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ISSN 2218-0885

International Arab Journal of Dentistry ‫المجلة العربية الدولية لطب االسنان‬

Revue arabe internationale de dentisterie

Vol. 4 – Issue 3


ISSN 2218-0885

International Arab Journal of Dentistry ‫اﻟﻤﺠﻠﺔ اﻟﻌﺮﺑﻴﺔ اﻟﺪوﻟﻴﺔ ﻟﻄﺐ اﻻﺳﻨﺎن‬

Revue arabe internationale de dentisterie

Vol. 4 – Issue 3

The International Arab Journal of Dentistry (IAJD) is a specialized, and refereed journal that is published quarterly in French and English. IAJD is the official journal of the Society of Arab Dental Faculties (SARDF) and is published by the Faculty of Dental Medicine - Saint-Joseph University of Beirut.

Université Saint-Joseph 2013 - International Arab Journal of Dentistry - www.iajd.org Society of Arab dental Faculties - www.sardf.org Published by Facuty of Dental Medicine, USJ All rights reserved For any information concerning the IAJD, please contact us by e-mail :

info@iajd.org or fmd@usj.edu.lb


AUTHOR GUIDELINES Submission Manuscripts should be submitted by one of the authors of the manuscript through the online Submission System. Regardless of the source of the word-processing tool, only electronic PDF (.pdf) or Word (.doc, .docx, .rtf) files can be submitted through the MTS with priority for PDF file. There is no page limit. The attached file should not exceed 12Mb for low speed connection, and 32 Mb for high speed connection. Only online submissions are accepted to facilitate rapid publication and minimize administrative costs. Submissions by anyone other than one of the authors will not be accepted. The submitting author takes responsibility for the paper during submission and peer review. If for some technical reason submission through the MTS is not possible, the author can contact info@iajd.org for support.The attached file should be scanned with an antivirus software before submitting. Terms of Submission Papers must be submitted on the understanding that they have not been published elsewhere (except in the form of an abstract or as part of a published lecture, review, or thesis) and are not currently under consideration by another journal published by Hindawi or any other publisher. The submitting author is responsible for ensuring that the article’s publication has been approved by all the other coauthors. It is also the authors’ responsibility to ensure that the articles emanating from a particular institution are submitted with the approval of the necessary institution. Only an acknowledgment from the editorial office officially establishes the date of receipt. Further correspondence and proofs will be sent to the author(s) before publication unless otherwise indicated. It is a condition of submission of a paper that the authors permit editing of the paper for readability. All enquiries concerning the publication of accepted papers should be addressed to info@iajd.org. Peer Review All manuscripts are subject to peer review and are expected to meet standards of academic excellence. Submissions will be considered by an editor and—if not rejected right away—by peer-reviewers, whose identities will remain anonymous to the authors. Units of Measurement Units of measurement should be presented simply and concisely using System International (SI) units. Title and Authorship Information The following information should be included: t 1BQFSUJUMF t 'VMMBVUIPSOBNFTonly in the submission form and not in the manuscript

www.iajd.org t 'VMMJOTUJUVUJPOBMNBJMJOHBEESFTTFT t&NBJMBEESFTTFT Abstract The manuscript should contain an abstract. The abstract should be self-contained and citation-free and should not exceed 150 words. Introduction This section should be succinct, with no subheadings. Acknowledgments All acknowledgments (if any) should be included at the very end of the paper before the references and may include supporting grants, presentations, and so forth. References Authors are responsible for ensuring that the information in each reference is complete and accurate. All references must be numbered consecutively and citations of references in text should be identified using numbers in square brackets (e.g., “as discussed by Smith [9]”; “as discussed elsewhere [9, 10]”). All references should be cited within the text; otherwise, these references will be automatically removed. Proofs Corrected proofs must be returned to the publisher within 2-3 days of receipt. The publisher will do everything possible to ensure prompt publication. It will therefore be appreciated if the manuscripts and figures conform from the outset to the style of the journal. Copyright Open access authors retain the copyrights of their papers, and all open access articles are distributed under the terms of the Creative Commons Attribution license, which permits unrestricted use, distribution and reproduction in any medium, provided that the original work is properly cited. The use of general descriptive names, trade names, trademarks, and so forth in this publication, even if not specifically identified, does not imply that these names are not protected by the relevant laws and regulations. While the advice and information in this journal are believed to be true and accurate on the date of its going to press, neither the authors, the editors, nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein.

Statements and opinions expressed in the articles and communications herein are those of the author(s) and not necessarily those of the editor or the publisher. Professional qualifications stated in each article are provided by authors. The editor and the publisher disclaim any responsibility or liability for such material and do not guarantee, warrant or endorse any product or service advertised in this publication nor do they guarantee any claim made by the manufacturer on such product or services.


COMITÉ DE RÉDACTION - EDITORIAL BOARD Rédacteur en chef – Editor-in-Chief Prof. Edgard NEHMÉ Faculty of Dental Medicine, Saint-Joseph University, Lebanon

Comité exécutif de l’association des facultés dentaires arabes - Officers Society of Arab Dental Faculties

Rédacteur en chef adjoint - Associate Editor

Prof. Nada BOU-ABBOUD NAAMAN, General Secretary, Dean Faculty of Dental Medicine, Saint-Joseph University, Lebanon

Dr. Hiam WEHBÉ Faculty of Dental Medicine, Saint-Joseph University, Lebanon

Prof. Ihab ABDEL MOHAMMAD HAMMAD, Dean Faculty of Dental Medicine, University of Alexandria, Egypt

Comité de Direction – Editorial Advisory Board

Prof. Elham ABU ALHAIJA, Dean Faculty of Dentistry, Jordan University of Science and Technology, Jordan

Ass. Prof. Roula ABIAD Prof. Nabih BADAWI Ass. Prof. Antoine BERBERI Dr. Pascale HABRE HALLAGE Ass. Prof. Jeanine HOYEK GEBEILY Ass. Prof. Alfred NAAMAN Ass. Prof. Balsam NOUEIRY Dr. Ziad NOUJEIM Prof. Issam OSMAN Prof. Khaldoun RIFAI Prof. Fayez SALEH Prof. Lucette SEGAAN

Prof. Jawad BEHBEHANI, Dean Faculty of Dental Medicine, Kuwait University, Kuwait Prof. Amal AL-WAZZANI, Dean Faculty of Dental Medicine, Hassan 2 University, Morocco Prof. Razan KHATTAB, Dean Faculty of Dental Medicine, University of Damascus, Syria Prof. Antoine KHOURY, telltale & treasurer, Saint-Joseph University, Lebanon

COMITÉ DE LECTURE – SCIENTIFIC BOARD Ass. Prof. Alfred Naaman, Lebanon Prof. Nada Naaman, Lebanon Prof. Balsam Noueiry, Lebanon Dr. Ziad Noujeim, Lebanon Prof. Issam Osman, Lebanon Prof. Lamia Oualha, Tunisia Prof. Herve Reychler, Belgium Dr. Faouzi Riachi, Lebanon Prof. Sana Rida, Morocco Prof. Khaldoun Rifai, Lebanon Prof. Nouhad Rizk, Lebanon Prof. Joseph Sader, Lebanon Prof. Fayez Saleh, Lebanon Prof. Elizabeth Sarkis, Syria Prof. Lucette Segaan, Lebanon Dr. Bassel Tarkaji, Syria Prof. Georges Tawil, Lebanon Prof. Abed Yakan, Syria Prof. Nadia Ahmad Yehia, Sudan Dr. Ronald Younes, Lebanon Prof. Mohamed Youssef, Syria Ass. Prof. Carina Zogheib, Lebanon

