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ARTICLES 12.

Clinical Outcomes Following Middle Third Root Fractures Of Adjacent Incisors: A Case Report Dr. Ines Kallel, Dr. Eya Missaoui, Dr. Nour Zorgui, Pr. Nabiha Douki

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INTERNATIONAL CALENDAR

11

w w w.dentalnews.com Volume XXI, Number I, 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 SUBSCRIPTION Micheline Assaf, Nariman Nehmeh ADVERTISING Josiane Younes PHOTOGRAPHY Albert Saykali TRANSLATION Gisèle Wakim, Marielle Khoury DIRECTOR Tony Dib ISSN 1026-261X

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

DENTAL NEWS – Sami Solh Ave., G. Younis Bldg. POB: 116-5515 Beirut, Lebanon. Tel: 961-3-30 30 48 Fax: 961-1-38 46 57 Email: info@dentalnews.com Website: www.dentalnews.com www.facebook.com/dentalnews1

April 2 - 4, 2014 Alexandria, EGYPT Email: eheikal@jmoritamiddleeast.com www.aoiaegypt.com

Stars Meeting

May 6 - 9, 2014 Teheran, IRAN Email: ida54@padidavaran-intl.com

Iranian Dental Association The Jordan University Of Science And Technology In Irbid

May 7 - 8, 2014 The faculty of Dentistry at JUST, JORDAN Email: ziadd@just.edu.jo Website: www.just.edu.jo/jidc

CAD/CAM & Digital Dentistry

May 9 - 10, 2014 at the Jumeirah beach Hotel Dubai, UAE Email: info@cappmea.com Website: www.cappmea.com

Journées Odontologiques

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

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The 18th Kuwait Dental Association Dental Conference

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

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


12 Endodontics

Clinical outcomes following middle third root fractures of adjacent incisors: a case report Abstract Dr. Ines Kallel ineskallel@yahoo.fr Dr. Eya Missaoui

Dr. Nour Zorgui

Pr. Nabiha Douki

Intra-alveolar root fractures in permanent teeth are uncommon injuries among dental traumas. Generally, the principles of treating horizontal root fractures of permanent teeth are repositioning, fixation and monitoring. The present paper reports a 15-year-old boy who presented two horizontally middle third root-fractured teeth. Pulp necrosis in the coronal fragment of teeth 11 and 21 occurs 1 month after trauma and internal resorption in apical fragments at 4 month control appointment; thus root canal treatment of the coronal fragments was performed as well as endodontic surgery was conducted in order to remove these apical fragments and granulation tissues around the fractured area, followed by preparation of a retro cavity associated with a filling with MTA at the 11 and 21 teeth.

Keywords Dental trauma, endodontic, healing, intra-alveolar root fracture, internal resorption.

Introduction Intra-alveolar root fracture is a rare injury in permanent teeth (0.5–7%), most commonly involving the maxillary central incisors.10 Although the diagnosis of root fracture depends entirely upon the radiographic examination, clinically the fractured tooth is often extruded and displaced palatally. It normally affects individuals aged 11–20 years and the occurrence in males is higher than or equal to that in females.1,2 The principles of treating root fractures of permanent teeth are stabilizing the tooth with a flexible splint for 4 weeks.14 If the root fracture is near the cervical area of the tooth, stabilization is beneficial for a longer period of time (up to 4 months).3,4 The sequelae of root fractures can be complex because of the combined damage to the pulp, dentine, cementum, bone and periodontal ligaDental News, Volume XXI, Number I, 2014

ment.5 Andreasen et al. (2004) suggested that pre-injury and per-injury factors such as patient age, degree of root development, proximity to gingival sulcus, fragment mobility, dislocation and separation between fragments appeared to have a significant influence upon the pattern of healing. Some changes that may affect the tooth fragment such as pulp calcification, ankylosis, external and internal resorptions may be found in follow-up examinations (Andreasen & Andreasen 1994, Davidovich et al. 2005).1, 11,15 The present paper reports two middle third root-fractured teeth treated by repositioning and fixation; presented in follow-up examination pulp necrosis in the coronal fragments and 4 month later internal resorption in apical fragments. The coronal fragment was root filled and periapical surgery was performed to remove the apical fragments. Two years after the clinical procedures and 2 years 4 months after trauma: bone healing was satisfactory in the periapical region of tooth 21 and 11. The teeth now have normal mobility. The appearance of traumatized maxillary central incisors was similar to the noninjured lateral incisors.

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24 14 Endodontics case report

The intra-oral examination revealed that there were lacerations in the mucosa of the anterior teeth and the maxillary right central (tooth 11) and the maxillary left central incisor (tooth 21) appeared extruded with minor mobility and slightly sensitive to cold. The gingival sulcus showed signs of mild bleeding fig. 2. fig. 2: Mild bleeding from gingival sulcus

Fig 2

Radiographic examination was performed for the maxillary anterior teeth and revealed horizontal root fractures in the middle thirds of teeth 11 and 21. fig. 3. fig. 3: Radiographic: horizontal root fractures in the middle thirds of teeth 11 and 21

Fig 3

fig. 5: In 15 days: insufficient hygiene, periodontal pocket of 4 mm at the 11 and 21

In 30 days, these teeth (11 and 21) did not respond to pulp sensibility tests, root canal treatment of the coronal fragments of these teeth was performed with 1% sodium hypochlorite irrigation. Calcium hydroxide paste was inserted to full working length and left in place for 15 days, the splint was removed, but because teeth 11 and 21 were still mobile it was decided to splint these teeth again. After 6 weeks, the coronal fragments of teeth 11 and 21 was filled with gutta-percha, and the splint was removed fig. 6. Fig 6

The attempt of repositioning of the luxated tooth after local anesthesia was administered failed because of delay of consultation. The anterior teeth were splinted with 0.4 stainless steel wire and composite resin from the maxillary right canine to the maxillary left canine fig. 4. fig. 4: Splinting (with 0.4 stainless steel wire and composite resin) from tooth13 to 23

Fig 5

Fig 4

fig. 6: In 6 weeks: the coronal fragments of teeth 11 and 21 was filled with gutta-percha

After 4 months we noticed internal resorption in the apical fragments of these teeth fig. 7. Fig 7

Fig. 7: After 4 Months: internal resorption in the apical fragments of teeth11 and 21

Follow-up examinations were performed at 15– 30 days, 2, 4, 5, 6, 8, 12, 22 months and finaly 2 years 4 months. In 15 days, we noticed that hygiene is insufficient, presence of periodontal pocket of 4 mm at the 11 and 21 fig. 5. Dental News, Volume XXI, Number I, 2014

endodontic surgery was conducted in order to remove these apical fragments and granulation tissues around the fractured area , followed by preparation of a retro cavity associated with a filling with MTA at the 11 and 21 teeth fig. 8.


16 Endodontics case report

fig. 8: Removing the apical fragments and granulation tissues around the fractured area

Fig 8

Clinical follow up was performed and periapical radiographs were obtained 1, 2, 4 8, 18 months and 2 years post-surgery (fig. 9, fig. 10) Radiographs revealed that bone healing was satisfactory in the periapical region of teeth 11 and 21. fig. 9: radiographs 2 years post-surgery: satisfactory bone healing in the periapical region of teeth 11 and 21.

Fig 9

fig. 10: clinical control of root fractured teeth after 2 years 4 months: regression of periodontal pocket

Fig 10

Discussion Root fracture occurs usually because of a frontal impact that creates compression zones labialy and lingually. The resulting shearing stress zone then dictates the plane of fracture. Maxillary central incisors are the most vulnerable to injury, followed by maxillary lateral and mandibular incisors. Fractures of the middle third of the root were reported to be the most frequent, while fractures of the apical and cervical thirds occurred with equal frequency.3, 5 Root fracture healing was divided into four events by radiographic and histological observations: healing with calcified tissue, interposition Dental News, Volume XXI, Number I, 2014

of connective tissue, interposition of bone and connective tissue, interposition of granulation tissue6, 7, 13 In this case, dislocation of the coronal fragment was pronounced in teeth 11 and 21, mobility is important; the fractured tooth had mature root formation. This fact could explain occurrence of pulp necrosis and infection in the coronal fragments necessitating endodontic treatment of coronal fragments. The wide root canal opening at the fracture site and the separation of the fragments made it difficult to achieve proper mechanical cleansing and adequate filling of the root canal; this is in agreement with the finding in the literature.8, 12 Andreasen & Hjørting-Hansen (1967) reported that even though necrosis may occur in the coronal fragment, the pulp of the apical fragment usually remains vital. In our case the pre-injury factors may explain also the occurrence of internal resorption in the apical fragments of these teeth. Therefore, periapical surgery was performed in order to remove apical fragments granulomatous and contaminated tissues around the fracture site. Even though the crown root ratio was unfavorable, a decision was made to retain the coronal fragment. Our decision is in agreement with literature; Cvek et al. (2004) think that surgery is a potentially arduous procedure, especially in children and adolescents, but the prognosis was considered favorable. The presence of roots in alveolar process maintains bone volume and avoids atrophy (Andersson et al. 2003). In fact replacing lost teeth after trauma presents particular problems as many of the patients are young and growing like our patient. Procedures for the management of dental trauma should follow a logical sequence to promote healing and preserve teeth along with their supporting tissues. The prognosis for root fractures can only be confirmed by follow up, as late complications may occur but not always arise (Davidovich et al. 2005).9

Conclusion This case report supports the published literature that healing in root-fractured teeth may follow different patterns. Therefore, a multidisciplinary approach should be taken in order to monitor problems in periodontal, periapical region and pulp healing and intervention should be on the basis of emergent issues.


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18 Endodontics case report

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1. SCHMITZ MS, MONTAGNER F, MONTAGNER H, ESCOBAR CAB, DOS SANTOS RA, GOMES BPFA.DIFFERENT CLINICAL OUTCOMES FOLLOWING ROOT FRACTURES OF ADJACENT INCISORS: A CASE REPORT. INTERNATIONAL ENDODONTIC JOURNAL, 41, 532–537, 2008 2. ISIL SAROGLU, HAYRIYE SONMEZ ;HORIZONTAL ROOT FRACTURE FOLLOWED FOR 6 YEARS CASE REPORT. DENTAL TRAUMATOLOGY; 24: 117–119, 2008 3. TERATA R, MINAMI K, KUBOTA M. CONSERVATIVE TREATMENT FOR ROOT FRACTURE LOCATED VERY CLOSE TO GINGIVA. DENT TRAUMATOL; 21:111–114.2005 4. FLORES MT, ANDERSSON L, ANDREASEN JO ET AL. GUIDELINES FOR THE MANAGEMENT OF TRAUMATIC DENTAL INJURIES. I. FRACTURES AND LUXATIONS OF PERMANENT TEETH. DENTAL TRAUMATOLOGY; THE INTERNATIONAL ASSOCIATION FOR DENTAL TRAUMATOLOGY23: 66–71 _ 2007 5. THOMAS VON ARX, VIVIANNE CHAPPUIS ET STEFAN HÄNNI .TRAUMATOLOGIE DES DENTS DÉFINITIVES – 3E PARTIE: TRAITEMENT DES FRACTURES RADICULAIRES R E V M E N S S U I S S E O D O N T O S T O M A T O L , V O L 1 1 7: 2 / 2 0 0 7 6. ANDREASEN JO, HJORTING-HANSEN E. INTRAALVEOLAR ROOT FRACTURES: RADIOGRAPHIC AND HISTOLOGIC STUDY OF 50 CASES. J ORAL SURG; 25:414–26. 1967 7. JOO-HEE SHIN, RYAN JIN-YOUNG KIM. MANAGEMENT OF HORIZONTAL ROOT FRACTURES BY FABRICATION OF CANINE PROTECTED OCCLUSION USING COMPOSITE RESIN. RESTOR DENT ENDOD; 37(3):180-184. 2012 8. CVEK M, MEJARE I, ANDREASEN JO CONSERVATIVE ENDODONTIC TREATMENT OF TEETH FRACTURED IN THE MIDDLE OR APICAL PART OF THE ROOT. DENTAL TRAUMATOLOGY 20, 261–9. 2004 9. DAVIDOVICH E, HELING I, FUKS AB THE FATE OF A MID-ROOT FRACTURE: A CASE REPORT. DENTAL TRAUMATOLOGY 21, 170–3. 2005 10. KAANORHAN,UMUTAKSOY, AND ATAKANKALENDER CONE-BEAM COMPUTED TOMOGRAPHIC EVALUATION OF SPONTANEOUSLY HEALED ROOT FRACTURE: JOE VOLUME 36, NUMBER 9, SEPTEMBER 2010 11. MAN QIN, LIHONG GE, REICHUN BAI: USE OF A REMOVABLE SPLINT IN THE TREATMENT OF SUBLUXATED, LUXATED AND ROOT FRACTURED ANTERIOR PERMANENT TEETH IN CHILDREN DENTAL TRAUMATOLOGY 2002; 18: 81–85 12. SAHANA,RAMYA RAGHU: MANAGEMENT OF HORIZONTAL AND MULTIPLE CROWN- ROOT FRACTURES.WORLD JOURNAL OF DENTISTRY; 2011,2(4):338-341. 13. MELAHAT GORDUYSUS1, NIHAL AVCU2, OMER GORDUYSUS: SPONTANEOUSLY HEALED ROOT FRACTURES: TWO CASE REPORTS :DENTAL TRAUMATOLOGY 2008; 24: 115–116 14. ANDREASEN JO, ANDREASEN FM, MEJA`RE I, CVEK M. HEALING OF 400 INTRA-ALVEOLAR ROOT FRACTURES. 2. EFFECT OF TREATMENT FACTORS SUCH AS TREATMENT DELAY, REPOSITIONING, SPLINTING TYPE AND PERIOD AND ANTIBIOTICS. DENT TRAUMATOL 2004; 20: 203–211 15. ROBERT CHARLAND, NORMAND AUBRE: TRAUMATISMES DES DENTS ANTÉRIEURES PERMANENTES DIXIÈME PARTIE: FRACTURES RADICULAIRES.JOURNAL DE L’ORDRE DES DENTISTES DU QUÉBEC VOLUME 44 MAI/JUIN 2007

