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Volume XXII, Number II, 2015


Can We Increase Patient’s Compliance ? Root Canal Shaping by Continuous or Reciprocating Rotation ? Maxillary Immediate Loading Implant Placement in Esthetic Zone The Use of Mini-Implants in Complete Denture Treatment


Dental News, Volume XXII, Number II, 2015


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Dental News, Volume XXII, Number II, 2015

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Dental News, Volume XXII, Number II, 2015





Can We Increase Patient’s Compliance by Improving Quality and Efficiency of Functional Appliances?


April 16 - 18, 2015 Saint Joseph University, Beirut, LEBANON

Dr. Elie Callabe


Root Canal Shaping by Continuous or Reciprocating Rotation: the ProTaper System versus the Endo-Eze Tilos System Dr. Chems Belkhir, Dr. Rim Naifar, Dr. Jihed Ben Ammar, Dr. Sana Bagga, Dr. Mohammed Semir Belkhir


Maxillary Immediate Loading with Fixed Implant-Supported Restoration in an Edentulous Patient: A Case Report

ICOI Lebanon 1st International Implant Symposium


10th Edition CAD/CAM & Digital Dentistry International Conference May 8 - 9, 2015 Jumeirah Beach Hotel, Dubai, UAE


UPGRADE TO MODERN DENTISTRY 14th International Convention of the Lebanese University School of Dentistry May 13 - 16, 2015 Lebanese University, Hadath, LEBANON

Dr. Rola Mortada, Dr. Mohamad Al Bazzal, Dr. Ibrahim Mortada, Dr. Khaldoun Rifai


Implant Placement in Esthetic Zone After Bone Block Reconstruction: A Case Report Dr. Rita Farhat, Dr. Mansour Chantiri, Dr. Cherine Farhat, Dr. Chadi Choueiry, Dr. Badri Meouchy


The Use of Mini-Implants in Complete Denture Treatment Dr. Danielle El Hakim, Dr. Emilie El Mouchantaf, Dr. Maha Ghotmi, Dr. Pierre El Khoury




Dental News, Volume XXII, Number II, 2015

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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

Dental News, Volume XXII, Number II, 2015

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Dental News, Volume XXII, Number II, 2015



w w Volume XXII, Number II, 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.

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

FDI 2015 Annual World Dental Congress

September 22 - 25, 2015 Bangkok, THAILAND Email: Website:

International orthodontic congress: WFO

September 27 - 30, 2015 London Website:

BIDM 2015 - The 25th Lebanese Dental Association Congress

October 8 - 10, 2015 at the BIEL, Beirut, LEBANON Website:

The International Team for Implantology Congress Middle East - ITI

October 15 - 16, 2015 Dead Sea, JORDAN Email: Website:

PAEC 2015 - The 4th Pan Arab Endodontic Conference

October 29 - 31, 2015 Hamamet, TUNISIA Website:

The Egyptian Dental Association Meeting

November 11 - 13, 2015 Cairo, EGYPT Email:

7th Dental - Facial Cosmetic International Conference

November 13 - 14, 2015 at the Jumeirah Beach Hotel, Dubai, UAE Email: Website:

AEEDC 2016 - The 20th UAE International Dental Conference & Arab Dental Exhibition

February 2 - 4, 2016 at the Dubai International Convention & Exhibition Centre, Dubai, UAE Website: Dental News App on both Appstore & Google play

Mona Lisa’s smile hides the hole tooth

This magazine is printed on FSC – certified paper.

The truth behind the inscrutable smile of the Mona Lisa may have been as banal as bad teeth, according to archaeologists compiling the history of dentistry. Evidence that Leonardo da Vinci’s probable model, Isabella of Aragon, suffered from such severe enamel-staining that she used pumice stone, cuttlefish, crude toothpicks, brick dust, china fragments and ground cattle hooves which removed not only staining from her teeth but some of her enamel as well, as for the archeologist Chrissie Freeth from Bradford University. Dental News, Volume XXII, Number II, 2015

12 Orthodontics

Can We Increase Patient’s Compliance by Improving Quality and Efficiency of Functional Appliances? Dr. Elie Callabe

The PUL Concept 4D Harmonizer: functional, sagittal, transversal and vertical.

Fig 2

The PUL characteristics: “Propulseur Universal Light”. The PUL is a new-generation multi-tasking removable appliance : - Better compliance: it has been lightened, thanks to its laser welded frame, its miniaturized mandibular advancing system and using TMA wire. - Comfortable, light, aesthetic: It allows a good diction, can be worn at school. - Physiological: gentle propulsion thanks to inserted coil springs (TMJ shocks absorbers). - Universal: it is indicated to all Classes II, all facial typologies. - Multi actions: thanks to its Laser welded frame, it allows several simultaneous actions, saving treatment time. ( fig. 1, 2, 3, 4, 5, 6 )

Fig 1: PUL multi-tasks with anterior elastic and expansion screws Fig 3

Fig 1

Fig 4

Fig 1: PUL multi-tasks with TMA loop Dental News, Volume XXII, Number II, 2015

The Proof is in the Numbers

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14 18 Orthodontics Fig 5

Fig 7

Fig 6

Fig 7: Before PUL Fig 8

Clinical Effects 4D harmonization of malocclusions : sagittal, transversal, vertical and functional. 1- In young patients with hyperdivergent (dolychofacial) growth and multiple dysfunctions: oral breathing, deglutition and mastication (hypotonia). a. The mandibular propulsion helps bi-labial contact and increases the pharyngeal space, improving nasal breathing. b. The posterior occlusal contact induces a proprioceptive stimulation and contraction of the masseter temporal fibers, improving mastication. c. Improvement of the lingual function (position and deglutition) and natural correction of openbites. This leads to a change in growth direction, from dolycho to mesofacial. ( fig. 7, 8 )

Fig 9 Fig 9: Correction of Class II by mandibular anchorage

Dental News, Volume XXII, Number II, 2015

Fig 7: After PUL

2- In patients with hypodivergent (brachyfacial) growth: the mandibular propulsion and posterior nonocclusion lead to a change in the direction and neutralization of the temporo-masseter muscles and a suppression of the occlusal forces. This induces rapid Class II correction by distalizing upper lateral teeth (mandibular anchorage) and overbite correction by natural extrusion of the posterior teeth. ( fig. 9 )

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16 Orthodontics Protocol of Treatment Three phases: 1- PUL multi-tasking 4D harmonization of the malocclusion: sagittal (Class II), transversal (expansion), vertical (deepbite or openbite), and functional (nasal breathing, swallowing

and chewing muscles). Duration : from 6 to 12 months. 2- Fixed appliance low friction without or with few elastics. Duration: 12 months. 3- 4D stabilization by PUL retainer. Night wearing. ( fig. 10, 11)

Fig 10

Fig 11

Fig 10: Early treatment: Hyperdivergent growth: before PUL, after PUL, and after braces

Fig 11: Teenager’s treatment: before PUL, after PUL, and after braces

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Dental News, Volume XXII, Number II, 2015

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17 Orthodontics Class II malocclusions Class II represent more than 75% of all malocclusions that orthodontist have to treat, about 30% of these patients have hyperdivergent facial growth. Like every medical treatment, orthodontist began with a diagnosis. The aim is to treat the causes of malocclusion before or simultaneously treating symptoms. In almost all malocclusions, the cause of the malocclusion are the functional dysfunctions like oral breathing, thumb sucking, hypotonic muscle or atypical deglutition.

Case 1: Syndrom of Class II division 1 Amandine , a young girl of 12 years old who complains from ectopic maxillary canines and lower crowding. Functional diagnosis: Oral breathing, snoring (sleep apnea), past thumb sucking, labial inocclusion, gummy smile and short upper lip. (fig.1, 2)

Fig 1

Fig 2

Dental News, Volume XXII, Number II, 2015

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18 Orthodontics Dento-maxillary diagnosis: Full Class II, crowding, mandibular retrognathic, hyperdivergent facial growth. (fig.3, 4)

Fig 3

Treatment objectives are to stop the hyperdivergent growth by improving the functions and mandibular growth, and avoid extractions.

Fig 4

Treatment plan 1- PUL 4D harmonization: functional, sagittal, tranversal and vertical. PUL multi-tasks with expansion screws, wearing 22 hours a day. Duration 9 months. (fig.5, 6, 7) Fig 5



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Dental News, Volume XXII, Number II, 2015

Fig 7

20 Orthodontics 2- Alignment and finition by multibraces self ligating low friction. Duration 13 months. (fig.8, 9, 10)

Fig 12

Fig 8

Fig 12

Fig 9

Discussion Fig 10

3- 4D stabilization by PUL retainer antirelapse night wearing. Duration 12 months and decreasing. (fig.11, 12, 13)

“Changing the functions for changing the shape” Linder-Arronson The advantage of combination of these three phases is to reduce time of treatment and improve patient’s comfort and compliance thanks to the lightness of the PUL appliance. The benefit for the patient is obvious: facial aesthetics and non-extraction short treatment. Fig 14

Fig 11 Fig 15

Dental News, Volume XXII, Number II, 2015



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22 Orthodontics 12. Callabe E. Revue L’Orthodontiste N°157 : Novembre-Décembre 2010:


L’asymétrie chez l’Ado.

13. Callabe E, Morin JC : Bulletin PulConcept : Traitement de la récidive chez

1. Cambiano, A., Controllo della divergenza nel trattamento delle maloc-

clusioni di II classe. Tesi di specializzazione in ortodonzia. Università di Palermo; anno accademico 2006-2007.

2. Patti A., Perrier d’Arc G. I trattamenti ortodontici precoci. OrthoPlanet ed. 2006.

3. Patti A. et coll : Traitement de la Classe II, Ed Quintescence, 2010 4. Callabe E. Traitement de la Classe II hyperdivergente. Congres JO 2010-

11-26 5. Eschard-Charbonnier C : Analyse des modifications dento-squelettiques apportées par le P.U.L. d’Elie Callabe.Etude rétrospective d’un échantillon de 30 cas traités : Thèse Cecsmo Université de Reims 2009 6. Geyselinck H :Le Propulseur Universel Light et le traitement des classes II: étude d’efficacité (étude sur 60 cas): Thèse Cecsmo Faculté de Lille 2009 7. Dumotier A :Le propulseur universel « light » (PUL) et les activateurs monobloc: descriptif et effets thérapeutiques: Thèse Cecsmo Faculté de Marseille 2009 8. Melka V: Evaluation clinique de la correction du décalage de classe II par un appareil amovible : le Propulseur Universel Light : Thèse Cecsmo Faculté de Montpellier 2009 9. Joulia C : Comparaison des effets morphologiques de thérapeutiques fonctionnelles de classe II par la méthode Procuste. Thèse Cecsmo Faculté de Reims 2009 10. Popelut R : Le propulseur universel light (PUL) au travers de deux études rétrospectives. Thèse Cecsmo Faculté Paris VII 2010 11. Martin S : Variation de la position de l’incisive mandibulaire dans le sens sagittal chez une population de patients traités par PUL® (étude céphalométrique de 20 cas). Thèse Cecsmo Faculté de Montpellier 2010

w e n

l’adulte : intérêt du PUL. Janvier 2011

14. Callabe E : La contention Classe II Classe III. Bulletin Innovortho-News: Juillet 2010 15. Penin X. (1999) Analyse et prévision de croissance crânienne par superposition procuste. Revue d’Orthopédie Dento-Faciale 33(2) pp275-286 16. Patti A. : Traitement des Classes II, de la prévention à la chirurgie. Edition Quintessence International. Octobre 2010 17. Callabe E: La Classe II division 1 brachyfaciale avec biproalvéolie. Revue L’Orthodontiste N°158. Février-Mars 2011 18. Callabe E : ORL et Syndrôme médical de l’hyperdivergence maxillo-faciale de l’enfant: Importance de la collaboration Ortho // ORL. Conference Paris “Les journées de l’orthodontie” Mars 2011 19. Castelain C : Effets du Propulseur Universel Light selon la divergence faciale (étude statistique sur 56 cas) . Thèse de diplôme d’état de Doctorat en Chirurgie Dentaire. Faculté dentaire de Lille 2. Avril 2011 20. Callabe E : Le syndrome médical de l’hyperdivergence. Revue L’Orthodontiste N°162 . Février-Mars 2012 21. Brame JC : Le SAHOS et les ronchopathies : effets attendus et indésirables de l’orthèse d’avancée mandibulaire. Exemple du Snorlight. Thèse de diplôme d’état de Docteur en Chirurgie Dentaire. Faculté de Lille 2. Janvier 2012. 22. Migliorati M : PUL: A New Functional Appliance for Class II Growing Patients. A Prospective Controlled Study.” University of Genova Italy.


