XXII, Number I, 2015

Fig 4: The clasps are made of the same material as the denture polyamide base.

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36 Prosthetic Dentistry Material Free of Monomer Complete biocompatibility is a major advantage of polyamide resins, because the material is free of monomer and metal, these being the principle causes of allergic reactions in conventional denture materials.14

Applications of Polyamide Resins in Removable Dentures Flexible denture bases may be indicated in patients requiring replacement of teeth in esthetic zone, patients with restricted mouth opening,13 severe soft and hard tissue undercuts,2,13,14 sensitivity to PMMA monomer or metal,2,13,14,18 bruxism cases, thin mucosa and excessive bone resorption, cases where the patient cannot tolerate the force applied by the denture, very old patients with low motor capacity,14 temporary prosthesis after implants,13,14 precision attachment, combination with metal framework, single cast partial dentures, preformed partial denture clasp, immediate dentures,9 space maintainers,13 occlusal appliances,18 flexible tooth born partial denture framework,9,18 denture bases of RPDs without metal clasps, the flexibility of polyamide allows retentive elements that match the color of the gums or teeth.11,12,18

Conclusions Thermoplastic resins have been used in dentistry for many years. During that time the applications have continued to grow and the interest in these materials by both the profession and the public have increased. The materials have superior properties and characteristics and provide excellent esthetic and biocompatible treatment options. Polyamide denture base materials proved to be a useful alternative to conventional denture base resins in clinical situations, including patients who demonstrate a certain degree of tissue undercuts or repeated fracture of dentures and also persons who have sensitivity or allergy to methyl methacrylate monomer. In spite of the various advantages and indications of thermoplastic polyamide resin, further longterm studies are recommended to assess the overall usefulness of the material.

Dental News, Volume XXII, Number I, 2015

References 1. KürkçüoğluI, KöroğluA, ÖzkırSE, ÖzdemirT. A comparative study of polyamide and PMMA denture base biomaterials: I. Thermal, mechanical, and dynamic mechanical properties. International Journal of Polymeric Materials 2012; 61: 768-777. 2. Abuzar MA, Bellur S, Duong N, Kim BB, Lu P, Palfreyman N, Surendran D, Tran VT. Evaluating surface roughness of a polyamide denture base material in comparison with poly (methyl methacrylate). Journal of Oral Science 2010; 52: 577-581. 3. Soygun K, Bolayir G, Boztug A. Mechanical and thermal properties of polyamide versus reinforced PMMA denture base materials. Journal of Advanced Prosthodontics2013;5:153-160. 4. Yu SH, Lee Y, Oh S, Cho HW, Oda Y, Bae JM. Reinforcing effects of different fibers on denture base resin based on the fiber type, concentration, and combination. Dental Materials Journal 2012; 31: 1039-1046. 5. Phoenix RD, Mansueto MA, Ackerman NA, Jones RE. Evaluation of mechanical and thermal properties of commonly used denture base resins.Journal of

Prosthodontics 2004; 13:17-24. 6. Yu SH, Ahn DH, Park JS, Chung YS, Han IS, Lim JS, Oh S, Oda Y, Bae JM. Comparison of denture base resin reinforced with polyaromatic polyamide fibers of different orientations. Dental Materials Journal 2013; 32: 332-340. 7. John J, Gangadhar SA, Shah I. Flexural strength of heat-polymerized polymethylmethacrylate denture resin reinforced with glass, aramid, or nylon fibers. Journal of Prosthetic Dentistry 2001; 86: 424-427. 8. Negrutiu M, Bratu D, Rominu M. Polymers used in technology of removable dentures.Romanian Journal of Stomatology 2001; 4:30-41. 9. Kohli S, Bhatia S. Polyamides in dentistry. International Journal of Scientific Study 2013; 1: 20-25. 10. Ucar Y, Akova T, Aysan I. Mechanical properties of polyamide versus different PMMA denture base materials. Journal of Prosthodontics 2012; 21: 173-176. 11. Wieckiewicz M, Opitz V, Richter G, Boening KW. Physical properties of polyamide-12 versus PMMA denture base material. BioMed Research International 2014. 12. Hamanaka I, Takahashi Y, Shimizu H.Mechanical properties of injection-molded thermoplastic denture base resins. ActaOdontologicaScandinavica 2011; 69: 75-79. 13. Shah J, Bulbule N, Kulkarni S, Shah R, Kakade D. Comparative evaluation of sorption, solubility and microhardness of heat cure polymethylmethacrylate denture base resin & flexible denture base resin. Journal of Clinical and Diagnostic Research 2014; 8: 1-4. 14. Durkan R, Ayaz EA, Bagis B, Gurbuz A, Ozturk N, Korkmaz FM. Comparative effects of denture cleansers on physical properties of polyamide and polymethylmethacrylate base polymers. Dental Materials Journal 2013; 32: 367-375. 15. Parvizi A, Lindquist T, Schneider R, WilliamsonD, Boyer D, Dawson DV. Comparison of the dimensional accurancy of injectionmolded denture base materials to that of conventional pressure-pack acrylic resin.Journal of Prosthodontics 2004; 13: 83-89. 16. Korkmaz FM,BagisB,Özcan M, Durkan R, Turgut S, AtesM. Peel strength of denture liner to PMMA and polyamide: laser versus air abrasion. Journal of Advanced Prosthodontics 2013; 5: 287-295. 17. Szalina LA. TehnologiaexecutariiprotezelortermoplasticeFlexite. Dentis 2005; 4:36. 18. Mustafa MJ, Amir HM. Evaluation of Candida albicans attachment to flexible denture base material (valplast) and heat cure acrylic resin using different finishing and polishing techniques. Journal ofBagh College Dentistry 2011; 23: 36-41.

