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Volume XXI, Number II, 2014


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3

ARTICLES 12.

CONGRESSES CAD/CAM technology for fabricating complete dentures Dr. Maha Ghotmi, Dr. Danielle El Hakim Dr. Najib Abou Hamra, Dr. Rita Eid

20.

65.

May 12, 2014 Bensheim, Germany

68. Adhesion to mild fluorosed enamel: a comparative study of two etching protocols.

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Oral Ulcers in Infants and Children Part I: General Points and Clinical Examination Dr. Sawsan Nasreddine, Dr. Antoine Cassia

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CA速 CLEAR-ALIGNER Therapeutic Possibilities Dr. Pablo Echarri

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Effect of different surface treatments on prefabricated fiber posts: a literature review. Dr. Rita Eid, Dr. Najib Abou Hamra Dr. Danielle Hakim, Dr. Maha Ghotmi

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INTERNATIONAL CALENDAR

11

w w w.dentalnews.com Volume XXI, Number II, 2014 EDITORIAL TEAM Alfred Naaman, Nada Naaman, Jihad Fakhoury, Dona Raad, Antoine Saadé, Lina Chamseddine, Tarek Kotob, Mohammed Rifai, Bilal Koleilat, Mohammad H. Al-Jammaz COORDINATOR Suha Nader ART DEPARTMENT Ibrahim Mantoufeh Elie Hajj SUBSCRIPTION Micheline Assaf, Nariman Nehmeh ADVERTISING Josiane Younes PHOTOGRAPHY Albert Saykali TRANSLATION Gisèle Wakim, Marielle Khoury DIRECTOR Tony Dib ISSN 1026-261X

APDC 2014 - The 36Th Asia Pacific Dental Congress

June 17 - 19, 2014 at the World Trade Center, Dubai, U.A.E Website: www.apdentalcongress.org

FDI Annual World Dental Congress

September 11 - 14, 2014 at the India Expo Mart, New Delhi, INDIA Website: www.fdi2014.org.in

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.

BIDM 2014 - The 24th Lebanese Dental Association Congress

September 11 - 13, 2014 at the BIEL, Beirut, LEBANON Website: www.bidm-lda.com

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: info@dentalnews.com Website: www.dentalnews.com www.facebook.com/dentalnews1

JIDC 2014 - The 24th Jordanian International Dental Conference

October 21 - 24, 2014 at the Landmark Hotel in Amman, JORDAN Email: : jidc.inf@jda.org.jo Website: www.jidc2014.jda.org.jo

AIDC 2014 - The 19th Alexandria International Dental Congress

October 22 - 24, 2014 Alexandria Int’l Dental Congress Alexandria, EGYPT Email: info@aidc-congress.com Website: www.aidc-congress.com

IQADC 2014 - The 4th International Quintessence Dental Arab Congress

October 24 - 25, 2014 at the Riyadh Colleges, Riyadh, KSA Email: info@iqdac.org Website: www.iqdac.org

KDA 2014 - The 18th Kuwait Dental Association Conference

November 20 - 22, 2014 KUWAIT Email: info@kda.org.kw Website: www.kda.org.kw

www.facebook.com/dentalnews1 twitter.com/dentalnews Dental News App on both Appstore & Google play

This magazine is printed on FSC – certified paper. Dental News, Volume XXI, Number II, 2014


12 Prosthetic Dentistry

CAD/CAM technology for fabricating complete dentures Abstract Dr. Maha Ghotmi

Dr. Danielle El Hakim

Dr. Najib Abou Hamra nhamra@gmail.com Dr. Rita Eid

The process for fabricating complete dentures has three major steps: the impression procedures, the denture design and the denture fabrication. This paper is about the fabrication of a removable complete denture using CAD/CAM technology. It has the potential to simplify the traditional process and resolve the associated problems. CAD/CAM technique is a two-step appointment process. Impressions, jaw relation records, occlusal plane orientation, tooth mold, shade selection and maxillary anterior tooth positioning record are registered in the first appointment. The second appointment is for insertion.

Introduction Computer Aided Design – Computer Aided Manufacturing (CAD/CAM) technology has already been used significantly in dentistry. CAD software defines the geometry of an object while the CAM software directs the fabrication process.1,2 In the early 1980s, CAD/CAM was used to produce clinical dental restorations when Andersson envisioned the use of titanium for fabrication of crowns.1 Another important dental application of CAD/CAM technology also occurred in the 1980s. Mörmann developed an interest in tooth-colored restorations. In September of that same year, he placed the first chairside fabricated ceramic restoration with equipment introduced and marked as the CEREC 1 system.3 In the recent 20 years, dozens of dental CAD/CAM systems have been presented for inlay, crown, veneer and fixed partial denture.4,6 However, the development on CAD/CAM for removable complete denture has been very slow.4 Dental News, Volume XXI, Number II, 2014

Advanced Manufacturing Technology (AMT) has not been successfully applied in this field. Goodacre et al. wrote, “When the CAD/CAM technology for fabricating complete dentures becomes commercially available, it will be possible to scan the denture base morphology and tooth positions recorded with this technique and import those data into a virtual tooth arrangement program where teeth can be articulated and then export the data to a milling device for the fabrication of the complete dentures”. Over years, different methods for duplicating7 and fabricating complete dentures using CAD/CAM system have been tried. With the introduction of commercially available CAD/CAM denture systems like AvaDent and Dentca, Inc., the era of digital complete dentures has arrived.2,4,8 The purpose of this article is to describe the clinical procedure required to fabricate a complete denture using CAD/CAM technology.

Conventional fabrication technique of a removable complete denture Removable complete denture is a dental prosthesis, which replaces the entire dentition and associated structures of the maxilla and mandible.9 A complete denture functions to restore aesthetics, mastication and speech. It has various parts and surfaces such as denture base, flange of denture, denture teeth and denture border. The conventional complete denture technique is a five-step appointment process:2,10 - Making preliminary impressions - Making final impressions - Creating jaw relationship records - Arranging prosthetic teeth and try-in - Placement/insertion of complete dentures


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14 Prosthetic Dentistry CAD/CAM Technology

CAD/CAM fabrication technique of a removable complete denture

Fig 1 Figure1: Dentca and AvaDent starting kits (Courtesy of Dr Tony Daher)

The advanced fabrication technique is a twostep appointment process:2 - Impressions, jaw relation records, occlusal plane orientation, tooth mold and shade selection, and maxillary anterior tooth positioning record - Insertion of dentures The process for fabricating complete dentures has three major steps: the impression procedures, the denture design and the denture fabrication.11 The impression procedures: The procedure involves the fabrication of a putty cast formed by pressing mixed polyvinyl siloxane putty into the intaglio surface of the patient’s existing dentures. If these dentures are unacceptable then diagnostic casts can be generated from a preliminary impression. And if the denture is not adapted to the mucosa, a refitting or relining can be made.2,10 It is important to check the adaptation of the thermoplastic trays on the cast and try them in the patient’s mouth to make the necessary adjustments. It is also important that the maxillary tray extends posteriorly to cover the area of the vibrating line and the pterygomaxillary fissures while the mandibular tray covers the retromolar pads.2 After applying an appropriate adhesive and adding tissue stops, a border molding impression material or a medium body polyvinyl siloxane impression material is then used to border mold the maxillary and mandibular trays employing the method used with conventional custom trays. Final impressions of the maxillary and mandibular arches are made using either with a specific impression material or with a light-body polyvinyl siloxane impression material.2 (Goodacre et al. use speech method to identify muscular and phonetic locations for the prosthetic teeth and to establish palatal morphology; this requires impressions that record the shape of both the intaglio and cameo surfaces of complete denture bases.)1 The AvaDent denture technique uses an Anatomical Measuring Device (AMD) that can be adjusted to the desired occlusal vertical dimension. This AMD maintains this dimension while centric relation is recorded using the incorporated gothic arch tracing plate and stylus. The AMD

Dental News, Volume XXI, Number II, 2014

is also used to determine the correct amount of upper lip support, the position of the maxillary six anterior teeth, and the desired mediolateral orientation of the occlusal plane. The AvaDent orientation ruler is attached to the maxillary AMD for determining the appropriate occlusal plane. The angle is noted and recorded on the laboratory work authorization form. The midline on the lip support flange as well as the smile line are marked. The size of the maxillary anterior teeth is selected from the three available tooth size templates that matches the patient’s desired tooth size. To serve as a guide during denture fabrication, flowable composite resin is applied to the inside of the selected tooth mold template, then positioned carefully in place and light polymerized to affix the template in position. AvaDent registration material is injected into the space between the maxillary and mandibular arches, with the jaw stabilized in centric relation. (Dentca uses another specific device for these important registrations.)2,8

Fig 2 Figure 2: Maxillary and mandibular final impressions (Courtesy of Dr Tony Daher)


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16 Prosthetic Dentistry CAD/CAM Technology

The denture design After disinfection, the final impressions and all the registrations are mailed to the company producer of the digital dentures, along with any special instructions. At this stage, the impressions and interocclusal records are scanned, virtual casts are created and articulated, teeth are arranged and bases are virtually formed.1,2 Fig 3 Figure 3: Interocclusal records (Courtesy of Dr Tony Daher)

Fig 4 Figure 4: Virtual casts and teeth arrangement (Courtesy of Dr Tony Daher)

The denture fabrication The denture base is milled from a block of pink denture base resin with recesses that accurately fit each denture tooth, and the teeth are bonded with a proprietary bonding mechanism. The denture base can be fabricated from different choices of base material, and different options are available for the denture teeth.1,2,10 Another technique for the denture fabrication exists: the 3-D laser lithography. This rapid prototyping (RP) technology was originally developed to fabricate prototypes for industrial purposes. This method automatically constructs physical models from computerized three-dimensional (3D) data. The RP systems join liquid, powder, or sheet materials to form physical objects. Through Layer by layer technique, RP machines process plastic, paper, ceramic, metal, and composites from thin, horizontal cross sections of a computer model. RP has recently seen successful application in various medical fields, such as in the fabrication of implant surgical guides,12,13 maxillofacial prosthetics14,16 and frameworks for removable partial dentures.17,18 After finishing the dentures, it’s time for the second appointment where the insertion of the complete dentures is made. The placement and post-placement adjustments of CAD/CAM complete dentures are similar to the placement of conventional dentures. The patient is seen as needed for routine follow-up and maintenance appointments.1,2

Advantages and disadvantages of CAD/ CAM technology Several advantages to the patient and the dental practitioner are offered:2

- The clinical chair time is reduced considerably; all clinical data needed are recorded in the same appointment. - The digital data for each case is saved; a spare denture or a radiographic or surgical template Dental News, Volume XXI, Number II, 2014

C

M

Y

CM

Fig 5 Figure 5: Milling and gluing stages (Courtesy of Dr Tony Daher)

MY

CY

CMY

can be made rapidly. - Because the digital data are associated with a specific practitioner, patients will return to the same dentist when future treatment is needed. - Because the denture base is fabricated by machining, polymerization shrinkage of the resin is eliminated, and the fit of the denture base is superior to that of conventionally denture bases. - Due to the method of processing the acrylic resin for denture bases at fifty times the conventional processing pressure, there is less porosity, and denture base material may have less C. Albicans adherence.

Fewer disadvantages are present: - The artificial teeth and denture base are equipped with different colors and properties. The artificial teeth need high abrasion resistance and an aesthetic appearance. It is difficult to cut the artificial teeth from a single property block. Thus, only the denture base is fabricated by cutting then, commercially available artificial teeth are adhered to the denture base. Special adhesives with higher adhesive properties are being developed10. - Another disadvantage is the missed trial in-

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18 Prosthetic Dentistry CAD/CAM Technology

sertion appointment. This step allows making judgments of esthetics and pronunciation and verification of jaw relationship records, including orientation of the occlusal plane, vertical dimension, tongue space, tooth positioning, palatal seal and soft tissue support for proper external form. This is why a third appointment in the advanced fabrication technique could be added19. AvaDent Advanced Try-In (ATI) uses the final base with teeth waxed on. This technique provides teeth adjustment, relining, VDO modification, full adjustment capabilities. The only problem is the additive cost. Dentca Try-In is a Stereo Lithographic Analog (SLA) of the digitally designed denture that fits like the final denture with a close final contours and the possibility of checking the midline, the incisal plane and the lip support. The problem is the frosty clear appearance of teeth that cause difficulties to evaluate shade and esthetics, plus the fact that we cannot move the teeth8.

Conclusions It is now possible to fabricate a complete denture with CAD/CAM technology. This fabrication has positive benefits for both the patient and the practitioner. However the final result depends on the skill and knowledge of materials, anatomy, occlusion, function, making excellent impressions, registering the interocclusal record with a special device and determining the proper esthetic parameters.