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In the December 2013 issue, in the article entitled «Effect of irrigation solutions on adhesion of Endorez sealer to root canal dentin» the name of Dr. Chiraz Ellouzi was missing. The list of authors is as follows : Dr. Chems Belkhir: Associate Professor of Endodontics Dr. Chiraz Ellouzi: Dentist Dr. Saida Sahtout: Professor of Endodontics Dr. Latifa Berrezouga: Professor of Microbilogy Dr. Mohammed Semir Belkhir: Professor of Endodontics and chairman Department of Endodontics. Monastir Dental Clinic. Monastir University, Tunisia. Coordonnées : Dr Belkhir Chems. Faculté de Médecine dentaire. Service d’odontologie conservatrice et endodontie. Avenue Avicenne 5019 Monastir. Tunisie. E-Mail : chemsbelkhir@gmail.com Tel : (+216)52243116. (+216)96203116.

Dental News, Volume XXI, Number I, 2014


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20 Endodontic Dentistry

An in vitro study of the effectiveness of R-Endo, ProTaper Universal Retreatment and MTwo-R in removing gutta percha ďŹ lling material Abstract Pr. Najet Aguir Mabrouk najetmab@yahoo.fr

Introduction: the purpose of this study was to evaluate the efficiency of R Endo, Protaper Universal Retreatment and MTwo R for removal of gutta percha during retreatment. Methods: Sixty extracted anterior teeth were instrumented with Protaper manual files, filled using cold lateral compaction and randomly divided into three groups of 20 specimens each. The root fillings were removed using R-Endo, Protaper Universal retreatment and MTwo R. The amount of filling debris remaining on root canal walls was assessed radiographically . Bucco-lingual and proximal digital radiographs of the roots were captured in JPEG format. The areas of the cervical, middle and apical thirds and the area of remaining filling materials in each third, were outlined and measured by the image J program. The ratios between these areas were calculated as percentages of remaining debris. Data were statistically analysed by means of one-way ANOVA and the post hoc Duncan test to identify the differences between the three techniques. Results: Multiple comparisons of the percentages of remaining filling material in each third revealed significant difference between groups. The apical third had the most remaining material (P=0,000<0,05). Comparison of the three techniques revealed that MTwo rotary instruments left cleaner root canal walls with a lower ratio of remaining material in the apical third (P=0,008<0,05). Conclusion: None of the three devices used guaranteed complete removal of the root filling materials. R-Endo and Protaper Universal Retreatment files were less effective in removing gutta percha from canal walls than MTwo R files.

Introduction Conventional root canal retreatment is one of Dental News, Volume XXI, Number I, 2014

the greatest technical difficulties faced by endodontists. It aims to eliminate persistent bacteria and substantially reduce the microbial load from the canal1. This requires regaining access to the root canal system by removal of the original filling to enable effective cleaning, shaping and re-obturation2, 3 ; Nickel Titanium rotary instruments have been used successfully in root canal cleaning and shaping.1 Recently, new rotary instruments have been designed for the removal of filling material, R-Endo Retreatment (Micro mega, Besançon, France), ProTaper Universal Retreatment (Dentsply Maillefer, Ballaigues Switzerland), MTwo R (VDW, Munich, Germany) and D Race (FKG Dentaire, Swiss Dental Products). The purpose of this in Vitro study was to evaluate comparatively the effectiveness in retreating gutta percha obturated straight root canals, using three different NiTi endodontic retreatment files: R-Endo, Protaper Universal Retreatment and MTwo without the aid of solvents.

Materials and methods Root canal preparation and obturation Sixty single rooted straight teeth of similar length and diameters extracted for periodontal reasons with fully formed apices were selected. The experimental procedure was conducted by the same operator in order to reduce interoperator variation. Standard access preparations were made. Each root canal was explored with a size 10 K type file which was passively advanced into the canal until the tip of the instrument, was seen emerging through the apical foramen of each canal. The working length was established 0.5 mm shorter than this length. Thereafter, ProTaper Manual files (Dentsply/ Maillefer) were used to clean and shape the root canal. The canals were all prepared to an F3


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22 Endodontic Dentistry Removing Gutta Percha Filling Material

ProTaper file under irrigation with 3% Sodium Hypochlorite. The 30-K-type file was the first instrument to bind at the working length with a resistance to traction. All canals were then obturated using cold lateral condensation of ProTaper master gutta percha cone and accessory gutta percha cones (size 20) coated with an eugenol base. The root canal filling was vertically condensed with a cold plugger then the access cavities were filled with cavit (Espe Dental, Germany). All teeth were radiographed in bucco lingual and mesio distal directions to confirm the adequacy of the root canal obturation and were stored at 100% humidity and 37째 for a period of 7 days to alloy the sealer to set completely.

Retreatment techniques A single operator carried out all retreatment procedures. The teeth were randomly assigned to three groups. All instrumentation of the R Endo, ProTaper Universal Retreatment files and MTwo R groups was performed using a 128:1 reduction gear handpiece (Anthogyr NiTi Control, NSK). The instruments were activated by an electric engine (TCmotor3000; Nouvag, Goldach, Switzerland) at 300 rpm. No solvent was used in these groups so that the sealers did not have their removal affected by solvent use. For all techniques, the canals were irrigated with 3% NaOCl between files. The files were frequently removed to inspect the blade and clean the debris from the flutes. Removal of filling materials was judged complete when the working length was reached and no more gutta percha could be seen on the last instrument when inserted and removed. One set of instrument was used for the retreatment of five specimens.

ProTaper Universal Retreatment group The system is formed by D1, D2 and D3 files which have a convex cross section with a respectively taper/tip diameter of 0.09/0.30, 0.08/0.25 and 0.07/0.20 . They were used with a brushing action in a crown down manner, file penetration was carried out by using light apical pressure: the D1 file was used to remove the coronal filling material, the D2 file for the middle and the D3 file for the removal of the apical filling material until D3 reached the working length.1, 9, 12, 20, 23 Dental News, Volume XXI, Number I, 2014

The R Endo retreatment (Micro-Mega) group A size 25, 0.04 taper Rm hand file was used with 1/4 turn pressure directed towards the apex to create a pathway thus allowing the centering and the alignment of the next instrument. A size 25, 0.12 taper Re NiTi rotary file was used 1 to 3 mm beyond the pulp chamber floor with circumferential filling. A size 25, 0.08 taper R1 NiTi rotary file was used to penetrate from the coronal third to the beginning of the middle third through repeated apically directed pushing actions. A size 25, 0.06 taper R2 NiTi rotary file was used from the middle third to the beginning of the apical third. A size 25, 0.04 taper R3 NiTi rotary file was used at the working length with circumferential filling action. Finally, the retreatment procedure was concluded with the use of a size 30, 0.04 taper Rs NiTi rotary file at the working length.12

The MTwo Retreatment group MTwo retreatment files consist of two instruments with active cutting tip: R1 (size 2, 0.05 taper) and R2 (Size 15, 0.05 taper). They have an S shaped cross section and a shorter pitch length to enhance the advancement of the file into the filling material. They are characterized by two cutting edges which are claimed to cut dentine effectively. The canals were instrumented in a simultaneous technique into the working length using MTwo R size 25, 0.05 taper in a brushing action with a lateral pression movement. Progression was performed by applying slight apical pressure. 4, 7, 9, 20

Evaluation criteria After filling removal, digital radiographs of each specimen were performed in mesiodistal and buccolingual directions. Films were automatically processed and transferred to a PC. Each root was divided, from the cemento enamel junction to the end of the apical preparation, in apical, middle and cervical thirds, which were evaluated separately. Root canal walls and remaining filling material were identified by a trained operator through the difference of radio opacity, and were outlined using an image analyzer software (Image J). Their areas were automatically measured in square millimeters. Two operators


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24 48 Endodontic Dentistry Removing Gutta Percha Filling Material

Fig1: Evaluation of the coronal third area by an image analyzer software (Image J)

evaluated the outline of areas, and the measurement was repeated until consensus was reached. The ratio between canal and material areas was calculated with the following equation and computed as a percentage of the remaining filling material in each third of the canal.23 ( Fig 1.)

Group

n

Mean (Standard deviation)

ProTaper Universal Retreatment

20

16,6 (13,44)

R-Endo

20

9,3 (11,10)

M Two R

20

4,1(6,38)

Area of remaining filling material in the third × 100 Area of canal third Fig 1

Fig 3: comparison between the 3 experimental groups for the Remaining Filling Materials

Results

Statistical Analysis For statistical analysis, measurements of means and standards deviations of areas of each third and the remaining filling material in each third and in each group were obtained. Data were analyzed by means of one-way analysis of variance ANOVA which was adopted to analyze the differences in the percentages of gutta percha and sealer covered areas amongst the three techniques. No attempt was made to distinguish between the gutta percha and sealer. The post hoc Turkey-kramer was used to identify differences between the groups at the apical, middle and coronal levels. The significance level was set at P< 0.05. Results were processed and analyzed with the SPSS 17 software. Fig 2 Fig 2: Mean areas of remaining filling material

Dental News, Volume XXI, Number I, 2014

All treatment techniques used in this study left some filling material inside the root canal. Multiple comparison by means of ANOVA test transformations detected statistically significant differences between ProTaper Universal Retreatment and MTwo R. (P=0,002<0,05). The differences between ProTaper Universal Retreatment and R-Endo. (P=0,142>0,05). R-Endo and MTwo R (P=0,248>0,05) were not statistically significant. The mean ratio of remaining filling material in the whole canal was less with the MTwo R (4,1 ±6,38) than with R-Endo ( 9.3 ± 11,10 ) and with ProTaper Universal Retreatment (16.6 ± 13,44 ). (Fig 2,3) An effect of the canal third under analysis was observed. In the MTwo R technique there was a statistically significant difference between the three thirds (P=0,018<0,05). The remaining filling material was significantly less in the coronal third (0,005%) than in the middle (2,885 %) and the apical third (9,35%). In the R- Endo technique, the coronal third showed significantly less remaining filling material than in the apical third (P=0,000<0,05). Furthermore, in the ProTaper Universal Retreatment technique, the analysis showed that the remaining filling material was significantly less in the coronal than in the middle and the apical third (P=0,000<0,05). Regarding the differences in the mean ratio values between the three techniques in each third there was a significant difference among techniques in the apical third (P=0,008<0,05) and in the middle third (P=0,011<0,05). However, in the coronal third, there was no significant difference (P=0,074>0,05) among the three groups.