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18 38 Oral Surgery

Coronectomy: A Review

Introduction Dr. P. Dhanrajani, BDS, MDS, MSc, MSC, FRACDS, FDSRCS, FFDRCSI Oral Surgeon

Dr R. Weld-Moore, BDS Dentist, Australia


extraction of the tooth, thus reducing risk to the nerve. Reports of permanent nerve damage as a result of wisdom tooth removal have been reported in 1% to 4% of cases which is quite significant considering lower third molar removal is one of the most commonly performed oral surgery procedures. Review of the literature shows coronectomy procedure is becoming more commonly reported and recent studies show quite favourable outcomes when compared to extraction. Due to increasing amount of favourable evidence it will likely become a more common practice, and therefore it is important that general dental practitioners are familiar with the procedure, as patients may present with post op complications such as infection, dry socket in the short term following coronectomy and re-eruption of the roots which tends to present some time later, and thus clinicians will need to consider this in their differential diagnosis. There are many factors to consider when treatment planning for coronectomy on a third molar tooth. History of the patient’s presenting complaint and a full medical history need to be taken. A patient who is medically compromised is not an ideal candidate for coronectomy due to risk of poor healing. Patients should not be immunocompromised (uncontrolled diabetes, long term steroid therapy, HIV) or due to have radiotherapy to the jaw. 5,11,12,13

Coronectomy or partial odontectomy is the elective decoronation of a tooth and removal of tooth structure below the level of crest of the alveolar ridge with the intention of allowing the tissue to heal over the remaining vital roots maintaining their vitality and desirably with formation of bone over the roots. This is performed on lower third molars that have an intimate relationship with the inferior dental nerve (IDN) as an alternative to complete

Patients are assessed clinically and radiographically. If a plain film x-ray is suggestive of an intimate relationship with the ID nerve then cone beam computerized tomography (CBCT) should be utilised to determine the relationship with the nerve as well as the lingual and buccal plate. If it is found that there is not an intimate relationship then complete removal of the tooth rather than coronectomy is indicated. 14,15,16

The problem of inferior alveolar nerve involvement during surgical procedure of the removal of lower third molars is often a source of litigations.1,2,3 At the same time the impact of this on a person’s quality of life should not be overlooked. Coronectomy or partial odontectomy reduces the likelihood of nerve injury by insuring retention of the vital roots when they are close or associated with the inferior alveolar nerve as evaluated by plain radiography or CBCT. 4,5 The method aims to remove only the crown part of an impacted mandibular third molar while leaving the root and pulp undisturbed, thereby avoiding direct or indirect damage to the inferior alveolar nerve. 6,7,8 Literature so far has hailed its merits and many practitioners regularly use the approach of coronectomy in order to minimise Inferior alveolar nerve injuries. This technique got in lime light in last decade although results are encouraging but long term outcome needs to be followed. 9,10 This paper presents a comprehensive review on coronectomies and discusses indications, procedure and its complications. We are encouraged by the initial patients satisfaction and requires further long term assessment.

Dental News, Volume XXII, Number I, 2015

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References: 1. Burwell A et al. J Clin Dent 2010; 21(Spec Iss): 66–71. 2. LaTorre G, Greenspan DC. J Clin Dent 2010; 21(3): 72-76. 3. West NX et al. J Clin Dent 2011; 22(Spec Iss): 82-89. 4. Earl J et al. J Clin Dent 2011; 22(Spec Iss): 62-67. 5. Efflandt SE et al. J Mater Sci Mater Med 2002; 26(6): 557-565. Prepared December 2011, Z-11-516.

40 Oral Surgery Fig 1: orthopantomogram showing

Fig 1

a: darkening of root as the ID canal crosses b: interruption of the lamina dura of the canal c: narrowing of the canal as it passes over the root d: sudden diversion of the course of the canal.

Fig 1: Signs of an intimate relationship with the nerve on a plain film x-ray include: - Darkening of the root as the ID canal crosses - Interruption of the lamina dura of the canal - Sudden diversion of the course of the canal - Narrowing of the canal as it passes over the root - Narrowing of the third molar roots The tooth itself ideally should be non carious or in the very least not have any pulpal involvement or periapical infection. A non-vital tooth with a

is unlikely to resolve if left in situ. 8,9,17 Following assessment if it is determined that the third molar is suitable for coronectomy the implications of both procedures need to be explained to the patient and then fully informed consent is obtained for both coronectomy and full removal of the tooth. This is because if the root becomes mobilized during the procedure it will require removal. This is not uncommon and in one study 38% of teeth planned for coronectomy required removal due to mobilisation of the roots.

necrotic pulp is a source of infection and this is a contraindication for coronectomy. While most clinicians would find the idea of decoronating a tooth and leaving the pulp tissue in the roots somewhat counter-instinctive, evidence has shown that the tooth maintains its vitality. Histological examination of roots that erupted into the oral cavity following coronectomy shows vital pulp tissue in the canal, and also there are reports of roots being sensitive when they re-erupt which suggests vitality. In fact a control study by Sencimen et al 201012 showed that roots that were endodontically treated

actually had quite a high infection rate resulting in these roots requiring removal whereas in the control group there was no reports of infection. Also coronectomy is contraindicated in a horizontal tooth that is lying directly over the nerve as the process of decoronating the tooth may in fact result in damaging the nerve. Other contraindications include pre–existing tooth mobility, patients due to have orthognathic surgery on the mandible, and cystic tissue that Dental News, Volume XXII, Number I, 2015

The most commonly described technique is as follows Adequate local anaesthetic is administered. A triangular full thickness buccal mucoperiosteal flap is raised; a lingual flap is not used. A gutter of bone is made around the buccal aspect of the tooth to expose the cementoenamel junction (CEJ). A fissure bur is then used to drill into the tooth at the CEJ and at a depth of 2/3 to 3/4 through the crown making sure not to cut completely through to the lingual plate as the lingual plate needs to be preserved and also to avoid any damage to the lingual nerve. A small elevator is used carefully to decoronate the tooth taking as much care as possible to apply as little torque as possible so as not to mobilise the roots. If the roots are mobilised then they will require removal. A bur is then used to remove any pieces of enamel which may be present as enamel is non vascular and will be recognised by the body as

41 Oral Surgery Fig 2: immediate post operative orthopantomogram showing sectioning of crown at cementoenamel junctionabove the furcation of roots.

Fig 2

Fig 3: one year postoperative orthopantomogram showing roots covered with bone.