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18 24 Endodontics

Root Canal Shaping by Continuous or Reciprocating Rotation: the ProTaper System versus the Endo-Eze Tilos System

Dr. Chems Belkhir Associate Professor of Endodontics

Dr. Rim Naifar Private clinician

Dr. Jihed Ben Ammar Student in Endodontics

Dr. Sana Bagga Associate Professor of Endodontics

Dr. Mohammed Semir Belkhir Professor of Endodontics and chairman

Keywords Reciprocating motion, continuous rotation, root canal shaping, root canal centring, canal surface increase.

Abstract Introduction The aim of this in vitro study is to compare between two systems of canal shaping: the ProTaper® system (used in continuous rotation) and the Tilos® (used in reciprocating motion), in order to evaluate, after endodontic preparation, the increase in canal surface, the canal centring and the respect of the initial canal shape. Materials and method Thirty human teeth (first and second mandibular molars) with straight or slightly curved mature roots were sectioned 3mm below the neck, the access cavities established and the working length of the mesial roots measured. Each tooth was slipped into a transparent block of resin. Each block was perforated, one on the mesial and one on the distal part of the tooth; with a drill and then sectioned within 4mm of the tooth apex. A picture of each section was taken before canal preparation with a digital camera mounted on a stereo microscope. The teeth were distributed into two groups: group 1 was prepared with the ProTaper® and group 2 with the Tilos® . A second picture of the sections was taken after preparation. The images obtained were processed with the CS5 Photoshop program in order to color the preoperative and the postoperative canal surfaces. The superimposition of both images of the same root was achieved by the RealDraw Pro program. Thanks to the PhotoShop CS5, it was possible to measure the canal surfaces in pixels. The statistical analysis of the data on the progression of the canal surface for both groups was based on the unilateral test. The statistical analysis of the data on the canal centering and

Dental News, Volume XXII, Number II, 2015

the modification of the canal shape was carried out with the chi-square (x2). Results The unilateral test showed a p = 0.039 so that the difference between both systems is statistically significant. The chi-square test didn’t show any significant difference between both groups: P=0.5775 for the canal centring and P=0.4202 for the canal shape modification. Conclusions The ProTaper system is more efficient than the Tilos system in extending the canal surface. Both preparation systems are quite the same concerning the respect of the centring and the initial shape of the canal.

Introduction Canal shaping should enable irrigating solutions to clean thoroughly the entire canal system. This is to eradicate bacteria and toxins and all the pulp debris likely to serve as nutriments for bacteria proliferation. It will also make it possible a three-dimensional obturation of the canal system and its airtight sealing.12, 15 The manufacturers continuously seek to facilitate the job of dentists with more reliable instruments and by making faster canal preparation possible. Canal preparation thus becomes easier, quicker and more accurate, with less debris thrown onto the periapex. The objectives to achieve also depend on the practitioner’s dexterity when using these instruments. For fifteen years, the rotary nickel-titanium (NiTi) instruments have facilitated endodontic practice as it allows faster shaping, better canal centring and less risk of ledging and tearing the apical

Route to successful endodontics


26 Endodontics foramen. The instrumental fracture remains the main problem when using these instruments.4 The concept of reciprocating motion makes it possible to reduce the risk of fracture with endodontic instruments. This concept uses a clockwise – anticlockwise movement with unequal amplitude similar to the movement of the balanced forces described in the 1980s. 4,7 Mastering canal preparation and preventing incidents require from the practitioner to have an accurate knowledge of the impact of the instruments characteristics on the mechanical behaviour of the instrument. Nowadays, many systems are available on the market to achieve the best possible biological and mechanical objectives of canal treatment: a regular conical shape, the respect of the canal trajectory as well as keeping a narrow foramen in its initial position. The many systems available make it complicated for the practitioner to choose the best one. The aim of this in vitro study is to compare between two systems of canal shaping: the ProTaper® system (DENTSPLY Maillefer); used in continuous rotation; and the Tilos® (Ultra dent); used in reciprocating motion; in order to evaluate: - The increase in the canal surface - The canal centring - The respect of the initial canal shape.

Materials and method 1- Teeth selection Thirty human, caries-free teeth (first and second mandibular molars) were used in this study. These teeth were stored in tap water and in a refrigerator until operating processes. All these teeth presented an apex without any fracture and mature roots – either straight or slightly curved ones. In this study, only mesial roots were used. 2- Teeth preparation - The teeth were cleaned using a brush and pumice stone powder mixed with water to eliminate dental plaque. - The vestibular faces were marked by letter “V” and the lingual faces by an identification number. Dental News, Volume XXII, Number II, 2015

- The occlusal face of each tooth was sectioned 3mm below the neck with a 0.5mm thick metallic disk. - The access cavities were established by Endo Z and tungsten carbide bur drills mounted on a multiplying contra angle. - The teeth were divided haphazardly into two groups. Group Nr1, from nr1 to nr15, intended for the Tilos system and group Nr2, from nr16 to nr30, intended for the ProTaper system. - The working lengths of the mesial canals (16mm > WL < 18mm) were measured by means of a nr 0.8 K file. The value to be kept was the value measured as soon as the file tip was visible at the apex and the stop brought to the reference occlusal surface. - On each root, a line was drawn 4mm from the apex. This line marks the future cutting line performed by the Isomet. 3- Making of a resin block A silicon mould was made up to achieve a transparent resin block coating the roots of the selected teeth. Each tooth inserted into the block will be sectioned horizontally 4mm from its apex. Such a device will allow an exact and accurate repositioning of both block sections when taking shape. This cube was created according to the following steps: - A cubic shape mould is made from modelling clay in order for the tooth roots to be completely coated by resin. The location of the two tightening screws has been planned Nr. 3, 5. - The block faces are parallel. - On one of the block faces, a vertical indention was performed to show the location of the teeth vestibular face. - The block obtained with modelling clay was placed into silicon. Its impression was used as a mould for the transparent resin block. A silicon mould was thus obtained. Each tooth was slipped into a transparent resin. The vestibular face was placed opposite the indention. After the resin was set, two holes (one on the right and one on the left side of the tooth) were made with a drill equipped with an Nr4 drill bit. These holes serve to fix tightening screws Nr3.5 (Fig.1).

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28 Endodontics Fig 1

Fig 1: Resin block with screws

4- Isomet Law Speed Saw Section Each block was mounted on an Isomet BUEHLER saw and sectioned at the level of the marked line. The section was carried out with a 0.4mm thick, diamond-tipped disk (ref. 11-4244) with a 7 RPM speed. Two fragments were thus obtained, one apical and one coronary, the sample number reported on them. The apical fragment was the only one to be analyzed. 5- Stereo microscope observation and photos Each section was photographed with a digital camera mounted on a Zeiss Stemi 2000-c stereo microscope with a 2.5 enlargement. 6- Canal root preparation The two fragments of each tooth are repositioned and fixed with nr 3.5 screws and nuts. Group 1 was prepared with the Protaper® and group 2 with the Endo-Eze Tilos® . a- Protaper® protocol This system is used in continuous rotation with a constant speed between 150 and 350 RPM. Root canal preparation was performed according to the following protocol: • Coronal thirds preparation: initial negotiation of the canal using nr10 and nr15 K hand file until work length (WL). Use of the S1 and S2 mechanical shaping files to reach progressively WL. • Apical third preparation: using L1 and L2 mechanized finishers’ files until WL. After each instrument change, canals were abundantly irrigated with a 2.5% NAOCI solution. Dental News, Volume XXII, Number II, 2015

b- Endo-Eze Tilos® protocol The Endo- Eze Tilos® system (Ultradent) is a hybrid system which combines two techniques: manual and mechanical. It is used with a reciprocal contra angle with a 30° right and left brushing movement. Canal preparation was carried out according to the following protocol: • Coronal thirds preparation: initial step with nr15 hand file followed by S1 (mechanized shaping file) until WL -3mm. Recapitulation with nr15 hand file followed by S2 shaping files until WL -3mm. Recapitulation with nr15 hand file followed by S3 until WL -6mm. Recapitulation with WL nr20 hand file followed by S2 until WL. • Apical third preparation: nr 25 Tilos® Transitional files with a 6% and 4% conic shape were used. 6% transitional files were used until WL • After each change of instrument, all canals were irrigated abundantly with a solution of NaOCI at 2.5%. 7- Stereo microscope second observation and photographs Each section was photographed with a digital camera mounted on a Zeiss Stemi 2000-c stereo microscope with a 2.5 enlargement. The photos were made considering: • The widening at the start • The same arrangements as before the preparation 8- Image processing The images obtained were processed with the CS5 Photoshop program in order to color the preoperative canal walls in mauve and the postoperative canal surfaces in blue. Then, with the Real Draw PRO program, both photos of the same root were superimposed. This combination was then reprocessed with the Photoshop CS5 program in order to measure the canal surface which is given in pixels.

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30 Endodontics Fig 2: Stereomicroscope observation: Tilos sections photography: (a, b): V and L canals show a non- centred widening without canal walls damage. (c ): canal V show a centred widening without canal walls damage. Canal L show a non- centred widening with canal walls damage. (d) : V and L canals show a non- centred widening with canal walls damage. (e) : Canal V showed a centred widening without canal walls damage. Canal L show a non- centred widening without canal walls damage Fig 3: Stereomicroscope observation: ProTaper sections photography: (a): canal V show a centred widening without canal walls damage. Canal L show a non- centred widening with canal walls damage. (b): V and L canals show a non- centred widening with canal walls damage. (c, d, e) : V and L canals show a centred widening without canal walls damage.

Fig 2















Fig 3








e V




Material Free of Monomer Results 1- Image analysis The superimposition of the images, before and after preparation (Figs 2 and 3) made it possible to achieve different observations of nr2 Table. 2- Descriptive study a- Quantitative study (Table nr1) The mean values obtained, for canal surface increase, with the Tilos system were 195.419% and 231.443% with the Protaper system.

Table 1: Canal surface increasing. Dental News, Volume XXII, Number II, 2015



b- Qualitative study (Table nr2) • Canal centring: - The Tilos system: 68% of the canals showed a centred widening without the canal walls being damaged, 23% showed a centred widening with canal walls damaged and 9% a noncentred widening without any damage. - The Protaper system: 90% of the canals presented a centred widening without the canal walls being damaged, 5% showed a centred widening with the canal walls being damaged and 5% a non-centred widening without the canal walls being damaged.

Table 1




Standard deviation











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32 Endodontics

Canal centering

Canal shape modification

Table 2

Centered widening

Centered widening with damage

Non-centered widening

Non-centered widening with damage


Not Modified















Table 2: Canal centring and canal shape modification.

• Canal shape modification: - The Tilos system: 18% of the canals kept their initial shape while 82% did not. - The Protaper system: 29% of the canals kept their initial shape while 71% did not. 3- Statistical study • The statistical study of the canal surface increase data of both groups was based on the unilateral test. This test showed p=0.039, so the difference between the two systems is statistically significant. The Protaper system is more efficient than the Tilos system concerning canal surface widening. • The statistical analysis of canal centring and canal shape modification data was done with chi-square. This test did not reveal any significant difference between the two groups: P=0.5775 for canal centring P=0.4202 for canal shape modification It can be deduced that the two preparation systems are equivalent concerning the respect of canal shape.