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26 Endodontic Dentistry Removing Gutta Percha Filling Material

Discussion Conventionally, removing of gutta percha using hand files with or without chloroform can be a tedious and time consuming process, especially when the root canal filling material is well condensed.14 Several studies have been conducted to develop and investigate rotary retreatment instrument.1, 3, 11, 12, 20, 21, 22, 25 In this study, no solvent was used to minimize the number of variables involved in the study and because a previous study1 showed that solvent didnâ&#x20AC;&#x2122;t improve canal walls cleanliness. In the present study, remaining gutta percha was assessed radiographically1, 3, 4, 5, 6, 10, 12, 26 because radiography is the most clinical method to evaluate the remaining filling material during endodontic retreatment (1,3) Precise delineation of the remaining filling material on digitized images was done with Image J software. Although the image magnification on the computer provides better quality of images, this method provides 2-D informations of remaining filling material and is not the most precise method but it minimizes subjectivity with respect to the use of a scoring system based on scales.5,7,8 More recently, Barletta et al. used micro-CT for 3-D evaluation of remaining filling materials.15, 16 Several studies have found that NiTi instruments are not more effective than hand instruments in removing filling materials from canal walls9,13, 25 It appears to be almost impossible to completely remove gutta-percha and sealer from the canal walls with rotary instruments alone.1, 2, 10, 23 Our finding regarding the cleanliness of retreated canals agree with the literature;20, 24, 25 under the conditions tested in the present study and regarding the total amount of remaining gutta percha in the entire root canal or in each third, group MTwo R exhibited the best results with significant difference when compared with ProTaper universal retreatment and R Endo. However Bramante et al. found that MTwo R was less efficient in filling removal than ProTaper universal retreatment.21 It was observed that canals in all groups tended to accumulate more debris apically regardless of the protocol or the material used. This is in agreement with other studies.17, 19 The apical root third is especially a critical zone for cleaning, shaping, and filling procedures. It requires a considerable enlargement when Dental News, Volume XXI, Number I, 2014

cleaning and shaping the canals. This procedure can lead to apical deviations that might be responsible for maintenance of filling material in the canal during retreatment.25 This might be attributed to the fact that all canals were enlarged to a size F3 ProTaper file, which has a tip size of 30 and 9% taper, whereas the D3 ProTaper Retreatment file has a tip size of 20 and 7% taper, which meant that the D3 tip did not engage with the apical canal walls.23 The last instruments D3 ProTaper Retreatment file (size 20), R2 MTwo file (size 25) and R3 of R Endo system (size 25) are designed to reach the working length but does not permit a complete cleaning action.20 Although ProTaper Retreatment files left more debris than MTwo R files, the non-active tips of D2 and D3 reduce the incidence of ledging, perforation, and stripping during the removal of filling material. MTwo R has active tips for all retreatment instruments (MTwo R25/.05 and MTwo R 15/.05).22 The combined use of rotary and hand instruments appears to be a good option to improve apical cleanliness. The use of retreatment NiTi rotary files to remove filling material quickly should be followed by hand instrumentation to refine and complete its removal and to obtain better canal wall cleanliness especially in the apical third.9, 21, 3, 24, 25 It should also be considered that hand files can be precurved and directed to the regions in which the tactile sensation indicates the presence of filling material.24

Conclusion Based on the present methodology and obtained results, the following conclusions may be drawn: 1. None of the techniques investigated provided complete removal of filling material from root canals. 2. The instruments investigated may be arranged in the following increasing order of efficacy in removing filling debris: Protaper Universal Retreatment, R-Endo and MTwo R. 3. Comparing the thirds ,the cervical third exhibited the smallest amount of remaining filling material, followed by the middle and the apical thirds.


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Endodontic Dentistry Removing Gutta Percha Filling Material

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END2008,41, 288-295,. 2. SCHIRRMEISTER JF., WRBAS KT , SCHNEIDE FH. R, ALTENBURGER MJ AND HELWIG E. EFFECTIVENESS OF A HAND FILE AND THREE NICKEL-TITANIUM ROTARY INSTRUMENTS FOR REMOVING GUTTA PERCHA IN CURVED ROOT CANALS DURING RETREATMENT .OOOOE 2006, 101,4,542547 3. FARINIUK L F, DIETZEL WESTPHALEN VP, DA SILVA-NETO UX, CARNEIRO E, FILHO F B, FIDE S R L, SERGIO FIDEL R A . EFFICACY OF FIVE ROTARY SYSTEMS VERSUS MANUAL INSTRUMENTATION DURING ENDODONTIC RETREATMENT. BRAZ. DENT.J 2011,22, (4). 4. GERGI R, SABBEGH C, EFFECTIVENESS OF TWO NICKEL TITANIUM ROTARY INSTRUMENTS AND A HAND FILE FOR REMOVING GUTTA PERCHA IN SEVERELY CURVED CANALS DURING RETREATMENT. AN EX VIVO STUDY. INT ENDOD J 2007,40,532-537. 5. CARVELHO M AC, ZACCARO S MF. EFFICACY OF AUTOMATED VERSUS MANUAL INSTRUMENTATION DURING ROOT CANAL RETREATMENT: AN EX -VIVO STUDY. INT ENDOD J 2006, 39, 779-784 6.CUNHA R,DE MARTIN A, DA SILVA F, JACINTO R, BUENO C. AN IN VITRO EVALUATION OF THE RETREATMENT SYSTEM FOR GUTTA PERCHA REMOVAL

FROM ROOT CANALS. INTERNATIONAL

ODONTIC JOURNAL

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The most remarkable advantages of 1 2

CLEASING WORKING TIME AND ANALYSIS OF THE AMOUNT OF GUTTA PERCHA OR RESILON REMNANTS

extraction:

IN THE ROOT CANAL WALLS AFTER INSTRUMENTATION FOR ENDODONTIC RETREATMENT.

J ENDOD 2007; 33; 1426-1428 7.TASDEMIR T, YELDIRIM T, ÇELIK D. COMPARATIVE STUDY OF REMOVAL OF CURRENT ENDODONTIC FILLINGS. J ENDOD 2008;34 ;326-329. 8. HASSANLOO A, WATSON P, FINER Y, FRIEDMAN S. RETREATMENT EFFICACY OF THE EPIPHANY SOFT RESIN OBTURATION SYSTEM. INT ENDOD 2007; 40; 633- 643. 9. SOMMA F, CAMMAROTA G, PLOTINO G, GRANDE NM., CORNELIS HP.THE EFFECTIVENESS

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JOE, 2008, 34, 4,466-469. BARLETTA FB, EFFECTIVENESS OF DIFFERENT TECHNIQUES FOR REMOVING GUTTA PERCHA DURING RETREATMENT. INTER ENDOD. J 2005,38, 2-7. 11. ABDULHAMIED Y S, AL HADLAQ SM, AND AL KATHEERI NH.. EFFICACY OF TWO ROTARY NITI INSTRUMENTS IN THE REMOVAL OF GUTTA PERCHA DURING ROOT CANAL RETREATMENT. JOE 2007, 33, 1,38-41. 12. ÜNAG.C L, KAYA BÜ, TAÇ AG AND KEÇECI AD . A COMPARISON OF THE EFFICACY OF

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CANALS: AN EX-VIVO STUDY. INTERN.ENDO.JOURNAL 2009, 42, 344-350. 13. BETTI LV , BRAMANTE CM, DE MORAES I G, BERNARDINELI N , GARCIA RB. EFFICACY OF PROFILE .04 SERIES 29 IN REMOVING FILLING MATERIALS DURING ROOT CANAL RETREATMENT-AN IN VITRO STUDY. OOOOE, 108, N° 6, 46-50. 14. SAE LIM V , RAJAMANICKAM I , LIM BK AND LEE HL. EFFECTIVENESS OF PROFILE .04 TAPER ROTARY INSTRUMENTS IN ENDODONTIC RETREATMENT. JOE 2000, 26, 2, 100-104 15.BARLETTA FB, RAHDE NDE M, MOURA AA, ZANESCO C, MOZACCATO G. IN VITRO COMPARATIVE ANALYSIS OF 2 MECHANICAL TECHNIQUES FOR REMOVING GUTTA PERCHA DURING RETREATMENT. J CAN DENT ASSOC 2007, 73-65 16. BARLETTA FB, REIS M, WAGNER M, BORGES G, DALLAGNOL C, COMPUTED TOMOGRAPHY ASSESSMENT OF THREE TECHNIQUES FOR REMOVAL OF FILLING MATERIALS. AUSTR ENDOD J DOI: 10,1111/J , 1747-4747. 2007.00088.X. 17. PIRANI CH, PELLICCIONI GA , MARCHIONNI S , MONTEBUGNOLI L , PIANA G AND PRATI C. EFFECTIVENESS OF THREE DIFFERENT RETREATMENT TECHNIQUES IN CANALS FILLED WITH COMPACTED GUTTA PERCHA OR THERMAFIL: A SCANNING ELECTRON MICROSCOPE STUDY. JOE 2009, 35,10, 1433-1440. 18. SAAD AY, AL HADLAQ SM, AL KATHEERI NH, EFFICACY OF TWO ROTARY NITI INSTRUMENTS IN THE REMOVAL OF GUTTA PERCHA DURING ROOT CANAL RETREATMENT. JOE 2007, 33, 1,39-41,. 19. HULSMANN M., BLUHM V. EFFICACY, CLEANING ABILITY AND SAFETY OF DIFFERENT ROTARY NITI INSTRUMENTS IN ROOT CANAL RETREATMENT. INT ENDOD. J 2004 ;37; 468-476. 20. MARFIZI K., MARCADE M., PLOTINO G., DURAN-SINDREU F., BUENO R. & ROIG M. EFFICACY OF THREE DIFFERENT ROTARY FILES TO REMOVE GUTTA PERCHA AND RESILION FROM ROOT CANALS, INT.END.J, 2010 43,1022-1028,. 21. BRAMANTE CM, FIDELIS NS, ASSUMPÇAO T S, BERNADINELI N, GARCIA RB, BRAMANATE A S. HEAT RELEASE, TIME REQUIRED AND CLEANING ABILITY OF MTWO AND PTOTAPER UNIVERSAL RETREATMENT SYSTEMS IN THE REMOVAL OF FILLING MATERIAL. JOE, VOL 36, 11, 2010. 22. GIULIANI V, COCCHETTI R , PAGAVINO G. EFFICACY OF PROTAPER UNIVERSAL RETREATMENT FILES IN REMOVING FILLING MATERIALS DURING ROOT CANAL RETREATMENT. JOE 2008, 34, 11, 1381-1384. 23. HAMMAD M, QUALTROUGH A AND SILIKAS N. THREE-DIMENSIONAL EVALUATION OF EFFECTIVENESS OF HAND AND ROTARY INSTRUMENTATION FOR RETREATMENT OF CANALS FILLED WITH

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DIFFERENT MATERIALS. JOE-2008, 34, 11, 1370-1373. 24. REIS SO M V, SARAN C, MAGRO ML, VIER-PELISSIER FV AND MUNHOS M. EFFICACY OF PROTAPER RETREATMENT SYSTEM IN ROOT CANALS FILLED WITH GUTTA PERCHA AND TWO ENDODONTIC SEALERS. JOE 2008, 34, 10, 1223-1225. 25. DURATE MAH, REIS SO MV, CIMADON V B, ZUCATTO C, VIER PELISSER FV, KUGA MC. EFFECTIVENESS OF ROTARY OR MANUEL TZCHNIQUES FOR REMOVING A 6-YEAR-OLD FILLING MATERIAL. BRAZ DENT J 2010,21,(2)148-152. 26. SCHIRRMEISTER JF., WRBAS KT, MEYER KM., ALTENBURGER MJ. AND HELWIG E. EFFICACY OF DIFFERENT ROTARY INSTRUMENTS FOR GUTTA PERCHA REMOVAL IN ROOT CANAL RETREATMENT. JOE 2006, 32,469-472.