Fig 3

a foreign body. Also the bur is used to reduce the root to at least 3mm below the level of the buccal and lingual alveolar crest. The socket is then copiously irrigated to remove any debris. The flap is then sutured with resorbable sutures. The aim of suturing is to completely close the surgical site, as the desire is to have healing by primary intention. This may require scoring of the periosteum to advance the flap over the surgical site. 3,5,7,9 The patient is given the necessary post op instructions and is seen for post op review. Any post op complications are treated, as they would if it was an extraction. Patients are then seen for appropriate follow up. Patients have a panoramic X-Ray immediately post op (fig.2). Further radiographs are then taken at the discretion of the clinician (fig 3). Any postDental News, Volume XXII, Number I, 2015

operative complications are dealt with, as they would be with an extraction: irrigation and alvogyl in the case of dry socket, antibiotics, irrigation with chlorhexidine and drainage in the case of infection. Should infection persist then extraction of the root is indicated. There are variations in technique described in the literature. Pogrel 20076 describes a technique of raising both a buccal and a lingual flap. The intention of the lingual flap is to protect the lingual nerve and the lingual plate. The crown is sectioned completely using a bur at an angle of 45o. The aim is to completely transect the crown so it can be easily removed with a mosquito forceps, so as no to apply any torqueing forces to the roots thus reducing the chance of mobilisation.8,10,13 A less commonly described technique is to use a rose head bur to remove crown tissue.

42 Oral Surgery The disadvantages to this are that it takes longer to perform the procedure and produces more debris, and as such is not commonly used. Some authors advocate prophylactic administration of antibiotics however this does not appear to be universal.

Discussion In recent years there have been a number of studies showing quite favourable outcomes for coronectomy. To date there have been two randomised control trials of coronectomies: Leung 20093 and Renton 2005.9 The Leung et al. 20093 study consisted of a control group of extractions n=178 against a trial group of planned coronectomies n=171. Out of the trial group 16 coronectomies (9.4%) failed due to mobilisation of the roots and had to be extracted. Pain and dry socket were reported to be lower in the coronectomy group and there was no difference in infection rates in either group. 1 coronectomy patient required reoperation due to exposure of the root. In terms of IDN damage out of the extraction group, 9 (5.1%) presented with sensory deficit compared to 1 (0.65%) in the coronectomy group. While this does show quite favourable results the mean follow

Dental News, Volume XXII, Number I, 2015

up time was quite short being less than 12 months. Renton 20059 published a randomised study consisting of 128 patients being treated for 196 third molars. The coronectomy group n=94 had quite a high failure rate in terms of mobilisation of roots (38%). No sensory deficit was reported in the coronectomy group whereas 19 nerves were damaged after extraction. There was no difference in the incidence of dry socket in either group, 5%. The mean follow up was 25 months. Hatano et al. 200913 published a case control study. 220 wisdom teeth were divided into an extraction control group n=118 and a coronectomy group n=102. The mean follow up was 13 months in the control group and 13.5 months in the coronectomy group. 6 cases of IDN damage were reported in the extraction group compared to 1 in the coronectomy group. 4 of the coronectomy roots had to be subsequently removed due to post-operative infection, and out of these 4 there was no nerve damage. Pogrel et al. 20047 performed 50 coronectomies on 41 patients. A lingual flap was raised for each coronectomy. There were no cases of IDN damage and one case of lingual nerve deficient, which subsequently resolved. 1 patient required removal

43 Oral Surgery of both roots because of failure to heal and another patient required removal of a root due to migration to the surface. X-rays were taken immediately post op and after 6 months and root migration was evident in 30% of patients. Root migration has been reported in long-term follow up. Leung 20123 reported on a 3 year follow up of their original study. Of the original 108 patients 98 returned for 3 year follow up. Out of the 98 patients there were 135 coronectomies. These were reviewed at 3, 6, 12, 24 and 36 months follow up. Root migration was reported in most cases in the first 12 months and stopped at 24 months. The mean root migration was 2.8 mm at 36 months and root eruption occurred in 4 (3%) of cases. These 4 roots were extracted without any report of IDN damage. Dolanmaz14 in a study of 47 coronectomies reported a mean eruption of 4mm at 24 months. Knutsson16 1989 reported the most migration of up to 7mm after 1 year. It can be argued that with re-eruption patients may require two procedures rather than one, thus questioning the efficacy of coronectomy. Most authors report in cases where roots reerupt they migrate away from the IDN and therefore a counter argument could be made that taking the nerve into account,

Dental News, Volume XXII, Number I, 2015

this is safer, the outcome is ultimately the same as a planned extraction and considering the effect that permanent nerve damage could have on a patient’s quality of life then this is a much more favourable outcome. However there has been a case reported of the IDN migrating with the tooth as it reerupted following coronectomy, but this is quite a rare finding.

Conclusion As an alternative to extraction of lower third molars with an established high risk to the inferior dental nerve, coronectomy offers a safe alternative. The evidence that is emerging is quite positive and in general shows good outcomes when compared to extraction. As there is less radiation associated with cone beam CT than standard CT it has become more justifiable to assess third molars using this technology. This has allowed more accurate assessment of third molars and therefore it is likely in time coronectomy will become a much more routine procedure. Further research is required as there is little evidence in terms of long-term studies.





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Dental News, Volume XXII, Number I, 2015