References 1. Goodacre CJ, Garbacea A, Naylor WP, Daher T, Marchack CB, Lowry J. CAD/CAM fabricated complete dentures: concepts and clinical methods of obtaining required morphological data. J Prosthet Dent 2012; 107: 34-46. 2. Kattadiyil MT, Goodacre CJ. CAD/CAM technology: application to complete dentures. J Loma Linda University Dent 2012; 23: 16-23. 3. MĂśrmann WH. The evolution of the CEREC system. J Am Dent Assoc 2006; 137suppl: 7S-13S. 4. Sun Y, LĂź P, Wang Y. Study on CAD&RP for removable complete denture. Comput Methods Programs Biomed 2009; 93: 266-272. 5. Harder S, Kern M. Survival and complications of computer aideddesigning and computer-aided manufacturing vs. conventionally fabricated implant-supported reconstructions: a systematic review. Clin Oral Implants Res 2009; 20 Suppl 4: 48-54. 6. Kelly JR. Developing meaningful systematic review of CAD/CAM reconstructions and fiber-reinforced composites. Clin Oral Implants Res 2007; 18 Suppl 3: 205-217. 7. Kawahata N, Ono H, Nishi Y, Hamano T, Nagaoka E. Trial of duplication procedure for complete dentures by CAD/CAM. J Oral Rehabil 1997; 24: 540-548. 8. Kattadiyil MT, Goodacre CJ, Baba NZ. CAD/CAM complete dentures: a review of two commercial fabrication systems. J Calif Dent Assoc 2013; 41: 407-16. 9. Wittneben JG, Wright RF, Weber HP, Gallucci GO. A systematic review of the clinical performance of CAD/CAM single-tooth restorations. Int J Prosthodont 2009; 22: 466-471. 10. Kanazawa M, Inokoshi M, Minakuchi S, Ohbayashi N. Trial of a CAD/CAM system for fabricating complete dentures. Dent Mater J 2011; 30: 93-96. 11. Maeda Y, Minoura M, Tsutsumi S, Okada M, Nokubi T. A CAD/CAM system for removable denture. Part I: fabrication of complete dentures. Int J Prosthodont 1994; 7:17-21. 12. Sarment DP, Sukovic P, Clinthorne N. Accuracy of implant placement with a stereolithographic surgical guide. Int J Oral Maxillofac Implants 2003; 18: 571-577. 13. Di Giacomo GA, Cury PR, de Araujo NS, Sendyk WR, Sendyk CL. Clinical application of stereolithographic surgical guides for implant placement: preliminary results. J Periodontol 2005; 76: 503-507. 14. Al Mardini M, Ercoli C, Graser GN. A technique to produce a mirror-image wax pattern of an ear using rapid prototyping technology. J Prosthet Dent 2005; 94: 195-198. 15. Sykes LM, Parrott AM, Owen CP, Snaddon DR. Applications of rapid prototyping technology in maxillofacial prosthetics. Int J Prosthodont 2004; 17: 454-459. 16. Subburaj K, Nair C, Rajesh S, Meshram SM, Ravi B. Rapid development of auricular prosthesis using CAD and rapid prototyping technologies. Int J Oral Maxillofac Surg 2007; 36: 938-943. 17. Williams RJ, Bibb R, Rafik T. A technique for fabricating patterns for removable partial denture frameworks using digitized casts

Companies websites: - www.avadent.com - www.dentca.com

Dental News, Volume XXI, Number II, 2014

and electronic surveying. J Prosthet Dent 2004; 91: 85-88. 18. Williams RJ, Bibb R, Eggbeer D, Collis J. Use of CAD/CAM technology to fabricate a removable partial denture framework. J Prosthet Dent 2006; 96: 96-99. 19. Inokoshi M, Kanazawa M, Minakuchi S. Evaluation of a complete denture trial method applying rapid prototyping. Dent Mater J 2012; 31: 40-46.


Finally.

Aesthetics that your patients will love.

Contact your certified laboratory for more information (866) 248-9657 • www.zirlux.com Š 2014 Henry Schein, Inc. No copying without permission. Not responsible for typographical errors. 9486ME


20 Restorative Dentistry

Adhesion to mild fluorosed enamel: a comparative study of two etching protocols

Dr. Chems Belkhir chemsbelkhir@gmail.com Dr. Asma Arous

Dr. Mohammed Semir Belkhir

Abstract

Introduction The objective of this study was to evaluate the adhesion quality of a two-step total-etch adhesive system, to mild fluorosed enamel, by two different etching protocols.

Materials and methods Thirteen human teeth (molars and premolars) showing a mild fluorosis (TFI 1-3) according to Thylstrup and Fejerskov index were used. On each tooth two amelo-dentinal Class II boxonly cavities were prepared. The distal cavities were etched once for 30 seconds using orthophosphoric acid at 37%. The mesial cavities were etched twice for 30 seconds using orthophosphoric acid at 37%. Following the obturation with resin composite, thermocyling, infiltration with methylene blue and sectioning in the mesio-distal direction, the teeth were observed with a stereomicroscope. Three samples were observed with a scanning microscope. Methylene blue infiltration degree was evaluated in the cervical and occlusal enamel of each cavity. The statistical study was conducted using the Fisher exact test.

Results No significant differences were observed between the two etching protocols p=0.583 The significant differences were observed in adhesion quality between the cervical enamel and the occlusal enamel for the simple etching protocol p=0.035 and for the double etching protocol p=0.045.

Conclusion Our study showed that composite adhesion to mild fluorosed enamel is not influenced by the Dental News, Volume XXI, Number II, 2014

etching time and that adhesion is better in the occlusal enamel than in the cervical enamel.

Introduction Dental fluorosis is an hypomineralisation of the tooth hard tissues induced by an excessive intake of fluoride occurring during odontogenesis.4 Fluorosis is clinically manifested, depending on individual susceptibility, by opaque white spots, lines following the perikymata direction, or wavy yellowish and brownish striations of the enamel. Later, the opaque surfaces develop and turn into chalky and the enamel develops small cavities. After tooth eruption, the enamel pits and fissures turn into brown or black.11 A fluorosed tooth requires a particular therapeutics.3 The fluorosed enamel is hard, brittle and acido-resistant. These features represent a real problem for resin composite bonding to this enamel which is little studied. In Tunisia, dental fluorosis represents a real public health issues as it affects 50% of adults aged from 35 to 45.7 Despite the caries resistance of fluorosed teeth, the prevalence of caries remains high in this country (74%).7 The practitioner is therefore confronted in his daily practice with restoring these teeth, hence increasing the interest in addressing the problems raised by bonding. The objective of our study was to evaluate the adhesion quality of a two-step total-etch adhesive system, to mild fluorosed enamel (TFI 1-3), by two different etching protocols.

Materials and methods Thirteen recently-extracted, non-carious human teeth (molar and premolar, maxillary and mandibular) were stored in water and in a refrigerator until use after cleaning with a pumice water slurry in order to remove tartar, soft tissues and any other debris.


22 Restorative Dentistry Adhesion to Mild Fluorosed Enamel

All the collected teeth presented a mild fluorosis according to the Thylstrup and Fejerskov index (TFI 1-3).

Cavity preparation Class II box-only cavity preparation were prepared on the mesial and distal surfaces of each tooth. These preparations were accomplished with carbide burs in a high-speed handpiece with water spray. There was no occlusal connection between the preparations. Each cavity was placed at two millimeters of the cementoenamel junction and presents the following dimensions: - 2 mm in the bucco-lingual axis, - 2 mm in the mesio-distal depth - Buccal and lingual walls of the preparations were approximately parallel and connected to the gingival wall with rounded line angles. Prepared teeth were stored in distilled water.

Restoration Following cavity preparation, each tooth was rinsed with distilled water and dried. The distal surfaces: The cavities situated at the distal surfaces were etched for 30 seconds using ortho-phosphoric acid gel at 35 % and rinsed for 30 seconds with 5cc of distilled water. The preparations were moderately dried using a cotton pellet. A singlecomponent dental adhesive (Optibond Solo, Kerr®) was applied by friction on the surfaces for 10 seconds, gently air dried and light cured for 20 seconds. A micro hybrid composite (ProdigyTM, Kerr®) was used in the preparation in three successive layers and each layer was light cured for 40 seconds. A transparent strip was tightened and held by finger pression against the gingival margin of the cavity so that the preparation could not de overfilled at the gingival margin. The mesial surfaces: The cavities lying at the mesial surfaces received a double etching: the use of ortho-phosphoric acid gel at 35 % for 30 seconds, followed by a moderate rinsing and drying according to the previously described protocol. It was later followed by a second application of acid for 30 seconds, rinsing and moderate drying. The adhesive (Optibond Solo, Kerr®) and the composite (ProdigyTM, Kerr®) were applied and Dental News, Volume XXI, Number II, 2014

light cured according to the procedure used for the distal surfaces. The adhesive and the composite were light cured with a halogen lamp. All the restorations required a finishing using a silicon capsule. All the samples reconstituted were stored in distilled water at room temperature.

Thermocycling The apices were sealed with a transparent orthodontic resin. A complementary protection was brought with the application of two coats of transparent finger nail varnish on each crown while leaving 1mm around the restorations. The teeth were thermally cycled between 6°±2°c and 60°±2°c water baths for 400 cycles with a 30 seconds dwell time and 10 second transfer time

Infiltration at methylene blue A second application of two coats finger nail varnish on each crown was performed. The crowns were immersed in a methylene blue dye solution at 0,1% for 48 hours at room temperature. After withdrawing the teeth from the dye solution, they were rinsed with water and cleaned with abrasive disks to eliminate the dye traces.

Microtome sectioning The root of each tooth were inserted in a numerated methacrylate resin blocks. At the vertical plane, each tooth was sectioned mesiodistally with a microtome (Isomet® Buehler) across the center of the restorations using thicket 0,4mm diamond saw with continuous water irrigation. After separating the roots of each tooth from the crown, two sections were obtained: one buccal and the other lingual. Following this stage, twenty two obturations were obtained and four obturations were eliminated.

Stereomicroscope observation 22 composite resin obturations were analyzed. Each cut was photographed with a stereomicroscope (Zeiss) under magnification of 1,25 and with a digital camera. (fig1). The observation was separately performed by two observers. The infiltration degree of the


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24 Restorative Dentistry

Adhesion to Mild Fluorosed Enamel

D

Fig 1

M

D

Fig1: stereomicroscope observation of the degree of methylene blue infiltration: sample n째2 (a), sample n째8 (b), sample n째12 (c).

a

M

D M

Fig 2

product was noted in function of the following scores: 0: no infiltration 1: infiltration of the external third of the enamel 2: infiltration of the two external thirds of the enamel 3: infiltration of all the enamel thickness 4: infiltration of all the enamel and dentin thickness

b

SEM observation Two buccal cuts were selected for the observation at SEM: samples n째1 and 2. The selected samples were dehydrated with decreasing concentration of alcoholic solutions. The cuts were observed with SEM Philips XL30 according to the BSE mode at 917x, 2000x and 5000 x magnification.

c

Statistical study

Fig2: SEM observation: sample 1: distal cavity: occlusal enamel (a,b), cervical enamel (c).

The Fisher exact test was used to conduct qualitative analyses of the bonding efficacy between: - the two operative protocols: simple etching (distal) and double etching (mesial) - and between the cervical and the occlusal enamel of each cavity.

Dental News, Volume XXI, Number II, 2014

The absence of infiltration (0) and the presence of infiltration (1) were taken as selection criteria.

Results Stereomicroscope observation The score attributed to each sample depending on the infiltration is reported in table 1. The comparison of bonding between the two etching protocols did not present significant differences p=0,583. Significant differences were observed for the adhesion quality between the cervical enamel and the occlusal one for the protocol with simple etching p=0,035 and for the protocol with double etching p=0,045. The adhesion of composite to the occlusal enamel is better than its adhesion to the cervical enamel.

SEM observation Sample 1 showed an homogenous and perfect adhesive interface between composite resin and the enamel. The adhesive formed a thin film. Some small enamel cracks were visible at a great magnification. (fig2). Sample 2 presented an homogenous adhesive


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26 Restorative Dentistry Adhesion to Mild Fluorosed Enamel

a

Fig 3

interface between composite resin and the enamel. The cervical enamel interface showed a more irregular surface than the occlusal enamel interface. We notice the presence of fractures line both at the occlusal and cervical enamel. (fig3).

Discussion

b

c

d

Fig3: SEM observation: sample 2: Distal cavity: occlusal enamel (a). Distal cavity: cervical enamel (b). Mesial cavity:occlusal enamel (c). Mesial cavity: cervical enamel (d).