Discussion This in vitro study compares the shaping efficiency of two endodontic instruments on the mesial canals of inferior molars. There are numerous evaluation methods: radiography (classical, digital, cone beam), scanning electronic microscopy, computed tomography, tomodensiometry, etc… The modified Bramante technique is among the oldest and cheapest techniques. It is a method which makes it possible to compare Dental News, Volume XXII, Number II, 2015

the canals before and after instrumentation. It makes it possible to evaluate instrument efficiency by analyzing several parameters: canal shape modification, canal centring and canal transportation.2 The major drawback of the plaster spanner being a bad adaptation between the various fragments, the endodontic block (metallic device) was chosen to overcome this difficulty.8 The teeth were put into transparent resin, into a silicon mould (instead of the endodontic block) and the fragments fixed with two screws and their nuts (before sectioning by the drill). This technique proved easier than the endodontic block and just as efficient (no loosening between the fragments and a good adaptation). Very few studies have dealt with the Tilos® system. For this reason we are going to discuss the various parameters, with the most studied systems using the reciprocal movement, i.e. WaveOne® and Reciproc® . Our study showed that the Protaper® makes it possible a canal widening 4mm from the apex, which is more important than the Tilos® . This can be explained by the instruments shape, in particular their conical shape. The Protaper® consists of sharp files with triangular section and varying conical shapes (increasing for shaping files, decreasing for finishing files). With this system, the larger conical shape is 9% and the apical finishing shape is 8% with a diameter at the tip of 25/100(for F2). The maximum conical shape of the Tilos system is 6% and its apical diameter 25/100 for the transitional files. In a similar study to ours, Rosa and all11 tried to compare the Protaper® with the Tilos® . A group


34 Endodontics of 15 molars (first and second molars) were used with each system. It was shown that the rotating system provided the greatest increase in canal surface at the level of the cervical area of the canal. This difference is statistically significant but there is not any significant difference at the level of the medium third, nor at the level of the apical third in spite of the fact that the rotating system also provided a greater widening at both levels. In the You and al 15 study, comparing the Protaper® with Reciproc® system, (carried out on maxillar molars mesial and distal curved canals) it was not shown, after an evaluation by tomodensiometry, any significant difference between both systems concerning canal surface increase. The Versiani study 13 carried out on 54 mandibular canines with a similar morphology and comparing Protaper® , WaveOne® and Reciproc® , showed that the rotating system makes it possible a more significant canal surface than the systems with reciprocating motion. The Capar study 4, carried out on lower molars mesial canals, showed that with the Protaper and WaveOne® systems, there is a similar canal surface increase, but less than the Reciproc system with which more dentin is removed in that study and the difference is not significant. In the study carried out on resin blocks with FlexMaster instruments, Franco found out a more important canal surface increase with continuous rotation than with reciprocating motion at the apical third. There is no significant increase between the two protocols concerning the two median and coronal thirds. The Robinson study10, who worked on mesial roots of mandibular molars and evaluated the teeth by tomodensitometry, showed by comparison that the Protaper® leaves less debris in the canal than WaveOne® and this difference was statistically significant. Zokkar17, in another study comparing the Revo-S® system (continuous rotation) with the Endo-Express system (reciprocating motion) following a standard radiography analysis, showed that the Endo-Express system gives a more important widening at the level of the lower molars, but there is not any statistically significant difference. In our study, there wasn’t any significant Dental News, Volume XXII, Number II, 2015

difference between the two systems used concerning canal shape variation. The literature review shows diverging results. This might be explained by differences in methodology, operating protocol, instrumentation used… The Hartmann study 7 carried out on mesial canals of maxillar molars showed that the manual endodontic instruments, those used in continuous rotation and those used in reciprocating motion, canal transportation. This canal transportation is more important with mechanical systems than with manual instruments. The Lopez study 9, carried out on the mesial root of upper molars, showed a significant difference between the K3® system and the reciprocating NSK® handpiece. K3® allows a better canal centering than the reciprocating movement. The Berutti study 1, carried out on resin blocks, showed that with the WaveOne® system, the initial canal anatomy is better respected than with the ProTaper® system. The Capar study 4 on curved mesial roots of lower molars and comparing 6 systems (OneShape® , ProTaper® Universal, ProTaper® next X2, Reciproc® , Twisted File Adaptive and WaveOne®) did not show any significant difference concerning canal transportation. The Gergi study 6, devoted to centering and canal transportation (for the ProTaper® , Twisted and Hand-k files) on curved canals, showed a significant difference between the three systems. The Twisted File system generates less transportation, followed by the ProTaper® system. In this study it was observed that, for centering, there was a significant difference between these systems at the level of median and apical parts but not the cervical part. The Twisted Files system allows a more centered canal preparation. The Yang and all study 14, comparing two rotating systems, namely Mtwo® and Protaper® , carried out on 20 canals evaluated by tomodensitometry, showed that there is a difference in canal transportation, between both systems, at the apical level but not the cervical and medium levels and also that it generates more canal transportation. Concerning the possibility of roots becoming more fragile, comparing the Protaper® and

35 Endodontics Mtwo® systems with the Reciproc® and WaveOne® systems, the Bürklein 3 and all study showed that dentin defects are not linked with the type of instrument used (reciprocating or rotating system). The systems with reciprocating motion generate, on the apical part, a lot more cracks compared with rotating instruments.


References 1. Berutti E, Chiandussi G, Paolino DS and all. Canal shaping with Wave One Primary reciprocating files and ProTaper system: a comparative study. J Endod 2012;38:505-9.

2. Bramante CM, Berbert A, Borges RP. A methodology for evaluation of root canal instrumentation. J Endod 1987;13:243-5.

3. Bürklein S, Tsotsis P, Schüafer E. Incidence of dentinal defects after root canal preparation: reciprocating versus rotary instrumentation.

J Endod

In our in vitro study, two endo-mechanized systems were compared, the Protaper (continuous rotation) and the Tilos (reciprocating motion), carried on the mesial root of mandibular molars sectioned 4mm from the apex. The superimposition of preoperative and postoperative images led to the following conclusions:


• The Protaper® system allows a more important canal widening than the Tilos® system.

7. Hartmann MS, Barletta FB, Fontanell VR and all. Canal transportation

• The two preparation systems used are equivalent concerning the respect of the initial canal shape.

8. Kuttler S, Garala M, Perez R and Dorn SO. The Endodontic Cube: A

4. Capar ID, Ertas H, Ok E, Arslan H, Ertas ET. Comparative study of differ-

ent novel Nickel-Titanium rotary systems for root canal preparation in severely curved root canals. J Endod 2014; 40:852–56.

5. Franco V, Fabiani C, Taschieri S and all. Investigation on the Shaping Ability of Nickel-Titanium Files When Used with a Reciprocating Motion. J Endod


6. Gergi R, Rjeily JA, Sader J and all. Comparison of canal transportation and centering ability of twisted files,

Pathfile-ProTaper System, and stainless

steel hand K-Files by using computed tomography. J Endod 2010;36:904-7.

after root canal instrumentation: a comparative study with computed tomography. J Endod 2007;33:962-5.

System Designed for Evaluation of Root Cana Anatomy and Canal Prepara-

tion. J Endod 2001;27:533-36.

9. López FU, Fachin EV, Fontanella VR and all. Apical transportation: a comparative evaluation of three root canal instrumentation techniques with three

These results are in keeping with some studies5,11,15 where it was noticed that rotating systems allow a more significant widening than systems with reciprocating motion whereas in other studies 4,15,16,17, it was shown that both systems allow a similar canal widening. Dealing with centring capacity and canal transportation. some studies1,4,3,6 showed that the various systems studied allowed a relatively good centring and a minor canal transportation even if there are differences from one system to the other. It all depends on the operating protocol, instrumentation used as well as the practitioner’s skills. Each system has its advantages and drawbacks, but it could be suggested that the reciprocating motion, by eliminating the screwing effect, reduces the tip tightening risks, and delays plastic deformation moving to instrumentation fracture.

different apical diameters. J Endod 2008;34:1545-8.

Rev Odontol 2012; 41:353-9.

10. Robinson J, Lumley P, Cooper P

and all.



technique inducesreaterdebris accumulation than a continuous rotary technique as assessed by




J Endod

11. Rosa JM, Dametto FR, Gadê-Neto CR and all. Influence of the ro-

tary and/or oscillatory reciprocating systems in the morphological changes of narrow and curved molar root canals anatomy.


Rev Odontol 2012;

12. Schilder H. Cleaning and shaping the root canal. Dent Clin North Am 1974;18:269 –96.

13. Versiani MA, Leon GB, Steier L and all . Micro-computed tomography study of oval-shaped canals prepared with the self-adjusting file,

Reciproc, WaveOne, and ProTaper universal systems. J Endod 2013; 39:1061-6.

14. Yang G, Yuan G, Yun X, Zhou X, Liu B, Wu H. Effects of two nickeltitanium instrument systems,

Mtwo versus Protaper universal, on root canal

geometry assessed by micro-computed tomography. J Endod 2011;37:1412-


15. You SY, Kim HC, Bae KS, Baek SH, Kum KY, Lee W. Shapingability

of reciprocating motion in curvedrootcanals: a comparative studywith microcomputedtomography. J Endod 2011;37:1296-300.

16. Zmener O, Pameijer CH, Serrano SA and Hernandez SR. Cleaning ef-

ficacy using two engine-driven systems versus manual instrumentation in curved root canals: a scanning electron microscopic study.


J Endod 2011;

17. Zokkar N, Jemâa M and Zouiten S. Endodontie moderne: mouvement rotatif, mouvement alterné. J Ordre Dent Que 2012;49:7-14.

Dental News, Volume XXII, Number II, 2015

36 Implant Dentistry

Maxillary Immediate Loading with Fixed Implant-Supported Restoration in an Edentulous Patient: A Case Report Dr. Rola Mortada

Dr. Mohamad Al Bazzal

Dr. Ibrahim Mortada

Dr. Khaldoun Rifai

Introduction The original Bränemark protocol dictated that the initial phase of implant osseointegration should be at least 4-6 months before any prosthetic restoration is placed.1 However, technological advancements have resulted in modern dental implant protocols that provide the possibility to immediately load implants.2 Certain guidelines must be respected to reduce stress at the developing bone-to-implant interface and achieve osseointegration. Implants require primary stability of at least 45 Ncm insertion torque. Excessive micromotions exceeding 150 ¾m will prevent new bone formation and a noncalcified, collagenous poorly vascularized scar tissue will characterize the interface.3 There is an assumption that joining several implants together via a rigid construction will reduce micromotion then facilitate the healing process and the immediate loading especially when evaluating implant treatment in the maxilla.4,5 Furthermore, implant design and surface play an important role; a rough implant surface with deeper and more threads is recommended. (Tealdo et al., 2008 ; Pieri et al., 2009; Palattella et al., 2008). Kim compared clinical outcomes and stability following immediate loading of two types of tapered implants in posterior maxilla and mandible and concluded that whenever high primary stability is acquired, tapered implants with hybrid textured surfaces are predictable. In spite of the influence of implant design on marginal bone loss, all tapered implants showed successful clinical outcomes and stability in immediate loading.6 This concept has been used by many authors (Cannizzaro and Esposito, 2007) and is considered by many as a

Dental News, Volume XXII, Number II, 2015

viable treatment modality for the rehabilitation of the edentulous jaw.7 Over the past decade, immediate restoration of full-arch dental implants in the mandible has become a clinically validated mode of therapy.8 Ledermann used an immediate loading protocol with 4-screw designed endosseous implants in the anterior mandible using a bar-retained overdenture and showed a success rate of 92.80%.9 The reported success of immediate loading in the mandible has encouraged the application of similar treatment in maxilla. However, a more limited degree of success in maxilla v/s the mandible has often been attributed to poorer bone density. Lekholm and Zarb described maxillary bone as more trabecular and softer in nature (also known as type 3 or type 4), while mandibular bone is more cancellous and denser (type 1 or type 2).10 This anatomic difference results in lower primary stability, greater micromotion, and greater likelihood of fibrous healing and failure of implants to osseointegrate in maxilla when implants are immediately loaded.11 Despite the risks of failure in maxilla, reports demonstrating its viability, reliability, and success can be readily found in the literature.5 Romanos (2009) used an immediate loading protocol and concluded that it can be used successfully in maxilla when implant primary stability and a soft diet for the initial stages of healing are considered to 8 weeks of healing.12 Vervaeke and co-workers treated patients with immediately loaded implants in the maxilla supporting fixed full dentures and found that immediate loading in the maxilla is a predictable and reliable treatment option with high survival rates and limited peri-implant bone loss after 2 years when using fluoride-modified implants.13

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38 Implant Dentistry The purpose of the present clinical case report was to describe and discuss the rehabilitation of edentulous maxilla in a female patient with an implant-supported fixed restoration using an immediate loading protocol.