1. Renton T. Notes on Coronectomy. Br Dent J 2012; 212; 323-326 2. Patel V, Kwok J, Sproat C, McGurk M. To Retrieve or not to Retrieve the Coronectomy Root The Clinical Dilemma. Dental Update 2013; 40; 370-376 3. Leung YY, Cheung LK. Coronectomy of the Lower Third Molar Is Safe Within the First 3 Years. Journal of Oral and Maxillofacial Surgery 2012; 70; 1515- 1522 4. McArdle L, McDonald F, Jones J. Distal cervical caries in the mandibular second molar: an indication for the prophylactic removal of third molar teeth? Update. British Journal of Oral and Maxillofacial Surgery 2014; 52; 185-189 5. Gleeson C, Patel V, Kwok J, Sproat C. Coronectomy practice. Paper 1. Technique and trouble-shooting British Journal of Oral and Maxillofacial Surgery 2012; 50; 739 -744 6. Pogrel MA. Partial Odontectomy. Oral and Maxillofacial Surgery Clinics of North America 19 2007; 19; 85-91 7. Pogrel MA, Lee JJ, Muff DF. Coronectomy: A technique to protect the inferior alveolar nerve. Journal of Oral and Maxillofacial Surgery 2004 62 (12) 1447-1452 8. Leung YY, Cheung LK. Safety of coronectomy versus excision of wisdom teeth: A randomized controlled trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108; 821-827 9. Renton T, Hankins M, Sproate C, McGurk M. A randomised controlled clinical trial to compare the incidence of injury to the inferior alveolar nerve as a result of coronectomy and removal of mandibular third molars. British Journal of Oral and Maxillofacial Surgery 2005; 43; 7-12 10. Patel V, Sproat C, Kwok J, Beneng K, Thavaraj S, McGurk M Histological evaluation of mandibular third molars retrieved after coronectomy British Journal of Oral and Maxillofacial Surgery 2014; 52; (5) 415-419 11. Cilasun U, Yildirim T, Guzeldemir E, Pektas ZO. Coronectomy in patients with high risk of inferior alveolar nerve injury diagnosed by computerised tomography. Journal of Oral and Maxillofacial Surgery 2011; 69;(6): 1557-61 12. Sencimen M, Ortakoglu K, Ayclin C, Aydintug YS, Ozyigit A, Ozen T, Gunaydin Y. Is endodontic treatment necessary during coronectomy procedure? Journal of Oral and Maxillofacial Surgery 2010; 68;(10) 2385-90 13. Hatano Y, Kurita K, Kuroiwa Y, Yuasa H, Ariji E. Clinical evaluations of coronectomy (intentional partial odontectomy) for mandibular third molars using dental computerised tomography: a case-control study. Journal of Oral and Maxillofacial Surgery 2009; 67;(9) 1806-14 14. Dolanmaz D, Yildirim G, Isik K, Kucik K, Ozturk A. A preferable technique for protecting the inferior alveolar nerve: Coronectomy. Journal of Oral and Maxillofacial Surgery 2009; 67;(6): 1234-8 15. O’Riordan BC. Coronectomy (intentional partial odontectomy of lower third molars). Oral Surg Oral Med Oral Pathol Oral Radiol Endo 2004; 98;(3): 274-80 16. Knutsson K, Lysell Leif, Rohlin M. Postoperative status after partial removal of the mandibular third molar. Swedish Dental Journal 1989;13;15-22 17. Drage NA, Renton T. Inferior alveolar nerve injury related to mandibular third molar surgery: an unusual case presentation. Oral Surg Oral Med Oral Pathol Oral Radiol Endo 2002; 93;(3): 358-361




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46 18 Restorative Dentistry

Direct Replacement of Anterior Tooth with Fiber-Reinforced Composite and Natural Tooth Pontic: A Case Report Abstract Mayada Jemâa, Assistant Professor Bassem Khattech, Professor

Military Principal Hospital of Instruction, Tunis, Tunisia

Nouha Mghirbi, Assistant Professor

Hayet Hajjami, Professor

Sonia Zouiten, Professor

Abdellatif Boughzala, Professor

Hospital Farhat Hached, Sousse, Tunisia

The fiber-reinforced composite (FRC) bridges can be an excellent alternative to conventional prosthetic techniques since it is a conservative, fast and cost effective treatment method. Properties of FRC, such as strength, desirable esthetic characteristics, ease of use, adaptability of various shapes, and potential for direct bonding to tooth structure make it suitable for various applications (Hyeon Kim et al, 2014) The anterior permanent extracted tooth can be directly bonded to the adjacent teeth with the FRC. 8 This non invasive provisional method leads to exact repositioning of the coronal part of the anterior extracted tooth in its original intraoral three-dimensional position. 8 The purpose of this article was to present a clinical case of a single anterior tooth replacement by means of fiber- reinforced composite and natural tooth pontic.

Key Words Case report, Fiber-reinforced composite, anterior tooth replacement, esthetic, function

Introduction Every day, dentists are exposed to various and complex esthetic, functional and restorative challenges. Following traumatic loss of the anterior tooth, it is important that an immediate replacement is provided in order to avoid esthetic, masticatory and phonetic difficulties, and to maintain the edentulous space (Smriti Bhargava et al. 2011) A wide range of treatment options can be proposed as solutions for the replacement of a traumatically missing anterior permanent incisor. Some authors consider that implants are the treatment of choice in this clinical situation, since they enable a more conservative approach.

Dental News, Volume XXII, Number I, 2015

Of course, they are indicated when general and local conditions are favorable. 9, 11 However, the need for surgical procedures and its high cost may reduce its accessibility for some patients (Hyeon Kim et al. 2014). In addition, we should not ignore the patient anxiety and fear about this surgical process. 9 The missing incisor can be replaced with conventional porcelain-fused-to-metal or all ceramic bridge or even with resin-bonded fixed partial denture (Maryland Bridge). 10, 11 The disadvantages of these treatment options: invasive reduction of healthy tooth structure (conventional bridge), non esthetic aspect of the metal framework, dental reduction (grooves‌) and lack of longevity (partial denture) and sometimes compromised esthetics. 10, 11 Over the last few years, the development of an innovative treatment using fiber-reinforced composite (FRC) has been reported to replace a single anterior tooth. It offers the possibility of fabricating resin-bonded, esthetically good and metal-free tooth restorations. 3, 7, 9 In some studies, even the missing posterior teeth can be replaced by means of prefabricated FRC technique. 5 The development of the FRC materials and technologies may also allow alternatives for directly made molar replacements (Sufyan Garoushi et al. 2012). Using the natural tooth as a pontic offers the benefits of being the right size, shape, and color. Moreover, the positive psychological value to the patient in using his or her natural tooth is an added benefit (Smriti Bhargava et al. 2011). The current article describes a clinical case treated with a FRC bridge, which was fabricated using the natural tooth as a pontic for immediate replacement of a central permanent incisor in a teenage patient.


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48 Restorative Dentistry Clinical significance

Fig 3

The use of FRC restoration as a novel concept for immediate replacement of missing anterior tooth can provide minimally invasive and esthetically promising clinical result.