Fluorosed enamel is acido-resistant and its etching remains a delicate act. Few authors were interested in this subject and the rare studies showed contradictory results. Most of the authors agree that there is a difference in the fluorosed enamel response compared to normal enamel, in the etching technique. Difference will become more evident when fluorosis is more intense.13,16,19 Al Sugair and Akpata1 found that the etching of fluorosed enamel with Thylstrup and Fejerskov index TFI 1-3 does not present significant differences with the normal enamel. Weerainhe et al.16 have shown that fluorosis severity does not influence the adhesion force to the enamel when we use phosphoric acid etching as well as a self-etching adhesive. De Goes et al.6 have noticed that ortho-phosphoric acid at 35 % used for 15 to 60 seconds produces the same effect for the normal enamel. Ateyah and Akpata 2 have shown that the etching time affects the shear bond strength of composite for the fluorosed enamel. An etching for 120 seconds is better than an etching for 60 seconds. Belkhir, El Araby, Ermis 4,8,9 think that renewing the etching gel leads to a linear dissolution in the enamel thickness, while the same product used for long time on the enamel surface is rapidly neutralized and risks as well to act on the width of micro-retentions created in the enamel by decreasing their retentive value. In our study, we noticed that to mild fluorosed enamel, double etching did not give better results than the simple etching: etching of one time 30 seconds is enough. However, in case of severe fluorosed enamel other investigations remain necessary to find the best way to treat this enamel. Our SEM observation showed that micro reliefs are not very well visible on the totality of the samples. They are not pronounced as in the literature and resemble more to vacuoles. But the fact that we applied the etching gel for one time during 30 seconds and twice for 30 seconds without

Dental News, Volume XXI, Number II, 2014

finding differences in the statistical study as well in the SEM observation leads us to believe that bonding to the enamel is not only a micro mechanical keying. The enamel etching modifies as well the tissue surface state, both fluorosed and normal, by ameliorating the resin wettability and in ensuring a physic-chemical link in addition to micromechanical one. For Goldberg 10 the resins are infiltrated in inter- crystalline spaces. This is as well the reason why the fluorosed enamel, despite being brittle and acid resistant, reacts positively to bonding techniques. The adverts of self-etching adhesives have allowed simplifying the bonding protocol but their efficacy in the enamel is still questionable. Weerainhe et al. 16 have shown the superiority of bonding on fluorosed teeth by etching with phosphoric acid compared to the self-etching systems. Our study showed that bonding on the occlusal enamel is better than the cervical enamel for the two protocols. This can be explained by the difference of prisms orientation. The enamel prisms of permanent teeth have an orientation essentially parallel to the dentino-enamel junction except for the cervical enamel where the prisms are oriented towards the exterior with an apical direction.14 The prisms present a transversal orientation in the occlusal enamel and a longitudinal one in the cervical enamel. The base unit of prisms is the crystallite.10,14 Dissolution which depends on its orientation in the presence of an acid attack: the crystal dissolves easier at its extremities than on the sides.14,15 Moreover, in a practical point of view, the application of orthophosphoric acid and of the adhesive is much better controlled at the occlusal level than the cervical level. The practitioner should therefore pay a particular attention to the restoration of this area. Besides, the SEM observation of the samples puts into evidence the extreme fragility of the fluorosed enamel which is known for being hard, brittle and porous.4,5 The presence of several enamel fissures and fractures of enamel masses confirms these characteristics. These cracks and breaks are observed only in the occlusal enamel (for the two samples). Despite the fragility of the cervical enamel and mainly its weak thickness, the disposition of prisms reinforced the tissue at this level. (It is easier to cause micro cracks at


28 Restorative Dentistry Adhesion to Mild Fluorosed Enamel

the extremity of a prism than on the length of its axis). Ateyah and Akpata 2 observed breaks of cohesive type generalized on the fluorosed enamel of elderly patients for any time of etching. The observation of mesial obturation of sample n°2 at the cervical enamel shows decaled enamel prisms but still adherent to the composite resin. It seems to be drowned in the resinous mass, which implies that the enamel fracture has taken place before the bonding, therefore during the cavity preparation. The presence of an adhesive layer of variable thickness (samples 2) is an iatrogenic origin, due to the excessive intake of the adhesive although it was applied by micro-brush by rubbing it against the different walls and by photo polymerizing it immediately. The literature is silent concerning all these details for fluorosed teeth, we think that the success of a bonded restoration depends as well on the severity of fluorosis, the patient’s age and the adhesive system used. It is interesting to know that drilling greatly ameliorates bonding.9 Other investigations are required to evaluate the resistance to fracture.

Conclusion Fluorosed enamel is hard and brittle. These characteristics are relative to the degree of fluorosis. This fragility associated to the acid resistance makes of composite resin bonding a very delicate stage. Our study shows that composite adhesion to mild fluorosed enamel is not influenced by the etching time and that adhesion is better in the occlusal enamel than in the cervical enamel. This study may lead us to deduce that the mild fluorosed enamel (TF1 1-3) is likely to react to etching by ortho-phosphoric acid as a normal enamel would. However the practitioner should be vigilant and should work delicately during cavities preparation to avoid any risk of micro fractures and micro cracks of this enamel. He should as well

Dental News, Volume XXI, Number II, 2014

pay a particular attention to the restoration of the cervical wall which has a difficult access and where the enamel seems to be particularly resistant to the bonding procedures.

Acknowledgments The authors thank Mister Samir Boukottaya for revision of the manuscript.

References 1. AL-Sugair AL, Akpata E. Effect of fuorosis on etching of human enamel. J Oral Rehabil 1999;26:521-8. 2. Ateyah N, Akpata E. Factors affecting shear bond strength of composite resin to fluorosed human enamel. Oper Dent. 2000; 25:216-22. 3. Belkhir MS, Douki N A new concept for removal of dental fluorosis stains. J Endod 1991;17:288-92. 4. Belkhir MS, Triller M. Modifications ultrastructurales de la dent fluorotique et conséquences cliniques. Actual Odontostomatol 1987 ; 158 :223-38. 5. Chen H, Czajka-Jakubowska A, Spencer NJ, Mansfield JF, Robinson C, Clarkson BH. Effects of systemic fluoride and in vitro fluoride treatment on enamel crystals. J Dent Res2006; 8:1042-45. 6. De Goes MF, Sinhoreti MA, Consani S , Silva M. Morphological effect of the type, concentration and etching time of acid solutions on enamel and dentin surfaces. Braz Dent J 1998; 9: 3-10. 7. Deuxième enquête nationale sur la santé bucco-dentaire. République Tunisienne, ministère de la santé publique. Tunis : Direction de la médecine scolaire et universitaire ; 2007. 8. El Araby AM, Talik YF The effect of thermocycling on the adhesion of self—etching adhesives on dental enamel and dentin. J Contemp Dent Pract 2007;8:1-11 9. Ermis RB, De Munck J, Cardoso MV, Coutinho E, Van Landuyt KL, Poitevin A, Paul Lambrechts P, Van Meerbeek B. Bonding to ground versus unground enamel in fluorosed teeth. Dent Mater J 2007 ; 23 : 1250–55. 10. Goldberg M. Histologie de l’émai. EMC (Elsevier Masson SAS Paris), stomatologie, 22-007-A-10,2007l) 11. Piette et Goldberg. La dent normale et pathologique. Paris :De Boeck université ; 2001. 12. Roberson TM, Heymann HO, Swift EJ jr, Sturdevant’s art and science of operative dentistry, 4th ed. Mosby, 2002). 13. Shida K, Kitasako Y, Burrow MF, Tagami J Micro-shear bond strengths and etching efficacy of a two-step self-etching adhesive system to fluorosed and non fluorosed enamel Eur J Oral Sci 2009 ;117 : 182-86. 14. Summit JB et coll. fundamentals of operative dentistry. A contemporary approach. 3th ed. Quintessence books, 2006) 15. Ten Cate A.R. Oral Histology. Development, structure and function. 5th ed. Mosby, 1998 16. Weerasinghe DS, Nikaido T, wettasinghe KA, Abayakoon JB, Tagami J. Micro-shear bond strength and morphological analysis of a self etching primer adhesive system to fluorosed enamel. J Dent 2005; 33:419-26.


30 Oral Pathology

Oral Ulcers in Infants and Children Part I: General Points and Clinical Examination

Dr. Sawsan Nasreddine, BDS, DESS Pediatric Dentistry, DESS Public Health Dentistry, Department of Public Health Dentistry. sawsan-n25@hotmail.com Dr. Antoine Cassia, Dr. Chir. Dent., Dr. Sc. Odont., DUPRMF, Associate Professor and Former Chairperson, Department of Oral Pathology and Diagnosis, Director of LASER Unit.

Lebanese University School of Dentistry, Beirut.

Abstract This paper describes the basic principles of assessing pediatric dental patient with oral isolated or multiple oral ulcers. History should include significant medical and social facts as well as dental problems. Initial extra-oral examination covers visual appearance of patient’s Head and Neck region. Intra-oral examination let us understand the significance of features of ulcers such as form, site and pain.

Keywords Ulcer, etiology, generalities, extra-oral examination, intra-oral examination, diagnosis, and clinical features. Fig 1

Epithelial tissue

Epithelial tissue

Ulcer

Vesicle

Connective tissue

Connective tissue

Epithelial tissue Bulla

Fig. 1: a - ulcer, b - vesicle, c - bulla Dental News, Volume XXI, Number II, 2014

Connective tissue

Introduction Oral ulcers in infants and children are observed in dental office settings: they are source of discomfort and frustration for patients; it is often a challenge to distinguish one type of ulcer from another. Because many ulcers share many similarities, they are easy to misdiagnose. The diagnosis requires a systematic approach based on taking an adequate history, clinical examination, investigations as needed, treatment planning and, finally, examination allows for any necessary modifications of that management.1

Definition An ulcer (Fig. 1a) is a complete breach of the epithelium1, an uncovered wound of mucosal tissue that exhibits gradual tissue disintegration and necrosis. It extends beyond the basal layer of the epithelium into the connective tissue.2 It is either a primary lesion or secondary to vesicles or bullas. A vesicle (Fig. 1b) is a small, fluid filled elevation in the epithelium that is less than one centimeter in diameter. The epithelial lining of a vesicle is thin and will eventually break down, thus causing an ulcer.2 A bulla (Fig. 1c) is termed when a vesicle achieves a diameter greater than one centimeter. This condition develops from the accumulation of fluid in the epithelium connective tissue junction or a split in the epithelium.2


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32 Oral Pathology Oral Ulcers

Pathway to diagnosis

Onset

We should go up gradually via several steps to reach the differential diagnosis, top of the pyramid (Fig. 2), which leads us to attempt in most cases or not the definitive diagnostic. These steps are: - History of present illness (HPI) - General information - Medical observation - Extra-oral examination - Intra-oral examination

Oral ulcer which appears after dental treatment is usually an indicator of minor recurrent aphthous ulcer. Minor trauma to tissues can precipitate ulcers in susceptible patients. Some patients may report many ulcers (at the same site in the mouth) occurring after dental treatment.1 “When did the problem start?” Identify the duration, mode of onset and progression of the problem. Also remember to ask whether this is the first incidence of the problem or the latest of a series of recurrences.3, 4

Fig 2

Evolution

Diagnosis Intra-oral examination

The progression of the oral ulcer since onset can be helpful in establishing whether the ulcer is becoming more severe or not.1

Duration

Extra-oral examination Medical observation General information History of present illness (HPI) History of present illness (HPI) “What is the problem?” Record his/her patient’s symptoms.3 When a child presents in pain or has a particular concern, complaint should be recorded in the child’s own words.4 It should be obviously an ulcer. A full and accurate history is of primordial importance in assessment of a pediatric patient. In some cases, history may provide diagnosis while in the remainder it will provide essential clues to the nature of the problem. The approach to history taking needs to be tailored to the type of complaint being investigated.3 It is also an excellent opportunity for the dentist to establish a relationship with the child and his/her parent.4 A priority should be given to patients who have pain. A patient who has oral ulcer should be examined as soon as possible, because the more time, we loose the less accurate diagnosis we get. Dental News, Volume XXI, Number II, 2014

Duration of the ulcer is partly related to the age of onset and age at presentation and will also depend upon whether ulcer is persistent or intermittent.1 While examining the patient we should ask if it is the first time of ulcer’s appearance if no, we should ask about the number of reoccurrence and duration of each one. A more typical pattern of recurrent oral ulcer will be characterized by periods of ulcer with remissions between phases of ulcer. The progression of the ulcer since onset can be helpful in establishing whether the ulcer is becoming more severe.1

Localization Assuming that there are multiple ulcers, their location (Fig. 3) are important factors in establishing a diagnosis.1 Fig 3

Fig. 3 (from Bengel et al. 2006)


34 Oral Pathology Oral Ulcers

Previous treatment Sometimes, taking any medicines (for instance Zovirax®) give us a key in producing our diagnosis. Because any acyclovir medicine is prescribed for Herpes.