30 Prosthetic Dentistry

Comparison and agreement of visual and instrumental shade matching: an in-vivo evaluation

Abstract Dr. Fouda Homsy loubab3@hotmail.com Dr. Elias Smaira eliassmaira@hotmail.com Dr. Rita Eid

Dr. Wiam El Ghoul

Aim: to evaluate clinically the agreement in shade selection using a traditional Vitapan Classical and the new 3D Master shade guide Materials and methods: Thirty prosthodontists participated in the study by evaluating clinically the shade of an upper right central maxillary using a visual shade selection guides (Vitapan Classical and 3D Master shade) and compared to an instrumental shade selection system (Easy shade, Vita). The intra-examiner Kappa coefficient (k) and Pearson Chi square test was used to evaluate agreement or no-agreement (§=0.05). Results: A poor agreement was observed between the visual shade selection and the instrumental values while no significant difference was noted between visual shade selections. Conclusion: clinical training is advised for visual shade selection especially with the new 3D Master system while instrumental shade selection gave accurate values. Key words: shade selection, instrumental shade guide, tooth color.

Introduction Closely matching artificial restorations with natural teeth can be one of the most challenging procedures in restorative dentistry. A key factor is the duplication of the color of the natural tooth, which include the determination of the tooth shade clinically and communication of the selected shade to a dental laboratory technician1,2. Esthetically superior restorations are now possible as a result of improvements in dental material properties and the use of layering techDental News, Volume XXI, Number I, 2014

niques in fabrication process. Traditionally, shade selection was performed visually by using a dental shade guide. Various shade guides exist to facilitate the matching process with more accurate results3, 4. However, visual color determination has been found unreliable and imprecise5, 6. The perception of color by the bare eye is rather subjective but not objective or even measurable and is therefore felt differently by every individual7, due to differences in physiological and psychological responses to radiant energy stimulation, experience, environment and lighting conditions.7, 8, 9,10 A phenomenon called metamerism occurs when two colors appear to match under a given lighting condition but have a different spectral reflectance.11,12 Commercial shade guides donâ&#x20AC;&#x2122;t cover all range of available shades13, 14 with different batches of one shade guide.15 Electronic shade selection devices have the potential for more accurate and reliable selection of a tooth color16, 17, 18 since they are not influenced by the visual color determination parameters.19 Currently available electronic shade-matching devices are spectrophotometers colorimeters, digital color analyzers, or combinations of both. Spectrophotometers are useful in the measurement of surface color. A prism disperses white light from a tungstenfilament bulb in the spectrophotometer into a spectrum of wavelength bands between 10 and 20 nm.20 The amount of light reflected from a specimen is measured for each wavelength in the visible spectrum. Of all devices, a spectrophotometer is the most accurate for absolute color measurement. These instruments have a


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32 Prosthetic Dentistry shade matching

longer working life than colorimeters and are unaffected by object metamerism20, 21 Colorimeters are useful in quantifying color differences between specimens. These devices measure tristimulus values according to CIE illuminant and observer conditions.22 One such instrument is an “intra-oral spectrophotometer” (EasyshadeTM, Vita Zahnfabrik, Bad Säckingen, Germany) with specific modes to identify reference shades from two commercial dental shade guides: the Vita 3D-Master (Vita Zahnfabrik, Bad Säckingen, Germany) and the Vitapan Classical (Vita Zahnfabrik, Bad Säckingen, Germany). According to Dozic et al. (2007) 11 the intra-oral spectrophotometer, Easyshade, was the most reliable instrument in both in vitro and in vivo circumstances. While color instrumentation and shade matching procedures have been widely addressed in dental literature, the most popularly used shade guides have not changed much through the last 50 years. The Vita shade guide 3D-Master (3D) was developed with a systematic arrangement for a wide range of natural dentition shades 23. The 3D shade guide is arranged in five discernible value levels with multiple chroma levels, as differentiated from the traditional Vitapan Classical (VC) grouping primarily by hue. The aim of this clinical study is to evaluate the percent agreement between the human observer using a traditional Vitapan Classical and the new 3D shade guide. The null hypothesis tested was that no significant difference is observed between the uses of both shade guides.

Materials and Methods Test subject An informed consent was obtained from the patient selected to participate in this study, after the approval of the ethical committee at the school of Dentistry at the Lebanese University, Beirut, Lebanon. The inclusion criteria were: patient with one upper right central maxillary free from caries, restorations, or any dental anomalies (such fluorosis), and that didn’t undergo any orthodontic treatment. The tooth was polished using a slow hand speed hand piece (Sirona Dental System, GmbH, Bensheim, Germany) with disposable brushes and pumice (Garreco, Heber Springs, USA) prior to being measured. Measurements were done according to the Dental News, Volume XXI, Number I, 2014

manufacturer’s recommendation in the middle third of the tooth. Visual shade selection Thirty prosthodontists (men and women, with a mean age of 37.5 years) with an average practice experience of 10 years participated to this study. All examiners were tested for color deficiencies (Farnsworth test, panel D15 desaturated). Two shade guide systems were chosen: the Vitapan Classical (VC) and the Vita 3D-Master (3D) (Vita Zahnfabrik, Bad Säckingen, Germany). The VC was ordered into the four common shade groups- A, B, C and D as the testers were familiar with it. None of the investigators had any experience with the 3DM and thus 1 day training was conducted 3 days before the investigation started. The patient examination was performed in a lightened area by daylight fluorescent tubes of 36W/5,000K each (Just Normlicht, 73235 Weilheim/Teck, Germany). The illumination of the tested area was done at 45° angle using two reflectors cases (Kaiser, RB 5004, Buchen, Germany). The walls of the operatory in which shade selection was performed were neutral gray and the personal clothing of the patient was covered with a grey coat. The patient was requested to remove her make-up and to brush her teeth to eliminate any soft deposit. Clinicians were requested to select the shade that was most congruent in color with natural tooth to be matched, starting with the VC then with the 3DM with 15 minutes of time interval between both shade guides. A time limit of 10 seconds was imposed for each assessment. Instrumental shade selection Shade measurement was obtained using VITA Easy Shade (VES) (VITA, Zahnfabrik Bad Sachingen, Germany) (Figure 1). The VES consists of a base unit and a hand piece connected by PVC stainless steel monocoil-fiberoptic cable. The hand piece contains a fiberoptic probe assembly for illuminating and receiving light from a tooth, multiple spectrometers and microprocessors for communication with the base unit. Cross contamination was controlled using provided polyurethane infection control shield. Calibration of the machine was performed according to the manufacturer’s recommendation after applying the shield, and the machine was adjusted on a single tooth area mode. When mea-


34 Prosthetic Dentistry shade matching

Fig 1

Table 1

Table 1 agreement measurement using the intra-examiner Kappa coefficient (k) between the visual shade selection and the instrumental values.

Figure 1: Instrumental shade guide device (easy shade, Vita) and the visual shade guides (Vitapan Classic and 3D-Master, Vita) used in the study.

suring the shade, the tip of the probe was held at 90 Degrees in contact with the tooth surface as recommended. The VES base unit displays the results of the measurements as compared to the system of the Vita Classic shade guide and 3DMaster shade guide. This measurement was performed by an independent examiner and checked by a second procedure to ensure measurements errors. Data was recorded for both systems (VC and 3D) and used as basis for comparison. The intra-examiner Kappa coefficient (k) was calculated as previously described.24 Each observer shade selection was recorded as a visual (VC and 3D)-instrumental “agreement or nonagreement” based on the instrumental shade identification (control). Pearson Chi square test was performed with level of significance at §=0.05, and SPSS software used for statistical analysis.

Results

Figure 2: matching and no matching frequency between visual shade selection using Vitapan Classic (VLV) and 3D-Master (V3DM)

A poor agreement was observed between the visual shade selection and the instrumental values (k=0.19) and p= 0.0001 (Table 1). When comparing the values selected by the 30 examiners in both visual shade selection (VC and 3D) there was no difference (P>0.05) (Fig 2) Fig 2

When the results for the two shade guides (VC and 3D) were grouped and analyzed, there was no significant difference between the two shade guides (P>0.05)

Discussion Data of the present study support the rejection of the null hypothesis that no difference exists between visual and instrumental shade matching. Previous studies reported that visual shade determination independent of the type of shade guide used remains a very challenging procedure.25, 27 The Vita 3D-Master guide is associated with a high intrarater repeatability 8 and success in achieving acceptable color match.28 The 3D shade guide design presents a new viewing arrangement for value and chroma with 26 shades rather than the familiar 16 VC shades29 The observers in this study were not familiar with the 3D shade guide even so there was no significant difference between both visual determinations, this may be explained by the color science principles followed by the specialists even when using the VC shade guide. Other study reported significant improvement in agreement and intrarater repeatability when a 3D shade guide was used, wich was not in agreement with the results of the present study.30 , 31 Several studies showed that instrumental shade determination was more accurate than the visual shade evaluation32, 33, 34, while others reported no significant difference between both techniques35. In the present investigation, there was no agreement between the instrumental and visual shade determination, even so the VES used showed very high accuracy36, this might be explained by the amount of light that is reflected back into the instrument from the surface being targeted. Consequently, positioning of the probe is reported to be critical, for this reason an experienced operator performed the evaluation.29 Illumination is essential to minimize errors in color evaluation37, as in the present study a


36 Prosthetic Dentistry shade matching

standardized lighting was used for both instrumental and visual determination. Further in-vitro and in-vivo studies should be conducted in order to validate the results obtained in this study and try to find an accurate process to achieve accurate shade selection.

References: 1. LI Q, WANG NY. COMPARISON OF SHADE MATCHING BY VISUAL OBSERVAJ ORAL REHABIL 2007;34: 848- 854. 2. DOUGLAS RD, BREWER JD. ACCEPTABILITY OF SHADE DIFFERENCES IN METAL CERAMIC CROWNS. J PROSTHET DENT 1998;79: 254-260. 3. HASSEL AJ, KOKE U, SCHMITTER M, BECK J, RAMMELSBERG P. CLINICAL EFFECT OF DIFFERENT SHADE GUIDE SYSTEMS ON THE TOOTH SHADES OF CERAMIC-VENEERED RESTORATIONS. INT J PROSTHODONT 2005;18:422-426. 4. WEE AG, KANG EY, JERE D, BECK FM. CLINICAL COLOR MATCH OF PORCELAIN VISUAL SHADE-MATCHING SYSTEMS. J ESTHET RESTOR DENT 2005;17:351-357. 5. OKUBO SR, KANAWATI A, RICHARDS MW, CHILDRESS S. EVALUATION OF VISUAL AND INSTRUMENTAL SHADE MATCHING. J PROSTHET DENT 1998;80:642-648. 6. VAN DER BURGT TP, TEN BOSCH JJ, BORSBOOM PC, KORSTMIT WJ. A TION AND AN INTRAORAL DENTAL COLORIMETER.