Case report A 13-year-old patient who lost a maxillary central incisor due to trauma reported to the Dental Department for replacement of the same. On discussion, for this adolescent patient, noninvasive transitory prosthetic solutions are indicated. The replacement was performed using FRC Bridge because of its conservative nature, the favorable occlusal conditions, esthetic result, and preserving tooth substance. This treatment is an ideal and esthetic option for patients who need a provisional fixed prosthesis before a definitive treatment is chosen (between a classical prosthetic and the implant one). The treatment was accomplished in a one-visit appointment. Fig 1: Intra-oral preoperative labial view, showing the missing central maxillary incisor

Fig 1

Fig 2: The tooth was immersed in saline solution, and then scaled from the remaining soft tissue

Fig 2

Fig 3: Decoronation of the tooth, removal of the pulp tissue and the apical end of the root was formed into an ovate pontic design with finishing diamond burs. The pulp space was restored with light cure composite. Fig 4

Fig 4: Fitting of the crown Fig 5

Fig 5: Palatal view Fig 6

Fig 6: Conservative box preparations are prepared (limited to enamel), Dimensions: 1.5 to 2 mm long, 1.5 to 2 mm wide, and 2 mm deep the proximal aspects of the abutment two teeth Dental News, Volume XXII, Number I, 2015



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50 Restorative Dentistry Fig 7: Premeasured FRC material was cut with the Ribbond cutter

Fig 7

Fig 12

Fig 12: The pontic was placed into the predetermined position and the fibers were condensed through the resin composite Fig 8 - 9: The adhesive bonding agent was applied to all the prepared tooth structure according to the manufacturer’s guidelines

Fig 8 Fig 13

Fig 9

Fig 13: The adhesive was polymerized for 20 seconds Fig 14

Fig 10

Fig 14: A tunnel was prepared across the pontic from one proximal side to another with round burs at the predetermined level

Fig 15

Fig 11: Premeasured FRC was immersed into the specified bonding agent and flowable composite for 15 minutes. Then, it was passed through the tunnel with clear cotton pliers

Fig 11

Fig 15: The Box preparations on the two abutment teeth were etched (37% phosphoric acid gel, 30 seconds), rinsed and gently air-dried Dental News, Volume XXII, Number I, 2015

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52 Restorative Dentistry Fig 16: Measuring of the surface of the pontic from one side to another

Fig 16

Fig 17: Immediate final restoration

Fig 17

Fig 18: Palatal view of the final restoration. The Occlusion was carefully adjusted, especially the anterior guidance using articulating paper

Fig 18

Fig 19: Frontal view

Fig 19

We recommended to the patient to keep a good hygiene and maintain the FRC restoration free from dental plaque. 1 Fig 20: 3 months following up restoration

Fig 20

Dental News, Volume XXII, Number I, 2015

Discussion The replacement of a traumatically missing permanent anterior maxillary tooth can be performed by different treatment options. 6, 11 The missing tooth can be replaced with conventional 3-unit bridge or even with resinbonded fixed partial denture (Maryland Bridge) or a single implant. 10, 11 A traditional 3-unit bridge (porcelain-fusedto-metal or all ceramic) is a viable solution (Gerard J et al. 2001). However, this treatment leads to excessive reduction of the structure of the abutment two teeth and high risk of pulp exposure. 1, 10, 11 Referring to the study of Garoushi S et al. 2011, the conventional fixed partial denture was not indicated in our clinical case due to the young age of the patient. The resin-bonded fixed partial denture (Maryland Bridge) has some disadvantages as the non-esthetic aspect of the metal framework and the necessity of preparation of the dental grooves. 11 It is also considered that partial removable dentures can be exposed to fracture and can irritate the palatal mucosa when used for a long period. 8 Dental implant can be a suitable solution for the replacement of the missing central maxillary incisor but it is considered as an expensive, invasive treatment and we should not ignore the anxiety and fear of the patient about the surgical procedure. 1, 9, 10, 11 Systemic problems may also contraindicate surgery (H Kermanshah et al. 2010). In our case report and referring to other studies, the young age of the patient was a clear contraindication for an implant therapy. 4 Over the last few years, the development of fiber reinforced composite (FRC) has given the dental profession the possibility of fabricating adhesive, aesthetic, and metal-free dental replacements (Kaur Inderjeet et al. 2011). The FRC prosthesis are considered as an innovative and conservative alternative treatment to conventional fixed bridges or partial dentures and even to implants. 2 Compared to traditional prosthetic options, a fiber-reinforced composite bridge is generally less costly (Amir Chafaie et al. 2004) The thin filaments that are incorporated to a

54 Restorative Dentistry base resin offer an excellent fracture resistance, fatigue strength, improved flexural and tensile strength. 2 While clinical performance is the final determinant of success, flexure is still the most widely reported mechanical property (H Kermanshah et al. 2010). The FRC restorations can be performed directly or indirectly with an artificial acrylic tooth, a direct build up by composite resin or with the crown of the expulsed tooth. 11 The primary type of failures identified were either bulk fracture at the connector or the pontic area, debonding of the veneering composite or fiber exposure (H Kermanshah et al. 2010). In the literature, some authors do not recommend the use of composite materials for definitive restoration because of the risk of the increased wear, accumulation of dental plaque and unstable esthetic clinical result. 1 In our clinical case, all these risks are diminished since we used the natural crown as a pontic. Thus, we avoided complicated laboratory procedure. 8 In the study of Hyeon Kim et al. 2014, the extracted tooth presented no esthetic problems, but the pontic was build up with composite because of the difference of the shape of the adjacent teeth and presence of malalignement of the anterior teeth. The biggest advantage of using the natural crown of the patient as a pontic for the FRC Bridge is the better patient acceptance and tolerance of the tooth loss. Added to that the better shape, color, size and alignement of this natural pontic. 8 The preparations (grooves) of the two abutment teeth were minimal and confined to enamel, it was a non-invasive approach.2 In this case report, the immediate restoration of the missing central permanent maxillary incisor by means of FRC using the natural tooth as a pontic offered promising esthetic result and psychological acceptance from the patient. The technique is practical, economically feasible, requires limited laboratory support and materials, and can be accomplished in a single appointment (Smriti Bhargava et al. 2011). In the visit of control (three months after restoration), the clinical evaluation showed successful result, no evidence of problems and Dental News, Volume XXII, Number I, 2015

the teenage patient maintained a good oral hygiene as it was recommended before. He was satisfied with the final restoration. It should be emphasized that FRC prosthesis cannot be a long-term treatment; it is a provisional treatment before conventional fixed prostheses or implant therapy. Garoushi S et al. in (2011, 2012) showed that there is a lack of long-term clinical research of FRC prostheses. Moreover, those longitudinal studies reported general failure rates between 5% and 16% over periods up to 4-5 years.