Past dental history “Do you consult your dentist regularly?”. It is an opportunity to evaluate the attitude of the parents to their child’s dental treatment.4 Obtain a general picture of his treatment experience (fillings, dentures, local analgesia and general anaesthetic experience).3

General information A note should be written of the patient’s name, age, address and telephone number. Details of the patient’s medical practitioner should also be noted.4 The age of the patient may be of relevance in relation to the age of onset of the ulcer. A child or adolescent presenting a recurrent oral ulcer may be evocative of a different diagnostic and management dilemma compared to an older patient. Some types of recurrent oral ulcer have a typical onset in childhood or adolescence, such as recurrent aphthous ulcer and stomatitis. This pattern of oral ulcer can sometimes be present in later life, but a middle-aged or elderly patient presenting with recurrent oral ulcer should also raise other diagnosis possibilities such as oral lichen planus and vesiculobullous disorders.1 A child is a product of his environment. Factors such as whether both parents are alive and well, number and age of siblings, parent’s occupations, ease of travel, as well as attendance at school or day-care facilities are all important if a realistic treatment plan is to be settled. This step of history-taking also presents an opportunity to engage the child in conversation.4

Medical observation Some medical conditions may have oral manifestations while others will affect the manner in which dental treatment is delivered.3 Asking a mother about her child’s health since birth will not infrequently stimulate the production of a complete medical history! Previous and current problems associated with each of the major systems should be elicited through careful questioning.4 Dental News, Volume XXI, Number II, 2014

It’s important to report the presence of general signs, because they can guide our diagnosis, for example in case of varicella. Details about hospitalizations, operations (or planned operations), illness, allergies (particularly adverse reactions to drugs) and traumatic injuries should be recorded, as well as those related to previous and current medical treatment: a negative response should be further confirmed by asking if the patient has visited their general medical practitioner recently.4 The medical history will include ascertaining any medication taken by the patient. Some medications are associated with oral ulcer, (for example, methotrexate, used for some forms of childhood arthritis).1 However, do not automatically assume that any medication being taken by a patient with oral ulcer is the cause of their ulcers.1 A nutritional deficiency such as a deficiency of iron, folate or vitamin B12 may predispose the patient to recurrent oral ulcer and it may aggravate it.1

Extra-oral examination It is of utmost importance to reach the top of pyramid, by reaching the differential diagnosis. As a general rule, use your eyes first, then your hands to examine a patient. Start with the extraoral examination before proceeding to examine the oral cavity. Take time to look at the patient. This process of medical observation will start while you are taking the history.3 Visual areas should cover: - general patient condition - lips - skin. Palpation should cover: - lymph nodes of the head and neck - temporomandibular joint (TMJ) - salivary glands (major and minor).3

General patient condition (Tab.1) a- Fever, malaise and anorexia are described in case of: - primary herpetic gingivostomatitis - varicella - herpangina - hand, foot and mouth disease5


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36 Oral Pathology Oral Ulcers

Lymph nodes of the head and neck

b- Pharyngitis is described in case of: - primary herpetic gingivostomatitis - varicella5 c- Vomiting, diarrhea, headache, myalgia and rhinorrhea are reported in case of: - herpangina - hand, foot and mouth disease5 d- Dysphagia is described only in case of: - herpangina5

Lips We can find ulcers on lips in case of : - traumatic ulcer - hand, foot and mouth disease - primary herpetic gingivostomatitis - tuberculosis

Skin manifestations In varicella, vesicular lesions on the skin, concentrated mainly on the trunk, head and neck then spreading all over the skin.6, 7, 8 In hand, foot and mouth disease, rash is on the skin of the hands, fingers and soles of the feet. Rarely, the legs and lower trunk are involved.2 A rash is not always present or may affect more proximal parts of the limbs or buttocks.8

Primary herpetic gingivostomatitis

Varicella

Fever

X

X

Malaise

X

X

Anorexia

X

X

Pharyngitis

X

X

The regional lymph nodes should be palpated as these may be enlarged in case of persistent or large ulcers.1 The submental, submandibular and the internal jugular nodes are of particular importance because these collect lymph drainage from the oral cavity.3 A common sequence would be to start in the submental region, working back to the submandibular nodes then further back to the jugulo-digastric node. Then continue by palpation of the parotid region downwards to the retromandibular area and down the cervical chain of nodes. When a node is perceived as enlarged, record the texture: a hard node of a metastasizing malignancy contrasts well with a tender, softer node in an inflammatory process.3 Lymphadenopathy is found in case of: -primary herpetic gingivostomatitis -varicella -herpangina -hand, foot and mouth disease -tuberculosis5

Tab. 1: General patient condition

Herpangina

Hand, foot and mouth disease

Vomiting

X

X

Diarrhea

X

X

X

X

Myalgia

X

X

Rhinorrhea

X

X

Dysphagia

X

Headache

X

Skin rash Lymphadenopathy Dental News, Volume XXI, Number II, 2014

X X

X

Tuberculosis

X X

X

X


38 Oral Pathology Oral Ulcers

Temporomandibular joint

Intra-oral examination

A detailed examination of the TMJ is probably only needed when a specific problem is suspected from the history.3 The TMJ can also be affected by diseases.4 The most frequent are rheumatoid arthritis3, juvenile idiopathic arthritis and traumatic injuries.4

Intraoral examination should assess first, at the present moment, the presence or absence of ulcers. If present, examination of an ulcer should include assessment of nine important features: - Number - Size - Shape - Base - Edge (margins) and surrounding tissues - Pain - Location - Duration - Etiologies Visual inspection is essential but palpation is also an important part of the examination of an ulcer. Gloves must be worn for palpation and the texture of the ulcer base, margin and surrounding tissues should be ascertained by gentle pressure.1, 3

Salivary glands As with the TMJ, examination of the salivary glands is only required when the history suggests this is relevant. For example, bacterial sialadenitis, involves the parotid glands, is accompanied by swelling, pain, fever and erythema of the overlying skin.3 Fig 4

Characteristics of an ulcer Number Fig. 4: Minor aphthous ulcer Fig 5

Fig. 5: Minor recurrent aphthous Fig 6

Fig. 6: Major aphthous ulcer Dental News, Volume XXI, Number II, 2014

There are two clinical situations; either there are one or multiple ulcers: so first, ulcers should be counted. If one ulcer is present, the following diagnosis should be considered: - Aphthous ulcer (Fig. 4) - Traumatic ulcer (Fig. 5) - Rare tuberculosis and malignant ulcers If more than one ulcer is present, the following diagnosis should be considered: - Recurrent aphthous ulcers (Fig. 6) - Traumatic ulcers (Fig. 7) - Primary herpetic gingivostomatitis - Varicella - Herpangina - Hand, foot and mouth disease (Fig. 8) - Tuberculosis ulcer For instance, recurrent minor aphthous ulcers tend to occur in crops of two to three but variable patterns are seen, ranging from occasional single ulcer to over 20 at any one time.2, 3, 9 The number of recurrent major aphthous ulcers varies between 2 to 510. Herpetiform ulcers are characterized by multiple small ulcers (10 to 100).2, 5 In primary herpetic gingivostomatitis, is characterized by multiple ulcers.11


40 Oral Pathology Oral Ulcers

Oral lesions in herpangina consist of two to six red macules which form fragile vesicles that break up quickly leaving ulcers.8 Hand, foot and mouth disease has few vesicles (5 to 10) that break up quickly leaving a shallow ulcers.8, 10

Size Unique and multiple minor aphthous ulcers are relatively small in size (2 to 6 mm in diameter).10 Unique and multiple major aphthous ulcers are large, more than 1cm in diameter and are often deeper.12 Herpetiform is a pinhead–sized ulcer.2, 3 Initially, ulcers are 1 to 3 mm in diameter.2, 10, 13, 14 The appearance of a mechanically induced traumatic ulcer varies according to the intensity and size of the agent.2 In primary herpetic gingivostomatitis, after 1-2 days small vesicles develop on the oral mucosa. They rupture, leaving ulcers with a diameter of 1-3mm.6 In varicella, lesions have varying degrees of development.6, 7 In herpangina, they are 2 to 4 mm in diameter.7 Hand, foot and mouth disease show small ulcers (2 to 6 mm in diameter).8, 10 Fig 7

a

b

c

Fig. 7: (a, b, c) Traumatic ulcers Dental News, Volume XXI, Number II, 2014

The size of tuberculosis ulcer varies from 1 to 5 cm.10

Shape Unique and multiple minor aphthous ulcers are round or oval, with a gray-white pseudo membrane.15 Unique and multiple major aphthous ulcers are often ovoid ulcers.8 Herpetiform ulcers occur in crops, gray-white erosions that enlarge, coalesce, and become illdefined.2, 3 The shape of traumatic ulcers often gives a clue as to the cause.3 Primary herpetic gingivostomatitis, is characterized by shallow ulcers that appear throughout oral cavity.11 In varicella, the typical rash goes through papules, vesicles, and pustules stages and then ruptures to produce round or ovoid ulcers.5, 8 Oral lesions in herpangina consist of shallow and round ulcers.8

Base In unique and multiple minor aphthous ulcers, there is little or no induration.15 Unique and multiple major aphthous ulcers are covered with a yellowish-white membrane necrotic tissue.10 Typically, herpetiform ulcers become confluent.3,12,14 On gentle palpation, traumatic ulcers lack indurations and are tender.3 There is no induration in traumatic ulcers unless the site is scarred from repeated episodes of trauma.13 The base of the ulcer is usually yellow-grey.2 The clinical appearance of traumatic ulcers is usually followed by the development of a whitish pseudo-membranous mucous lesion.6 With a soft base, we should think about primary herpetic gingivostomatitis, herpangina and hand, foot and mouth disease are to be considered.10 The surface of tuberculosis ulcer has vegetation with coating is gray-yellowish. The surrounding mucosa is mildly indurated and inflamed.10 The deep ulcer of squamous cell carcinoma has large exophytic mass.10


42 Oral Pathology Oral Ulcers

Edge

Fig. 8: (a, b, c) Hand, foot and mouth disease (courtesy Dr. Hajj G.)

The clinical examination of minor aphthous ulcers and minor recurrent aphthous ulcers usually shows a lightly erythematous lesion with regular borders.15 Unique and multiple major aphthous ulcers are with thin red (inflammatory) erythematous halo and irregular edges.10 Herpetiform ulcers have thin red erythematous halo and irregular edges.2, 13, 14 The edges of the traumatic ulcers are raised and everted, and mild induration of the margins is palpable.16

a

b

Primary herpetic gingivostomatitis has edematous edges with fibrin (yellowish-gray) background.10 The lesion develops as intraepithelial vesicles that burst leaving areas of erosion and ulcers with erythematous margins.11 In varicella, the oral manifestations are ulcers with an inflammatory halo.8 Herpangina is circumscribed by a narrow red erythematous halo.8, 10 Tuberculosis ulcer is with an irregular outline and has no red erythematous halo.10 Squamous cell carcinoma has a vegetative background with an elevated edge with an absence of erythematous halo.10

Fig 8

Pain All following ulcers are painful: - unique and multiple minor aphthous ulcers which recur at intervals of a few days or up to 2-3 months14 - unique and multiple major aphthous ulcers10 - herpetiform ulcers2, 13 - traumatic ulcers3 - primary herpetic gingivostomatitis6 - varicella: the lesions are also extremely pruritic6, 7 - herpangina8 - hand, foot and mouth disease (slightly)10, 14 In tuberculosis, ulcer is painless.10

Location

c

Dental News, Volume XXI, Number II, 2014

Some ulcers may have particular sites. Unique and multiple minor aphthous ulcers affect only the non-keratinized oral lining mucosa3 - buccal mucosa - labial mucosa17 - floor of the mouth - soft palate - lateral borders of the tongue13, 14 Moreover, ulcers are usually concentrated in the anterior part of the mouth; the pharynx and tonsillar fauces are rarely implicated.14 Unique and multiple major aphthous ulcers involve the soft palate10, tonsil areas, labial mucosa, buccal mucosa, and dorsum of the tongue, occasionally extending onto the attached gingiva2,8,17, often the oropharynx is affected.1 Herpetiform ulcers are seen on the non-keratinized mucosa with the possibility of more ragged ulcers by virtue of adjacent ulcers enlarging and fusing.1 But particularly affected the anterior tip


44 Oral Pathology Oral Ulcers

of the tongue, margins of the tongue, floor of the mouth and labial mucosa.2,17 Traumatic ulcers are most common on the lateral border of the tongue and buccal mucosa1, 3, lips, gingiva and palate.18 The most common situation is cheek or lip bites after dental local analgesia.6, 13 If caused by the sharp edge of a broken tooth, they are usually on the tongue or buccal mucosa.13 Sublingual ulcer was noticed in a natal tooth, suggestive of the role of infantile swallowing and suckling.16 In primary herpetic gingivostomatitis, ulcers covere the gingival and the oral mucosa bilaterally.19 In varicella, lesions are located mostly on the mucosa of the lips, buccal, and tongue.6 In herpangina, disease is limited to the oropharynx with vesicles/ulcers on the soft palate and faucal pillars.7, 10 In hand, foot and mouth disease, oral lesions are usually more anterior, primarily on the lips, tongue and buccal mucosa.7 Tuberculosis ulcer may involve dorsal surface of the tongue, buccal mucosa, lips and palate.10 Most common site for intraoral squamous cell carcinoma is lateral border and ventral surface of the tongue, floor of the mouth, and lower lip. Other intraoral sites, in descending order of involvement, are the oropharynx, gingival, buccal mucosa, lip, and palate.2, 10