Case Report A 50-year old female consulted our clinic with defectuous restorations and remaining underlying roots. Most teeth were lost due to deep decay, periodontal pockets and furcation involvement. The patient had high esthetic and functional concerns. Extraoral examination revealed no asymmetry, no swellings, and no tender or palpable cervical or submandibular lymph nodes. Intraoral examination revealed residual decayed roots with deep periodontal pockets, bone resorption and mobility. Radiographic examination revealed bone resorption and furcation involvement in maxillary and mandibular teeth (Fig.1). Patient had a noncontributory medical history, she was a light smoker. Fig 1

esthetics and phonetics. It was converted later into a provisional fixed bridge over the implants.

Surgical Procedure Initial OPG revealed a resorbed alveolar bone with insufficient height in left and right posterior maxillary regions with maxillary sinus pneumatization (Fig.1). So sinus floor elevation was performed 9 months prior to implant placement. The day of the intervention, after the application of local analgesia with 1:100,000 epinephrine, existing crowns were removed and remaining roots (#13, #12, #11, #21, #24) were extracted (Fig.3). A crestal incision was performed in edentulous ridges to place implants (Zimmer, ScrewVent). Mucoperiosteal flap was raised, and alveolar ridge was exposed. 8 implants were placed in maxilla: 5 implants were placed in healed bone ( in areas #16, #15, #14,#26,#27) and 3 others were immediately placed in fresh extraction sockets (in areas #12, #23, #24) (Fig.4). When the latter fixtures were placed, the space between the vestibular cortex and implant surface was filled with bone substitute (Puros), and a connective tissue graft taken from the palate was used to thicken soft tissues in anterior maxillary region (Fig.5). Implants were placed with a preset insertion torque of 35 to 45Ncm. Implant length ranged from 10 to 13mm and implant diameters were 4.1 and 4.5mm Fig 2

Fig 1: Pre-operative OPG showing bone resorption and furcation involvement in maxillary and mandibular teeth as well as sinus pneumatization

Initial Prosthetic Treatment The patient desired implant-supported fixed prostheses and was qualified for an adequate treatment protocol. After clinical and radiographic examinations, the treatment planning included teeth extraction followed by immediately loaded implant prostheses in the maxilla and conventional delayed loading in the mandible. This clinical case illustrates surgical and fixed prosthetic implant-supported immediate loading protocol in the edentulous maxilla. A maxillary immediate complete denture was fabricated. It was implemented in centric relation with respect to proper vertical dimension,

Dental News, Volume XXII, Number II, 2015

Fig 2: Surgical template in place

39 Implant Dentistry Fig 3


Fig 3: Removal of defectuous anterior crowns and fixtures surgical placement

Fig 4

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Fig 5

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Dental News, Volume XXII, Number II, 2015

© Carestream Health, Inc. 2014.

40 Implant Dentistry Provisionalization technique Temporary abutments were screwed on the top of each maxillary implant to support the provisional fixed restoration. Mucoperiosteal flaps were finally sutured with 4.0 suturing resorbable material (Vicryl) (Fig.6). Fig 6

It was made in immediate functional loading with bilateral simultaneous anterior and posterior occlusal contact to distribute the load over a large area16 Only centric markings were kept; in fact, there is a general disagreement on when and how to provide occlusal contacts but all authors agree to adjust the occlusion intraorally and eliminate interferences when performing lateral movements keeping only the centric contacts.16

Postoperative Care

Fig 6: Maxillary provisional abutments screwed in place and sutures

The maxillary denture was perforated according to the emergence of these temporary abutments. The pink acrylic resin was removed to convert the denture into a provisional bridge. (Fig.7) Fig 7

Fig 7: Perforation of the denture according to emergence of provisional abutments

Cotton pellets covered the provisional abutment screws and the maxillary denture was filled completely with autopolymerizing acrylic resin (Alike, GC-FUJI- USA). The resin was allowed to fully polymerize on temporary abutments. The patient was instructed to close in centric relation and correct vertical dimension was achieved. After acrylic polymerization, abutments were unscrewed and the entire provisional device (acrylic provisional incorporating the 8 provisional abutments) was removed in one piece. Provisional restoration was trimmed, and polished for optimal strength and cleansability (Fig.8). The provisional was then screwed on top of implants and abutment screws were covered with a cotton pellet and the access holes were covered with composite. Occlusion was tested in static position and in all excursive movements; minor adjustments were made. The provisional prosthesis had flat cusps to minimize lateral forces14 and distribute them over a large area.15

Dental News, Volume XXII, Number II, 2015

Soft/liquid diet was advised for the first 4 to 6 weeks. Rinsing of the oral cavity with chlorhexidine digluconate 0.2% solution (Zordyl) was necessary. Postoperatively Augmentin 625 mg was prescribed 3 times a day for one week. Ten days after surgery, sutures were removed. 3 weeks after surgery, teeth extraction followed by implants placement was performed in the mandible as it was previously decided in the treatment planning. An acrylic provisional denture was inserted in the mandible, respecting the vertical dimension and the centric relation. This denture was going to be replaced after the healing period of 3 months by a fixed ceramometallic restoration. However, due to recent and unexpected personal considerations, the patient decided to postpone the prosthetic final rehabilitation in the mandible keeping the acrylic denture in place. Fig 8

Fig 8: Maxillary provisional fixed restoration: Convex pontics and interdental spaces kept open to improve the self-cleaning effect Fig 9

Fig 9: OPG 3 weeks after surgery with the maxillary provisional restoration in place

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42 18 Implant Dentistry Final Restoration Procedure After a conventional healing period, a final impression was made using Impregum impression material (Espe, Co. Germany). Determination of the correct vertical dimension of occlusion for edentulous patients is one of the most important steps in making dentures with adequate esthetics and function.17 Many techniques have been used for measurement of the vertical dimension of occlusion in edentulous patients.18 These range from using of preextration records (Wright, 1939) to the use of swallowing (Shanahan, 1956), functionally acquired jaw positions associated with phonetics (Pound, 1962) and cephalometric radiographs (Ellinger, 1968). Furthermore, many studies recommend a freeway space range of 2-4mm (Fenn, Liddelow and Gimson, 1961; Mitchell and Mitchell, 1995). Tyson and McCord stated that freeway space could be increased above this range for elderly patients and patients with atrophic mucosa overlying the residual ridge.19 In the present case report, an accurate assessment of the amount of freeway space was made; 3 mm were considered sufficient to provide comfort during function and speech. Given that the provisional restoration could be screwed on top of implants, the centric relation recorded in the correct vertical dimension was transferred by simply screwing the provisional bridge on top of implant analogs that were included in the final cast, without the need of registering centric relation with wax interocclusal rims.

In fact, the anterior and posterior determinants of occlusion give two necessary parts of the successful occlusal scheme- support and guidance.20 Balanced occlusion was followed to establish harmonious contact between the working and balancing cusps. In establishing the height of the balancing cusps, any contact beyond the length of the working cusp was considered as interference. Contacts were made simultaneous on both the working and balancing cusps from centric occlusion to the end of the stroke. On another hand, Zinner et al. proposed use of guidelines to test anterior contours recommending that the maxillary anterior incisal edges follow the contour of the lower lip, the “smile line”, and all 6 maxillary anterior teeth should be in contact with their antagonists in maximum intercuspation. Evaluation of labiodental (“F” and “V”) and sibilant (“S” and “CH”) sounds are useful methods of ascertaining the lengths of maxillary incisors.21 Once esthetics and phonetics were satisfying, a silicone index of the artificial teeth setting was made and the record was sent to the laboratory. Definitive abutments were screwed on implants and the laboratory returned maxillary full arch framework for try in. X-Rays were taken to assure an adequate fit of the metallic copings. Final ceramo-metallic restorations were then delivered and cemented with temporary cement (Temp bond; Kerr, Co., Karlsruhe, Germany) and patient was allowed to chew. Occlusion was carefully checked in all excursive movements. Patient was re-evaluated once every 3 months for professional oral hygiene control. The clinical as well as radiological examinations showed an optimal soft tissue condition (Fig.1112). No pain or infection or bone loss was observed during the entire 2 years observation period.

Fig 10

Fig 11 Fig 10: Cast mounting according to Vertical Dimension of Occlusion obtained after screwing the prosthesis on the top of implant analogs

Final casts were mounted on articulator in the correct centric relation and vertical dimension and artificial teeth setting was prepared for maxillary arch with respect to the scientific published guidelines. (Fig.10)

Dental News, Volume XXII, Number II, 2015

Fig 11: Maxillary final restoration

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44 Implant Dentistry Fig 12

implants is necessary in the maxilla with a good bone quality and high primary stability.28,29,30 The present case report describes the treatment protocol in a patient using immediately loaded implants for full arch fixed restoration in maxilla. The patient experienced the virtues of implant therapy from the very beginning of treatment without having to endure a relieved and relined provisional removable denture.

Fig 12: OPG 2 years after loading

Discussion An increasing concern regarding the possibility to shorten the healing time period in the implantprosthetic rehabilitation has become evident. Clinical studies (Calandriello et al., 2003; Glauser et al., 2005; Lindeboom et al., 2006; Donati et al., 2008; Esposito et al., 2009; Romanos et al., 2010) demonstrated that immediate functional loading implants placed with conventional installation technique and with sufficient primary stability may be considered a valid treatment alternative.22 Recent recommendations indicate that torque values at the time of placement should be greater than 32 N-cm.23 Quantity and quality of bone at the implant site also affect primary stability. When compared with bone from the mandible, maxillary bone can be particularly challenging for immediate implant placement because it has lesser bone density, a thin cortical plate, and proximity to the maxillary sinus.24 Implant designs that include threads and roughened surfaces significantly contribute to primary stability.5 Many studies have focused on the number of implants required for the immediate loading with a fixed prosthesis in the edentulous maxilla. Jaffin & kumar reported a 93% success rate when the number of implants placed is from 6 to 8.25 Capelli & Zuffetti showed a success rate of 97.5% when 4 to 6 implants were placed.26 Agliardi &Panigatti showed a 98.36% success rate when 2 axial and 2 tilted implants were placed.27 In fact, the number of implants needed when restoring cases with fixed prosthesis in the maxilla is greater than the number of implants needed to restore a fixed prosthesis in the mandible. At least 4 implants are needed in the anterior mandible to support a fixed prosthesis and a greater number of Dental News, Volume XXII, Number II, 2015

The treatment protocol was based on the surgical and prosthetic guidelines presented in earlier reports.12,5,31 Surgery was atraumatic; Understanding the quality and type of bone and preserving that bone via atraumatic extractions are necessary for promoting successful osseointegration when loading implants immediately.32 Micromotions were minimal, in fact although early reports indicated that osseointegration could succeed with micromovements up to 500 μm currently accepted levels of micromovement ranging between 50 and 150 μm are known to produce no detriment to osseointegration.5 Insertion torque was greater than 45 N-cm for all implants. The patient’s absence of any systemic diseases or specific medications intake were also encouraging. Appropriate imaging investigation (CBCT) was used for calculations of bone mineral density prior to the implant placement and showed that the patient had an acceptable quantity and quality of alveolar bone. The patient’s preference for a fixed restoration during the entire treatment time was also taken into consideration. This case report showed new bone formation at the interface of immediately loaded implants without fibrous encapsulation or implant loss. (Fig.9- 12) The provisional prosthesis was not removed at any time during the early period of osseointegration. Tarnow and co-workers showed that this procedure is advantageous regarding success of immediate, full-arch loading treatments.33 A screw-retained temporary restoration obviated the need for cement and the possibility of early de-cementation and biologic complications related to submucosal presence of cement. There is an increasing awareness among clinicians that undetected cement might be the cause of

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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.