Ass. Prof. Khansa Ababneh, Jordan Prof. Nabil Abdel Fattah, Iraq Prof. Maha Abdel Salam, Egypt Ass. Prof. Roula Abiad, Lebanon Prof. Elham Abu Alhaija, Jordan Prof. Salem Abu Fanas, UAE Prof. Hani Amin, Egypt Ass. Prof. Ola Al- Batayneh, Jordan Prof. Fouad Al-Belassi, Egypt Prof. Fahed Al-Harbi, KSA Prof. Abadi Al-Kadi, Egypt Dr. Qasem Al- Omari, Kuwait Prof. Abdallah Al-Shammari, KSA Prof. Khaled Al-Wazzan, KSA Prof. Amal Al-Wazzani, Maroc Prof. Athanasios Athanasiou, Greece Prof. Nabih Badawi, Lebanon Prof. Zaid Baqaeen, Jordan Ass. Prof. Nayla Bassil- Nassif, Lebanon Prof. Jawad Behbehani, Kuwait Prof. Joseph Bou Serhal, Lebanon Ass. Prof. Antoine Berberi, Lebanon Ass. Prof. Paul Boulos, Lebanon Dr. Diego Capri, Italy

Dr. Robert Cavezian, France Prof. Nada Chedid, Lebanon Dr. Maroun Dagher, Lebanon Dr. Maha Daou, Lebanon Prof. Azmi Darwazeh, Jordan Prof. Mounir Doumit, Lebanon Miss Lea El Korh, Lebanon Prof. Kifah El-Jemaani, Jordan Prof. Rabab el-Sabbagh, Syria Dr. Amine El Zoghbi, Lebanon Dr. Pascale Habre- Hallage, Lebanon Prof. Ahmad Hamdan, Jordan Prof. Ihab Abdel Mohammad Hammad, Egypt Prof. Raed Moheiddine Helmi, Iraq Ass. Prof. Jeanine Hoyek Gebeily, Lebanon Prof. Mohammad Mazen Kabbani, Syria Prof. Imad Keaid, Syria Prof. Carlos Khairallah, Lebanon Prof. Razan Khattab, Syria Prof. Ammar Laika, Syria Ass. Prof. Nada Mchayleh, Lebanon Prof. Ahmed Medra, Egypt Prof. Raad Mehieddine Helmi, Iraq Dr. Nadim Mokbel, Lebanon

Secrétaire de rédaction – Editing Secretary

Conception et mise en page – Design and Layout

Impression et diffusion – Printing and Promotion

Miss Mireille Abdallah Faculty of Dental Medicine, Saint-Joseph University, Lebanon

Alarm sarl, Beirut, Lebanon

Dental News group, Beirut, Lebanon

mireille.abdallah@usj.edu.lb


EDITORIAL « Le propos de toute morale, c’est de considérer la vie humaine comme une partie que l’on peut gagner ou perdre et d’enseigner à l’homme le moyen de gagner » Pour une morale de l’ambigüité, Simone de Beauvoir

Pr. Edgard Nehmé Editeur

ETHIQUE, MORALE ET RÉDACTION MÉDICALE

Chères lectrices, Chers lecteurs, Les nombreux articles régulièrement réceptionnés par le comité de rédaction font l’objet d’une première lecture avant d’être soumis à une double évaluation, ou plus, de la part d’éminents experts. Cette procédure n’a rien d’extraordinaire. Elle est appliquée par la majorité des éditeurs du monde scientifique. En plus de la présélection des articles, le rôle du comité éditorial est de veiller au respect par les auteurs des évaluations anonymes, c.a.d. des remarques touchant le fond et la forme, dans le but d’améliorer au mieux la qualité des publications. Le comité se doit aussi de s’assurer que l’article n’a pas été déjà soumis puis publié dans une autre revue. Malheureusement, il nous est arrivé de refuser les quelques rares articles dont leurs auteurs avaient intentionnellement ou non occulté leur parution préalable dans d’autres revues. La rédaction leur a signifié la décision d’éviction de la procédure d’évaluation. Tout article portant dorénavant la signature de ces mêmes auteurs sera automatiquement rejeté. Afin d’éviter la répétition de ce genre d’incidents, il nous parait utile de rappeler certaines règles et exigences universellement appliquées par les revues médicales. D’abord celles relatives aux publications secondaires. Celles-là sont admises, voire bénéfiques, dès qu’il s’agit d’une meilleure diffusion de l’information, encore que le thème et la qualité du contenu et de la rédaction puissent être scientifiquement précis, crédibles et vérifiables. Publiées dans la même langue ou soumises à une traduction dans une autre langue avec laquelle elles ont déjà été publiées, les publications secondaires se doivent de respecter certaines conditions :


tMBVUFVSEPJUPCUFOJSMBQFSNJTTJPOEFTS�EBDUFVSTFODIFGEFTEFVYSFWVFTDPODFSO�FT-FOWPJ au rÊdacteur qui assume la publication secondaire d’une photocopie, d’un manuscrit de la première version ou d’un tirÊ-à -part est impÊratif ; tMBQSJPSJU�EFMBQSFNJÒSFQVCMJDBUJPOFTUSFTQFDU�FTJMFE�DBMBHFFTUEBVNPJOTVOFTFNBJOF  sauf si les deux rÊdacteurs en conviennent autrement ; tMBQVCMJDBUJPOTFDPOEBJSFFTUBESFTT�FËVOFDPNNVOBVU�EFMFDUFVSTEJGG�SFOUT6OFWFSTJPO abrÊgÊe est recommandÊe ; tMBWFSTJPOTFDPOEBJSFEPJUSFGM�UFSMFTEPOO�FTFUMFTJOUFSQS�UBUJPOTEFMBQSFNJÒSF tJOGPSNFSMFMFDUFVSFOCBTEFQBHFTVSMBQBHFUJUSFRVJMTBHJUEVOFWFSTJPOTFDPOEBJSF QVJT les pairs et les organismes de documentation que l’article a dÊjà ÊtÊ publiÊ en tout ou en partie et donner la rÊfÊrence de la première version. Nous rappelons enfin que la protection du droit des patients à la vie privÊe est une obligation morale et juridique et que tout empiÊtement sur ce droit sans leur consentement ÊclairÊ est considÊrÊ comme une infraction. Ce sur quoi la rÊdaction ne peut transiger et se voit obligÊe de refuser tout article dÊrogeant à ces principes de moralitÊ et d’Êthique. Nous espÊrons avoir pu Êclairer à travers ces informations les nombreux auteurs qui sollicitent des publications secondaires. Par la même occasion, nous remercions tous ceux qui ont enrichi la revue de travaux que nous avons eu le plaisir de publier depuis la crÊation de l’IAJD. Cordialement et bonne lecture


EDITORIAL “The purpose of all morality is to consider human life as a part that can win or lose and teach men the way to win.� For moral of ambiguity, Simone de Beauvoir

Pr. Edgard NehmĂŠ Editor-in-chief

ETHICS, MORALITY AND MEDICAL WRITING Dear readers, The numerous articles regularly received by the editorial board are subject to a first reading before being submitted to a double assessment, or more, from leading experts. This procedure has nothing extraordinary. It is applied by the majority of editors of the scientific community. In addition to the screening items, the role of the editorial board is to ensure compliance by the authors of anonymous evaluations, i.e. remarks concerning the form and content in order to better improve the quality of publications. The committee must also ensure that the article has not been previously submitted and published in another journal. Unfortunately, few papers which their authors had intentionally or not hidden their prior publication in other journals were excluded from the procedure of evaluation. The decision of eviction was immediately notified to authors. Therefore any item signed by these authors will be automatically rejected. To avoid the repetition of such incidents, it seems useful to recall certain rules and requirements universally applied by medical journals. First, those relating to secondary publications. These articles are accepted, even beneficial, since it allows a better dissemination of information, although the theme and the quality of content and writing are scientifically accurate, credible and verifiable. Published in the same language or subject to a translation into another language in which they have already been published, secondary publications must respect certain conditions: t5IFBVUIPSNVTUPCUBJOQFSNJTTJPOGSPNUIFFEJUPSTJODIJFGPGUIFUXPKPVSOBMTJOWPMWFE