Duration Unique and multiple minor aphthous ulcers heal within 4 to 14 days, rarely with scarring.12, 13 Unique and multiple major aphthous ulcers can persist for up to 3 months and often heal with scarring.2, 3, 17 Typically, herpetiform ulcers become confluent and heal with scar formation, but this is probably a result of coalescence, the healing takes up to 40-50 days.3, 8, 12 Lesion of traumatic ulcers is self-limiting may persist for just a few days or may last for weeks (especially ulcers of the tongue).6, 18 In Varicella, infection generally resolves within 2 weeks.18

Etiologies The cause of recurrent aphthous ulcers is yet unknown. There is some evidence that this disease Dental News, Volume XXI, Number II, 2014

could be an immunological hypersensitivity reaction to an L-form streptococcus. There is no reliable evidence of autoimmune disease.5 Traumatic ulcers are usually caused by dental local analgesia, denture irritation or chemical, mechanical and thermal trauma, rough fillings and clumsy use of cutting dental rotating instruments, toothbrush trauma, tic, orthodontic treatment13 and presence of a natal or neonatal tooth.16 The traumatic incident is may be incidentally self-inflicted or iatrogenic.18 Herpetic gingivostomatitis is caused by herpes simplex virus-1 (HSV1) and communicated through personal contact, e.g., transmission via the saliva of the mother. Primary oral infection occurs following the first exposure to the virus.6 Varicella is a highly contagious herpes virus infection of children, caused by Varicella-zoster virus (VZV).7, 8 Herpangina is a disease mainly of children and is caused by various strains of enterovirus mainly Coxsackie viruses A1-A6, A8, A10, A12 or A22, but similar syndromes can be caused by other viruses, especially Coxsackie B and echoviruses.7, 8 Hand-foot-and-Mouth disease is an enterovirus infection, caused by Coxsackie virus A.7, 8

When should you be alerted? The below factors should determine if doctor needs to refer the patient. Time is very important in treating and relieving the patient. Ulcer - long-term ulcer - if it grows in size, after removing the cause - chronic ulcer - elevated edge - indurated base - painless

General status - fever - dehydratation - contagious disease diagnosed

When should you refer? - any ulcer persisting for more than 3 weeks - general signs - if diagnosis is hard to establish


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47

To whom should you refer? - Pediatrician With general signs - Pathologist Without general signs

To remember - Number of common infectious diseases in children is manifested by oral lesions, apart from specific skin lesions. Unnecessary dental treatment should be avoided during the child’s disease and the week following recovery due to risk of infectious transmission - Any persistent ulcer (more than 3 weeks) despite the removal of its presumed cause, should be biopsied and suspected malignant until proven the contrary - Where general signs are present, refer the patient to a pediatrician even though the diagnosis is established.

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References 1. Talacko A.A., Gordon A.K., Alfred M.J. The patient with recurrent oral ulceration. Australian Dental Journal. 2010; 55 (1 Suppl):14-22 2. Langlais R.P., Miller C.S., Nield-Gehrig J.S. Color atlas of common oral diseases. Philadelphia, The Point, 4th edition, 2009:17-30 3. Coulthard P., Horner K., Sloan P., Theaker E. Oral and maxillofacial surgery, radiology, pathology and oral medicine. Master Dentistry. Edinburgh, Elsevier, 2nd edition, 2008, Vol.1:11-20 4. Welbury R.R., Duggal M.S., Hosey M.Th. Paediatric dentistry. Oxford, 3rd edition, 2005:41-62 5. Scully C., Cawson R.A. Oral disease. Edinburgh, 2nd edition, 1999:23-56 6. Koch G., Poulsen S. Oral mucous lesions and minor oral surgery. Pediatric dentistry (a clinical approach). Copenhagen, Munksgaard, 2nd edition, 2009:298-307 7. Lewis M. Herpangina: an enteroviral febrile associated vesiculo-bullous disease Oklahoma Dental Association Journal. March 2008:32-34 8. Scully C., Welbury R. Color atlas of oral diseases in children and adolescents. Europe, Mosby, 1994:82-108 9. Cameron A.C., Widmer R.P. Pediatric oral medicine and pathology; ulcerative and vesiculobullous lesions. Handbook of pediatric dentistry. Edinburgh, Mosby, 3rd edition 2008:177-180 10. Laskaris G. Atlas des maladies buccales. Paris, Flammarion, 2nd edition, 1994 11. Brugnera A. jr, Garrini dos Santos A. E. C., Bologna E. B., Pinheiro Ladalardo Th. Ch. C. G. Atlas of laser therapy applied to clinical dentistry. Chicago, quintessence editora, 2006:34-35 12. Altenburg A., Krahl D., Zouboulis C.C. Non infectious ulcerating oral mucous membrane diseases. Journal of the German Society of Dermatology. 2009(7):242-257. 13. Cawson R.A., Odell E.W. Diseases of the oral mucosa: introduction and mucosal infections. Oral pathology and oral medicine. 8th edition, 2008:206-216 14. Field E.A., Allan R.B. Review article: oral ulceration, aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic. Aliment Pharmacol Ther. 2003, 18:942-962 15. Descroix V., Coudert A.E., Vigé A., Durant J.P., Touenay S., Molla M., Pompignoll M., Missika P., Allaert F.A. Efficacy of topical 1% lidocaïne in the

Tradition and Technology

symptomatic treatment of pain associated with oral mucosal trauma or minor oral aphthous ulcer: a randomized, double-blind, placebo-controlled, parallel-group, single-dose study. Journal of

Orofacial Pain, 2011, 25(4):327-332 16. Padmanabhan M. Y., Pandey R. K., Aparna R., Radhakrishnan V. Neonatal sublingual traumatic ulceration-case report & review of the literature. Dental Traumatology. 2010, 26:490-495 17. Gurenlian J.R. Differentiating herpes simplex virus and recurrent aphthous ulcerations. Access, Feb 2003:30-34 18. Sällberg M. Oral viral infections of children. Periodontology 2000. 2009, Vol.49:87-95 19. Wood N.K., Goaz P.W. Differential diagnosis of oral lesions. USA, Mosby, 4th edition, 1991:195-221

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48 Orthodontics

CA® CLEAR-ALIGNER Therapeutic Possibilities

Dr. Pablo Echarri, DDS echarri@centroladent.com

Abstract In this article, different CA® CLEAR-ALIGNER therapeutic possibilities are demonstrated through the case reports presentation.

Keywords CA® CLEAR-ALIGNER. Therapeutic possibilities.

Introduction Definition

The CA® CLEAR-ALIGNER technique is an orthodontic treatment whose appliances consist of transparent, esthetic, comfortable, effective, progressive and sequential aligners. It allows the treatment of many patients who don’t want to wear fixed appliances. Normally, the CA® CLEAR-ALIGNER is used in adult patients, but it also can be used in mixed dentition.

Characteristics - Three different aligners which vary in thickness are used: CA®-soft, CA®-medium and CA®hard. - It is made step by step and one at the time with each impression. It is sequential. According to our experience and depending on the characteristics of the case or circumstances of a patient (if a patient is able to attend the appointments at the dental office, if he is on a holiday, traveling, etc.), 2 or 3 steps can be carried out using the same impression. - It is a progressive treatment, carried out on the basis of the plaster cast set-ups. The precision of a planning and a set-up realization is a basic principle of an effective treatment. Dental News, Volume XXI, Number II, 2014

- It covers 3-4 mm of gingival tissue to improve the esthetics and to optimize the movement.

Advantages CA® CLEAR-ALIGNER is made from plaster casts poured from the impressions taken at each appointment. This procedure allows: - To adapt to the changes that might happen in the teeth, such as abrasions, fractures, fillings, etc. - To use it in mixed dentition, adapting the treatment to the changes that the dentition undergoes, such as exfoliation of temporary teeth, or eruption of permanent teeth. - To adapt to the possible relapses or dental movements produced due to the poor use of CA® CLEAR-ALIGNER. Being sequential, the CA® CLEAR-ALIGNER has additional advantages for a specialist. - It allows the specialist to study the case evolution at each step, and to readjust the treatment plan, if necessary. Therefore, an evaluation and readjustment at the end of the treatment are not necessary. - The adjustment of CA® CLEAR-ALIGNER is very precise, so any kind of change that might occur in dentition (fillings, etc.) would affect its retention and effectiveness. It is possible that a patient needs some kind of intervention during the treatment, and with a new impression, the CA®CLEAR-ALIGNER can be adjusted again. - It is very hard to carry out the stripping in a patient with the precision of 0.25 mm. Therefore, in CA® CLEAR-ALIGNER technique, the stripping


pola is carried out before taking the new impressions. In this way, the trimming carried out in a patient is reproduced in the plaster cast, instead of reproducing the trimming carried out on the plaster cast in the patient. - The relapse doesn’t normally happen in a symmetrical way, reverse to the treatment. That’s why a patient who interrupted the treatment cannot use the same appliances again if he wants to continue his treatment. The relapse, among other things, depends on habits or dysfunctions the patient might have. With the CA®CLEAR-ALIGNER, the treatment can be readjusted by taking a new impression at any moment of the treatment. - It is not necessary that the whole treatment is paid at the beginning of it - it can be paid step by step, as they are finished. - The CA® CLEAR-ALIGNER offers a solution to those patients who need smaller movements treatment or a relapse treatment. - The CA® CLEAR-ALIGNER is: esthetic and comfortable, it doesn’t cause any difficulties in pronunciation (although some patients may need reading exercises during the first days of the treatment). - It has a simple mechanics, reduced chair-time, it is fast, and the relation cost/benefits is favorable. - The CA® CLEAR-ALIGNER can also be used in mouth breathers or sleep apnea patients.

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CA® CLEAR-ALIGNER Principles - It should be an orthodontic treatment with esthetic and comfortable appliances, compatible with the social and professional life of patients. - The diagnosis and the treatment control should be carried out by dentists and orthodontists. - It should offer a rapid and efficient solution to the patients who don’t want to use fixed orthodontic appliances. - It should have a detailed clinical procedure. - It should have a detailed laboratory procedure. - It should have an efficient clinic-laboratory communication protocol. - The results should be predictable. - The aligners of different thickness are used, and they cover approximately 3 mm of gingival tissue for more effective movement and more esthetic effect. - The impressions should be taken periodically to adapt the appliances to treatment evolution and to the changes that can occur in teeth and gingival tissues. - It is mainly aimed at patients who need treatments based on minor tooth movement or treatments of relapse in incisors and canines.

Indications - Space closure up to 4 mm. - Crowding correction up to 4 mm (6 mm).

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50 Orthodontics Clear Aligner

- Correction of anterior teeth rotation. - Anterior deep bite treatment. - Anterior open bite treatment (with CA® POWER GRIPS). - Cross bite treatment. - Molar uprighting up to 10º. - CA® CLEAR-ALIGNER used in mixed dentition. - CA® CLEAR-ALIGNER as a part of other treatments. - CA® CLEAR-ALIGNER in a relapse treatment. - CA® CLEAR-ALIGNER as a passive /active retention appliance. Double retention.

Limitations - Closure of more than 4 mm (6 mm) spacing. - Correction of more than 4 mm crowding. - Correction of posterior teeth rotation. - Extraction cases. - Bodily movement of the teeth.

- Anterior open bite treatment (without CA® POWER GRIPS). - Intercuspation and extrusion treatments (without CA® POWER GRIPS). - Treatments that imply strict control of torque or mesio-distal tipping. - Class II treatments. - Class III treatments.

Counter indications CA® CLEAR-ALIGNER is counter indicated in patients who present: - Bruxism clenching and grinding. - Cranio-mandibular dysfunction. - Habits like nail biting, lip biting, object biting, etc. - Hyper sensibility to materials CA® CLEARALIGNER is made of, although up to now, such cases weren’t still reported (Polyethylene terephthalate). - Non-cooperative patients.

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52 Orthodontics Clear Aligner

Case reports The CAÂŽ CLEAR-ALIGNER therapeutic possibilities can be studied through the following case reports.

Case NÂş 01416: Case with spacing in maxilla (8 steps) and crowding in mandible (4 steps).