46 Implant Dentistry delayed peri-implant bone loss, occurring many years after delivery of the restorations (Wilson, 2009). A multicenter 3-year prospective study reported that peri-implant soft tissues responded more favorably to screw retained crowns when compared with cement retained crowns (Weber et al., 2006). Restoring edentulous maxilla with a complete denture, a fixed implant-supported restoration or a removable overdenture is a complex and challenging procedure. All of these designs have been tested for safety, efficacy, and effectiveness in clinical studies.34 However, prosthesis design in edentulous maxilla should not be selected randomly or just on the basis of the patient’s or the practitioner’s preference. Rather, specific clinical parameters should be evaluated indicating whether a fixed or a removable implant-supported prosthesis or simply a conventional complete denture is preferable.35 These clinical factors are mostly related to bone and/or soft tissue deficiencies. The resorptive process can cause pseudoprognathism, deficient facial support, speech disruption, and/or esthetic problems. The smile line and length of upper lip should also be considered in deciding on the appropriate prosthesis design as it may influence a patient’s satisfaction with the treatment outcome.36 In the literature, patients’ perceptions of maxillary implant treatment have been reported. Chan and co-workers treated patients with an atrophic maxilla with implant-supported overdenture prostheses after pretreatment with bone augmentation and staged implant placement and reported improvements in patients’ assessments of comfort, appearance, mastication, and speech.34 Lundqvist and Carlsson restored patients with maxillary hybrid fixed prostheses screwed on standard abutments, and 19 of 21 patients thought that their self-confidence had improved after treatment.37 Jemt and associates showed that implant treatment in the edentulous upper jaw functions well in a 15-year time perspective.38 While most of the reviewed studies reported improved quality of life after treatment with implant-stabilised restorations, other studies did Dental News, Volume XXII, Number II, 2015

not find significant differences in the general quality of life between these patients and those restored with conventional complete dentures. Studies have proved that the great majority of completely edentulous patients are satisfied with their complete dentures.39 Patients with low level education and those with better selfperception of their affective status and quality of life were highly satisfied in general with the aesthetic appearance of their complete denture. The quality of dentures showed the strongest correlation with patient satisfaction;40 the satisfactory arrangement of the artificial denture teeth and their appearance during function and speech, as well as the satisfactory adaptation of the dentures to the denture bearing area and the excellent retention reached during denture fabrication are sufficient for a good satisfaction.39 In addition to this, patients may resist implant supported restorations due to barriers, including cost, fear, and lengthy treatment times.41 In the present case report, the treatment selection was based on a thorough examination and diagnosis of specific scientific criteria to prevent any disappointing results. The extra-oral examination revealed a convex profile with no need for facial or lip support and a relatively low smile line. The intra-oral examination showed a Class I Angle, a keratinized mucosa with an absence of advanced resorption anteriorly and a minimal vertical resorption leading to optimal length of the clinical crown if the fixed design was adopted. The examination of these data combined with the evaluation of the patient’s preference justified the adoption of the implant-supported fixed restoration as a final treatment option.

Conclusion In conclusion, although maxillary immediate loading with fixed implant-supported restorations has yet to prove itself in longterm evidence-based studies, results of current various investigations suggest that by carefully following guidelines and respecting anatomical limitations of maxilla and the biology of alveolar bone, clinicians may achieve long-term success rates similar to those consistently realized in the mandible.



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References 1. Bränemark PI. Osseointegration and its experimental background. J Prosthet Dent. 1983;50:399–410. 2. Francetti L et al.- bone level changes around axial and tilted implants in full-arch fixed immediate restorations. Interim results of a prospective study.- Clin Implant Dent Relat Res. 2012 Oct.14(5):646-54 3. Brunski JB, Moccia AF, Pollack SR, et al. The influence of functional use of endosseous dental implants on the tissue implant interface. I. Histological aspects. J Dent Res. 1979;58:1953–1969. 4. Fibberg B, Henninsson C, Jem T. Rehabilitation of edentulous mandibles by means of turned Bränemark system implants after one stage surgery: a 1 year retrospective study of 152 patients. Clin Implant Dent Relat Res 2005;7:1-9 5. Chung S et al.- Immediate loading in the maxillary arch: evidence-based guidelines to improve success rates: a review.- J Oral Implantol. 2011 Oct; 37(5):610-21 6. Kim YK et al.- A randomized controlled clinical trial of two types of tapered implants on immediate loading in the posterior maxilla and mandible.- Int J Oral Maxillofac Implants 2013 Nov-Dec;28(6):1602-11 7. Cannizzaro G, Leone M, Esposito M. Immediate functional loading of implants placed with flapless surgery in the edentulous maxilla: 1-year follow-up of a single cohort study.- Int J Oral Maxillofac Implants 2007;22:87-95 8. Barry P. Levin.- A Team approach to cost-effective, full-arch immediate loading.- Compend Contin Educ Dent. 2013 Jul-Aug;34(7):530-2 9. Romanos GE et al.- Immediate loading with fixed implant-supported restorations in an edentulous patient with an HIV infection: a case report.- Implant Dent. 2014;23:8-12 10. Lekholm U, Zarb GA. Patient selection and preparation. In: Branemark PI, Zarb GA, Alrektsson T, eds. Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry. Chicago, III: Quintessence Publishing Co; 1985:199-209. 11. Trisi P, Perfetti G, Baldoni E, Berardi D, Colagiovanni M, Scogna G. Implant micromotion is related to peak insertion torque and bone density. Clin Oral Impl Res. 2009,20:467471. 12. Romanos GE et al.- Immediate functional loading in the maxilla using implants with platform switching: five-year results.- Int J Oral Maxillofac Implants 2009;24:1106–1112 13. Vervaeke S et al.- Immediate loading of implants in the maxilla: survival and bone loss after at least 2 years of function.- Int J Oral and Maxillofac Impl.2013 Jan-Feb;28(1):216-21 14. Achilli A, Tura F, Euwe E. Immediate/early function with tapered implants supporting maxillary and mandibular posterior fixed partial dentures: preliminary results of a prospective multicenter study. J Prosthet Dent 2007;97:S52-58 15. Kinsel RP, Liss M. Retrospective analysis of 56 edentulous dental arches restored with 344 single-stage implants using an immediate loading fixed provisional protocol: statistical predictors of implant failure.- Int J Oral Maxillofac Implants 2007;22:823-830. 16. Horwitz J et al. Immediate and delayed restoration of dental implants in periodontally susceptible patients: 1-year results. Int J Oral Maxillofac Impl 2007;22:423-429. 17. Heartwell CM et al.- Syllabus of complete dentures. 4th ed. Philadelphia: Lea and Febiger, 1986; 228-30. 18. Ellinger CW.- Radiographic study of oral structures and their relation to anterior tooth position. J Prosthet Dent 1968; 19: 36-45. 19. Tyson KW et al.- Chairside options for the treatment of complete denture problems associated with atrophic mandibular ridge. British Dental Journal; 2000. 188, 10-14. 20. Jensen WO.- Alternate occlusal schemes. J Prosthet Dent 1991; 65:54-55. 21. Zinner ID et al. Provisional restorations in fixed partial prosthodontics. Dent Clin North Am 1989;33:355-77. 22. Donati M, Botticelli D, La Scala V, Tomasi C, Berglundh T.- Effect of immediate functional loading on osseointegration of implants used for single tooth replacement. A human histological study.- Clin. Oral Impl. Res. 2013 Jul; 24(7):738-45. 23. Ottoni JM et al. Correlation between placement torque and survival of single-tooth implants. Int J Oral Maxillofac Implants. 2005;20:769-776. 24. Nordin T et al. Early functional loading of sand-blasted and acid-etched (SLA) Straumann implants following immediate placement in maxillary extraction sockets: clinical and radiographie result. Clin Oral Implants Res. 2007;18:441-451. 25. Jaffin RA, Kumar A, Berman CL. Immediate loading of dental implants in the completely edentulous maxilla: a clinical report. Int J Oral Maxillofac Implants 2004;19:721-730. 26. Capelli M, Zuffetti F, Del Fabbro M, Testori T. Immediate rehabilitation of the completely edentulous jaw with fixed prostheses supported by either upright or tilted implants: a multicenter clinical study. Int J Oral Maxillofac Implants 2007;22:639-644. 27. Agliardi E, Panigatti S, Clerico M, Villa C, Malo P. Immediate rehabilitation of the edentulous jaws with full fixed prostheses supported by four implants: interim results of a single cohort prospective study. Clin Oral Impl Res 2010;21:459-465 28. Bergkvist G. Immediate loading of implants in the edentulous maxilla. Swed Dent J Suppl 2008,196:10-75. 29. Biscaro L, Becattelli A, Poggio P, Soattin M, Rossini F. The one-model technique: a new method for immediate loading with fixed prostheses in edentulous or potentially edentulous

Your Smile. Our Vision. Dental News, Volume XXII, Number II, 2015

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jaws. Int

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49 Implant Dentistry

30. Capelli M, Zuffetti F, Del Fabbro M, Testori T. Immediate

rehabilitation of

the completely edentulous jaw with fixed prostheses supported by either upright or tilted implants: a multicenter clinical study. Int

J Oral Maxillofac Implants

2007;22:639-644. 31. Romanos GE.- Immediate Loading in the Posterior Area of the Mandible. Animal and Clinical Studies. Berlin, Germany: Quintessence Publishing; 2005:73–91. 32. Degidi M, Piattelli A, Shibli JA, Perrotti V, Lezzi G. Bone formation around immediately loaded and submerged dental implants with a modified sandblasted and acid-etched surface after

4 and 8 weeks: a human histologie and histomorphometJ Oral Maxillofac Impl. 2009;24:896-901. 33. Tarnow D, Emtiaz S, Classi A. Immediate loading of threaded implants at stage 1 surgery in edentulous arches: ten consecutive case reports with 1- to 5-year data. Int J Oral Maxillofac Implants.1997:12(3):319-324. 34. Chan MF et al.- Treatment of the atrophic edentulous maxilla with implantsupported overdentures: a review of the literature.- Int J of Prosthodont. 1998 Jan/Feb;11(1):7-15 35. Zitzmann NU et al.- Treatment plan for restoring the edentulous maxilla with implant-supported restorations: Removable overdenture versus fixed partial denture design.- J Prosthet Dent.1999;82(2):188-96. 36. Zitzmann NU.- Treatment outcomes of fixed or removable implant-supported prostheses in the edentulous maxilla. Part I: Patients’ assessments.- J Prosthet Dent 2000;83:424-33. 37. Lundqvist S, Carlsson GE. Maxillary fixed prostheses on osseointegrated dental implants. J Prosthet Dent 1983;50:262-70. 38. Jemt T et al.- Implant treatment in the edentulous maxillae: a 15-year followup study on 76 consecutive patients provided with fixed prostheses.- Clinl Imp Dent Rel Res 2006;8(2):61-9. 39. Kovac Z et al.- Multivariate analysis of different factors affecting the patient general satisfaction with complete dentures.- Coll. Antropol.2012 Sept;36(3):791-4. 40. Celebić A.- Factors related to patient satisfaction with complete denture therapy.- J Gerontol A Biol Sci Med Sci. 2003 Oct;58(10):M948-53. 41. Pennington J et al.- Improving quality of life using removable and fixed implant prostheses.- Compend Contin Educ Dent. 2012 Apr;33(4):268-70, 272, 274-6. ric analysis. Int







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Dental News, Volume XXII, Number II, 2015

46 18 50 Implant Dentistry

Implant Placement in Esthetic Zone After Bone Block Reconstruction: A Case Report Abstract Dr. Rita Farhat DES Periodontology Dr. Mansour Chantiri DES Periodontology

Dr. Cherine Farhat CES Periodontology

Dr. Chadi Choueiry DES Periodontology

Dr. Badri Meouchy DES Periodontology

Missing teeth in the esthetic zone compromise functional, esthetical and phonetic status of the patients. Also advancement in dental implant treatment leads to predictable survival rates. Meticulous evaluation of both bone quality and quantity is a major requirement for a successful osseointegrated dental implant treatment. Bone defect associated with extraction sites in anterior maxilla affect both surgical placement of implant and subsequent prosthetic rehabilitation, a correction can be done by using a variety of techniques including barrier membrane with guided bone regeneration, bone block grafts, distraction osteogenesis‌ This case report is a step-by-step procedure in which missing tooth 21 is restored with dental implant after autogenous bone block grafting. An immediate provisional restoration was used to create esthetical gingival contour.