He also must imperatively send to the editor who takes a secondary publication, a copy, a manuscript or a shot -for- share of the first version; t5IFQSJPSJUZPGUIFGJSTUQVCMJDBUJPOJTNFUJGUIFHBQJTBUMFBTUBXFFL VOMFTTPUIFSXJTFBHSFFE by the two editors; t4FDPOEBSZQVCMJDBUJPOJTBEESFTTFEUPBEJGGFSFOUDPNNVOJUZPGSFBEFST"OBCSJEHFEWFSTJPO is recommended; t5IFNJOPSWFSTJPONVTUSFGMFDUUIFEBUBBOEJOUFSQSFUBUJPOTPGUIFGJSTU t*OGPSNUIFSFBEFSJOBGPPUOPUFPOUIFUJUMFQBHFUIBUUIJTJTBNJOPSWFSTJPO UIFQFFSTBOEUIF documentation agencies that the article has already been published in whole or in part and give the reference of the first version. Finally, we recall that the protection of patients’ rights to privacy is a moral and legal obligation and that any infringement on that right without their consent is considered as an offense. That on which the editorial board can not compromise and is obliged to refuse any item at variance with the principles of morality and ethics. We hope to have enlightened through this information many authors seeking secondary publications. At the same time, we thank all those who have enriched the review of their work that we had the pleasure of publishing since the founding of the IAJD. Regards and good reading


SOMMAIRE | TABLE OF CONTENTS 97 97

ARTICLE SCIENTIFIQUE / SCIENTIFIC ARTICLE Endodontie / Endodontics A novel nano-calcium carbonate-polyurethane-based root canal obturation material: Synthesis and evaluation of some physical properties Jaafar Bahar / Salim Alsalim / Raad Niama Dayem

103

Dentisterie Restauratrice / Restorative Dentistry Evaluation of the microleakage of different class V cavities prepared by using Er:YAG laser, ultrasonic device, and conventional rotary instruments with two dentine bonding systems Gulshang Ahmed Muhammed / Raad Niama Dayem

109 109

A PROPOS D’UN CAS / CASE REPORT Orthodontie / Orthondontics Improving facial esthetics using miniscrews: A case report Elie Khoury

119

Médecine Orale / Oral Medicine Concomitant occurrence of type I neurofibromatosis and lobular capillary hemangioma in the oral cavity – A case report Issrani Rakhi

126

CONGRÈS SCIENTIFIQUES INTERNATIONAUX 2014 SCIENTIFIC INTERNATIONAL MEETINGS 2014


ARTICLE SCIENTIFIQUE | SCIENTIFIC ARTICLE

Endodontie / Endodontics

A NOVEL NANO-CALCIUM CARBONATEPOLYURETHANE-BASED ROOT CANAL OBTURATION MATERIAL: SYNTHESIS AND EVALUATION OF SOME PHYSICAL PROPERTIES Jaafar Bahar * | Salim Alsalim ** | Raad Niama Dayem ***

Abstract The aim of this study was to prepare a new root canal obturation material named “nano-calcium carbonate-polyurethane” and to evaluate three of its physical properties which are solubility, water sorption and radiopacity. Polycarbonate 1, 6-hexamethylene diisocyanate, NCO 49.79%, and 1, 4-butanediol were mixed together to form polycarbonatebased thermoplastic polyurethane (TPU). Additive materials like nano-calcium carbonate powder, zinc oxide, calcium hydroxide and barium sulfate with different ratios were blend together with the polycarbonate-based thermoplastic polyurethane to form the final obturation material. The nano-calcium carbonate-polyurethane was found to be a promising root canal filling material; the percentages of solubility, water sorption and radiopacity were consistent with ISO standards. Keywords: Polyurethane - nano-calcium carbonate - root canal obturation - water sorption – solubility – radiopacity.

Résumé Le but de cette étude était de préparer un nouveau matériau d’obturation canalaire et d’évaluer trois de ses propriétés physiques qui sont la solubilité, l’absorption d’eau et la radio-opacité. Le polycarbonate 1, 6-hexaméthylène diisocyanate, NCO 49,79%, et le 1, 4-butanediol ont été mélangés pour former le polyuréthane thermoplastique à base de polycarbonate (TPU). Des matières additives comme le nano poudre de carbonate de calcium, l’oxyde de zinc, l’hydroxyde de calcium et le sulfate de baryum ont été mélangés à des proportions différentes au polyuréthane thermoplastique à base de polycarbonate pour former le matériau d’obturation définitive. Le produit obtenu est un matériau de remplissage canalaire prometteur, les pourcentages de solubilité, d’absorption d’eau et de radio-opacité étant conformes aux normes ISO. Mots-clés: polyuréthane - nano poudre de carbonate de calcium - obturation canalaire - absorption d’eau - radio-opacité – solubilité.

* BDS, MSc ** BDS, HDD, PhD College of Dentistry, University of Hawler, Iraq College of Dentistry, University of Hawler, Iraq

*** B.D.S., M.Sc., Ph.D, NBD Conservative Dentistry, Troy, Michigan, USA raad_niama2003@yahoo.com


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Introduction The success of endodontic therapy depends not only on adequate access and thorough biomechanical preparation but also on proper obturation. Several techniques and materials have been used for root canal obturation. The most popular and tested materials of choice are gutta percha and Resilon™. Despite its several advantages, gutta percha has some disadvantages such as the lack of bonding to root dentin leading to microleakage, the increased shrinkage when used as thermoplasticized material and the non-reinforcement of the root structure. Resilon™ has been introduced as a superior alternative to gutta percha. This synthetic polymer provides a better seal and reinforces the tooth structure through a combination of primer, dual cure sealer and resin obturating material [1]. The polyester chemistry containing bioactive and radiopaque fillers have been developed and tested. It performs and looks like gutta-percha. In addition, when used in conjunction with a resin-based sealant or bonding agent, it forms a monoblock that bonds to the dentinal walls. However, Resilon™ presents some disadvantages such as low push-out bond strength [1], low cohesive strength and stiffness [2] and inability to achieve a complete hermetic apical seal [3]. These results indicate that a more appropriate material for root canal obturation still needs to be developed. Lee et al. [4] in 2008 developed a new polyurethane-based composite to serve as a root canal obturation material and a visible-light curable urethane-acrylate/tripropylene glycol diacrylate (UA/TPGDA) oligomer to serve as a root canal sealer. This material has excellent properties; its major disadvantage was its chemical composition containing polybutylene adipate polyol (PBA) which decomposes with time [4]. So, in the long run, this material may lose some of its physical and mechanical properties. Polycarbonate is a stable polyol and lasts for long time without biologi-

cal disintegration. Calcium carbonate nanopowder exhibited good properties when mixed with polyurethane. The major aim of this study was to prepare a root canal filling material by using polycarbonate polyol in combination with calcium carbonate nanopowder and other additives to enhance the physical properties of the previously prepared thermoplastic polyurethane obturating material [5]. The absorption of water by polymers is a phenomenon of considerable importance since it is accompanied by dimensional changes; it reduces the tensile strength of the material. Regarding the solubility, it represents the mass of soluble materials of the polymers that may affect the periapical tissue [6]. Moreover, the root canal filling material should present enough radiopacity to allow its distinction from the adjacent anatomical structures (bone, tooth structure).