COMPARISON OF NEW AND CONVENTIONAL METHODS FOR QUANTIFICATION OF

TOOTH COLOR. J PROSTHET DENT 1990;63: 155-62. 7. HUGO B, WITZEL T, KLAIBER B. COMPARISON OF IN VIVO VISUAL AND COMPUTER-AIDED TOOTH SHADE DETERMINATION. CLIN ORAL INVEST 2005;9:244-250. 8. PRESTON JD, WARD LC, BOBRICK M. LIGHTING IN DENTAL OFFICE. DENT CLIN NORTH AM 1978;22:431-451. 9. SPROULL RC. COLOR MATCHING IN DENTISTRY. PART I. THE THREE-DIMENSIONAL NATURE OF COLOR. J PROSTHET DENT 2001;86:453-457. 10. LEE YK, YU B, LIM JI, LIM HN. PERCEIVED COLOR SHIFT OF A SHADE GUIDE ACCORDING TO THE CHANGE OF ILLUMINANT. J.PROSTH.DENT.2011 FEB;105(2):91-99. 11. DOZIC A, KLEVERLAAN C, EL-ZOHAIRY A, FEILZER A, KHASHAYAR G. PERFORMANCE OF FIVE COMMERCIALLY AVAILABLE TOOTH COLOR-MEASURING DEVICES. J PROSTHODONT 2007;16:93-100. 12. BERNS RS. BILLMEYER AND SALTZMAN’S PRINCIPLES OF COLOR TECHNOLOGY. 3RD ED. NEW YORK: JOHN WILEY & SONS; 2000. P. 88-92. 13. PRESTON JD. CURRENT STATUS OF SHADE SELECTION AND COLOR MATCHING. QUINTESSENCE INT 1985;1:47-58. 14. ANALOUI M, PAPKOSTA E, COCHRAN M, MATIS B. DESIGNING VISUALLY OPTIONAL SHADE GUIDES. J PROSTHET DENT 2004;92:371-376. 15. SCHWABACHER WB, GOODKIND RJ. THREE-DIMENSIONAL COLOR COORDINATES OF NATURAL TEETH COMPARED WITH THREE SHADE GUIDES. J PROSTHET DENT 1990;64: 425-431. 16. PAUL S, PETER A, PIETROBON N, HAMMER-LE CH. VISUAL AND SPECTROPHOTOMETRIC SHADE ANALYSIS OF HUMAN TEETH. J DENT RES 2002; 81: 578-82. 17. PAUL SJ, PETER A, RODONI L, PIETROBON N. CONVENTIONAL VISUAL VS SPECTROPHOTOMETRIC SHADE TAKING FOR PORCELAIN-FUSED-TO-METAL CROWNS: A CLINICAL COMPARISON. INT J PERIODONTICS RESTORATIVE DENT 2004;24:222-31. 18. LEHMAN KM, DEVIQUS A, IGID C, WEYHRAUCH M, SCHMIDTMANN I, WENTASCHEK S, SCHELLER H. ARE DENTAL COLOR MEASURING DEVICES CIE COMPLIANT. EUR.J.ESTH.DENT.2012 AUNTUMN;7(3):324-33. 19. DAGG H, O’CONNELL B, CLAFFEY N, BYRNE D, GORMAN C. THE INFLUENCE OF SOME DIFFERENT FACTORS ON THE ACCURACY OF SHADE SELECTION. J ORAL REHABIL 2004;31:900-4. 20. BERNS RS. BILLMEYER AND SALTZMAN’S PRINCIPLES OF COLOR TECHNOLOGY. 3RD ED NEW YORK: JOHN WILEY & SONS INC; 2000. P.88-92. 21. PARAVINA RD, POWERS JM. ESTHETIC COLOR TRAINING IN DENTISTRY. ST. LOUIS: MOSBY; 2004. P. 17-28, 169-170. 22. CIE (COMMISSION INTERNATIONALE DE L’ECLAIRAGE). COLORIMETRY, OFFICIAL RECOMMENDATIONS OF THE INTERNATIONAL COMMISSION ON ILLUMINATION, PUBLICATION CIE NO.15:2004: COLORIMETRY, 3RD ED. 23. YUAN JC, BREWER JD, MONACO JR EA, DAVIS EL. DEFINING NATURAL TOOTH COLOR SPACE BASED ON A 3-DIMENSIONAL SHADE SYSTEM. J PROSTHET DENT 2007;98:110–9. 24. MEIRELESS SS, DEMARCO FF, SANTOS IS, DUMITH SC, DELLA BONA

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A. VALIDATION AND RELIABILITY OF VISUAL ASSESSMENT WITH A SHADE GUIDE FOR TOOTH CLASSIFICATION. OPER DENT 2008;33:117-22. 25. LAGOUVARDOS PE, DIAMANTI H, POLYZOIS G: EFFECT OF INDIVIDUAL SHADES ON RELIABILITY AND VALIDITY OF OBSERVERS IN COLOUR MATCHING. EUR J PROSTHODONT RESTOR DENT 2004;12:51-56. 26. KLEMETI E, MATELA AM, HAAG P, KONONEN M. SHADE SELECTION PERFORMED BY NOVICE DENTAL PROFESSIONALS AND COLORIMETER. J ORAL REHABIL 2006;33:31-35. 27. OKUBO SR, KANAWATI A, RICHARDS MW, CHILDRESS S. EVALUATION OF VISUAL AND INSTRUMENT SHADE MATCHING. J PROSTHET DENT 1980;80:642-648. 28. SCHROPP L. SHADE MATCHING ASSISTED BY DIGITAL PHOTOGRAPHY AND COMPUTER SOFTWARE. J PROSTHODONT 2008;DEC 30 (EPUB AHEAD OF PRINT). 29. DELLA BONNA A, BARETT AA, ROSA V, PINZETTA C. VISUAL AND INSTRUMENTAL AGREEMENT IN DENTAL SHADE SELECTION: THREE DISTINCT OBSERVER POPULATIONS AND SHADE MATCHING PROTOCOLS. DENT MATER 2009;25:276-281. 30. OZAT PB, TUNCEL I, EROGLU E. REPEATABILITY AND RELIABILITY OF HUMAN EYE IN VISUAL STADE SLECTION. J.ORAL REHABIL.2013 DEC;40(12):958-64 31. LIENA C, LOZANO E, AMENQUAL J, FORNER L. RELIABILITY OF TWO COLOR SELECTION DEVICES IN MATCHING AND MEASURING TOOTH COLOR. J.CONTEMP.DENT.PRACT.2011 JAN 1;12(1):19-23. 32. DOZIC A, KLEVERLAN CJ, EL-ZOHAIRY A, FEILZER AJ, KLASHAYAR G. PERFORMANCE OF FIVE COMMERCIALLY AVAILABLE TOOTH COLOR MEASURING DEVICES. J PROSTHODONT 2007;16:93-100. 33. BREWER JD, WEE A, SEGHI R. ADVANCES IN COLOR MATCHING. DENT CLIN N AM 2004;48:341-58. 34. CHEN H, HUANG J,DONG X, QIAN J, HE J,QU X,LU E. A SYSTEMIC REVIEW OF VISUAL AND INSTRUMENTAL MEASUREMENTS FOR TOOTH SHADE MATCHING.

QUINTESSENCE INT. 2012 SEP;43(8):649-59. 35. OKUBO SR, KANAWATI A, RICHARDS MW, CHILDRESS S. EVALUATION OF VISUAL AND INSTRUMENT SHADE MATCHING. J PROSTHET DENT 1998;80:642-8. 36. PUSATERI KS, BREWER JD, DAVIS EL, WEE AG. RELIABILITY AND ACCURACY OF FOUR DENTAL SHADE-MATCHING DEVICES. J PROSTHET DENT 2009;101:193-199. 37. ISHIKAWA-NAGAI S, ISHIBASHI K, TSURUTA O, WEBER H-P. REPRODUCIBILITY OF TOOTH COLOR GRADATION USING A COMPUTER COLORMATCHING TECHNIQUE APPLIED TO CERAMIC RESTORATIONS. J PROSTHET DENT 2005;93:129-37.


38 Orthodontics

Surgical Correction of the Long Face Syndrome, In a NonGrowing Individual Part7two

Dr. Derek Mahony derek.mahony @fullfaceorthodontics.com.au

Dr. George Meredith

Fig 20

The Le Forte surgical procedure (maxillary impaction) reduces facial height, in these cases, and invariably widens the nasal base. Simultaneously, the Le Forte procedure rotates the alar cartilage laterally. In addition, Maxillofacial and ENT surgeons may perform partial resection of the inferior turbinates, to insure a good nasal airway, postoperatively, in their LeForte patients. The most common findings, in cases of longface syndrome (LFS), are visible increases in the lower third of the face. Because of the downward rotation of the mandible, the angle of the mandibular plane is steeper than normal. In the normal skull, the tangent to the inferior border of the mandible, when extended, is inferior to Fig 22

Fig 24

the cranium (occiput). In cases with steep mandibles, this tangent enters the cranium. The mandibular border can be palpated and an assessment made of the angle, in relation to the Frankfort plane. The average mandibular plane angle is approximately 27 degrees. A lateral cephalometric tracing will show the steeper mandibular plane. LFS patients frequently show a lip-incompetent posture. Nevertheless, this posture should not be regarded as pathognomonic for nasal obstruction because some of these patients can be nasal breathers, obtaining a posterior oral seal between the tongue and soft palate. Excessive appearance of the maxillary incisors is also a sign of LFS. On smiling, many of these patients show large amounts of gingiva, the so-called â&#x20AC;&#x153;gummy smile.â&#x20AC;? Either bilateral, or unilateral posterior cross-bite, may be present in LFS. Mandibular shifts can be seen in many of these cases, because interfering cusps are common when vertical growth is excessive. A characteristic marginal gingivitis can be seen around the anterior maxillary anterior teeth, because of the drying effect that accompanies chronic mouth breathing. Fig 26

Before LeForte procedure Fig 21

After LeForte procedure

Vertical Maxillary Excess Fig 23

After LeForte procedure

Dental News, Volume XXI, Number I, 2014

Before LeForte procedure Fig 25

After LeForte procedure

Fig 26: Chronic Mouth Breathing Patient


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40 Orthodontics Long Face Syndrome

As the posterior teeth erupt, and the alveolar bone develops vertically, it is necessary for the anterior teeth to erupt sufficiently, to prevent an anterior open-bite from developing. The anterior teeth must erupt approximately 3.0 mm for each 1 mm of posterior eruption, to maintain the same relationship. If the position of the tongue prevents this from occurring, an open bite may be produced (i.e. anterior tongue thrust). Figure 27 (a): Enlarged tonsils and an associated forward tongue posture

Figure 27 (b): We have found that very large faucial tonsils are a relatively common cause of an anterior tongue position.

Fig 29a

Fig 27a Figure 29 (a): Photo of fixed Hyrax in the Mouth.

Fig 27b

Excising an ellipse of skin, and subcutaneous tissue, in the nasofacial fold, can open the nasal valve by rotating the alar cartilage laterally… much like a Breathe Right nasal strip does for football players, and persons with head colds or nasal allergies. Because patients with LFS are more likely to have facial asymmetries, Quinn16 suggested that keeping the mandible in a lowered position would decrease the action of occlusal determinants, of mandibular growth, and thus allow uncoordinated growth. No crosssectional, or longitudinal studies, have been reported to support this theory. Fig 30a

Kissing faucil tonsils, in time, can exert significant forward pressure on the tongue, and thus the lower jaw (Figure 27). Long-standing nasal airway obstruction can lead to a “disuse” atrophy of the lateral crus of the lower lateral cartilage.30 The result is a slit-like external nares associated with a narrow nasal vault. After the airway obstruction is corrected, and a normal nasal airway is established, certain patients may still experience nasal collapse on inspiration, making reconstructive nasal surgery necessary. Figure 28. Hyrax appliance has justbeen placed. Note patient’s left but especially, right nasal alar collapse. Cottletermed this the “tension nose”.

Figure 30 (a): (High Palatal Vault) with severe dental crowding Fig 30b

Fig 28

Figure 30 (b): Patient with maxillary compression, blocked out canines and posterior cross bites. Dental News, Volume XXI, Number I, 2014


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42 Tooth Bleaching Orthodontics Long Face Syndrome

Fig 31

Fig 31

Figure 31. The Milwaukee brace has been used for years to treat scoliosis (curvature of the spine). There are a few variations to this brace but the most common type starts at the hips with a molded pelvic girdle (leather or plastic) and has 2 posterior metal bars that attached to the back of the pelvic girdle and one anterior bar in front. The metal bars run up the entire length of the spine and connect into a neck ring, which completely encircles the neck and has a small plastic throat mold in front and two small headpieces in back where the occipital portion of the skull rests.