Figs. 1-5: Initial intraoral photographs. Figs. 6-10: Final intraoral photographs. Dental News, Volume XXI, Number II, 2014

Fig 1

Fig 6

Fig 2

Fig 7

Fig 3

Fig 8

Fig 4

Fig 9

Fig 5

Fig 10


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Ask every patient about their gum health to identify the early stage of gingivitis and the need for appropriate action and/or treatment Increasing their knowledge Don’t let your patients ignore the ‘red alert’ of bleeding and inflammation Tell patients about long-term implications of gingivitis, which could lead to irreversible gum disease and tooth loss

Supporting your recommendation parodontax® campaign prompts patients to ask you about gum disease and its prevention Patients may ask you for a toothpaste recommendation

References 1. Data on file, GSK, June 2012. 2. Global Segmentation Study. Europe – Learnings from Research, Oct 2007. 3. NHS Adult Dental Health Survey 2009. http://www.ic.nhs.uk/ webfiles/publications/007_Primary_Care/Dentistry/dentalsurvey09/AdultDentalHealthSurvey_2009_Theme2_Diseaseandrelateddisorders.pdf. Accessed April 2012. 4. Data on file, GSK TN06-003, April 2006. 5. Data on file, GSK Armstrong J, March 2003. 6. Data on file, GSK E5931015, January 2011. 7. Data on file, GSK E5930966, January 2011. 8. Yankell SL et al. J Clin Dent 1993; 4(1):26-30. 9. Saxer U et al. J Clin Dent 1994; 5(2): 63-64. 10. Arweiler NB et al. J Clin Periodent 2002; 29: 615-621. 11. Data on file, GSK. Russian market research, June 2007. 12. Data on file, GSK. French market research, November 2011. 13. FDA U.S. Food & Drug Administration. Health Claim Notification for Fluoridated Water and Reduced Risk of Dental Caries. http://www.fda.gov/Food/LabelingNutrition/LabelClaims/FDAModernizationActFDAMAClaims/ucm073602.htm. Accessed April 2012. 14. ten Cate IM. Euro J Oral Sciences 1997; 105(5): 461-465. http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0722.1997.tb00231.x/abstract. Accessed April 2012. 15. Willershausen B et al. J Clin Dent 1991; 2(3): 75-78.

Date of preparation: June 2012


54 Orthodontics Clear Aligner

Case Nº 01377: 23 and 25 should be intercusped. One CA® CLEAR-ALIGNER step – Forced extrusion of 23-25. Fig 11

Fig 12

Fig 13

Fig 14

Fig 15

Fig 16

Fig 19

Fig 17

Fig 20

Fig 18

Fig 21

Perfectionis makingsmilesbeautiful.

Fig 22

Fig 23

Fig 24

Fig 25

Fig 26

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Make your patient’s smile perfect • make teeth alignment easier fabricating splints yourself in your practice Figs. 11-15: Initial intraoral photographs. Figs. 16-21: Treatment progress. Figs. 22-26: Final intraoral photographs.

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Dental News, Volume XXI, Number II, 2014

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56 Orthodontics Clear Aligner

Case Nยบ 00561: Crowding and rotation in both arches. Deep bite. Treated with expansion and stripping, and upper and lower incisors intrusion. Maxilla: 12 steps. Mandible: 13 steps.

Figs. 27-31: Initial intraoral photographs. Figs. 32-36: Final intraoral photographs. Dental News, Volume XXI, Number II, 2014

Fig 27

Fig 32

Fig 28

Fig 33

Fig 29

Fig 34

Fig 30

Fig 35

Fig 31

Fig 36


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Think beyond pain relief and recommend Sensodyne Repair & Protect References: 1. Greenspan DC. J Clin Dent 2010; 21(Spec Iss): 61–65. 2. LaTorre G, Greenspan DC. J Clin Dent 2010; 21(3): 72-76. 3. Burwell A et al. J Clin Dent 2010; 21(Spec Iss): 66–71. 4. West NX et al. J Clin Dent 2011; 22(Spec Iss): 82-89. 5. Earl J et al. J Clin Dent 2011; 22(Spec Iss): 62-67. 6. Efflandt SE et al. J Mater Sci Mater Med 2002; 26(6): 557-565. 7. Zhong JP et al. The kinetics of bioactive ceramics part VII: Binding of collagen to hydroxyapatite and bioactive glass. In Bioceramics 7, (eds) OH Andersson, R-P Happonen, A Yli-Urpo, Butterworth-Heinemann, London, pp61–66. 8. Parkinson C et al. J Clin Dent 2011; 22(Spec Issue): 74-81. 9. Earl J et al. J Clin Dent 2011; 22(Spec Iss): 68-73. 10. Wang Z et al. J Dent 2010; 38: 400−410. Prepared December 2011, Z-11-516. OH/CA/01/13/001


58 Orthodontics Clear Aligner

Case Nยบ 00581: Molar Class I with crowding. Maxilla: 4 steps. Mandible: 3 steps.

Figs. 37-41: Initial intraoral photographs. Figs. 42-46: Final intraoral photographs. Dental News, Volume XXI, Number II, 2014

Fig 37 27

Fig 42

Fig 38

Fig 43

Fig 39

Fig 44

Fig 40

Fig 45

Fig 41

Fig 46


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60 Restorative Dentistry

Effect of different surface treatments on prefabricated fiber posts: a literature review.

Dr. Rita Eid ritayeid@yahoo.com Dr. Najib Abou Hamra

Dr. Danielle Hakim

Dr. Maha Ghotmi

Abstract This literature review summarizes the recent research on fiber posts regarding surface treatment to improve their adhesive properties. Actual methods to treat the surface relied on chemical and/or micro-mechanical techniques. The majority of data was based on in vitro studies that investigated different chairside post surface treatments for enhancing and/or modifying the surface available for bonding. The tests used were microtensile and push out bond strength in combination with SEM analysis. Few studies included aging procedures and 3 point bending test to evaluate mechanical properties of the treated posts. According to the reviewed in vitro studies, surface conditioning improves fiber posts bonding properties and leads to a good bond strength between the post and the restorative materials. Results are promising especially regarding some new acidic treatments. Long term clinical studies are still needed before recommending their use.

Introduction Fiber posts are currently widely used in restoration of endodontically treated teeth.9 Many studies have investigated factors that may affect the retention of a post, such as design, length, diameter and surface treatments.19 The similar elastic modulus of fiber posts, resin cement, resin composites and dentin is considered to be advantageous for improving their performance. A proper bonding at the dentin/ cement, post/ cement interfaces is needed for dissipation of stresses generated by occlusal loads.16 In vitro and in vivo studies indicates that failure of fiber post and core restorations often occurs because of debonding between the fiber postresin and/or resin-root canal dentin interfaces as Dental News, Volume XXI, Number II, 2014

a result of inadequate bond strength.30 Perdigao et al. estimated that 60% of fiber posts failures occurred between post and resin cement.28 Retention of the composite core to prefabricated posts is affected by various factors, including surface treatment of the post, design of the post head and the composite core material. Surface treatments are commonly used for enhancing the adhesive properties of the post, by allowing chemical and micromechanical retention between the fiber post and the composite core in contact.27 These procedures fall into 3 categories 1- Treatments to optimize chemical bond between the post and the cement or the composite (coating with priming solutions) 2- Treatments that roughen the surface (sandblasting and etching) 3- Combine micromechanical and chemical components either by using the two above or a unique system (Co-Jet).18 Current fiber posts are composed of unidirectional fibers (carbon, quartz or glass) embedded in a resin matrix. Different matrices, among which epoxy resin, methacrylate resin and a proprietary composite resin are used by manufacturers. The fibers are responsible for the resistance against flexure, while the resin matrix provides resistance to compression. This resin matrix also forms the surface to which the functional monomers contained in the adhesive cements will interact with.32 Most of the matrix components of fiber reinforced composite (FRC) posts are epoxy resin which has a high degree of conversion and has also highly cross linked structures. In fact, no functional groups of the fiber post would


62 Restorative Dentistry Surface Treatments

react with the methacrylate group, which is the major component of dental composite resin. This results in the absence of chemical bonding between the 2 substrates.31 On the other hand, methacrylate resin matrix of some FRC posts exhibit a good affinity in terms of bonding between the post matrix and the methacrylate based adhesive and resin cements, this affinity will result in good chemical bonding between the fiber post and cement or core build up.1 This discrepancy in adhesive behavior opened the door for a large amount of research to study the optimal pretreatment of each kind of fiber post. This review will summarize the major surface treatments mentioned, their benefits in term of improving bonding to resin composites, their limitations, and their potential clinical indications.

1- Chemical Bonding to Fiber Posts Silane coupling agents are hybrid organic-inorganic compounds that can mediate adhesion between inorganic and organic matrices through an intrinsic dual reactivity.22 Treating the post surface with a silane-coupling agent may be advisable for enhancing adhesion. However opinion differs about the efficiency of post silanization. Perdigao et al.22 reported that silane did not improve the bond strength of several posts cemented with the respective cements at any level of the root. This outcome corresponds to other findings.9, 28, 32 The ineffectiveness of silanization is more likely attributed to a rather weaker or even absent chemical union between methacrylate based resin composites and the highly crosslinked epoxy resin, main constituent of fiber posts matrix.14, 25 It is also probable that incomplete evaporation of the solvent of the silane19 may compromise the coupling. 8 On the contrary other studies reported improved bond strength between silanized fiber posts and flowable composites used for core materials,2, 22, 24 Aksornmuang et al.2 confirmed the benefit of silane application for enhancing microtensile bond strength of a dual cure resin core material to fiber posts. Soares et al.27 assessed microtensile bond strength of glass fiber posts treated with silane and airborne particle abrasion and concluded that treatment with silane only was sufficient as surface treatment for adhesive bonding. These results rely on silanes capability to increase surface wettability, creating a chemical bridge with OH-covered substrates, such as glass (glass fibers on the post surface). However the interfacial strength is still relatively low when compared to the values achieved with dental substrates.9 Furthermore, silane and consecutive application of bonding have been investigated: Ferrari et al.10 reported no significant improvement in bond strength by separately applying silane and different adhesives on methacrylate based quartz fiber posts. The formation of a thick multi phase coupling layer with possible errors during each separate phase of application possibly explain the outcomes. On the contrary satisfactory results have been reported on epoxy resin based fiber posts2 and that by using the combination of a silane/ primer solution and a bonding agent. These combined silane / bonding agents allow the formation of siloxane bonds and the polymerization of functional groups in the resin in the same time. These separate silanes seem to perform more efficiently than completely pre-hydrolysed solutions.11 In addition the use of a separate hydrophobic resin coating after silane/primer solution created Dental News, Volume XXI, Number II, 2014

better seal of post surface than the one step self etch adhesive.19

2- Micromechanical Bonding to fiber posts Airborne Particle Abrasion Airborne particle abrasion with Al2O3 is the most studied. It increases the surface area and enhances mechanical interlocking between the cement and the roughened surface of a post. Several protocols were described.3, 5, 6, 17, 23, 27 They all seem to be effective in term of enhancing the bond strength and that by partial removal of the resin matrix, which increases the number of exposed glass fibers and consequently the surface area available for reaction.6 Of importance is the fact that even for a mild abrasive protocol (50¾m aluminum oxide, 2 bars, 10 seconds, 10 mm distance) the SEM analysis of post surface showed a disruption of the interface between the matrix and the fibers with fracture of fibers, even though the authors stated that no influence was reported on the mechanical properties of the posts.27 D’Arcangelo et al.7 have also reported that flexural strength and flexural modulus of fiber posts were not influenced by pretreatment with silane, airborne particle abrasion and hydrofluoric acid. Lately, more promising results were achieved by Kern and Asmussen with the use of a specific protocol: 50¾m aluminum oxide, 2.5 bars, 5 seconds, 30 mm distance. This regimen did not produce any alteration in the shape of the post and resulted in increased bond strength with resin cement. Some studies3, 5, 6 preconize airborne particle abrasion as treatment of choice without additional treatment, and some others (Magni et al.24) show better bond strength with silane application.

Acidic Treatments To optimize the bonding of resin cements to FRC posts, etching with phosphoric acid and hydrofluoric acid has been proposed. Different concentrations and etching times were used in studies to investigate the effect of surface treatment of posts by conditioning with these


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64 Restorative Dentistry Surface Treatments

2 acids, since clear information regarding the most appropriate etching conditions is still lacking.12 When H3PO4 was used at 35% for 3 min, it showed better bond strength to epoxy based fiber posts without modifications in the post surface in SEM examination.12 Albashaireh et al. stated that treating post surface with 36% phosphoric acid for 15 sec before cementation produced no significant improvement in post retention. His results were in agreement with other findings26, 28 ; this may be due to the removal of small amount of the uppermost layer of epoxy resin, thereby leading to weak micro-mechanical retention. Whereas conditioning the post surface with hydrofluoric acid seems to be very aggressive and attacks both fibers and epoxy resin.12 These SEM observations were confirmed by Vano and others: despite the improvement in post-to-composite bond strength, a remarkable surface alteration, ranging from micro cracks to longitudinal fractures of fiber layer, was detected. As a consequence, it is not possible to suggest general guidelines for using hydrofluoric acid in the surface etching of aesthetic fiber posts.