Materials and Methods Preparation of Nano CaCO3/TPU composite as a root canal–filling material Polycarbonate (Poly-CD® CD220, carbonic acid, dimethyl ester, polymer with 1,6-hexanediol. MW 2000. Arch Chemicals, Inc, USA ), 1,6-hexamethylene diisocyanate, NCO 49.79%, (HDI, Bayer Material Sciences, USA), and 1,4-butanediol (1,4-BD, Alfa Aesar, USA) were mixed in 1:1.12:0.1 molar ratios, dissolved in acetone (Acetone 99.5%, Sigma-Aldrich, USA) and reacted to form polycarbonate based TPU. All chemicals used in this study are listed in tables 1 and 2. Polycarbonate polyol and chain extender were checked for H2O content using Karl –Fischer device. Water content was in the range of 0.01-0.05. Isocyanate was used as received from the supplier and isocyanate content was determined by the di-n-Butylamine method. The NCO content was 49%. All other additives ingredients were used as received. The polymerization reaction was carried out in 600 ml reaction cattle which were equip-

ped with a mechanical stirrer, thermocouple, heater, nitrogen inlet and reflux condenser. Polycarbonate polyol was weighted and added to reaction cattle, then 1,4BD was added, followed by the catalyst. Then acetone was added to the mixture and mixed with a stirrer. The reaction mixture was heated up to 50°C and the HDI was added via funnel. After addition of HDI, the funnel was rinsed with a small amount of acetone and the reaction was continued for 2 hours at 50°C. During the synthesis, additional amount of acetone was added due to the high viscosity of polymer solution. After 2 hours of synthesis, clear viscous polymer solution was obtained. When polymerization was achieved, a sample for NCO% determination was taken. Additives mixing ratio Filler materials shown in table 3 were added to the solution of polyurethane in the following ratios: 50 (%) weight of polyurethane solution and 50% fillers to form CaCo3/TPU composite .

Water sorption and solubility Specimen preparation A total of 10 discs of the new materials were prepared using a metal mold. Each specimen disc was 20 mm in diameter and 1.5 ± 0.1 mm thickness. A plastic spatula was used to condense the mixed material. A piece of polyester transparent film was placed below and over the mold. Test procedure The specimens were transferred to the desiccators containing silica gel, freshly dried for 5 hours at 130°C. They were maintained in the desiccators at 37 ± 1°C. After 24 hours, the specimens were removed and stored in a second desiccator which contained silica gel (freshly dried for 5 hours at 130°C) and stored at the lower temperature (room) of 23 ± 1°C for 1 hour. The specimens were weighed using an analytical


99 Endodontie / Endodontics Material

Designation

Composition

Supplier

Polyols

Poly-CD® CD220 (PCA)

Carbonic acid, dimethyl ester, polymer with 1,6- hexandiol. MW 2000, OH-number 55.6

Arch Chemicals, Inc.USA

Chain extender

1,4 BD

1,4 –butanediol equivalent weight 45 (MW 90)

Alfa Aesar, USA

Isocyanate : Desmodur H (HDI)

Hexamethylene-1,6Diisocyanate, NCO %49.79.

Bayer Material Sciences, USA

Catalyst

Dabco® T-12 (0.1%)

Dibutyltin dilaurate

Air Products, USA

Solvent

Acetone

Aceton C3H6O 99.5%

Sigma –Aldrich,USA

Table 1: Raw materials used in the study.

Designation

Composition

Supplier

Zinc Oxid (ZnO)

$&6UHDJHQW•

Sigma- Aldrich

Barium Sulfate (BaSo4)

Reagent plus 99%

Sigma-Aldrich

Calcium hydroxide (Ca(OH)2)

$&6UHDJHQW•

Sigma –Aldrich

Calcium carbonte nanoparticles (CaCo3)

15-40 nm surface modified for adhesives

Sky Spring Nanomaterials, Inc.

Table 2: Additives raw materials.

% weight of additives

Calcium Carbonate

Zinc Oxide

Calcium hydroxide

Barium sulfate

50%

12

25

10

3

7DEOH:HLJKWSHUFHQWDJHRIWKHÀOOHUV

balance (Mettler Analytical Balance, Gallenkamp Mettler, E. Mettler, Zurich, Switzerland) to an accuracy of ± 0.1mg. This cycle was repeated until a constant mass (m1) was obtained, i.e. until the mass loss of each specimen was not more than 0.2 mg in any 24-hour period. The specimens were immersed in distilled water, and maintained at 37°C for seven days. After that, the specimens were removed, washed with water, surface water blotted away until free from visible moisture, and waved in the air for 15 seconds, then finally weighed 1 minute after being removed from the water. Their mass (m2) was recorded. The specimens were placed in the desiccator using the same cycle

as described above to obtain m1. This cycle was repeated until constant mass (m3) was obtained. Finally, the thickness of the specimens was measured by taking three readings in the center of each specimen. The mean value of thickness of each specimen was used to calculate the volume (V) in cubic millimeters [6]. Calculations and expression of results The values of water sorption (WSP) were calculated in micrograms per cubic millimeter for each specimen by applying the following equation: WSP = (m2 – m3)/ V where:

- m2 is the mass of the conditioned specimen in micrograms, after immersion in water for seven days. - m3 is the reconditioned mass of the specimen in micrograms. -V is the volume of the specimen in cubic millimeters. The values of water solubility were calculated in micrograms per cubic millimeter for each specimen by applying the following equation: WSL = (m1 – m3 )/ V where: -m1 is the conditioned mass in micrograms. -m3 is the reconditioned mass of the specimen in micrograms.


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Fig. 1: Densitometer, some specimens and aluminum step wedge used for radiopacity test.

-V is the volume of the specimen in cubic millimeters [6].

Radiopacity A washer of 10mm internal diameter and 1mm height was filled with the mixed material and radiographed together with an aluminum step wedge having an incremental thickness of 1 to 9mm. The radiopacity of ten specimens was compared with that of the step wedge by means of a densitometer (Heiland electronic, Wetzler, Germany (Fig. 1). The minimum requirement is 6 mm Al-equivalents, which may be on the low side considering that conventional gutta-percha points are about 6mm Al-equivalents. Most materials are in the range of 4–9 mm (ANSI/A.D.A Specification No.78) [7].

Results Solubility and water sorption The solubility of nano-calcium carbonate polyurethane material in micrograms per cubic millimeter was 0.0035 ±.0003, while the water sorption was 0.0047±.001. The allowable ratio for solubility for our material according to ISO specification is 0.026 g which represents 3% of the total weight (0.869 g) as shown in table 4 and figure 2. Radiopacity

N

Minimum

Maximum

Mean

m1

10

.576

1.079

.869±.147

m2

10

.577

1.088

.875±.149

m3

10

.563

1.059

.851±.145

Volume of cylinder = r2*height *3.14

10

3.45

6.500

5.105±.880

Water sorption

10

.004

.007

.0047.0.001

Water solubility

10

.003

.004

.0035±.0001

Table 4: Percent of solubility and water sorption of nano-calcium carbonate polyurethane material in micrograms per cubic millimeter.

Tables 4 and 5 show the mean gray value and equivalent aluminum thickness (mm) of nano-calcium carbonate polyurethane. Radiopacity was expressed in millimeters of aluminum and higher value represented greater radiopacity. Nano-calcium carbonate polyurethane possessed a radiopacity equal to 0.92 mm which is closest to the 0.93, the score of aluminum with 6 mm, complying with the ISO requirements (Fig. 3).