Introduction Restoration of missing anterior maxillary teeth is challenging due to compromised esthetic results associated with missing teeth, in addition to a gradual alveolar bone resorption.1 The presence of uncompromised bone of adequate volume at the implant site is a major factor in the functional success of the procedure. In addition, by providing predictable support both for the implant itself and for the gingival margin and papillae, it contributes to a pleasing esthetic outcome.2-3-4 In compromised sites, narrow implants, implants tilted buccally, and implants with oversized clinical crowns could be placed. But this can also lead to unesthetic results and mechanical complications due to improper biomechanics.5-6 Therefore, bone augmentation surgery is frequently a prerequisite for implant placement.2-4 Dental News, Volume XXII, Number II, 2015

A variety of allogenic, alloplastic and xenogenic bonegrafting materials have been suggested in recent years, based on wound-healing mechanisms and bone regeneration principles, such as tissue engineering, and osteoinductive and osteoconductive potential of different biomaterials. 7 Autogenous bone harvested from either extraoral or intraoral sites is regarded as the ÂŤgold standardÂť by some, and it remains the material of choice for cortical-cancellous blocks.8-9 Unlike the sinuses, alveolar ridge does not provide a natural cavity to contain particulated grafting material; therefore graft must display sufficient strength and rigidity to fixate at the recipient site and three-dimensional stability to withstand muscular forces. 10-11

Case Report A 21-year-old female patient consulted the Lebanese University Department of Periodontology complaining from absence of maxillary left anterior incisor (21). (Fig.1-2) Fig 1

Fig 1: Buccal view

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52 Implant Dentistry Fig 2

No periodontal pockets were detected. No other tooth mobility was found in the vicinity of the surgical wound. The thickness of the soft tissue of the edentulous ridge was about 2mm measured by a graduated periodontal probe. There were horizontal bucco-lingual bone defect and labial ridge in form of concavity on clinical occlusal view. (Fig.2)

Fig 2: Occlusal view

Her medical history revealed no medical contraindication for surgery. Radiographic evaluation A peri-apical radiograph displayed an impacted incisor 21 in a horizontal position below the apex of 22. (Fig.3) Fig 3

CBCT evaluation showed an excellent condition of the remaining teeth, and there was adequate bone height of 15 mm. Bucco-lingual bone thickness was 3mm. Bone block was indicated to fill the horizontal defect. Surgical technique Surgery was performed under local analgesia (lidocaine + 1/100.000 noradrenaline). A midcrestal incision was made on edentulous site and extended intrasulcularly around the cervical margins of adjacent teeth. Two releasing incisions were made on the distal third of the papilla of the adjacent teeth. Full thickness flap was raised exposing buccal and palatal aspects of alveolar ridge. Periosteal releasing incisions were made with at least 1 cm of overlapping tissue to assure a complete coverage of the graft. A decortication was done with a round bur. Bone block with suitable measures was harvested from left mandibular ramus under local analgesia, as well. Fig 4

Fig 3: Peri-apical radiograph

Treatment modality The impacted tooth was surgically removed in the department of Oral Surgery at the Lebanese University – School of Dentistry, and 3 months after surgery the clinical exam revealed a good oral hygiene and an acceptable clinical healing (no marginal gingival inflammation). Dental News, Volume XXII, Number II, 2015

Fig 4: Flap raising

54 Implant Dentistry Fig 5

The midcrestal incision and interdental papillae and vertical incisions were secured with interrupted sutures. (Fig.8) Oral antibiotics (amoxicillin 500mg, 1 tablet each 6 hours) and analgesics (acetaminophen 500mg, 1 tablet each 4 hours, when needed) were prescribed for 5 days postoperatively and antiseptic solution for 2 weeks. Removable partial denture was modified to prevent pressure the healing tissues and fitted and delivered to the patient immediately after surgery.

Fig 5: Donor site

It was seated and fixed with 1.6 mm x 10 mm bone screws. (Fig.6) Fig 6

Sutures were removed 15 days after surgery and a multiple control visits were scheduled every month to evaluate the progression of the healing. Fig 8

Fig 6: Fixation of bone block

A round surgical bur was reapplied to round any sharp cortical edges and shape the block in order to completely conform the defect site. Deficiencies at the edges of the graft were filled with bone substitute (Endobone速, Biomet 3i, Palm Beach, Garden, Florida, USA). Graft was covered with long term resorbable collagen membrane (Bio-Gide速, Geistlich biomaterials, Wolhonsen, Switzerland). (Fig.7)

Fig 8: Suturing the flap

After 6 months, a CBCT was taken before implant placement, there was 8mm bone thickness. (Fig.9) Fig 9

Fig 7

Fig 7: membrane and particule bone graft in place

Dental News, Volume XXII, Number II, 2015

Fig 9: 6 months post-operatively

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56 Implant Dentistry For the implant placement surgery, access to augmented ridge was obtained via midcrestal incision, and intrasulcular incision on the adjacent teeth. Surgical exposure revealed a well integrated block graft into surrounding bone. The fixation screws were removed, and the post-augmentation ridge was measured again to confirm bone gain. A (4.1, 10mm) (Biomet 3i®, Palm Beach, Garden, Florida, USA) dental implant was then placed in an ideal threedimensional position.(Fig.10-11)

Fig 12

Fig 12: Temporary crown

Fig 10

Three months later, implants were loaded with final restorations. (Fig.13) Fig 13

Fig 10: Implant placement

Fig 11

Fig 13: Final crown


After surgery, immediate screwed temporisation was performed. Occlusion adjustment was performed in order to keep acrylic tooth out of occlusion.(fig.12) Dental News, Volume XXII, Number II, 2015

Esthetic and functional compromises in implant restorations can be prevented by ridge augmentation procedures which results in enhanced emergence profile for an implant supported restoration. A thorough clinical and radiological examination should be done in order to diagnose the exact quantity of bone loss and accordingly plan for various bone augmentation procedures. Autogenous bone grafts are recommended in bone augmentations prior to implant placement because of their osteogenic potential.12 Intramembranous autogenous osseous grafts including the mandibular ramus, mandibular symphysis, angle of mandible, maxillary tuberosity and intraoral exostoses, are the “gold standard’’ for improving intraoral osseous volume to facilitate placement of implants.13 Alveolar defects can be restored by autologous grafting techniques including corticocancellous blocks, compressed particulate cancellous bone and marrow, and cortical grafts.

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58 Implant Dentistry Block grafts are associated with minimal resorption and do not usually require the use of an overlying membrane unless the dimensions of the graft are inadequate. Block grafts take longer time to integrate than cancellous bone grafts. When a block graft is used, a staged surgical approach is recommended as opposed to placing the implants in conjunction with the graft.14 The mandibular ramus is a useful, cortical graft that provides primarily dense cortical bone and high concentration of promoter proteins (eg, bone morphogenetic proteins). In addition, the mandibular ramus donor site is associated with fewer postoperative complications, in comparison to the symphysis region.9-15 Hence they can be successfully used for alveolar ridge augmentation prior to implant placement.

Conclusion This article addresses a case of alveolar ridge augmentation in a partially edentulous patient prior to implant placement, using autogenous bone grafts harvested from mandibular ramus and secured to the recipient site with osteosynthesis screws. The clinical indication for the case described was the lack of sufficient alveolar bone quantity, a situation that could interfere with esthetics and functional loading of implants. Mandibular ramus block bone grafts provide predictable outcome within a short healing time, exhibit minimum resorption, maintain dense quality of bone (type one or two) and provides ideal sites for endosseous implant placement.

References 1. Cawood JI, Howell RA (1991) Reconstructive prosthetics surgery: I. Anatomical considerations. Int J Oral Maxillofacial Surg 20:75-82. 2. Belser, U.C.; Schmid, B., Higginbottom, F. & Buser, D. (2004). Outcome analysis of implant restorations located in the anterior maxilla: a review of the recent literature. International Journal of Oral & Maxillofacial Implants 19, Suppl, pp. 30-42 3. Grunder, U.; Gracis, S. & Capelli, M. (2005). Influence of the 3-D boneto-implant relationship on esthetics. International Journal of Periodontics Restorative Dentistry, 25, pp. 113-119 4. Palacci, P. & Ericsson, I. (2001). Anterior maxilla classification. In. Esthetic implant dentistry. Soft and hard tissue management. Il, P. Palacci & I. Ericsson, (Eds.), pp. 89-100, Quintessence Publishind Co, Inc, Illinois, USA 5. Raghoebar, G.M.; Louwerse, C., Kalk, W.W.I. & Vissink, A. (2001). Morbidity of chin bone harvesting. Clinical Oral Implants Research, 12, pp. 503-507 6. Hsu, M.L.; Chen, F.C., Kao, H.C. & Cheng, C.K. (2007). Influence of off-axis loading of an anterior maxillary implant: a 3-dimensional finite element analysis. International Journal of Oral & Maxillofacial Implants, 22, pp. 301-309. 7. McAllister, B.S. & Haghighat, K. (2007). Bone augmentation techniques. Journal of Periodontology, 78, pp. 377-396 8. Lundgren, S.; Sjostrom, M., Nystrom, E. & Sennerby, L. (2008). Strategies in reconstruction of the atrophic maxilla with autogenous bone grafts and endosseous implants.

Periodontology 2000, 47, pp. 143–161

9. Misch, C.M.; Misch, C.E., Resnik, R.R. & Ismail, Y.H. (1992). Reconstruction of maxillary alveolar defects with mandibular symphysis grafts for dental implants:

A preliminary procedural report. International Journal Oral & Maxillofacial Implants, 7, pp. 360–366


10. Chaushu, G.; Mardinger, O., Calderon, S., Moses, O. & Nissan, J. (2009). The use of cancellous block-allograft for sinus floor augmentation with simultaneous implant placement in the posterior atrophic maxilla. Journal of Periodontology 80, pp. 422-428 11. Moy, P. & Palacci, P. (2001). Minor bone augmentation procedures. In. Esthetic implant dentistry. Soft and hard tissue management. Il, P. Palacci & I. Ericsson (Eds.), pp. 137- 158, Quintessence Publishing Co., Inc., Illinois, USA 12. Gerry M. Raghoebar, Rrutger H.K. Batenburg, Arjan Vissink, Augmentation of Localized Defects of the Anterior Maxillary Ridge With Autogenous Bone Before Insertion of Implants, J Oral Maxillofacial Surgery, 1996, 54:1180-1185. 13. Chiapasco M, Abati S, Romeo E,

et al.


outcome of autog-

enous bone blocks or guided bone regeneration with e-PTFE membranes for the reconstruction of narrow edentulous ridges.


Clin Oral Implants Res

14. Triplett RG, Schow S. Autologous bone grafts and endosseous implants. Complementary techniques. J Oral Maxillofac Surg 1996;54:486-494. 15. Bahat O, Fontanesi RV. Complications of Grafting in the Atrophic Edentulous or Partially Edentulous Jaw. Int J Perio Rest Dent, 2001;21:487-495.

Dental News, Volume XXII, Number II, 2015

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46 18 60 Implant Dentistry

The Use of Mini-Implants in Complete Denture Treatment Dr. Danielle El Hakim

Dr. Emilie El Mouchantaf

Dr. Maha Ghotmi

Abstract Mini-Implants in complete edentulous patients have become a treatment alternative for conventional dentures and conventional implant retained overdentures. They provide an improvement in stability and retention; they also improve subjective chewing ability and overall patient satisfaction. This article is an overview of mini-implants and their role in complete denture treatments.