Mechanism of LFS To understand the influence of nasal obstruction, on facial growth, it is necessary to review current concepts concerning the normal interactions between bone and adjacent soft tissues. Although bone is the second hardest substance in the human body, it is extremely pliable when subjected to even the smallest forces, esp over prolonged periods of time (as exemplified by the grooving of the inner surface of the calvarium, by small arterioles and venules). Teeth move through bone, under the smallest forces. It has been suggested that all forces are capable of moving teeth. Pathologic examples support the concept that the skeletal configuration of the face is influenced by the forces acting on the maxillomandibular complex. Many cerebral palsy patients have poorly innervated muscles of mastication, and perioral musculature. They develop the long face because of unrestrained vertical growth and excessive molar eruption. Patients with congenital hypotonia, involving the facial muscles, demonstrate similar changes. In contrast, patients with heavy facial musculature, such as football linemen and competition weight lifters, often show low mandibular planes, and deep dental overbites. Contractures after facial, and cervical burns, produce elongation of the dentofacial skeleton. In contrast, the Milwaukee Brace, used in cases of spinal scoliosis, can produce a compressed facial appearance (â&#x20AC;&#x153;short faceâ&#x20AC;? syndrome) as a result of the upward forces generated by the chin rest.47 The facial skeleton is very mouldable, and is predictably responsive to muscular forces acting on it. Thus, any alteration in function, that changes the forces acting on the facial skeleton, may produce changes in facial morphology. In general, nasal airway obstruction is promptly followed by the establishment of an oral airway, to ensure survival of the individual. Newborns may not have the muscular agility to create an oral airway, so that nasal obstruction in the infant can be life threatening. Bilateral congenital choanal atresia requires prompt intervention, to re-establish an adequate airway, because infants are obligate nasal respirators. The lowering of the mandible accompanies establishment of an oral airway, and alters the force system acting on the maxillomandibular complex. As the mandible is lowered, the hyoid

Dental News, Volume XXI, Number I, 2014

bone also drops, thus removing the tongue from the palatal vault. The weight of the buccinator muscles is no longer opposed, by the mass of the tongue, and thus unequal forces are created, which place constrictive forces on the palate. Unilateral, and bilateral, cross-bites are seen frequently in nasally obstructed patients, as the maxilla narrows (Figure 30). Posterior tooth eruption and excess vertical alveolar development can occur if the mouth-breather allows the jaw to continuously hang open. Moller48 and Sassouni49 have shown that the forces between the maxilla and mandible, generated by the muscles of mastication, are partly responsible for the spatial relationship of the maxilla and mandible. Some nasally obstructed patients may develop a rhythmic lowering of their mandibles, on inspiration, followed by elevation of their mandibles, on expiration. Harvold50 noted this response in some of his primate dentofacial studies. As expected, these patterns can be conductive to more normal facial growth. This may explain why some mouth-breathers do not develop LFS and only those patients whose mandibular posture is permanently altered may be at risk to develop the syndrome (Figure 26).

Treatment of LFS Conventional orthodontic treatment has limited influence on the vertical dysplasia associated with LFS. Bellâ&#x20AC;&#x2122;s work51 on the blood supply of the palate has led to the development of the LeForte operation to intrude the maxilla, in the LFS (Figure 32).

Figure 32: LeForte Impaction Procedure


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44 Orthodontics Long Face Syndrome

Typically, a section of bone is removed from above the maxillary teeth to allow the maxilla to be raised. This allows the mandible to rotate upward, shortening the lower face height, and allowing the lips to meet in response. This change also allows the mandible to move anteriorly, contributing to the correction of a Class II malocclusion. Conventionally, LeForte procedures are performed after facial growth is complete (ages 17 to 18 years in girls, and ages 19 to 20 years in boys).

long-standing duration, may persist for a year or more after the airway is restored and represents a “learned habit.” Nevertheless, within a year or so after re-establishment of normal oropharyngeal function, and normal nasal airway, the chronic mouth-breathing habit does revert to nasal breathing. Moreover, it is our belief that dentofacial development, for patients at risk, will proceed in a more normal fashion once chronic mouth-breathing ceases.

Summary Conclusion The largest increments of growth occur during the earliest years of life, so that by age 4 years the craniofacial skeleton has reached 60 percent of its adult size. By age 12 years (the age when many orthodontists initiate treatment) 90 percent of facial growth has already completed. To wait until 90 percent of a deformity is established, before instituting treatment, is not consistent with a “preventative philosophy”. Because successful treatment of anterior - posterior, and vertical, dentofacial discrepancies, is linked to growth changes, it is our philosophy that interceptive orthodontic, and early ENT measures, should be initiated much sooner than is conventionally recommended. Berman52 wrote: “Natural law did not divide man into three parts: dental, medical, and psychological. If Society choses this division for the purposes of healthcare delivery, then each professional group bears a special responsibility to be sufficiently informed, about the others, so that integrated total-health-care is an achievable goal.” The otolaryngologist (ENT doctor) should be receptive to referrals from orthodontists, and dentists, who express concern about adequate function of the oropharynx and the nasal airway. A thorough history and a careful examination should be performed. If allergy is a major consideration, a subsequent referral, or allergy treatment programme, should be initiated. After a diagnosis is made, the ENT clinician should confer with the orthodontist, and a riskto-benefit analysis, regarding possible early intervention, should be performed. It has been our experience that the earlier the return to normal nasal respiration, and normal oropharyngeal function, the more likely normal dentofacial development will occur. Mouth breathing, of Dental News, Volume XXI, Number I, 2014

The establishment of a patent oral airway, subsequent to upper airway compromise, is accompanied by postural changes of the maxilla and mandible. This alteration introduces forces on the bones of the facial skeleton that may result in characteristic findings termed the “long-face syndrome”. Primary care physicians, and dentists, must develop co-operative relations with oral myologists, otorhinolaryngologists, allergists, and orthodontists to promote normal nasal respiration throughout a child’s early years of facial growth. Normal respiration may reduce harmful long face dysplasia.

References 1. TOMES CS: ON THE DEVELOPMENTAL ORIGIN OF THE V-SHAPED CONTRACTED MAXILLA. MONTHLY REVUE OF DENTAL SURGERY 1872:1.2-5. 2. O’RYAN FS, GALLAGHER DM, LABLANC JP, ET AL: THE RELATION BETWEEN NASORESPIRATORY FUNCTION AND DENTOFACIAL MORPHOLOGY: A REVIEW. AM J ORTHOD 1982; 82:403-410. 3. TODD TW, COHEN MD, BROADBENT BH: THE ROLE OF ALLERGY IN THE ETIOLOGY OF ORTHODONTIC DEFORMITY. J ALLERGY 1939;10:246-249. 4. BALYEAT RM. BOWEN R: FACIAL AND DENTAL DEFORMITIES DUE TO PERENNIAL NASAL ALLERGY IN CHILDHOOD. INT J ORTHOD. 1934;20:445-449. 5. ANGLE EH: TREATMENT OF MALOCCLUSION OF THE TEETH, ED 7. PHILADELPHIA, SS WHITE DENTAL MANUFACTURING CO, 1907. 6. KETCHAM AH: TREATMENT BY THE ORTHODONTIST SUPPLEMENTING THAT BY THE RHINOLOGIST. LARYNGOSCOPE 1912;22:1286-1299. 7. MCCOY JD: APPLIED ORTHODONTICS. PHILADELPHIA, LEA AND FEBIGER, 1935. 8. MOSS ML: THE FUNCTIONAL MATRIX: FUNCTIONAL CRANIAL COMPONENTS IN KRAUS BS, REIDEL R, (EDS): VISTAS IN ORTHODONTICS. PHILADELPHIA, LEA AND FEBIGER, 1962, PP 85-90. 9. VAN DER KLAAUW CJ: SIZE AND POSITION OF THE FUNCTIONAL COMPONENTS OF THE SKULL. ARCH NEERL ZOOL, 1948;9:1-559. 10. HAWKINS AC: MOUTH-BREATHING AS THE CAUSE OF MALOCCLUSION AND OTHER FACIAL ABNORMALITIES. TEXAS DENTAL JOURNAL 1965; 83:10-15. 11. HOWARD C: INHERENT GROWTH AND ITS INFLUENCE ON MALOCCLUSION. J. AM DENT. ASSOC 1932;19;642-651. 12. LEECH HI: A CLINICAL ANALYSIS OF OROFACIAL MORPHOLOGY AND BEHAVIOR OF 500 PATIENTS ATTENDING AN UPPER RESPIRATORY RESEARCH CLINIC. DENTAL PRACTITIONER 1958;9:57-91. 13. SUBTELNY JD: THE SIGNIFICANCE OF ADENOID TISSUE IN ORTHODONTIA. ANGLE ORTHOD 1954;24:59-69. 14. RICKETTS RM: RESPIRATORY OBSTRUCTIONS AND THEIR RELATION TO TONGUE POSTURE. CLEFT PALATE BULL, 1958;8:3-6. 15. LINDER-ARONSON S, WOODSIDE D: THE CHANNELIZATION OF UPPER AND LOWER ANTERIOR FACE HEIGHTS COMPARED TO POPULATION STANDARDS IN MALES BETWEEN AGES 6 TO 20 YEARS. EUR J ORTHOD, 1979;1:25-40.