ISO and ANSI/ADA have standardized some technological tests to investigate the physical properties of endodontic filling materials. Assessment of radiopacity, solubility and water sorption properties were realized as recommended by ISO standard (4049:1988). It appears from the results of water sorption and solubility that nano-calcium polyurethane material behaved satisfactorily with this standard.

Discussion

Solubility of a root canal filling is undesirable since it can cause the release of components biologically incompatible; moreover, the formation of gaps can negatively affect the hermetic seal of the root canal filling. According to ISO standards, the solubility of a root canal filling should not exceed 3% mass fraction. The value of solubility of nano-calcium carbonate polyurethane was within this limit (0.4%) [6].

The ideal root canal filling material that fulfills all the requirements for a successful endodontic treatment doesn’t exist. Preparation of new root canal material that can overcome the drawbacks observed with previous material is a realistic demand [8]. The polyol used for the thermoplastized polyurethane preparation by Lee et al. [4] in 2008 had a short life span and it was liable for biological disintegration. The aim of this study was to prepare a canal filling material using polycarbonate polyol that has a very good stability in time in combination with calcium carbonate nanopowder and other additives to enhance the mechanical and physical properties of previous materials [9].

Gravimetric analysis and SEM showed exposure of glass-filler particles of Resilon™ following surface dissolution of the polymer matrix, creating a rough surface topography after incubation in lipase PS (from Burkholderia cepacia; Amano Enzyme Inc., Nagoya, Japan) or cholesterol esterase (from Pseudomonas species; Amano Enzyme Inc.) for 96 hours.


101 Endodontie / Endodontics

Fig. 2: The result of solubility and water sorption of nanocalcium carbonate polyurethane material in micrograms per cubic millimeter.

Sample 1

Sample 2

Sample 3

Sample 4

Sample 5

Sample 6

Sample 7

Sample 8

Sample 9

Sample 10

Mean

Standard deviation

0.92

0.89

0.84

1.07

0.89

0.89

1.07

0.84

0.89

0.92

0.92

±0.02

Table 5: The mean and standard deviation of radiopacity of nano-calcium carbonate polyurethane.

a

b

Figs. 3a and 3b: The mean gray value and equivalent aluminum thickness (mm) of nano-calcium carbonate polyurethane.

Similarly, the presence of spherical polymer droplets that appeared deformed, pitted or much reduced in dimensions was seen with Resilon™ after enzymatic hydrolysis. Rates of hydrolysis of Resilon™ by lipase PS and cholesterol esterase were much faster than those of polycaprolactone at 1 × or even 4 × enzyme concentrations. Field-emission SEM and energy dispersive spectrometric analyses showed that the resinous surface component of Resilon™ was hydrolyzed

after 20 minutes of sodium ethoxide immersion, exposing the spherulitic polymer structure, the subsurface glass and the bismuth oxychloride fillers. More severe erosion occurred after 60 minutes of sodium ethoxide treatment, while gutta-percha remained unaffected [9]. Furthermore, gutta-percha exhibited minimal surface changes after 4 months of incubation in wet dental sludge, while polycaprolactone and Resilon™ exhibited severe surface pit-

ting and erosion. In the latter, disappearance of the polymer matrix was accompanied by exposure of mineral and bioactive glass fillers. Bacteria and hyphae-like structures were present on the Resilon™ surfaces [9]. Radiopacity is widely acknowledged as a desirable property of all intraoral materials, including the endodontic root canal material. The root canal filling material must be radiopaque in order to detect the extension and the quality of the filling. Beyer-Olsen &


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$UWLFOHVFLHQWLĂ€TXH_6FLHQWLĂ€F$UWLFOH Orstavik [10] established a standardized system to evaluate the radiopacity. They used an aluminum step-wedge with 2mm increments as a reference to determine the equivalent aluminum thickness of the studied materials. In literature usually, conventional radiographic films and optical densitometers were used to evaluate the radiopacity of filling materials. However, in some studies, converting the radiographs to digital images was also used as an alternative to optical densitometer [8]. Rasimick et al. [11] stated that the imaging technique could affect the measured radiopacity values of the materials. Barium containing materials could have different radiopacities on film and phosphor store plates. Also differences could be found in the aluminum alloy of the step-wedge, exposure time, focal film distance, kVp, and mAs affects the radiopacity measurements of materials in situ [12]. The radiopacity of root canal filling should be at least 6 mm Al, but excessive radiopacity of the material is not mentioned by ISO standardization. The thermoplastic polyurethane base (TPU) is a radiolucent material, corresponding to 1 mm of the aluminum step wedge.

References

Conclusion

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The radiopacity rates of nano-calcium carbonate polyurethane used in the present study was consistent with ISO standards. The inorganic fillers like nano-calcium carbonate, zinc oxide, calcium hydroxide in addition to barium sulfate are considered radiopaque fillers, so they confer the radiopacity for the TPU. As a conclusion, the nano-calcium carbonate polyurethane is a promising root canal filling material with good physical properties that comply with ISO standardization.

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1. Gesi A, Raffaelli O, Goracci C, Pashley DH, Tay FR, Ferrari M. ,QWHUIDFLDOVWUHQJWKRI5HVLORQDQGJXWWDSHUFKDWRLQWUDUDGLFXODU dentin. J Endod 2005;31:809 â&#x20AC;&#x201C;13. 2. :LOOLDPV & /RXVKLQH 5- :HOOHU 51 3DVKOH\ '+ 7D\ )5 $ FRPSDULVRQRIFRKHVLYHVWUHQJWKDQGVWLIIQHVVRI5HVLORQDQG JXWWDSHUFKD-(QGRG² 3. 7D\)5/RXVKLQH5-:HOOHU51HWDO8OWUDVWUXFWXUDOHYDOXDWLRQ RIWKHDSLFDOVHDOLQURRWVĂ&#x20AC;OOHGZLWKDSRO\FDSURODFWRQHEDVHG URRWFDQDOĂ&#x20AC;OOLQJPDWHULDO-(QGRG²  /HH%+VLDQJ+XD/DL+/LDR./HH&+VLHK.DQG&KXQ3LQ/LQ $QRYHOSRO\XUHWKDQHEDVHGURRWFDQDO²REWXUDWLRQPDWHULDODQG XUHWKDQHDFU\ODWH²EDVHGURRWFDQDOVHDOHU3DUW(YDOXDWLRQ RISXVKRXWERQGVWUHQJWKV-(QGRG 5. 2HUWHO *XQWHU   3RO\XUHWKDQH +DQGERRN 1HZ <RUN 0DFPLOOHQ3XEOLVKLQJ&R,QF,6%1  (O+HMD]L$:DWHUVRUSWLRQDQGVROXELOLW\RIK\EULGDQGPLFURĂ&#x20AC;QH UHVLQVFRPSRVLWHĂ&#x20AC;OOLQJPDWHULDOV6DXGL'HQW-    7. $QGHUVRQ 7+ 0{QLFD &6 $QWRQLR /5 5DGLRSDFLW\ RI *ODVV ,RQRPHU&RPSRVLWH UHVLQ K\EULG PDWHULDOV %UD] 'HQW -    8. 'HHSWL 6KUHVWKD ;L :HL :DQ&XL :X -XQ4L /LQJ 5HVLORQ $ PHWKDFU\ODWH UHVLQEDVHG REWXUDWLRQ V\VWHP - 'HQW 6FL   ĂŻ 9. .XR+XDQJ +VLHK .HQ+VXDQ /LDR (GGLH +VLDQJ+XD /DL %RU 6KLXQQ /HH &KXQJ<L /HH DQG &KXQ3LQ /LQ $ QRYHO SRO\XUHWKDQHEDVHG URRW FDQDO² REWXUDWLRQ PDWHULDO DQG XUHWKDQHDFU\ODWH²EDVHGURRW&DQDOVHDOHUÂł3DUW,6\QWKHVLV DQGHYDOXDWLRQRIPHFKDQLFDODQGWKHUPDOSURSHUWLHV-(QGRG  10. %H\HU2OVHQ(02UVWDYLN'5DGLRSDFLW\RIURRWFDQDOVHDOHUV 2UDO6XUJ2UDO0HG2UDO3DWKRO0DU  