Treatment with Hydrogen Peroxide (H2O2)

Sandblasting and hydrofluoric acid can sometimes damage the glass fibers and affect the integrity of the posts. Therefore substances that selectively dissolve the epoxy matrix without interfering with the fibers have been studied: Potassium permanganate, methylene chloride, and hydrogen peroxide (H2O2) may effectively remove the epoxy resin and expose the fibers which are then available to be silanated. Hydrogen peroxide is frequently used in immunological electron microscopy to partially dissolve the resin surface of epoxy resin-embedded tissue section, and expose tissue epitopes for immunolabeling enhancement.28 The etching effect of hydrogen peroxide depends on its capacity to partially dissolve the resin matrix, breaking epoxy resin bonds through a mechanism of substrate oxidation. A similar hydrogen peroxide etching procedure is employed to improve the micromechanical retention between the epoxy resin matrix of fiber posts and methacrylate-based resin composites.30 H2O2 at concentrations of 10% and 24% for 10-20 min effectively removes the surface layer of the epoxy resin, but since these applications periods were clinically impractical, further studies were made to investigate more applicable protocols. Menezes et al. reported that both 24% and 50% hydrogen peroxide exposures increased the bond strength of resin to the post irrespective of the application time. Both concentrations were able to partially dissolve the epoxy resin and expose the glass fibers after a 1 minute exposure. Despite the slight etching obtained by 24% H2O2 after 1 minute exposure, it was sufficient to produce bond strength similar to that obtained with concentrations or longer application times.16 However the results of Elsaka9 were in conflict with the previous study as higher concentrations of H2O2 30% enhanced the bond strength of the different post/ core systems. The differences in the concentrations of H2O2 used, the testing methods, and the test tested materials could be the causes of such a discrepancy in the results. It is important to note that all treatments with H2O2 exposed the fibers without damaging them. Dissolution of the epoxy resin probably relies on an electrophilic attack of the H2O2 to the cured secondary amine. Thus, the spaces created between the fibers provide conditions for the micromechanical Dental News, Volume XXI, Number II, 2014

interlocking of the resin adhesive with the post. 16, 19, 28

Etching with 24% H2O2 for 1 minute represents an easy and clinically feasible method to enhance interfacial strength between fiber posts and resin core build up.16

Alkaline Potassium Permanganate It is a chemical treatment usually applied in an industrial process for conditioning epoxy resin surfaces for metal plating of printed circuit boards. This etching procedure consists in 3 complicated steps (swelling, etching and neutralizing). Commonly defined as desmearing, it is a process to remove the smeared epoxy resin byproducts, providing superior topography for increased adhesion.28 Monticelli et al.21 found that the application of 10% potassium permanganate for 10 minutes had a significant influence on microtensile interfacial bond strength values and that these results were superior to those found with 10% H2O2 for 20 minutes. But given the complicated technique of application, use of H2O2 or CH2CL2 was thought to be less aggressive and time consuming.30 Etching with potassium permanganate will remove the superficial layer of epoxy resin, exposing more fibers to react with silane. An improved interfacial strength will than occur because of increased chemical union between silanized glass fibers and methacrylate based core material or luting cements.28 Besides exposing the quartz fibers, it may also activate the latter by improving their hydrophilicity.21

Treatment with Methylene Chloride Methylene chloride (CH2CL2) had been proposed for use to improve the adhesion between acrylic resin denture base materials and acrylic resin repair materials by changing the chemical features and surface morphology of denture base resins increasing their repair strength.9 When first studied, CH2CL2 was applied to epoxy resin based fiber post for 5 seconds in order to improve the adhesion between fiber post and composite resin; however the results showed that this treatment was not effective. Recently, surface treatment of methacrylate resin–based glass fiber posts with CH2CL2 for 5 or 10 min enhanced the adhesion between fiber posts


65

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66 Restorative Dentistry Surface Treatments

and resin core materials. It appears to be a simple, effective and inexpensive method that might improve the clinical performance of fiber posts.9

3- Micromechanical and Chemical Bonding to fiber posts Sandblasting and Silane When sandblasting a fiber post, more fibers are exposed and thus able of chemical bonding with the alcoxy groups of the silane molecules, thus the advantage of using silane after sandblasting. However data is controversial on this issue, Choi et al.6 and others4, 13, 15 who compared sandblasting with sandblasting and silane found no improvement in bond strength with silane added. These results are most likely because of partial removal of the resin matrix as a result of air particle abrasion, the bond strength achieved between resin based cements and glass fibers is most likely mechanical

Tribochemical treatment This treatment uses the silicate-coated alumina particles by which the surface area roughness is not only increased but also a silicate layer is welded onto the post surface making it chemically more reactive to the resin via coupling agent. The most used is a chairside system called Co-Jet (Co-Jet, 3M ESPE, St Paul, MN, USA). This active sandblasting improved bond strength of FRC posts especially with methacrylate resin,32 whereas less effectively improved bond strength is observed with epoxy resin based posts. This may be explained by an inferior compatibility between cements and this kind of posts.32 However, a prolonged sandblasting time can reduce the post diameter and cause misfit resulting in lower retentive bond strength. The sensitivity of both matrix and fibers to these treatments impose the risk of damage of post structure. More recent studies confirmed that Cojet (3M ESPE) sandblasting under well controlled conditions may improve bond strength without visible changes and damages to the post surface.32 When comparing the retention of endodontic dowels following treatment with airborne particle abrasion and Cojet, Kelsy et al.13 it was concluded that no difference was found in the retention of the fiber post to the resin cement.

Acidic treatments and Silane Most of the studies reviewed tested the treatments with different etching procedures with silane and they reported that surface pretreatment increased the responsiveness to silanization, achieving better results for the tested chemicals.17, 18 Pretreatments with hydrofluoric acid, phosphoric acid and hydrogen peroxide and silane were compared to silane application17, 28 and were found to improve bond strength, but there is no clear data comparing these pretreatments with and without silane in order to preconize it as additional step before application of resin cements. Further studies are needed to clarify this subject.

Plasma Treatment Plasma is a partially or wholly ionized gas with a roughly equal number of positively and negatively charged particles. Plasma consists of energetic species that bombard the surfaces they contact transferring their energy. The transferred energy has various effects resulting in acid-base interactions and Dental News, Volume XXI, Number II, 2014

covalent linking,29 an improvement in bond strength is then achieved. Ar, N2 and H2+N2 plasma treatments seem to improve the shear bond strength of both types of fiber posts. Hence, further studies are needed on the parameters of plasma treatment, hydrothermal stability of the interface, and the aging effects of plasma-treated posts.29

UV Irradiation It has been used to improve adhesion property of coatings as well as wettability and printability of polymers, due to its capability to change the morphology and chemical properties of the polymer surface. UV radiations are generated in ultraviolet sterilizing ovens. When used from a distance of 1 cm for 3 min, they seem to activate the epoxy resin matrix of the surface of fiber post inducing chemical binding with resin cement without destroying surface structure of fiber posts. UV irradiation demonstrated stronger effect than silane and is much less destructive to the surface of the post than the other chemical and mechanical treatments.31 This technique is a less expensive, more applicable way to improve interfacial adhesion without affecting the integrity of FRC posts. Further studies have to focus on the optimal intensity for clinical application, and the aging effect on bond strength.

Conclusion Surface post treatments represent an important factor for improving bonding of resin cements on core material of FRC posts especially when dealing with epoxy resin-based fiber posts. Chairside post pretreatments are still considered a technique-sensitive step. However treatments with methylene chloride, hydrogen peroxide seem promising because of their simple, not expensive application resulting in the improvement of bond strength to fiber posts without damaging the post structure. Further studies are still necessary: - to clarify the potential effect of dissolving the epoxy matrix on the mechanical properties of the post in term of affecting the fatigue resistance and the flexural strength, - to evaluate whether the positive performance of the treated posts is similar in vivo as it is in


vitro - to evaluate the durability of fiber post/core bond strength subjected to the proposed chemical treatments to give reliable recommendations for dental practitioners. The possibility of an industrial conditioning of fiber posts may be a good alternative in order to simplify clinical procedures.

References 1- Abdel Mohsen C. Evaluation of push-out bond strength of surface treatments of two esthetic posts. Indian Journal of Dental Research 2012;23(5):596-602. 2- Aksornmuang J, Foxton RM, Nakajima M, Tagami J. Microtensil bond strength of a dual cure resin core material to glass and quartz fiber posts. J Dent 2004; 32:443-50. 3- Albeshaireh Z S, GhazalM, Kern M. Effects of endodontic post surface treatment, dentin conditioning, and artificial aging on the retention of glass fiber-reinforced composite resin posts. J Prosthet Dent 2010;103:3139. 4- Bolbosh A, Kern M. Effect of surface treatment on retention of glass-fiber endodontic posts. J Posthet Dent 2006;95(3):218-23 5- Braga N, Evangelista A, Messias D, Rached Junior F, Oliviera C, Silva R, Silva Sousa Y. Flexural Properties, Morphology and Bond Strenght of Fiber-Reinforced Posts: Inluence of Post Pretreatment. Bra Dent J (2012) 23 (6): 679-685. 6- Choi Y, Pae A, Park EJ, Wright RF. The effect or surface treatment of fiber-reinforced posts on adhesion of a resin-based luting agent. J prosthet Dent 2010;103:362-368. 7- D’Arcangalo C, D’Amario M, Vadini M, De Angelis F, Caputi S. Influence of surface treatments on the flexural properties of fiber posts. J Endod. 2007 Jul; 33(7): 864-7. 8- De la Fuente JL &Madruga EL. Solvent effects on free radical copolymerization of butyl acrylate with methyl methacrylate. Macromolecular chemistry and physics 2007 1639-43. 9- Elsaka SE. Influence of chemical surface treatments on adhesion of fiber posts to composite resin core materials. Dent Mater. 2013 May; 29(5):550-8. 10- Ferrari M, Goracci C, Sadek FT, Monticelli F, Tay FR. An investigation of the interfacial strengths of methacrylate resin based glass fiber post-core buildups. J Adhes Dent. 2006 Aug;8(4):239-45 11- Foxton RM, Pereira PN, Masatoshi N, Tagami J, Miura H. Long-term durability of the dual cure resin cement/silicone oxide ceramic bond. J Adhes Dent. 2002 Summer;4(2):125-35 12- Guler A, Kurt M, Duran I, Uludamar A, Inan O. Effects of different acids etching times on the bond strength of glass fiber-reinforced composite root canal posts to composite core material. 2012;43(1):1-8. 13- Kelsey WP 3rd, Latta MA, Kelsey MR. A comparison of the retention of three endodontic dowel systems following different surface treatments. J Prosthodont. 2008 Jun; 17(4): 269-73 14- Kern M, Thompson VP. Sandblasting and silica coating of a glass-infiltrated alumina ceramic: volume loss, morphology, and changes in the surface composition. J Prosthet Dent 1994;71:453-61. 15- Liu C, Liu H, Qian YT, Zhu S, Zhao SQ. The influence of four dual cure resin cements and surface treatment selection to bond strength of fiber post.Int J Oral Sci. 2013 Nov1; 83 16- Menezes M, Queiroz E, Soares P, Faria-e-Silva A, Soares C, Martins L. Fiber post etching with Hydrogen Peroxide: effect of concentration and application time. JOE 2011;37(3):398-402. 17- Mosharraf R, Ranjbarian P. Effects of post surface conditioning before silanization on bond strength between fiber post and resin cement. J Adv Prothodont 2013;5:126-32. 18- Monticelli F, Osorio R, Sadek FT, Radovic I, Toledano M, Ferrari M. Surface treatments for Improving Bond Strength to Prepafabricated Fiber Posts: A Literature Review. Operative Dentistry. 2008,33-3, 346-355. 19- Monticelli F, Ferrari M, Toledano. Cement system and surface treatment selection for fiber post luting. Med Oral Patol Oral Bucal. 2008 Mar 1;13(3):E214-21. 20- Monticelli F, Osorio R, Toledana M, Goracci C, Tay FR,Ferrari M. Improving the quality of the quartz fiber postcore bond using sodium etching and combined silane/adhesive coupling. J Endod 2006;32(5):447-51. 21- Monticelli F, Toledana M, Tay FR, Cury AH, Goracci C, Ferrari M. Post-surface Conditioning improves interfacial adhesion in post/core restorations. Dental Materials (2006) 22, 602-609. 22- Perdigao J, Gomes G, Lee I K. The effect of silane on the bond strengths of fiber posts. Dental Materials 22 (2006) 752–758. 23- Prithviraj DR, Soni R, Ramaswamy S, Shruthi DP. Evaluation of the effect of different surface treatments on the retention of posts: a laboratory study. Indian J Dent Res. 2010;21(2):201-6. 24- Rathke A, Haj-Omer D, Muche R, Haller B. Effectivness of bonding fiber posts to root canals and composite core build-ups. Eur J Oral Sci. 2009 Oct; 117(5):604-10. 25- Sahafi A, Peutzfeldt A, Asmussen E, Gotfreden K. Bond Strenght of resin cement to dentin and to surface treated posts of titanium alloy, glass fiber, and Zirconia. J Adhesv Dent 2003;5(2): 153-62. 26- Shori D, Panday S, Kubde R, Rathod Y, Atara R, Rathi S. To evaluate and compare the effect of different post surface treatments on the Tensile Bond Strengh between Fiber Posts and Composite Resin. Journal of international Oral Health. Sept-Oct 2013; 5(5):27-32. 27- Soares CJ, Santana FR, Pereira JC, Araujo TS, Menezes MS. Influence of airborne-particle abrasion on mechanical properties and bond strength of carbon/epoxy and glass/bis-GMA fiber -reinforced resin posts. JProsthet Dent. 2008 Jun;99(6):444-54. 28- Sumitha M, Kothandaraman R, Sekar M. Evaluation of post-surface conditioning to improve interfacial adhesion in post-core restoration. J conserve Dent 2011;14(1):28-31. 29- Yavirach P, Chaijareenont P, Boonyawan D, Pattamapun K, Tunma S, Takahashi H, Arkornnukit M. Effects of plasma treatment on the shear bond strength between fiber-reinforced composite posts and resin composite for core build-up. Dent Mater J . 2009 Nov;28(6):686-92. 30- Yenisey M, Kulunk S. Effects of chemical surface treatments of quartz and glass fiber posts on the retention of a composite resin. J Prothet Dent 2008;99(1):38-45. 31- Zhong B, Zhang Y, Zhou J, Chen L, Lee D, Tan J. UV irradiation Improves the bond strength of resin cement to fiber posts. Dental Materials Journal, 2011; 30 (4): 455-460. 32- Zicari F, De Munck J, Scotti R. Naert I. Van Meerbeek B. Factors affecting the cement-post interface. Dental Materials 28 (2012) 287-297.