Conclusion The replacement of the missing anterior maxillary incisor is an esthetic and functional challenge. The growing desire of patients for esthetic and metal free restorations led to an innovative, conservative, simple and cost-effective approach using FRC prostheses. The success of this technique depends on different factors such as the use of high quality materials and the correct clinical indication of this technique.

References 1. Immediate tooth replacement using fiber-reinforced composite and natural tooth pontic, H Kermanshah, F Motevasselian; Operative Dentistry, 2010, 35-2, 238-245 2. Replacing a Missing Anterior Tooth with Fiber Reinforced Composite Bridge - A Case Report, Kaur Inderjeet, Shresht Khandpur, Harneet Kaur, JIDA, Vol. 5, No. 4, April 2011 3. Fiber-reinforced Composite for Chairside Replacement of Anterior Teeth: A Case Report, Garoushi S, Vallittu PK and Lassila LVJ, Libyan J Med, AOP: 081001 4. Resin-Bonded Fiber-Reinforced Composite for Direct Replacement of Missing Anterior Teeth: A Clinical Report, Sufyan Garoushi, Lippo Lassila, Pekka K. Vallittu, International Journal of Dentistry, Volume 2011 5. Chairside Replacement of Posterior Teeth Using a Prefabricated Fiber-Reinforced Resin Composite Framework Technique: A Case Report, JONATHAN C. MEIERS, REZA B. KAZEMI, J Esthet Restor Dent 17:335–342, 2005 6. Anterior Fiber-reinforced Composite Resin Bridge: A Case Report Amir Chafaie, Richard Portier, Pediatric Dentistry – 26:6, 2004 7. Single Visit Replacement of Maxillary Canine using Fiber-reinforced Composite Resin, Sufyan Garoushi, Lippo Lassila, Pekka K Vallittu, The Journal of Contemporary Dental Practice, JanuaryFebruary 2012;13(1):125-129 8. Immediate fixed temporization with a natural tooth crown pontic following failure of replantation, Smriti Bhargava, Ritu Namdev, Samir Dutta, Rajkumar Tiwari, Contemporary Clinical Dentistry / Jul-sept 2011/vol2/Issue3 9. Esthetic rehabilitation of single anterior edentulous space using fiber-reinforced composite, Hyeon Kim, Min-Ju Song, Su-Jung Shin, Yoon Lee, Jeong-Won Park, Restor Dent Endod 2014;39(3):220225 10. Fiber- reinforced bridge replacement for congenitally missing lateral incisors, Gerard J. Lemongello Jr Contemporary Esthetics And Restorative Practice, February 2001 11. Anterior fiber- reinforced composite resin bridge: A case report Anuraag Gurtu, Chandrwati guha, Kanishka Dua, Journal of Dental Sciences and Oral Rehabilitation, Oct-Dec 2010, Vol.1 - Issue 1

‫‪56‬‬ ‫‪November 19 - 22, 2014‬‬ ‫‪Jumeirah Messilah Beach, KUWAIT‬‬

‫‪More Pictures Available On‬‬ ‫‪‬‬

‫‪The 18th Kuwait Dental Association International Scientific Conference‬‬

‫‪Photo from the Opening Ceremony‬‬ ‫معالي وزير الصحة الدكتور علي العبيدي راعي المؤتمر‪،‬‬ ‫البروفسور ايلي المعلوف أمين عام اتحاد أطباء األسنان العرب‪،‬‬ ‫السادة الوكالء‪،‬‬ ‫السادة النقباء ورؤساء جمعيات طب األسنان‪،‬‬ ‫السادة عمداء كليات طب األسنان‪،‬‬ ‫الزمالء والزميالت أطباء األسنان األعزاء‪،‬‬ ‫حضورنا الكريم‪.‬‬ ‫أبدأ كلمتي بتوجيه التحية لصاحب السمو أمير البالد الشيخ‬ ‫صباح االحمد الصباح باختيار سموه من قبل األمم المتحدة‬ ‫قائدا ً للعمل اإلنساني‪ ،‬ولذلك فإن دولة الكويت وبقيادة صاحب‬ ‫السمو أمير البالد ملتزمة بالتطوير المستمر لمنظومة الصحة في‬ ‫الكويت وعلى رأسها صحة الفم واألسنان‪.‬‬ ‫ومن هذا المنطلق‪ ،‬كانت دعوتنا لعقد هذا المؤتمر الذي يعد‬ ‫المؤتمر األضخم في الكويت في هذا المجال‪ ،‬حيث يجمع بين‬ ‫مؤتمرين دولي و عربي في الوقت نفسه‪ ،‬والذي يضم نخبة من‬ ‫كبار األطباء والمتخصصين على مستوى العالم‪ ،‬ووضعنا على‬ ‫رأس أهدافنا إثراء مجال طب األسنان بكل ما هو جديد من‬ ‫أبحاث علمية وطرق عالجية وتقنيات حديثة مما يساهم في‬ ‫مواكبة وإطالع جميع العاملين في مجال طب األسنان على آخر‬ ‫المستجدات العلمية‪.‬‬

‫‪Left to Right: Dr Sami Al Manih, Dr. Youssef Al Douery,‬‬ ‫‪Dr. Abdulwahab Alawadhi‬‬ ‫قدراتهم عبر اإلطالع على التقنيات الحديثة واستخدامها عن طريق نخبة من الخبراء والمتخصصون‪،‬‬ ‫وكما يضم المؤتمر معرض به نخبة من المؤسسات والهيئات و شركات القطاع الخاص المتخصصة في‬ ‫مجال طب األسنان والتي سوف تعرض آخر ما توصل اليه طب األسنان من أجهزة حديثة و تقنيات‬ ‫جديدة‪.‬‬

‫الدكتور عبد الوهاب العوضي‪،‬‬ ‫رئيس جمعية أطباء األسنان الكويتيين‬

‫والجدير بالذكر بأن مؤتمرنا سوف يوفر أكثر من ‪ ٣٠‬محاضرة‬ ‫علمية وما يقارب العشرون ورشة عمل‪ ،‬تعمل على تطوير‬ ‫‪Dental News, Volume XXII, Number I, 2015‬‬

The Power of 2. Combine the A-dec 200 with our A-dec 300 delivery system today and get more control over the way you work.

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To learn more visit or contact your local dealer.