103

ARTICLE SCIENTIFIQUE | SCIENTIFIC ARTICLE

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EVALUATION OF THE MICROLEAKAGE OF DIFFERENT CLASS V CAVITIES PREPARED BY USING ER:YAG LASER, ULTRASONIC DEVICE AND CONVENTIONAL ROTARY INSTRUMENTS WITH TWO DENTIN BONDING SYSTEMS : AN IN VITRO STUDY Gulshang Ahmed Muhammed * | Raad Niama Dayem**

Abstract The aim of this study was to evaluate the extent of microleakage in class V cavities prepared with bur, Er:YAG laser and ultrasonic, hybridized with two different bonding agents (“Single bonding”, a solvent-free bonding agent, and “Swiss TEC SL bond”, an alcohol-based solvent). Thirty freshly extracted human premolars were divided into three groups of ten teeth each according to the device used in cavity preparation: Group1) Er:YAG laser (500 mJ, 10 Hz, 63.69J/cm 2 ); group 2) ultrasonic device and group 3) diamond burs. On each tooth, two cavities were prepared, one on the buccal surface and one on the lingual surface. Each group was subdivided into two subgroups of 5 teeth each according to the bonding system used: subgroup a) “Single bonding” and subgroup b) “Swiss TEC SL bond”. Cavities were restored with a micro-hybrid composite resin. After thermocycling, the specimens were immersed in 2% methylene blue solution for four hours and then sectioned in the buccolingual direction. Dye penetration was scored using a stereomicroscope. The two-way ANOVA test and paired t-test revealed no statistically significant differences among the methods of preparation (conventional, laser and ultrasonic). However, statistical differences were found between the adhesives tested; the “Single bonding” had lower microleakage values than “Swiss TEC SL bond”. Based on the results of this study it can be concluded that the Er:YAG laser and ultrasonic device are as effective as the conventional method in preparing cavities. The extent of microleakage depends on the type of the bonding agents. Keywords: Er:YAG laser – ultrasonic device - Single bonding – Swiss TEC SL bond – microleakage.

Résumé Cette étude visait à évaluer l’ampleur de micro-infiltration dans les cavités de classe V préparées conventionnellement par fraisage, par irradiation au laser Er: YAG ou par les ultrasons, hybridées avec deux adhésifs (« Single bonding », adhésif sans solvant, et « Suisse TEC SL bond », un solvant à base d’alcool). Trente prémolaires humaines fraîchement extraites ont été réparties en trois groupes de dix dents chacun suivant la modalité de préparation des cavités: groupe 1) Er: YAG (500 mJ, 10 Hz, 63.69J/cm 2); groupe 2) appareil à ultrasons et groupe 3) fraises diamantées. Sur chaque dent, deux cavités ont été préparées, l’une au niveau de la face vestibulaire et l’autre sur la face linguale. Chaque groupe a été subdivisé en deux sous-groupes de 5 dents chacun selon l’adhésif utilisé: sous-groupe a) « Single bonding » et sous-groupe b) « Swiss TEC SL bond ». Les cavités ont été restaurées avec une résine composite microhybride. Après thermocyclage, les échantillons ont été immergés dans une solution de bleu de méthylène à 2% pendant quatre heures, puis sectionnés dans le sens bucco-lingual. L’infiltration du colorant a été évaluée à l’aide d’une loupe binoculaire. Le test ANOVA et le test de Student apparié n’ont révélé aucune différence statistiquement significative entre les méthodes de préparation des cavités (conventionnelle, laser et ultrasons). Toutefois, des différences statistiquement significatives ont été observées entre les adhésifs testés, le “Single bonding” avait des valeurs de micro-infiltrations inférieures à celles du “Swiss TEC SL Bond”. En se basant sur les résultats de cette étude, on peut conclure que le laser Er :YAG et le dispositif à ultrasons sont aussi efficaces que la méthode conventionnelle de préparation des cavités. L’étendue de la micro-infiltration dépend du type des adhésifs appliqués. Mots- clés : Laser Er :YAG – adhésif - micro-infiltration.

* B.D.S, M.Sc Conservative Dentistry, College of Dentistry, University of Sulaimani, Iraq

** B.D.S., M.Sc., Ph.D, NBD Conservative Dentistry, Troy, Michigan, USA raad_niama2003@yahoo.com


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Introduction Numerous devices have been suggested for cavity preparation and finishing in an attempt to further preserve tooth structures and benefit from new bonding systems [1]. The Erbium: Yttrium-Aluminum Garnet (Er:YAG) laser ablates hard dental tissues effectively due to its highly efficient absorption in water and in hydroxyapatite [2]. It produces minimal thermal damage to the surrounding tissues [3]. When dental hard tissues were irradiated by the Er:YAG laser accompanied with fine water mist, the temperature was controlled and the cutting efficiency was increased [2]. Effective ablation of dental tissues by means of an Er:YAG laser system has been reported and its application in the removal of carious tissues or cavity preparations for restorations has been described. The ability of this laser to remove dentine and enamel was found comparable to that achieved with the conventional dental drill [4]. Ultrasonic instrumentation was described in 1847. Its use in the dental field was suggested in 1934 and implemented in the 1950’s by Nielsen et al. [5]. The stainless steel tips are adaptable to the handpiece of any ultrasonic instrument commonly used in dental offices for calculus removal [1, 6]. Microleakage refers to very small or microscopic openings between the margins of the composite restoration and the tooth structure through which fluid and bacteria can penetrate [7]. The microleakage is considered a major problem that may hinder the longevity of dental restorations [8]. Dentin bonding agents are composite resins with very low viscosity containing a minimal percentage of filler particles, capable of forming a hybrid layer between the resin and tooth structures [9]. Since a variety of dentin bonding systems have been developed for clinical use and the debate on the impact of lasers and ultrasonic for cavity pre-

paration continues, it is necessary to evaluate the composite filling margins in laser and ultrasonic prepared cavities with different bonding systems. This in vitro study aimed to compare and assess: - The effect of different methods of cavity preparation (Er:YAG laser, ultrasonic and conventional methods) on the microleakage. - The effect of two types of dentine bonding systems (Single bonding (SB) and Swiss TEC SL bond, Coltène Whaledent) on the microleakage.

of 2.94μm, laser handpiece R02F. The laser irradiation was performed in a non-contact mode to remove the dental hard tissue with a focused beam of 500 mJ energy, with a repetition rate of 10 Hz, under a continuous water mist (6 ml/min). The spot size was 1mm. The laser beam was kept perpendicular to the target during irradiation and the delivery kept within 12mm from the target area by adapting the hand piece to the horizontal arm of a surveyor. Energy density = Energy per pulse / Area…… (J/cm 2) [12]. Energy density= 63.69 J/cm 2

Materials and Methods

Group 2 Twenty cavities were prepared using ultrasonic scaler (Dentsply, USA) with a stainless steel tip and a SteriMate Handpiece under a water spray cooling (water flow rate 20ml/min to 30ml/min) [13]. The tip was operated at 60Hz oscillation frequency; it was adapted to the horizontal arm of the surveyor so that it can be kept perpendicular to the tooth surface (buccal or lingual).