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46 Orthodontics Dentofacial Development 16. QUINN GW: AIRWAY INTERFERENCE AND ITS EFFECT UPON THE GROWTH AND DEVELOPMENT OF THE FACE, JAWS, DENTITION, AND ASSOCIATED PARTS. NORTH CAROLINA DENTAL JOURNAL 1978;60:28-31. 17. RUBIN RM: MODE OF RESPIRATION AND FACIAL GROWTH. AM J ORTHOD 1980;78-504-510. 18. MCNAMARA JA, JR.: INFLUENCE OF RESPIRATORY PATTERN ON CRANIOFACIAL GROWTH. ANGLE ORTHOD 1981;51:269-299. 19. BUSHEY RS: ALTERATIONS IN CERTAIN ANATOMICAL RELATIONS ACCOMPANYING THE CHANGE FROM ORAL TO NASAL BREATHING, THESIS. UNIVERSITY OF ILLINOIS, CHICAGO, 1965. 20. HARVOLD EP, CHIERCI G, VARGERVIK K: EXPERIMENTS ON THE DEVELOPMENT OF DENTAL MALOCCLUSIONS. AM J ORTHOD 1972;61:38-44. 21. HOROWITZ SL, HIXON EH: THE NATURE OF ORTHODONTIC DIAGNOSIS. ST. LOUIS, CV MOSBY, 1966. 22. RICKETTS RM: RESPIRATORY OBSTRUCTION SYNDROME (IN FORUM ON THE TONSIL AND ADENOID PROBLEMS IN ORTHODONTICS). AM J ORTHOD 1968;54:495-514. 23. SUBTELNY JD: WORKSHOP ON TONSILLECTOMY AND ADENOIDECTOMY. ANN OTOL RHINOL LARYNGOL 1974;84:250-254. 24. MARKS MB: ALLERGY IN RELATIONS TO OROFACIAL DENTAL DEFORMITIES IN CHILDREN: A REVIEW. J ALLERGY 1965;36:293-302. 25. SHAPIRO GC, SHAPIRO PA: NASAL AIRWAY OBSTRUCTION AND FACIAL DEVELOPMENT. CLIN REV ALLERGY 1984;2:225-235. 26. LINDER-ARONSON S: EFFECTS OF ADENOIDECTOMY ON THE DENTITION AND FACIAL SKELETON OVER A PERIOD OF FIVE YEARS, IN COOK JT (ED): TRANSACTIONS OF THE THIRD INTERNATIONAL ORTHODONTIC CONGRESS. ST. LOUIS, CV MOSBY, 1975, PP. 85-100. 27. HANNUKSELA A: THE EFFECT OF MODERATE AND SEVERE ATOPY ON THE FACIAL SKELETON. EUR J ORTHOD 1981;3:187-193. 28. LONG RE, MCNAMARA JA: FACIAL GROWTH FOLLOWING PHARYNGEAL FLAP SURGERY: SKELETAL ASSESSMENT ON SERIAL LATERAL CEPHALOMETRIC RADIOGRAPHS. AM J ORTHOD 1985;87:187-196. 29. VIG PS, SARVER DM, HALL DJ, ET AL: QUANTITATIVE EVALUATION OF NASAL AIRFLOW IN RELATION TO FACE MORPHOLOGY. AM J ORTHOD 1981;79:263-272. 30. ADAMS GL, BOIES LR, JR., PAPARELLA MM: BOIES’ FUNDAMENTALS OF OTOLARYNGOLOGY. PHILADELPHIA, WB SAUNDERS, 1978. 31. OGURA JH: PHYSIOLOGIC RELATIONSHIPS OF THE UPPER AND LOWER AIRWAYS. ANN OTOL RHINOL LARYNGOL 1970;79:495-501. 32. MENASHE WD, FARRHEI C, MILLER M: HYPERVENTILATION AND COR PULMONOLAE DUE TO CHRONIC UPPER AIRWAY OBSTRUCTION. J PEDIATR 1965;67:198-203. 33. NELSON WE, VAUGHAN VC, MCKAY RJ: TEXTBOOK OF PEDIATRICS PHILADELPHIA, WB SAUNDERS, 1969, PP 23-42. 34. PRINCIPATO JJ, OZENBERBER JM: CYCLICAL CHANGES IN NASAL RESISTANCE. ARCH OTHOLARYNGOL 1970;91:71-77. 35. COTTLE MH: NASAL SURGERY IN CHILDREN. EYE, EAR, NOSE, AND THROAT MONTHLY 1951;30:3238. 36. JENNES MI: CORRECTIVE NASAL SURGERY IN CHILDREN: LONG TERM RESULTS. ARCH OTOLARYNGOL 1964; 79:145-151. 37. FARRIOR RT, CONNOLLY ME. SEPTORHINOPLASTY IN CHILDREN. OTOLARYNGOL CLIN NORTH AM 1970;3:345-364. 38. GRAY LP, BROGAN WF: SEPTAL DEFORMITY MALOCCLUSIONS AND RAPID MAXILLARY EXPANSION. ORTHODONTIST 1972;4:1-13. 39. PRINCIPATO JJ: CHRONIC VASOMOTOR RHINITIS: CRYOGENIC AND OTHER SURGICAL MODES OF TREATMENT. LARYNGOSCOPE 1979;89:619-638. 40. DEVGAN BK: SUBMUCOSAL DIATHERMY OF INFERIOR TURBINATES. EYE, EAR, NOSE, AND THROAT MONTHLY 1976;55:19. 41. BECK JC: PATHOLOGY OF INTRAMURAL ELECTROCAOGULATION OF THE INFERIOR TURBINATE. ANN OTOL RHINOL LARYNGOL 1930;39:349. 42. FRY HJH: JUDICIOUS TURBINECTOMY FOR NASAL OBSTRUCTION. AUST NZ J SURG 1973;42-291. 43. SHEEN JH: AESTHETIC RHINOPLASTY. ST. LOUIS, CV MOSBY, 1978, PP 184-194. 44. SPECTOR M: PARTIAL RESECTION OF THE INFERIOR TURBINATES. EAR, NOSE, AND THROAT J 1982;61:28-32. 45. POLLOCK MD: INFERIOR TURBINATE SURGERY. PLAST RECONSTR SURG 1984;74:227. 46. COURTISS EH: RESECTION OF OBSTRUCTING INFERIOR NASAL TURBINATES. PLAST RECONSTR SURG 1978;62:249. 47. ALEXANDER C: THE EFFECTS OF TOOTH POSITION AND MAXILLOFACIAL VERTICAL GROWTH DURING SCOLIOSIS TREATMENT WITH THE MILWAUKEE BRACE: AN INITIAL STUDY. AM J ORTHOD 1966;52:161-189. 48. MOLLER E: THE ACTIVITY OF THE MUSCLES OF MASTICATION AS RELATED TO THE MORPHOLOGY OF THE FACIAL SKELETON. ACTA PHYSIOL SCAND 1966;69:280-284. 49. SASSOUNI V, FORREST EJ: ORTHODONTICS IN DENTAL PRACTICE, ST. LOUIS, CV MOSBY, 1971. 50. HARVOLD E: NEUROMUSCULAR AND MORPHOLOGICAL ADAPTATIONS IN EXPERIMENTALLY INDUCED ORAL RESPIRATION IN MCNAMARA JA, JR. (ED): NASO-RESPIRATORY FUNCTION AND CRANIOFACIAL GROWTH, CRANIOFACIAL GROWTH SERIES NO. 9 ANN ARBOR, THE UNIVERSITY OF MICHIGAN, 1979. 51. BELL WH: CORRECTION OF SKELETAL TYPE ANTERIOR OPEN BITE. J ORAL SURG 1971;29:706-714. 52. BERMAN C: PREFACE. JOURNAL OF PREVENTIVE DENTISTRY 1978;5:8.

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Dental News, Volume XXI, Number I, 2014


48

INTERVIEW WITH

MR. KAUFMAAN EXPLAINING THE ADVANTAGES OF

KAVO’ NEW ARCTICA CAD/CAM SYSTEM When it comes to state of the art CAD/CAM technology in dental laboratories, then patients are in best hands at ZTLM Vanik Kaufmann-Jinoian. His numerous lectures on the subject are impressive proof of this. Not only has the proprietor of the dental laboratory Cera-Tech in Liestal near Basel been a CAD/CAM user from the very beginning but he also has provided valuable input into the technology’s development through his active participation in it. Recently he has become the owner of KaVo’s new ARCTICA system. We wanted get his first impressions from work with the system. Mr. Kaufmann, you recently started using KaVo’s ARCTICA CAD/CAM system. You have extensive experience with CAD/CAM systems. What do you consider to be ARCTICA’S particular advantages? Mr. Kaufmann: “First of all there is the striped light scanner. I particularly like that it is a semi-automatic design. With fully automated systems I often encounter problems with cumbersome re-scans when the first scan was incomplete. Scans that require essentially no corrective work can be achieved with very little experience. In addition, it works extremely fast. And even in cases where the scan shows gaps the model can be repositioned accordingly, perhaps by tilting, and the software applies any subsequent corrections automatically.” And what are your experiences with the grinding unit? Mr. Kaufmann: “I really appreciate that it is a compact 5-axis system that not only uses blanks very economically but also that I am finally able to process metal, a think that up until now was not possible with small systems.” Is zirconium dioxide still important nowadays? Mr. Kaufmann: “There are still dentists who request metal frameworks. When CrCo alloys are required, we have them exDental News, Volume XXI, Number I, 2014

ternally made by selective laser sintering. When biocompatibility is required, it has to be titanium. We process a large number of titanium connecting bar and up until now had to have them fabricated externally. Now we are able to do this in house and design is simple and fast by means of the software provided. Regarding the software: How practical is it? Mr. Kaufmann: “It is fantastically simple. E.g. during the design of an anterior bridge, the automatically proposed crown can be moved and rotated through key combinations which is considerably faster and simpler that with other solutions that require multiple key clicks. And its operation is intuitive to learn: Within half an hour of receiving it I was able to do a bar design without a hitch and without receiving any training. KaVo’s hotline with remote support is equally fantastic and useful especially in the early stages when one might have the occasional problem: These consultants are highly competent, can log in remotely and point out mistakes on your own screen or give hints on how to do things even faster.” The multiCAD Software is equipped with open interfaces, but not every scanner supplier offers open interfaces. How much data transfer can you utilise? Mr. Kaufmann: “We are not only able to do this with manufacturers that provide STL files but also with others who still believe in the advantages of proprietary systems. We are using Rhino’s dental shaper for this purpose; it can convert all relevant data sets to compatible STL files. You also use a printer (Solidscope).” Are you using ARCTICA data in there as well? Mr. Kaufmann: “Yes. We have decided to no longer do the wax coating for precious metal castings by hand as this is very simple and fast done in the KaVo software. We design the framework on the PC and transfer the STL data directly to the printer. The


50 50 Orthodontics Dentofacial Development

printer is very accurate and saves us a lot of work.” Besides KaVo’s blocks of titanium, Zirconium, glass-infused ceramics and plastic, there is the option of using other materials. Do you use them? Mr. Kaufmann: “We have the open system and do both Alongside KaVo’s materials we use blocks by RealLife and Cad-Temp blocks by Vita. And we fabricate our own plastic / wax blocks that we can use via the exchangeable holder”

Dental News, Volume XXI, Number I, 2014

Could you share your experience with the Implant module? Mr. Kaufmann: “We fabricate connecting bars from titanium with bonded bases. We also use titanium bonded bases for our zirconium abutments since we have bad experiences with whole zirconium abutments with screw connection - they came lose over time. For lateral applications we also fabricate titanium abutments which we weld to the bonding base. The design of these abutments too is amazingly simple: One draws what one thinks.”


This is where

ďŹ ts in


52

SDS & KSU 2014 January 12 - 14, 2014 Convention and Exhibition center, Riyadh, KSA

More Pictures Available On www.facebook.com/dentalnews1

On behalf of the conference organizing committee, I would like to introduce to you the King Saud University 15th International Dental Conference and the 25th for the Saudi Dental Society under the theme “Research and Technology in Oral Health Care” This conference is a joint collaborative effort of King Saud University, College of Dentistry and the Saudi Dental Society. With the continuous success of our previous conferences and the Saudi Dental Society’s merit on being the top amongst all the dental organizations in the Kingdom, I enjoin you to remain committed to our practice by constantly updating ourselves and aspiring to be the best for the community we vow to serve. We have world renowned foreign speakers from all disciplines of the dental practice for the scientific seminars, the workshops and the hands-on education that our members have requested. One of the highlights of the conference is the Research Award for Graduates Students and Poster Award presentation. This is one way of providing the best service and support for our members and colleagues. The exhibition offers attendees the opportunity to explore the breadth and depth of the latest products, services, tools and technologies available in today’s global market. Dr. Mohammad Al-Obaida President of the Saudi Dental Society

PR. EDMOND KOYESS FROM LEBANON ON THE NEXT WAVE IN ENDODONTICS

DR. SAAD NAZHAN THANKING DR. IMRAN FAROOQ FROM DAMMAM

LECTURING

DR. ESAM A. TASHKANDI INTRODUCING DR. GUY GOFFIN FROM SWITZERLAND

DR. DINOS KOUNTOURAS PRESIDENT HELLENIC ACADEMY OF ESTHETIC DENTISTRY, GREECE


TROPHY DISTRIBUTION

TO

DR. RAGAB ELBEIALY FROM EGYPT

TO

DR. ELIE MAALOUF FROM LEBANON

TO

DR. MOHAMED DARWISH FROM QATAR

TO

DR. TONY DIB FROM LEBANON

TO

TO

DR. MOHAMED HAFEEDH FROM YEMEN

DR. ABDULWAHAB ALAWADHI FROM KUWAIT

TO

DR. RAED ALSADHAN

DR. SALEH ALSHAMRANI, DEAN RIYADH COLLEGE


PICTURES FROM THE EXHIBITION


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AEEDC 2014

56

February 4 - 6, 2014 World Trade Center, Dubai, UAE

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RIBBON CUTTING BY H.H. SHEIKH HAMDAN BIN RASHED AL MAKTOUM

OVER 110 LECTURES DELIVERED BY 96 SPEAKERS. 17 ADVANCED COURSES AND WORKSHOPS.

DR. ANAS AL MULLA TALKING ON PREVENTION IN ORTHODONTICS PATIENTS

DR. NAJI ABBOUD

LECTURING ON TISSUE REGENERATION

DR. WAHID TERRO LECTURING ON IMMEDIATE PLACEMENT OF DENTAL IMPLANTS

DR. HANI OUNSI TALKING ON NEW TRENDS FOR RESTORING ENDODONTICALLY TREATED TEETH

DR. ROBERT EDWAB TALKING ON AVOIDING THIRD MOLAR EXTRACTION COMPLICATIONS

DR. PHILIPPE SULEIMAN LECTURE ON CLEANING THE ROOT CANAL SYSTEM


The first fluoride toothpaste to harness advanced NovaMin® calcium and phosphate bone regeneration technology1 to help relieve the pain of your patients’ dentine hypersensitivity. Repairs exposed dentine: Building a hydroxyapatite-like layer over exposed dentine and within dentine tubules2–6 Protects patients from the pain of future sensitivity: The robust layer firmly binds to dentine6,7 and is resistant to daily oral challenges3,8,9,10

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


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ALL YOU NEED FOR THE PERFECT RESTORATION, AND NOTHING YOU DON’T WELCOME TO THE NEW REALITY In the new reality, the CS 3500 intraoral scanner creates highly accurate, true color 2D and 3D models of teeth without conventional impressions. 6 6 6 6

Truly handheld, portable with no trolley and plug and play Powder-free with slim scanner head for comfortable, custom-fit restorations Unique light guidance system for more patient-focused scanning Part of an open system and featuring a margin line drawing tool to better meet your practice needs

If you would like to arrange a demonstration please contact ernesto.jaconelli@carestream.com. Visit: carestreamdental.com © Carestream Health, Inc. 2014.