Introduction Dr. Pierre El Khoury

In patients with edentulous arches, the ability to speak, masticate and smile is all dependent on an accurately fitting and well-retained denture. The provision of complete removable dentures that satisfy all functional and esthetic requirements is one of the challenges in dentistry. Despite overall improvements in the oral health of the population, the demand for complete removable dentures will continue as the elderly population increases. This explains the importance of continuing to provide dental students with education on the provision of complete dentures as well as the necessity to acquire and retain the expertise that will continue to be needed to provide patients with functional and esthetic complete removable dentures. A number of anatomical and physiological challenges complicate the treatment, the wearing of dentures and can result in patient dissatisfaction.1 In terms of frequency, the first therapeutically option in the complete edentulism is represented by conventional dentures. But, in a large number of cases this therapeutic option does not satisfy patient’s expectations, a number of complains being found out, primarily related to functionality and adaptation. The implantsupported overdenture brings considerable benefits, including the increase of denture stability, functional efficiency, comfort and quality of life.

Dental News, Volume XXII, Number II, 2015

For this reason, not in a few cases, this treatment option has become elective.2 The main difficulties identified when the treatment plan includes implant application are correlated with an inadequate jaw morphology, due to the important bone resorption phenomena that occurs during edentulism evolution, and also to the poor bone quality, related to bone diseases that may affect elderly patients such as osteoporosis.3,4 Most times, surgical interventions prior to implants insertion are needed (bone addition, sinus lift, etc.), which are harder to accept by elderly patients, frequently with affected general status.5 Other disadvantages are related to longer duration of treatment and higher costs.2 In cases where jaw morphology does not allow the conventional implant application without helpful surgical interventions, using smalldiameter implants (≤ 2,8 mm), also known as mini-dental implants (MDI) can be, most often, a treatment alternative. Among benefits2,6-13 are: - The application method is easier and has much less intraoperative trauma. - The possibility to be loaded immediately. - A shorter recovery period. - Single-stage implants. - Lower cost. - Narrow ridge, treatment of difficult anatomic conditions as a thin buccolingual bone dimension. - Improved stability. - Better functionality. - Adaptation and higher satisfaction. When first introduced, mini-implants were considered as a transitional device for stabilizing provisional prostheses during implant healing6, with the objective of transitioning over to standard implants when the permanent prostheses were planned for. In 1997, mini-implants were cleared by the FDA for long-term use. Mini-im-

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62 Implant Dentistry plants are now used for short and for long-term prosthodontic treatment.2,7,14,15

Treatment Planning and Procedure Proper diagnosis and treatment planning are key factors in achieving predictable outcomes, which mean careful evaluation through clinical, imagistic and laboratory methods. Frequently there are identified some unfavorable conditions for implant insertion and a high degree of treatment difficulty. These issues (morphological and functional features, related to general health status, age, gender, etc.) must be linked to implants characteristics, in order to decide the particular treatment features, from surgical and prosthetic point of view. The length, diameter, number, topography, loading method of implants can present a large variety, depending on quantitative bone offer (ridge width and bone height), quality (bone density), functional features and patient’s wishes.2 It is most recommended to use minimum 4 miniimplants in the mandible and 6 in the maxillary.15,16 The necessary ridge width in order to apply a standard diameter implant must be ≥ 5 mm. Mini dental implant (≤ 2,8 mm) may be inserted also where the ridge width presents values of 3-4 mm. For the lower jaw the recommended implant is 1.8-2.1 mm diameter, a 3 mm bone width and 10 mm bone height are needed. For the upper jaw the recommended implant is 2.4 mm diameter, a 4 mm bone width and 10 mm bone height are needed.15 A new set of complete denture is fabricated for the patient. Mini-implants can be placed without surgical incision or flaps. The necks of the mini-implants are fully inserted into the soft tissue and only the abutments head are protruded into the oral cavity. Following placement of the mini-implants, a small shim is placed over each implant allowing only the o-ball of the implant to be exposed; the metal housings are then placed over them, the area is checked to make sure no undercuts are present. The tissue side of the patient’s prosthesis is relieved so that it could be seated passively over the top of the metal housings. A standard chair side self-cure acrylic mix is then prepared and placed into the denture, then seated with a functional bite into Dental News, Volume XXII, Number II, 2015

the patient’s mouth over the top of the mini implants with the metal housings attached. After an appropriate hardening time, the prosthesis is removed from the patient’s mouth and excess acrylic material trimmed. The finished prosthesis, containing the metal housings, is then replaced into the patient’s mouth for occlusal equilibration and border adjustment.8,17

Discussion In our clinical practice we regularly come across patients where it is difficult to achieve optimum denture performance due to problems associated with reduced denture retention and stability. This can be due to a number of factors, such as reduced vestibular depth, flabby ridges, hyperplasic mucosa, severe resorption, atrophic ridges, inadequate amount of saliva, xerostomia.8 From a technical viewpoint, successful prosthetic integration depends on the stability and maintenance of the prosthesis. In the past, the only strategy for preventing problems involved the use of prosthetic adhesive or retention by attachments. When using an attachment system, residual tooth roots can stabilize a denture and allow conservation of the alveolar bone structure.18 The use of dental implant to provide support and/or retention for a prosthesis offers multiple advantages when compared to the use of removable soft tissue restoration.9 Dental implants improve patient satisfaction and quality of life. However, implants have limitations related to high cost, anatomical considerations, health of the patient and the dentist’s technical ability.2,14 Mini-implant system can also be used for stabilization of a complete denture where bone status is inadequate for standard implants. The surgical procedure is less complex, quicker, less invasive, and the insertion of the implants is simpler.8 The immediate-load nature of mini-implants gives patients immediate satisfaction without delays in treatment to accommodate conventional healing, permitting full osseointegration. There is improvement in stability and retention, subjective chewing ability and overall patient satisfaction.17

64 Implant Dentistry As with any other type of implant, independent acute complications could appear, in particular, cases of primary implant loss or severe inflammatory reaction. Some chronic disorders, such as peri-implantitis, can be observed but rarely due to the characteristic of the “one-part” implant, which decrease this specific risk.18 This procedure requires regular inspections and replacements of retention components in the frequencies required by their producers. Occasional repair resulting from denture material damages around the nests, as well as relining and damage in the acrylic denture base might also occur. It is then necessary to remove a damaged nest or a fragment of a denture and filling the place with autopolymerizing acrylate.19 The overall MDI survival rate was 94.2% in a retrospective analysis of 2514 implants placed over a five-year period.20 Other studies reported survival rates beyond 90%.21-22 Patients should be advised of their role in maintenance, and a comprehensive recall system is mandatory to obtain satisfactory long-term results.

References 1. Douglass CW, Shih A, Ostry L. Will there be a need for complete dentures in the United States in 2020? Journal of Prosthetic

Dentistry 2002; 87: 5-8.

2. Proteasa E, Melescanu-Imre M, Preoteasa CT, Marin M, Lerner H. Aspects of oral morphology as decision factors in mini-implant supported overdenture.

Romanian Journal of Morphology and Embryology 2010; 51: 309-314. 3. Melescanu M, Preoteasa E. Mandibular panoramic indexes predictors of skeletal osteoporosis for implant therapy. Current Health Sciences Journal 2009; 35: 291-296. 4. Friedlander AH. The physiology, medical management and oral implications of menopause. Journal of American Dental Association 2002; 133: 73-81. 5. Preoteasa E, Bancescu G, Lonescu E, Bancescu A, Donciu D. Epidemiologic aspects of the totally edentulous mouth. (1) General aspects. Bacteriol Virusol Parazitol Epidemiol 2004; 49: 115-120. 6. Šćepanovic Ḿ, Calvo-Guirado JL, Markovic A, Delgado-Ruiz R, Todorović A, Miličić B, Mišic T. A 1-year prospective cohort study on mandibular overdentures retained by mini dental implants. European Journal of Oral Implantology 2012; 5: 367-379. 7. Yu CY, Lin LD, Wang TM, Hsu YC, Lee MS. Using Mini Dental Implants to Improve the Stability of an Existing Mandibular Complete Denture in a Patient with Severe Ridge Resorption. Journal of Prosthodontics and Implantology 2012; 1: 48-52. 8. Singh RD, Ramashanker, Chand P. Management of atrophic mandibular ridge with mini dental implant system. National Journal of Maxillofacial Surgery 2010; 1: 176-178. 9. Sabet ME, Shawky AMOA, AlyRagad DAM. Evaluating the use of ERA Mini Dental Implants Retaining Mandibular Overdenture (In Vitro Study). Dentistry 2014; 4: 1-4. 10. Elsyad MA, Ghoneem NE, El-Sharkawy H. Marginal bone loss around unsplinted mini-implants supporting maxillary overdentures: A preliminary comparative study between partialand full palatal coverage. Quintessence International 2013; 44: 45-52. 11. Jayaraman S, Mallan S, Rajan B, Anachaperumal MP. Three-dimensional finite element analysis of immediate loading mini over denture implants with and

Mini-implants are an excellent and profitable addition to every dental practice. Mini-dental implant supported overdenture can be in complete edentulous patients a treatment alternative to both conventional dentures and conventional implant retained overdenture. This system provides an immediate and ongoing stabilization for the patient in an economical and efficient manner. It is an extremely simple and safe procedure and can be done in cases with poor bone quality as well. It opens many treatment modalities to the dentist and the patient.

O-ring. Indian Journal of Dental Research 2012; 23: 840-841. 12. Melefcanu Imre M, Preoteasa E, Tâncu AM, Preoteasa CT. Imaging without acrylonitrile

technique for the complete edentulous patient treated conventionally or with mini implant overdenture. Journal of Medicine and Life 2013; 6: 86-92.

13. Wright MD. The basics and beyond with mini dental implants. Implant Practice 2013; 6: 28-30.

14. Christensen GJ. The ‘mini’-implant has arrived. Journal of American Dental Association 2006; 137: 387-90.

15. Lerner H. Minimal invasive implantology with small diameter implants. Implant Practice 2009; 2: 30-35.

16. Shatkin TE, Shatkin S, Oppenheimer A. Mini dental implants for the general dentist: a novel technical approach for small-diameter implant placement.

Compendium, 2003; 24: 26-34.

17. Kurtzman GM, Dompkowski DF. Improving Mandibular Denture Retention with Sterngold ERA® Mini-Implants. Inside Dentistry 2008; 1: 2-4.

18. Huard C, Bessadet M, Nicolas E, Veyrune JL. Geriatric slim implants for complete denture wearers: clinical aspects and perspectives. Clinical, Cosmetic and Investigational Dentistry 2013; 5: 63-68.

19. Zmudszki J. Can typical overdentures attachments prevent from bone overloading around mini-implants? Journal of Achievements in Materials and

Manufacturing Engineering 2010; 43: 542-551.

20. Shatkin TE, Shatkin S, Oppenheimer BD, Oppenheimer AJ. Mini dental

implants for long-term fixed and removable prosthetics: a retrospective analysis

2514 implants placed over a five-year period. Compendium of Continuing Education in Dentistry 2007; 28: 92-99. 21. Bulard RA, Vance JB. Multi-clinic evaluation using mini-dental implants for long-term denture stabilization: a preliminary biometric evaluation. Compendium of Continuing Education in Dentistry 2005; 26: 892-897. 22. Mazor Z, Steigmann M, Leshem R, et al. Mini-implants to reconstruct missing teeth in severe ridge deficiency and small interdental space: a 5-year case series. Implant Dentistry 2004; 13: 336-341. of

Dental News, Volume XXII, Number II, 2015

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66 April 16 - 18, 2015 Saint Joseph University, Beirut, Lebanon

More Pictures Available On

Group Photo at Saint Joseph University during the Opening Ceremony Lebanon international implant symposium. This international event, held under the patronage of the faculty of dental medicine of the Saint Joseph University of Beirut, is the culmination of an enormous collective work that began a year ago, when the newly created ICOI Lebanon chapter decided to organize its first implant symposium. It is the fruit born from the joint efforts of one of the most prestigious academic institutions in the Middle East – St Joseph university- and definitely one of the largest professional associations in the world– and I mean the ICOI.

Dr. Christian Makari Reverend Father Salim Daccache, Rector of the Saint Joseph University of Beirut, Presidents of the Lebanese dental associations, Dear friends and colleagues,

Under the theme “cutting edge technology in oral implantology” our meeting today gathers world leaders in this field. Specialized Workshops and lectures will be presented, covering the newest topics in modern implantology, Esthetics, Hard and soft tissue reconstruction, piezosurgery, sinus grafting, PRF and growth factors. Also, a table top presentation session dedicated to latest achievements in the field of clinical research in implantology will give young faculty and postgraduate students the opportunity to expose their work.