Sample selection A total of thirty extracted human premolars free of caries, restorations, cracks or obvious defects had been cleaned and restored in 50% ethanol at 8°C for a maximum of one month following their extraction in order to avoid microbial contamination. This storage medium was chosen because it produces little change in dentin permeability. Prior to the experiments, the teeth were placed in water for 24 hours at 20°C [10]. Cavity preparation Standardized class V cavities were prepared on the buccal and lingual surfaces (3mm height, 3mm width and 2mm depth) about 1mm occlusal to the cemento-enamel junction. The outline of the cavity was drawn on the tooth surface with a 0.5 mechanical pencil using a matrix band with a precut hole of 3x3 mm which was fixed on the tooth with a retainer. The depth of the cavity was calibrated using a premarked periodontal probe. The cavities were prepared with a butt-joint in accordance with the international guidelines and the margins were not beveled [11]. Sample grouping Group 1 Twenty cavities were prepared using an Er:YAG laser system (TwinLight laser, Fotona, Italy) with a wave length

Group 3 Twenty cavities were prepared using a high speed turbine under water cooling and a straight, flat end, standard grain size bur n. 109/010 ISO oriented perpendicularly to the buccal or lingual surfaces of the tooth [11]. The bur was renewed after the preparation of 10 cavities. Conditioning of the enamel and dentin All cavities were acid-etched with a 37% phosphoric acid gel (Ivoclar Vivadent, Germany) for 15 seconds, washed with water spray for 30 seconds, air dried for 20 seconds and divided into two subgroups: - Subgroup 1a (10 cavities): Single bonding (DMP, USA) was applied to enamel/dentine surfaces with light brushing motion for 15 seconds and cured with halogen light for 30 seconds (according to the manufacturer’s instructions).


105 'HQWLVWHULH5HVWDXUDWULFH5HVWRUDWLYH'HQWLVWU\

Er:YAG cavity preparation Swiss TEC SL bond (alcohol-based bonding system)

Ultrasonic cavity preparation

Conventional cavity preparation

N

Mean

occlusal

10

1.30 ± 0.923

gingival

10

2.25 ± 0.639

occlusal

10

1.20 ± 0.410

gingival

10

1.55 ± 0.605

occlusal

10

1.50 ± 0.513

gingival

10

2.45 ± 0.510

N

Mean

occlusal

10

“

gingival

10

“

occlusal

10

“

gingival

10

“

occlusal

10

“

gingival

10

“

Table 1: Means of microleakage for Er:YAG laser, ultrasonic and conventional cavity preparations treated with “Swiss TEC SL bond” bonding system.

(U<$*ODVHUFDYLW\ SUHSDUDWLRQ Single bonding (solvent-free bonding system)

Ultrasonic cavity preparation

Conventional cavity preparation

Table 2: Means of microleakage for Er:YAG laser, ultrasonic and conventional cavity preparations treated with “Single bonding” system.

- Subgroup 1b (10 cavities): Swiss TEC SL bond (Coltene, Germany) was applied directly from the syringe onto a disposable brush, massaged into the cavity for 20 seconds and cured with halogen light for 30 seconds (according to the manufacturer’s instructions). Restoration procedure After application of the adhesive systems, all the cavities were filled with a microhybrid composite resin (Tetric® Ceram, Ivoclar- Vivadent, Germany), in one layer (using a plastic instrument) and light cured for 30 seconds. All the restored teeth were stored in distilled water at 37°C for one week using an electrical incubator.

Thermocycling and dying step To simulate clinical stress, the samples were thermocycled for 700 cycles. Each cycle consisted of a water bath at 5°C ± 2°C and 55°C ± 2°C with 60 seconds of dwell time [12]. After thermocycling, the apices of the samples were sealed with sticky wax to prevent dye penetration. The samples were also coated with two coats of waterproof nail varnish except for the 1mm rim of the margins of restoration. They were then immersed in 2% buffered methylene blue solution at pH 7 and stored for 4 hours. Following storage, the samples were rinsed with tap water for 5 minutes and prepared for sectioning. They were sectioned in the bucco-lin-

gual direction through the center of the restoration vertically, using a low speed water-cooled diamond disc in order to assess the degree of microleakage [12]. Scoring The sectioned teeth were examined under a stereomicroscope (power x40) and classified according to the dye penetration to the following grades [14]: Grade 0: No leakage. Grade 1: Leakage between cavo-surface and dentino-enamel junction. Grade 2: Leakage between dentinoenamel junction and axial wall. Grade 3: Leakage involve or beyond the axial wall.


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Results

Discussion

By using stereomicroscope (x40), two readings of dye penetration were done by two examiners for all the specimens. These readings corresponded to the microleakage of tooth restoration interfaces occlusally and gingivally. Descriptive statistics including means and standard deviations (SD) for the scores of dye penetration of all the treatments combination for restoration according to the type of bonding agents and the cavity preparation modality are shown in tables 1 and 2. When the cavities were treated with “Swiss TEC SL bond” bonding system, the conventional cavity preparation gave the highest value of microleakage (1.50) and the ultrasonic cavity preparation gave the lowest value (1.20) on the occlusal surface. On the gingival surface, the lowest value (1.55) of microleakage was observed for the ultrasonic cavity preparation while the highest value (2.45) was obtained with the conventional cavity preparation. When the cavities were treated with “Single bonding” bonding system, on the occlusal surface, the highest value of microleakage was observed for ultrasonic cavity preparation (1.10); the lowest value (0.45) was obtained with the conventional cavity preparation. However, on the gingival surface, the lowest microleakage value was obtained with the ultrasonic cavity preparation (2.00) whereas the Er:YAG laser cavity preparation gave the highest value (2.45). The two-way ANOVA test did not indicate a statistically significant difference in the occlusal and the gingival microleakage among the three groups (Er:YAG laser, ultrasonic and conventional cavity preparations) for the “Single bonding” system (p>0.05) However when the “Swiss TEC SL bond” was applied on the gingival wall, the ANOVA test showed a highly significant difference among the three modes of cavity preparation (p<0.01).

The ability of a dentin bonding agent to minimize the extent of microleakage at the tooth/restoration interface is an important factor in predicting clinical success. Failure of the restoration may contribute to marginal staining, adverse pulpal response, postoperative sensitivity and recurrent caries [15]. Therefore, the search for a material or technique that ensures appropriate adhesion of the restoration material to the tooth structure in order to minimize potential leakage is constant [4]. Our study examined the quality of composite filling margins in Er:YAG laser and ultrasonically prepared cavities compared to conventionally prepared restorations; all cavities were treated with either “Single bonding” or “Swiss TEC SL bond” bonding agents. The mean of occlusal microleakage of the restorations placed in the cavities treated with “Single bonding” system was the highest for the ultrasonically prepared cavities and the lowest for the conventionally prepared cavities. Several studies have reported a higher degree of microleakage around composite restorations when cavity preparation was done or treated by Er:YAG laser [16]. Furthermore, shear bond strength studies showed that Er:YAG laser created a laser-modified layer that adversely affected adhesion to dentin [16]. De Munck et al. [17] in 2002 observed that cavities prepared by laser appeared less receptive to adhesive procedures than conventionally prepared cavities. The authors stated that after acid-etching the laser-conditioned dentin, the hybridization effectiveness is compromised because of the selective ablation of organic tissue, leading to less exposed collagen and consequently less hybridized. These findings diverge from those of the present study in which laser-prepared cavities showed similar results to conventionally prepared ones. This might be explained by the fact that in the past studies, acid treatment was