Dr. Abdulwahab Alawadhi greeting Dr. Mohamed Alobeida from the KSA

Photo of the Members of the Organizing Committee D . Abdulwahab the President of the Kuwait Dental Association

r Dental News, Volumearound XXII, Number I, 2015

Assistina 3x3: Clean inside, clean outside

The new Assistina 3x3 cleans and maintains up to three instruments automatically. Automatic internal and external cleaning, short cycle time, easy to use: perfect preparation of straight and contra-angle handpieces and turbines for sterilization.

Bring me to life! Download the ÂťW&H ARÂŤ App free of charge from Google Play (for Android) or the Apple App Store. Open the App and hold your device 50 cm from the ad.

‫‪SDA‬‬ ‫‪2014‬‬


‫‪December 2 - 4, 2014‬‬ ‫‪Khortoum, SUDAN‬‬

‫‪More Pictures Available On‬‬ ‫‪‬‬

‫‪The 8th Sudanese Dental Association Conference‬‬

‫‪Ribbon Cutting by the Minister of Health‬‬ ‫األخوة ‪ /‬أطباء األسنان الكرام‪،‬‬ ‫إن ما شهده السودان من تطور في طب األسنان كما وكيفا‬ ‫في السنوات السابقة يجعل التحديات امامنا كبيرة والتخطيط‬ ‫السليم واجب ال بد منه‪ .‬إن أعداد أطباء األسنان في السودان‬ ‫قد قاربت الستة الف طبيب وأن كليات األسنان عشر كليات‬ ‫وإن أعداد الخريجين سنوياً يفوق الخمسمائة طبيب‪ .‬وقد زادت‬ ‫مراكز وعيادات األسنان بصورة بلغت الستت تستدعي اإلهتمام‬ ‫بالجودة وتكاتف كل األصعدة لتحقيق ذلك‪ ،‬ومحاولة اإلرتقاء‬ ‫بالتدريب والتعليم المستمر كبيرة‪.‬‬ ‫في رحاب هذا المؤتمر الثامن‪ ،‬ظهر جلياً قدرة اإلتحاد في تنظيم‬ ‫المؤتمرات الدولية التي تعكس تطور وقدرة وتكاتف الجميع‬ ‫إلبراز الصورة المشرفة لطب األسنان في السودان خاصة وإننا‬ ‫من أوائل الدول التي قامت بها كليات لطب األسنان في المنطقة‬ ‫العربية واالفريقية‪.‬‬ ‫نشكر كل أطباء األسنان في مختلف بقاع السودان على‬ ‫مشاركتهم ودعمهم الكبير لنشاطات اإلتحاد‪ ،‬ونرجو ان يكون‬ ‫هذا المؤتمر بداية موفقة لهذه الدورة الجديدة‪ ،‬سائلين اللّه ان‬ ‫يمهد لنا الطريق لتحقيق كل األهداف المرسومة لإلرتقاء بمهنة‬ ‫طب األسنان في السودان‪ ،‬إنه سميع مجيب‪.‬‬ ‫الدكتور أحمد عثمان حسن رزق‬ ‫رئيس إتحاد أطباء األسنان السودانيين‬

‫‪Dr. Ahmad Othman Rizk,‬‬ ‫‪President of the Sudanese Dental Association‬‬ ‫‪Dental News, Volume XXII, Number I, 2015‬‬

Pr. Ibrahim Ghandour Between Guests from Around the World

Pictures from The Exhibition Floor

Dental News, Volume XXII, Number I, 2015

OptiBond™ XTR Unmatched power for all your direct and indirect restorations.

AD_OptiBond_XTR_bullet let 12.11.2010 10:46 12.11.2010 Pagina 1


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SDS 2015


January 13 - 15 Riyadh, KSA

More Pictures Available On

Prince Turki Bin Abdallah opens the Saudi International Conference

DR. Mohammad Al-Obaida On behalf of the Organizing Committee, it is a pleasure for me to welcome you to the 26th Saudi Dental Society International Dental Conference held at Riyadh International Convention and Exhibition Center from 13-15 January 2015. So far this Conference is Riyadh’s largest annual event devoted to the dental care in Saudi Arabia, and it will give participants a platform to exchange ideas, discover new trends in dentistry, reacquaint with colleagues, meet new friends, and broaden their knowledge. The Ministry of Health gives its utmost priority to provide the best health care services throughout the Kingdom making use of the latest technology in the sector. The health care policy of the Kingdom has been designed according to the vision of Custodian of the Two Holy Mosques, who once said: “Nothing is more important than the health of the people”.

Dental News, Volume XXII, Number I, 2015

Recognition to Dr Hoda Abdullatif from Princess Noura Unversity Aside from the scientific sessions during the Conference, there will be hands-on teaching workshops and of course our popular poster sessions to give the presenter as much exposure as possible to their peers, and research awards for the Graduates, Young Dentists and Dental Interns. We are thankful to the many international speakers who will shed light on the research and clinical issues that shape our field today. We hope that presentations from many different speakers from other countries shared during this Conference will enrich knowledge to the dental professions in Saudi Arabia and help provide even better treatment, and dental care to the community they served. Your participation will make this conference wonderful, fruitful and successful. DR. MOHAMMAD I. AL-OBAIDA President The Saudi Dental Society

unique electric solution Transforms your existing unit by seamlessly adding the latest technology iOptima – I am the one and only Bien-Air Dental SA länggasse 60 case postale cH-2500 Bienne 6, switzerland tel. +41 (0) 32 344 64 64 Fax +41 (0) 32 344 64 91

Pictures from The Exhibition Floor

Dental News, Volume XXII, Number I, 2015

68 February 17 - 19, 2015 Dubai, UAE

His Highness Sheikh Hamdan Bin Rashid Al Maktoum, Deputy Ruler of Dubai, Minister of Finance and President of the Dubai Health Authority inaugurated the 19th edition of the UAE International Dental Conference and Arab Dental Exhibition (AEEDC Dubai) held at the Dubai International Convention and Exhibition Center with the participation of a large number of regional and international officials, heads of delegation, representatives from 130 countries, and more than 1400 company