SCAN

DESIGN

MILL


11TH GLOBAL SCIENTIFIC DENTAL ALLIANCE MEETING

WITH THE PARTICIPATION OF 29 COUNTRIES

REPRESENTATION OF MORE THAN 66 HEADS AND DIRECTORS FROM THE DENTAL ASSOCIATIONS AND MINISTRY OF HEALTH

DR. MOHAMED AL OBEIDA

DR. JACK DILLENBERG

DR. ZIAD SALAMEH

DR. TONY DIB OFFERING THE LDA-TRIPOLI PLATE TO DR. ABDULSALAM AL MADANI

CERTIFICATE DISTRIBUTION TO

DR. ROBERT EDWAB

PR. ELIE MAALOUF

DR. MOHAMED AL JISHI

DR. HANI OUNSI

DR. AISHA SULTAN

DR. ABDULAZIZ AL SHAMMERI

DR. RAFI AL JOBORI


THE BEST COMPRESSED AIR | SUCTION |  IMAGING | DENTAL CARE | HYGIENE

X-ray solutions work in partnership.

m eam tea

Dr VistaIntra ini View nM + VistaSca y solution = the x-ra

New: intraoral x-ray generator VistaIntra Exemplary ergonomic designt Perfect match for all image receptors t DC technology for steady and reduced radiation

New: image plate scanner VistaScan Mini View High-resolution touchscreen display t WiFi t ScanManager for optimal work flow in your practice t Superior image quality t All intraoral formats More at www.duerr.de


30,000 DENTAL PROFESSIONALS AND TRADE VISITORS FROM 130 COUNTRIES

Dental News, Volume XXI, Number I, 2014


HENRY SCHEIN BRAND Beyond Satisfaction! Henry Schein Brand products offer our clients maximum value without compromising on quality. We offer quality products you can trust to fulfill your practice merchandise needsâ&#x20AC;&#x201D;each bearing the Henry Schein Seal of Excellence, your guarantee of satisfaction. #""" " #  #      

Henry Schein, Inc. is the worldâ&#x20AC;&#x2122;s largest provider of health care products and services to office-based dental, medical, and animal health practitioners.


PICTURES FROM DENTAL NEWS BOOTH


66

FROM LEFT, DRS. IMTIAZ TURKISTANI, CEDRIC HADDAD, RIAD BACHO, PRESIDENT ALI ALEHAIDEB, IBRAHIM NASSEH AND NADIM ABOUJAOUDE

Handing over ceremony

This was a historic moment for Section X with the handing over of the presidency taking place for the first time outside Lebanon. The meeting took place in Dubai at the Fairmont Hotel on February 4th in the presence of fellows from both districts and guests. The event was sponsored by CARE and Planning for Hospitals Ltd who were represented by the chairman Mr Elie AbouChedid. CARE are the agents of Planmeca in the Kingdom of Saudi Arabia. Also present at the event, was the President of Planmeca Mr Heikki Kyostila and Mrs Kyostila from Finland. President Riad Bacho gave a brief word and then handed over the presidency medal to President Ali Alehaideb. President Alehaideb thanked all those present as well as the event sponsors and praised the work of fellow Youssef Talic, the sectionâ&#x20AC;&#x2122;s past vice president, who had done the groundwork for the organization of District 2. Councilor Cedric Haddad also gave an update of the activities of the International Council and of the changes that were taking place in the College. Mr Elie AbouChedid then introduced his company (CARE) and gave a presentation of the technically advanced services that it provided. A banquet followed the meeting and gave all those present the chance to socialize, renew acquaintance and exchange ideas.


3RD PAN ARAB ENDODONTIC CONFERENCE

68

More Pictures Available On

November 28 - 30, 2013 Hilton Habtoor, Beirut, Lebanon

www.facebook.com/dentalnews1

MEMBERS OF THE LEBANESE SOCIETY OF ENDODONTOLOGY Distinguished delegates, Dear colleagues, On behalf of the Arab Association of Endodontists, the Lebanese Society of Endodontology and myself, I am honored and delighted to welcome you to the third Pan Arab Endodontic Meeting. The conference has attracted more than four hundred and fifty participants from 19 countries. We will hear 46 oral presentations in almost all aspects of endodontics,14 poster research presentations, 6 different workshops to share new trends of instruments and techniques and 3 live demonstrations. I feel honored because in spite of all the events that occurred in the past few weeks in Lebanon I can see among the audience my dearest friends who came from Libya, Tunis, Jordan, Palestine, Syria, Egypt, Iraq, Iran, United Arab Emirates, France, Poland, Italy, Spain, Canada, Lithuania, Malta, USA and Brazil. I would like to express my gratitude and recognition for your support. Dear friends thank you so much for being here! Dr. Walid Nehme President of the Lebanese Society of Endodontology

Trophy distribution to:

PRESIDENT RAHIL DOUEIHY

DR. IBRAHIM ABU TAHUN

DR. HEDIA JAOUADI

DR. FAYSAL ALAMEDDINE

DR. CHARBEL ALLAM

DR. ROGER RBEIZ

DR. PIERRE SOUHAID

PR. JOSEPH SADER


70

Who is StyleItaliano? Feasible, teachable and repeatable: the Styleitaliano recipe for a daily success dentistry. The styleitaliano movement has its origins in a good hunch, a meeting between two friends, Dr Walter Devoto and Professor Angelo Putignano, worldwide recognized experts in conservative and aesthetic dentistry. Operative dentistry with white materials, composite and ceramics, is one of the most interesting and thrilling subjects in congresses and debates between professionals. In daily dentistry we find: who are confused, who celebrate the opportunities and who remark their own capacity to obtain outstanding results. Italian aesthetic dentistry is worldwide well-considered due to its quality and class: for many this is justified because of the Italian artistic skills, related to the sensibility, to our own traditions, to our history, a difficult task to copy. Styleitaliano believes that the modern dentist need clear and precise ideas, practical suggestions to face their own daily challenges on their own dental chairs. So these are the keywords of our mission: FEASIBLE: Materials found on the market are the INGREDIENTS of our daily work: We as experts, can provide a RECIPE to the dentist, or in other words, how to use and mix perfectly these ingredients in order to obtain a high quality average dentistry without confusion. Our attempts are not focused on suggesting materials, but to offer and IDEPENDENT vision and understanding of their usage methods, comparing our experience with research and pointing our tips and tricks. Different companies are listening to what we are saying and proposing, and have accepted and supported our work programs. This is for us a great pride.

TEACHABLE: Each week we are busy teaching dentistry in some corner of the world: We do it with passion, thinking always to the normal dentists that want to emulate their own teachers and idols and that want to offer the best to their own patients If some technique or a method is not fully understandable, then is not useful to increase the average quality. We work every day over this arguments: This way we have projected instruments, technical supports, small and great ideas that come from more than 20 years of professional experience teaching in all levels. Just to make life SIMPLER. The answer is given by numbers: our website www. styleitaliano.org, our facebook.com platforms www.facebook.com/styleitaliano and www.facebook.com/groups/ styleitaliano are one of the most followed communities in the world, the response we had are very enthusiastic. Sharing our knowledge responsibly. REPEATABLE: The techniques, ideas and suggestions must be useful to everyone and is not convenient to link them to the individual skills: from the beginning we relied that the power of the GROUP is SHARING. A courageous experiment to do, but extremely engaging and exciting! That is why STYLEITALIANO is a TEAM that discusses, faces each other and shares. YOU CAN DO WHAT WE DO: This is our slogan. Every week we publish some news, some article, a new case, and allowing everyone to publish their own work in our COMMUNITY page. Form this year we have launched the STYLEWORLD program: We have identified colleagues from around the world that are AMBASSADORS of our philosophy and STYLE, talking a common â&#x20AC;&#x153;languageâ&#x20AC;? constructed from FRIENDSHIP, SHARING, RECIPES, INNOVATIONS, SIMPLICITY, TECHNOLOGY, ART, PASSION, DEDICATION AND LONGEVITY. All of this is Styleitaliano.


All in one ! TotalCem, Self-etching and self-adhesive cement Exceptional bonding strength Self-adhesive to enamel, dentine, metal, ceramic, porcelain, zirconium & composites All in one! Etching + Primer + Bonding + Cement For any indications: post, crown, bridge, inlay & onlay Optimized gel state for an easy excess removal Auto/photo-polymerizable

Fine intra oral tips Extra ďŹ ne intra oral tips

Clinical excellence

Made in France www.itena-clinical.com


76

X-ray-free caries diagnostics in the everyday dental practice routine DIAGNOcam basically relies on a tried & tested technology that is used today in many practices: transillumination. In contrast to conventional technology with an interdental light source, DIAGNOcam practically uses the entire tooth as a light propagation medium. At places where there is a carious lesion which blocks light propagation, a shadow is produced and is captured by an integrated video camera. The light is introduced via the gingiva and bones at root level. With the DIAGNOcam software, live images and stills can be viewed on a monitor and a connection established to the network and the practice management software. website: www.kavo.com/diagnocam

Effective whitening without a tray The innovative VivaStyle Paint On Plus varnish system from Ivoclar Vivadent offers a professional method for whitening teeth without having to use a tray. The VivaStyle Paint On Plus varnish system contains 6 percent hydrogen peroxide. It is suitable for whitening stained vital and non-vital teeth. VivaStyle is prescribed by the dentist once a diagnosis has been made and the patient has been appropriately instructed. The patient carries out the treatment at home in accordance with the treatment plan set up by the dental practitioner. In the dental office VivaStyle Paint On Plus can be used as an intensive treatment by applying the varnish several times during one appointment. website: www.ivoclarvivadent.com

Endodontic treatments get hi-tec FKG Rooter, a new motor for endodontic treatments, has been designed to improve patient comfort and to bring exclusive functionalities for the dentist. The Rooter from FKG Dentaire has a range of innovative features, for instance a wide range of speeds from 250 to 1200 rpm, 10 programmable memory locations, greater freedom of movement thanks to the wireless technology with Li-Ion battery, a particularly ergonomic with 360째 orientation in 5 positions or a powerful white LED light focused on the work zone. website: www.fkg.ch

Dental News, Volume XXI, Number I, 2014


78

Transforming Gutta-Percha from the Inside Out GuttaCore™, from DENTSPLY, is the first obturator with a crosslinked gutta-percha core. Crosslinking is a process that bonds a stabilizer to the molecular structure of gutta-percha. This gives GuttaCore unique inner strength, and because the strong core is gutta-percha rather than conventional plastic, it’s easier to re-treat. Superior 3D Filling. GuttaCore offers a superior 3D fill with the ease of a single insertion. The centrally compacted gutta-percha creates a predictable and consistent 3D fill that follows curves, finds accessory canals and flows into intercanal isthmuses. Ease of Retreatment & Post Space Simplified. With GuttaCore obturators, you can remove the handle by bending to either side of the canal wall without affecting the seal. In addition, you can create post space and remove the obturation material with unprecedented ease. You will see the familiar gutta-percha characteristics when your drill engages the material. The crosslinked core comes out efficiently, saving you time and hassle. website: www.dentsplymea.com

New Exclusive PIEZOSURGERY® Explantation Inserts Mectron has recently launched on the market a new PIEZOSURGERY® surgical kit dedicated to explantation technique, consisting of 4 different insert shapes specifically developed for this procedure: EXP3-R, EXP3-L, EXP4-R, EXP4-L. Their right and left curved shape allows to better follow the implant surface assuring the maximum alveolar bone saving as well as the maximum cut precision compared with a traditional rotative instruments or trepan drills. EXP inserts are characterized by three or four teeth to better manage cylindrical and tapered implants. They are also suitable for eight tooth extractions providing the maximum cutting precision. website: www.mectron.com

MICRO-MEGA® présents… My MM Solutions! Discover MICRO-MEGA® solutions, developed for you and with you… All our savoir-faire for your comfort and that of your patients… Your MM Solutions! One Shape®: My single file in continuous rotation Simplicity, Effectiveness, Solution Revo-S™: My sequence with asymmetrical cross section files Solution, Safety, Universality website: www.micro-mega.com

Dental News, Volume XXI, Number I, 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.


Profile for Dental News

Dental News March 2014  

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

Dental News March 2014  

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

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