Dental News, Volume XXI, Number II, 2014


DENTAL INNOVATION FORUM

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March 16 - 17, 2014 Hilton, Jeddah, Saudi Arabia

More Pictures Available On www.facebook.com/dentalnews1

Members of the Organizing Committee of the Dental Innovation Forum Dear Guests, On behalf of the organizing committee, we are honored and delighted to welcome you to our Dental Innovation Forum in Jeddah, Saudi Arabia on March 16-17, 2014. Our program is rich with eight international speakers, two poster sessions each day, and six workshops. The Umm Al-Qura University Faculty of Dentistry (UQUDENT) is considered one of the youngest dental schools in Saudi Arabia. It was established in 2007. Despite being the 15th among 25 Saudi dental schools in the chronological order, the achievements over the past five years have been exceptional. The faculty has close to 150 faculty members in four departments. To maintain a high standard of education, and a good faculty to student ratio; UQUDENT has maintained a maximum intake of 50 undergraduate students per year. Collaborations with multiple North American and European dental schools, such as Tufts University and King’s College London, have helped UQUDENT to implement a stateof-the-art undergraduate curriculum, students’ engagement activities, postgraduate residency programs, and an ambitious research strategic plan. We consider research an integral part of the academic environment of UQUDENT to nurture critical thinking among our undergraduate students, guide our clinical practice through implementing evidence-based healthcare and promote knowledge-based economy and technology transfer among our postgraduate students and faculty members. Although this forum focuses on technology transfer, this did not distract us from paying extra efforts to enforce evidence-based dentistry in UQUDENT’s curriculum and spread the awareness of this aspect of translational research through the establishment of the UQUDENT EvidenceBased Dentistry Center. Dental News, Volume XXI, Number II, 2014

Implementing the vision of the Custodian of the Two Holy Mosques, King Abdullah Bin Abdulaziz Al-Saud, to lay the foundation of knowledge-based economy; we have planned this forum to be an event that gathers international experts to share their experience in technology transfer in the area of biotechnology and oral health. This event comes in harmony with the strategic plans of Umm Al-Qura University to embark on technology transfer and science park establishment through its company, Makkah Techno Valley Company, a private company owned completely by the University. Recognition should go to the Organizing Committee members who have all worked extremely hard for the details of important aspects of the Forum programs and social activities. Dr. Mohammad Beyari Dean Faculty of Dentistry, Umm AlQura University. Chair, Dental Innovation Forum


The President of Umm Al-Qura University Dr. Bakry Assas cutting the ribbon of the exhibition floor

Dean Beyari offering the trophies to the President of the University


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MM control: Endo motor with torque and speed control + integrated apex locator The introduction on the market of Nickel-Titanium methods in the 1990s created a real revolution in endodontics. These new methods proved to be simpler and more efficient than the traditional manual methods. However, the risk of breakage remains a permanent concern for every general practitioner. That is why using an endo motor with torque and speed control is essential in order to achieve an optimal security in daily practice of endodontics employing rotary systems. MICRO-MEGA® is pleased to introduce you MM.control, its endo motor with torque and speed control and integrated apex locator. The MM.control motor is used to control the speed and torque of all NiTi instruments in the market. It also enables apical measurement, whether used with stainless steel hand files (glide path) or with NiTi instruments. MM.control is the indispensable tool in endodonctics which offers reliability, simplicity and safety. website: www.micro-mega.com

Mectron Implant Cleaning Inserts Mectron’s newest innovation, an insert for implant cleaning, is easy to use, soft on the implant and friendly on the budget!
 It’s available for all mectron scalers (tipholder ICS) and for Mectron Piezosurgery® (tipholder ICP). The tipholder ICS/ICP and the IC1 tip, allow optimal access and gentle plaque removal! The long and ergonomic form of the tipholder ICS/ICP facilitates access even in the posterior region and simplifies user handling during the maintenance treatment of implants in order to prevent periimplantitis. The IC1 tip consists of biocompatible plastic material (PEEK), known to be gentle and soft on titanium implant surfaces. Its long and thin diameter allows good access into the pockets while removing effectively plaque around the implant neck. Not having a metal core, it prevents damages on the implant surface once the plastic got consumed. website: www.mectron.com Dental News, Volume XXI, Number II, 2014


BIDM BEIRUT INTERNATI0NAL DENTAL FORUM

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Medesy is glad to introduce you its New Rubber Dam Instruments New CLAMPS , superior quality in all details and a longer endurance to stress - Superior Quality Stainless Steel ensuring Long Life High Elasticity - Universal anchoring holes, compatible with any type of clamp forceps - Beveled edges for more comfort. - Standard finish or Satin with Anti-Reflection treatment to increase visibility and better suited for dental photography. - The rubber dam clamp anchors the dental dam to the tooth. DENTAL DAMS are Powder free - Improves the visibility of the tooth under treatment. - Protects the patient’s airway from any materials which may fall into it during treatment. website: www.medesy.it

EQUIA – the straightforward and intelligent solution for posterior restorations from GC EQUIA is a two-step concept. The cavity is first filled with EQUIA Fil, a glass ionomer technology based filling material. Protective EQUIA Coat adds a layer of highly-filled, lightcuring resin. The synergetic effect of the two components enhances all the physical and aesthetic properties of the definitive filling (GC Research and Development Data, 2007). Over the past years EQUIA has been tried and tested in numerous studies and has proven its capabilities: It can be used as a long-term filling material for all class I cavities as well as for less extensive class II cavities, assuming the isthmus occupies less than half the intercuspal space. EQUIA is fast and easy to use. This allows the dentist to place an entire posterior restoration in a few minutes – from mixing right up to curing. website: www.gc-dental.com

Implacare II: Hu-Friedy re-engineers successful implant scalers Hu-Friedy presents a re-engineered version of the successful implant scaler line: The scaler of the new line Implacare II are characterized by 20 percent thinner working ends for allowing the even more precise removal of tartar and plaque. Additionally, the treating dentist can choose from among five different working ends and therefore adapt his working method even better to the individual needs of patients. Hu-Friedy introduced the scalers of the Implacare line, especially conceived for cleaning implants, for the first time in the market in 2006. Their working ends are made from PlasteelTM, a fiber-free and cured plastic resin that systematically prevents damages to the implant surfaces caused by conventional scalers. Optimized implant care thanks to thinner working ends. Customized treatment through larger variation width. New scientific and dental practice advances taken into account. website: www.hu-friedy.com Dental News, Volume XXI, Number II, 2014


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SDR is the bulk-fill material of choice in 20 million global restorations SDR (Smart Dentin Replacement) (DENTSPLY Ltd) has been used with great success in restorative dentistry with over 20 million restorations being placed across the globe since 2010. SDR was chosen for these restorations because it offers a number of unique characteristics including self-levelling for excellent cavity wall adaptation and reliable marginal fit, even in unfavourable cavity geometries. SDR also exhibits the lowest polymerisation shrinkage stress (up to 60% less shrinkage stress) of all bulk-fill materials available on the market which allows it to be bulk-filled in increments of 4mm helping to save precious chair time. SDR is the ideal material for safely and rapidly restoring class II cavities, as well as being the ideal material for post-endodontic cavities with a high C-factor. website: www.dentsplymea.com

FKG Dentaire high performance Race instruments supplied in sterile blister packs In line with its strategy, FKG Dentaire launches its NiTi-Race rotary instruments on the market packaged singly and ready-for-use in sterile blister packs. Leading in innovation and safety, FKG Dentaire provides every endodontic treatment with the benefits of the latest techniques, top efficacy and optimum safety in use for dentists and patients. The immense advantage of sterile instruments for the dentist is that apart from optimum hygiene (for example, the risk of cross-contamination is eliminated) a great deal of time is saved as they are supplied ready-for-use (consequently there is no need for handling, disinfection or sterilisation). It is essential that these nickel-titanium instruments are sterile as they are used by dentists for treating root canals. website: www.fkg.ch

Impressive technological innovations Ivoclar Vivadent introduces the new generation of press furnaces: the combination furnaces Programat EP 5010 and EP 3010. Both furnace models are optimally coordinated with the company’s pressed ceramic materials. The new QTK2 muffle technology with the SiC bottom reflector ensures excellent homogeneous heat distribution in the investment ring, producing high-quality results. A further innovation of the Programat EP 5010 represents the integrated infrared camera, which monitors the temperature and automatically recognizes the size of the preheated investment ring. The IPS e.max materials from Ivoclar Vivadent can be optimally fired and pressed with the new Programat EP 5010 and EP 3010. The material-specific press programs are specially coordinated with this new furnace generation and are supplied pre-installed with the material parameters for Ivoclar Vivadent materials. website: www.ivoclarvivadent.com Dental News, Volume XXI, Number II, 2014


SHIFTING THE WAY YOU THINK ABOUT ORTHODONTICS. The Carriere® Distalizer™ Appliance

Carriere Self-Ligating Bracket

* Typical case: Patient 16 years Start of treatment, prior to placement of Carriere Distalizer Appliance 5.10.10

Class II to Class I achieved, and Carriere Distalizer Appliance treatment completed 8.30.10

Total orthodontic treatment completed 3.7.12

Turn Complex Class II into Simple Class I Cases With its non-invasive design, the Carriere Distalizer Appliance corrects Class II malocclusion at the beginning of treatment, prior to bracket placement when patient motivation is highest. Call us today at 888.851.0533 or visit us online at OrthoOrganizers.com.

Carriere Ortho 3D

A FREE App. for iPads, iPhones, and Android tablets and phones

Works great with our Cu Nitanium® Archwires!

Visit us on line at OrthoOrganizers.com or contact your exclusive O2’s partner listed below: Bahrain – Bahrain Plus Gen. Trading faisalm03@gmail.com

Egypt – Medi Tech Trading info@meditech-eg.com

India – Sawhney Trading Co. sawbros@gmail.com

Iran – Pouyan Ted Noor Co. Ltd. pouyanteb@yahoo.com

Kuwait – Advanced Technology Co akar@atc.com.kw

Lebanon – Expo Ortho cbardawl@inco.com.lb

Morocco – Ortho Zenith orthozenith@menara.ma

Pakistan – Chughtai Dental Supply wasibhanif@gmail.com

Qatar – Shine Technology Co. medical@qatar.net.qa

Saudi Arabia – Abdulrehman Algosaibi GTC Dental dental@aralgosaibico.com

United Arab Emirates – Gulf & World Traders LLC gwtdental@gwtuae.com

* Images courtesy of Dr. Clark Colville. © 2013 Ortho Organizers, Inc. All rights reserved.


Dental News, Volume XXI, Number II, 2014

Profile for Dental News

Dental News June 2014  

Covering the latest articles, dental congresses, and the innovation in dental products.

Dental News June 2014  

Covering the latest articles, dental congresses, and the innovation in dental products.

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