Pictures from The Exhibition Floor

Dental News, Volume XXII, Number I, 2015

More Pictures Available On

Pictures from The Exhibition Floor

Representatives from

130 countries More than

1400 company

Pictures from The Exhibition Floor

Dental News, Volume XXII, Number I, 2015

The invisible way of teeth correction. biocompatible material clinically proven 3-splint-system for effective treatment individual fabrication solutions in cooperation with CA LAB or CA DIGITAL treatment corrections are possible at any time intelligent software CA速 SMART, digital measurement technique for set-up, visual data transfer in real time by webcam

IDS 2015 in Cologne Hall 10.1 Stand: C040 D049

For more information please see:

SCHEU-DENTAL GmbH Dubai Office phone +971 50 6255046

The Global Scientific Dental Alliance GSDA meeting was held with participation from 40 countries


Trophy Distribution To

The Oman Dental Society

The Umm Al Qura University

The American Dental Association

The Turkish Dental Association

The French Dental Association

Dental News

Dental News, Volume XXII, Number I, 2015

The Kuwait Ministry of Health

The Saudi Ministry of Health

Dr. Hany Ounsi

The Egyptian Dental Association

The Bahrain Ministry of Health

The Saudi Dental Society

The Lebanese Dental Association

The Italian Dental Association

The Greater New York Dental Meeting

The Emirates Dental Association

Visitors of the DENTAL NEWS Booth From

Dental News, Volume XXII, Number I, 2015

Around the Globe


FKG Dentaire: 2014 has seen great developments in Endo. In 2015 FKG Dentaire propels Endo in the future...

The number of dentists and specialists considering a more conservative and biological approach for Endo treatment has grown dramatically these last years. FKG Dentaire, pioneer in this approach has developed the largest range of NiTi files in the world with over 120 different sizes to fit all kinds of canals anatomy and avoiding the use too stiff files that may change the roots anatomy, which could create dangerous micro cracks or weaken the tooth by over treating the case. Here the concept is to give the dentists the best endo tool box with high quality and efficient Swiss endo files so dentists can adapt their sequence to the best treatment in accordance with the patients root canals and reach higher success rate. FKG has in its range the renown user friendly sequences iRace, BioRace (non-sterile or sterile) and BTRace (sterile and single-use). In 2014 we have launched Rooter, a new generation of endo wireless motor with LED light and TotalFill, one of the latest development in Bioceramic Sealer and root repair materials. These new products, this trend for a more conservative approach and following a high demand for continuous education has led FKG Dentaire to open microscopes equipped training centers around the globe (Switzerland, United Arab Emirates). Any dentists willing to get trained on FKG Products locally or in our Training Centers can get in touch with their local FKG distributors. Website:

GC continuously seeks to offer the most adequate products for your daily use • G-aenial Anterior & Posterior G-ænial is one of the rare composite materials that can be really qualified as being userfriendly, not only because of the shade concept, but because it is a unique composition that offers effortless manipulation. Consistency and working times are accommodated to all restorative classes. • G-aenial Universal Flo an innovative concept in composite restorative New concept, new composition: the art of injectable composite G-ænial Universal Flo benefits from a composition that features a unique filler technology. It has a higher filler load and a homogeneous dispersion of fillers. The resulting improved strength and wear resistance are two key features of this product, opening up the potential for a broader use than standard flowables and making it more suitable for class I to V restorations. Essentially, it looks like a flowable but behaves like a restorative. Its indications are for direct restorations, minimum intervention cavities and fissure sealing. • G-aenial Bond One bonding agent, two choices Offering a selective etching approach, G-ænial bond offers the best of both worlds: the simplicity and reduced post-operative sensitivity of a self-etch adhesive together with the greater bond strength that was traditionally found only with etch & rinse adhesives. It is a reliable bonding that had proven its efficiency and durability via several studies. Dental News, Volume XXII, Number I, 2015


Faculté de

médecine dentaire

Under the patronage of the Faculty of dental medicine Saint-Joseph University

Lebanon Campus of Medical Sciences, Saint Joseph University, Beirut - Lebanon

April 16-18, 2015

Lecturers Jochen Alius (GER) Wael Att (GER) Joseph Choukroun (FRA) Georges Goumenos (GRE) Georges Khoury (FRA) Alvaro Ordonez (USA) Stavros Pelekanos (GRE)

In collaboration with:

Gerardo Pellegrino (ITA) Pedro Peña (SPA) Alberto Rebaudi (ITA) Marco Ronda (ITA) Gerard Scortecci (FRA) Simone Verardi (ITA) Tomaso Vercellotti (ITA)

Co-Chairpersons Prof. Nada Naaman Dr. Kenneth Judy Contacts Dr. Christian Makary Dr. Ghassan Yared Scientific chairperson Tel. +961-1-421283

International Piezosurgery Academy

Chairperson organizing committee


NEW! Cavex Bite&White ExSense - Tooth Conditioner Cavex Bite&White ExSense offers fast and long-lasting relief from sensitive teeth thanks to a revolutionary blend of hydroxyapatite and a ‹hydro-dispersing clay›. The unique properties of the hydro-dispersing clay ensure accelerated dispersion that helps boost the hydroxyapatite penetration. Thanks to the synergetic composition of Cavex Bite&White ExSense, the hydroxyapatite penetrates deep into the tubules and microcracks in the enamel. This means that the areas causing sensitivity are sealed off completely, while at the same time, a process of crystallisation helps to restore micro-hardness and accelerates the re-mineralisation process. Website:

NEW PERIOTOME – 868 Kit • Handle with 4 interchangeable blades, for atraumatic extraction of teeth with minimal damage to the surrounding alveolar bone. • Thanks to the sharp and delicate blades, the marginal gingiva and periodontal ligament can be carefully detached. • Its use is particularly important when considering dental implants.








Upgradings: • Innovative design «DALILA» handle, specially designed to ensure fast cleaning, easier sterilization and a more comfortable and secure grip • New inclined blade allowing full detachment at mesial & distal position. This blade replaces the previous one article 868/3 • Improved with a locking air-tight mechanism • A new holding system for the blade ensures maximum stability website:

Dental News, Volume XXII, Number I, 2015





06-10 May 2015

TARGET AUDIENCE: These events are designed for Dentists, Dental Technicians & Dental Team



Organized By:

Supported By:

Centre for Advanced Professional Practices (CAPP) is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.

CAPP Designates this activity for 14 CE Credits

FDI 2015BANGKOK Annual World Dental Congress 22 - 25 September 2015 - Bangkok Thailand

Dental News, Volume XXII, Number I, 2015