They say “where there’s a will, there’s a way”. But should you take that will, fuel it with passion, support it with science, imbellish it with generosity and surround Dr. Christian Makari it with friendship, you would have not only found a way, President of ICOI Lebanon but the right way to put together a meeting such as ICOI and Scientific Chaiperson of the Meeting Dental News, Volume XXII, Number II, 2015

Dr. Kenneth Judy, Dr. Gerard Scortecci, Pr. Nada Naaman Cutting the Ribbon

Reverend Salim Daccache and Pr. Nada Naaman Inaugurating the Sculpture by Dr. Wadih Haswani

68 May 8 - 9, 2015 Jumeirah Beach Hotel, Dubai, UAE

More Pictures Available On

Group Photo in front of the Jumeirah Beach Hotel Welcome to the CAD/CAM & Digital Dentistry International Conference, 10th Edition. Thank you all very much for your support and loyalty year after year. This year marks the 10th anniversary of our conference. What starts as a simple idea 10 years ago proved, without doubt , to be a success beyond compare. Our societies are becoming more and more dependent on technology and what it can offer to make our lives easier and more enjoyable. Dentistry is no exception. Our patients are all the way different than they used to be a couple of decades ago. They have unrestricted easy access to knowledge through the web. They are becoming more and more demanding in terms of services that we provide as well as the technology we employ to do so.

“Do you provide CEREC restorations in your office”. “Does this office use Zirconia and Emax for crowns and veneers”. “Are you Doc in CAD/CAM technology”. These are quite common questions our patients usually ask nowadays. Questions that are very hard to answer unless we are really involved in this fast moving technology. This is precisely the importance of our conferences. Our team of Organizers, Sponsors, as well as Speakers will continue our quest to keep all of you well ahead and updated in all fields of CAD/CAM and Digital Dentistry.

Dr. Munir Silwadi Conference Chairman & Scientific Program Advisor

Celebrating the 10th Anniversary in front of the Burj El Arab

Dental News, Volume XXII, Number II, 2015

Distribution of Recognitions in The Exhibition Floor

‫‪UPGRADE TO‬‬ ‫‪MODERN DENTISTRY‬‬ ‫‪14th International Convention‬‬ ‫‪of the Lebanese University‬‬ ‫‪School of Dentistry‬‬ ‫‪More Pictures Available On‬‬ ‫‪‬‬


‫‪May 13 - 16, 2015‬‬ ‫‪Lebanese University, Hadath, Lebanon‬‬

‫‪Picture of the Audience from the Opening Ceremony‬‬ ‫ايها الحفل الكريم‪،‬‬ ‫أرحــب بكــم أح ـ ّر ترحيــب رغــم أنكــم فــي منزلكــم فالجامعــة اللبنانيــة حاملــة‬ ‫إســم وطننــا الحبيــب هــي بيــت الجميــع‪.‬‬ ‫يشــكل أي مؤتمــر علمــي تحدي ـاً كبي ـرا ً ومســؤولية عاليــة‪ .‬ففــي الوقــت الــذي‬ ‫تتســارع فيــه وتيــرة اإلكتشــافات العلميــة والتقنيــة بشــكل مطــرد‪ ،‬تجــد الجامعــة‬ ‫نفســها ملزمــة بلعــب دور البوصلــة ال بــل المنــارة فــي التوجيــه والتقريــر بيــن مــا‬ ‫هــو علمــي ومــا هــو تجــاري بســبب تضخــم التكنولوجيــا فــي القطاعــات الطبيــة‬ ‫ممــا يضــع طبيــب األســنان أمــام تحديــات أساســية متعلقــة بكافــة جوانــب المهنة‬ ‫والخيــارات الواجــب إعتمادهــا‪.‬‬ ‫وإذا كان الــدور األساســي للمؤتمــر يكمــن فــي تقديــم آخــر التطــورات العلميــة‬ ‫ونتائــج األبحــاث والنظريــات المختلفــة‪ .‬باإلضافــة الــى التعــاون مــع الشــركات‬ ‫ومؤسســات القطــاع الخــاص لتقديــم آخــر المســتجدات التقنيــة والعالجيــة‪ ،‬يبقــى‬ ‫للجامعــة دور الرقابــة والنقــد والتوجيــه‪ ،‬خاصــة مــن خــال البحــث العلمــي‬ ‫المحايــد والمراجعــة النقديــة والتوجيــه األكاديمــي‪ ،‬وهــو مــا يشــكل الطريــق‬ ‫الصحيــح نحــو التقــدم والحداثــة‪.‬‬ ‫منــذ بدايــة اإلعــداد لهــذا المؤتمــر‪ ،‬تحولــت الكليــة الــى مــا يشــبه خليــة النحــل‪.‬‬ ‫حركــة متواصلــة وإجتماعــات متالحقــة مــن أجــل اإلعــداد الصحيــح والتنظيــم‬ ‫الجيــد وتحقيــق غايتنــا بتقديــم مــا يليــق بحضوركــم وثقتكــم الكبيــرة‪.‬‬ ‫لقــد قامــت اللجنــة العلميــة بوضــع برنامــج طمــوح ومتنــوع‪ ،‬مســتقطبة أســماء‬ ‫كبيــرة ومميــزة فــي المجــاالت المتنوعــة ومــن بينهــم علمــاء مــن أصــل لبنانــي‬ ‫أبدعــوا فــي البلــدان التــي هاجــروا إليهــا‪ .‬كمــا وضعــت اللجنــة التنظيميــة هيكلية‬ ‫‪Pr. Fouad Ayoub, Dean of the Dental School‬‬ ‫متكاملــة مــن أجــل تأميــن حســن ســير األمــور واإلشـراف علــى تنفيذهــا‪.‬‬ ‫وال بـ ّد لــي أن أشــكر اللجنتيــن‪ ،‬رؤســاء وأعضــاء‪ ،‬كمــا باقــي أســاتذة الكليــة علــى‬ ‫ ‬ ‫الجهــد الكبيــر والعطــاء المميــز‪.‬‬ ‫وأخــص بالشــكر الجهــاز اإلداري والتقنــي علــى تفانيــه فــي المســاعدة فــي التنظيم عميد كلية طب االسنان‬ ‫البروفسور فؤاد أيوب‬ ‫والتنفيــذ وكل مــن ســاهم معنــا لهــذه الغاية‪.‬‬ ‫‪Dental News, Volume XXII, Number II, 2015‬‬

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Dental News, Volume XXII, Number II, 2015

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Drs. Fouad Ayoub, Norbert Gutknecht, Hani Ounsi and Ziad Salameh, surrounded by the Pisters authors

Left to right; Pr. Samir Nammour, Pr. Toni Zeinoun, Dr. Tony Dib

Left to right ;D rs R ola andII, N ajib Khalaf, Ali Awada, Tony Dib, Hani Ounsi, Giacomo Fabbri, Ziad Salameh Dental News, Volume XXII, Number 2015

NE W Inseparable: Zirconia and PermaCem 2.0 PermaCem 2.0 is the new generation of self-adhesive luting cement. The special adhesive monomer formula enables superior natural self-adhesion on zirconia. This ensures excellent adhesive strength with zircon ceramics and

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Left to right; President Adib Zakaria, Dean Fouad Ayoub, President Elie Maalouf and Colonel Joseph Chaer

Drs. Said Halabi, Nabil Barakat, Sami Jad

Dental News, Volume XXII, Number II, 2015

Drs. Tony Dib, Ibrahim Nasseh, Mounir Doumit, Nada Naaman, Charles Pilipili

Û WHAT WAS YOUR REASON FOR NOT BUYING ONE? NEW PIEZOSURGERY® white Û BEST CUTTING EFFICIENCY AND MAXIMUM INTRAOPERATIVE CONTROL mectron s.p.a., via Loreto 15/A, 16042 Carasco (Ge), Italy, tel +39 0185 35361, fax +39 0185 351374,,



New – Cavex Cream Alginate - Perfection in detail. Cavex is proud to present the newest addition to its already impressive range of alginates; we have called it ‘Cavex Cream Alginate’. As the name suggests, this stateof-the-art alginate is very easy to mix into a superior smooth, creamy substance. With its fresh purple colour and delicious bubble gum flavour, Cavex Cream Alginate is just begging to be bitten into! Cavex Cream Alginate has an innovative new formula which gives it an unequalled accuracy of no less than 5 μm. This and the ‘standard’ Cavex alginate characteristics, high tear strength, snap setting and five-year shelf life, mean that the quality of Cavex Cream Alginate very nearly matches that of silicones. Of course, this alginate is also scannable. Website:

OPALESCENCE GO - Fast, Easy, Effective! Opalescence Go is the perfect option for patients who are looking for convenient, ready-to-go whitening. A professional whitening gel delivered in prefilled, disposable trays, Opalescence Go features the enhanced UltraFit™ tray and can deliver dramatic results in as a little as 15 minutes per day. The UltraFit tray sets Opalescence Go apart with its unique material that warms with the temperature of the body so that it comfortably molds and adapts to any patient’s smile​for an even more effective and enjoyable whitening experience. With no impressions, models, or lab time required, Opalescence Go is the professional alternative to less-effective over-the-counter options and is an excellent introduction to whitening as well as a perfect follow-up to in-office whitening. • New unique UltraFit™ tray conforms and adapts to any patients’ individual smile, providing an extremely comfortable custom-like fit • Molar-to-molar coverage ensures the gel comes in contact with more posterior teeth • Available in 10% hydrogen peroxide (with wear times from 30–60 minutes) and 15% hydrogen peroxide (with wear times from 15–20 minutes) • Opalescence tooth whitening gel contains PF (Potassium Nitrate and Fluoride). Potassium nitrate has been shown to help reduce sensitivity. Fluoride has been shown to help reduce caries and strengthen enamel. Together they help to improve the overall health of the teeth • Delicious Mint, Melon, and Peach flavors • Convenient prefilled trays can be worn right out of the package website:

Dental News, Volume XXII, Number II, 2015


AFFINIS heavy body BLACK EDITION - Precious impressions Documented in black and white Since more than 10 years AFFINIS stands for perfect impressions. A high contrast version has now been added to the renowned family of the Swiss dental expert COLTENE. As of now the new AFFINIS heavy body BLACK EDITION, the proven tray material, is also available in precious black. The heavy body consistency offers, in contrary to conventional materials, optimal stability with fast pressure build-up, ideal for an excellent die effect. The impression can be read exceptionally well in combination with gold or silver colored AFFINIS PRECIOUS. This unique color and contrast combination presents details even more precisely and supports the qualitative assessment of the impression result. Visible precision with attention to detail The gold or silver colored AFFINIS PRECIOUS corrective impression materials have an innovative and unique surface affinity, thus wetting tooth and gingiva quickly. The excellent flow properties of AFFINIS PRECIOUS enable capturing of all critical surface details of the preparation, even under the most difficult moist conditions. Website:

GC continuously seeks to offer the most adequate products for your daily use • 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. Website:

KaVo ARCTICA CAD/CAM System The dental KaVo ARCTICA CAD/CAM System provided numerous possibilities to use dental CAD/CAM efficiently, cost-effectively and precisely in the laboratory and dental practice. Benefits of the dental KaVo ARCTICA CAD/CAM system: • High cost-effectiveness of investment due to an extremely wide range of applications and material versatility • Maximum precision for all results combined with easy handling • High flexibility and future security – due to open CAD/CAM interfaces, a diversity of possibilities of integration and the possibility to process additional materials from other providers. Website:

Dental News, Volume XXII, Number II, 2015

Dentures contain surface pores in which microorganisms can colonise.1 Corega速 cleanser is proven to penetrate the biofilm* and kill microorganisms within hard-to-reach surface pores.2

Help your patients eat, speak and smile with confidence with the Corega速 denture care regime.

SEM images of denture surface. *In vitro single species biofilm after 5 minutes soak References: 1. Glass RT et al. J Prosthet Dent. 2010; 103(6): 384-389. 2. GSK Data on File, Lux R. 2012.

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/0008/14c We value your feedback Saudi Arabia: 8008447012 All Gulf and Near East countries: +973 16500404

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