not performed in laser-prepared cavities [17]. Several studies [18-21] stated that enamel and dentine surfaces treated with the Er:YAG laser are capable of decreasing microleakage of composite resin restorations; no significant differences between the laser and conventionally prepared cavities were found. In the study of Visuri et al. [22], laser-irradiated samples had improved bond strengths compared with acidetched and handpiece controls. Er:YAG laser preparation of dentin left a suitable surface for strong bonding or an applied composite material. When evaluating the microleakage in the occlusal wall, its value was statistically the highest when the “Swiss TEC SL bond” bonding system was applied in the Er:YAG laser irradiated cavities and conventionally prepared cavities. However, no statistically significant difference was observed between the two bonding systems in the ultrasonically prepared cavities. On the other hand, in the gingival microleakage, no statistically significant difference was found between the “Single bonding” and “Swiss TEC SL bond” systems in Er:YAG laser and conventional cavity preparations; however, a significant difference was observed in cavities prepared with ultrasonic device. Primer has been used to improve the bonding between the composite resin and the cavity walls. Current adhesive systems contain hydrophilic primers that utilize acetone, alcohol and/or water as solvent. These solvents carry the resin primers into the demineralized dentin by displacing water from the collagen network. Resin penetration into the collagen network and its occupation of the demineralized dentin is responsible for forming the interdiffusion zone or hybrid layer. HEMA is a hydrophilic monomer that penetrates into the collagen network. Its molecules are usually dissolved in different solutions with acetone, alcohol and/or water which work as chasers. These chasers compete with water present at the dentin sur-


107 'HQWLVWHULH5HVWDXUDWULFH5HVWRUDWLYH'HQWLVWU\ face by promoting a union of the water molecules and displacing water when compressed air is applied, permitting the penetration by the monomer [23]. Since “Single bonding” system contains special chemical components composed of HEMA with no other solvent, the water remnant in the dentin substrate would bend to HEMA within the “Single bonding”. Jacobsen et al. [24] showed that adhesive systems with alcohol are less sensitive to the technique utilized. Requirements for an effective dentin adhesive system include the ability of the system to thoroughly infiltrate the collagen network and the partially demineralized zone, to commingle and encapsulate the collagen and the hydroxyapatite crystallites at the surface of the demineralized dentin and to produce a well-polymerized durable hybrid layer [24]. In the present investigation all groups showed higher leakage on the gingival than on the occlusal walls with a highly significant statistical difference. The reason for this difference between gingival and occlusal leakage scores might be due to the fact that bonding to dentin is much more technique- and substrate-sensitive than bonding to enamel. There is no guarantee that bonding to dentin is as durable as to enamel. These results came in agreement with the results of Cagidiaco et al. [25] who suggested that the leakage observed at the cervical margins may be related to the relatively limited number of tubules and to the mainly organic nature of the dentin substrate. Enamel, when present at the cervical margin, is usually thin, aprismatic and bonds less well to resins. When polymerized, the resin composite shrinks towards the stronger bond at the occlusal margin and pulls away from the weaker bond at the gingival margins [25-27].

Conclusion The modality of cavity preparation didn’t have any effect on the microleakage values. The type of the bonding

agents was the major factor that affected the results. Within the confines of this in vitro study, it may be concluded that the “Single bonding” system, the solventfree bonding agent, showed lower microleakage values than the “Swiss TEC SL bond” system, the alcoholbased bonding agent.


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Orthodontie / 2UWKRQGRQWLFV

IMPROVING FACIAL ESTHETICS USING MINISCREWS: A CASE REPORT Elie Khoury*

Abstract The number of patients seeking treatment to improve their facial attractiveness is increasing. Nowadays orthodontic patients are requiring solutions to problems such as a minor gummy smile, a protruded lip, a posterior rotated mandible or even an open naso-labial angle. These problems are rarely all combined in one case, as biprotrusive lips are opposed to an open naso-labial angle, and solving one problem could aggravate the other. In this case report we describe the treatment of a hyperdivergent pattern patient resulting in a posterior positioning of the mandible with lack of chin. The patient had also a dental biprotrusion creating protruded lips combined to an open naso-labial angle and a minor gummy smile. The treatment consisted in correcting the protruded lips with concern not to widen the naso-labial angle. The vertical control for the anterior chin rotation and the gummy smile correction were done using miniscrews. Keywords : Miniscrews - naso-labial angle – gummy smile.

Résumé Le nombre de patients voulant améliorer l’esthétique du visage ne cesse d’augmenter. Les patients consultant pour un traitement orthodontique exigent, de nos jours, des solutions à des problèmes comme le sourire gingival, la biproalvéolie, un manque de menton par rotation postérieure mandibulaire ou même un angle naso-labial ouvert. Ces problèmes coexistent rarement chez un même patient puisque des lèvres protrusives vont à l’encontre d’un angle naso-labial ouvert, et la solution d’un problème pourrait aggraver l’autre. Ce cas clinique décrit le traitement d’une patiente hyperdivergente avec une rotation postérieure de la mandibule et un manque de menton. La patiente présente aussi une biproalvéolie créant des lèvres protrusives, un angle naso-labial ouvert et un sourire gingival. Le traitement a consisté à corriger la biproalvéolie avec le souci de ne pas aggraver l’angle naso-labial. Le control vertical nécessaire pour avancer le menton et éliminer le sourire gingival a été effectué à l’aide de minivis. Mots-clés : minivis – angle naso-labial – sourire gingival.

* PhD, Senior lecturer, Dpt of Orthodontics and Dentofacial Orthopedics Faculty of Dentistry, Saint Joseph University of Beirut, Lebanon khoury.es@gmail.com


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Introduction Besides aligning the teeth in order to get a beautiful smile, facial esthetics is becoming a major concern for many orthodontic patients. As a matter of fact, patients are much more aware and requiring solutions to problems such as a minor gummy smile, protrusive lips, a posterior rotated mandible or even an open naso-labial angle. In the presence of exaggerated protrusive lips, premolars extraction is usually recommended followed by the retraction of the anterior teeth, with maximum anchorage, to prevent a forward movement of the molars [1, 2]. In contrast, for posteriorly rotated mandible cases, molar drifting is regarded as very important to obtain a control of the vertical dimension during orthodontic treatment, and therefore a forward movement of the chin [3-5]. However, many authors consider this procedure alone to be insufficient for vertical control, as all orthodontic mechanics are extrusive to some degree, which also increases the vertical dimension [6].That is why several strategies concerning treatment mechanics have been proposed to control vertical dimensions, such as a high-pull head gear, a low palatal bar, posterior bite-blocks or even posterior magnets [5, 7, 8]. All these appliances need patient compliance in a way, and some are considered too demanding for most patients, resulting in a vertical control loss [1]. The introduction of skeletal anchorage as a source of fixed anchorage to orthodontic treatment has solved many problems including patient cooperation. Nowadays, miniscrews have become a chosen appliance for securing anchorage in clinical orthodontics [9, 10]. Because of their small dimensions, miniscrews offer many advantages such as immediate loading, multiple placement sites including interdental areas, relatively simple placement and removal, and minimal patient expenses [10]. Miniscrews are used mainly for maximum anchorage

by stabilizing the posterior teeth and pulling the anterior bloc backwards. They are also implemented for vertical control or dental intrusion especially in the presence of a gummy smile [11-13]. This case report describes the treatment of a hyperdivergent pattern patient with protruded upper and lower incisors creating a convex profile combined to a contrasted open nasolabial angle and a minor gummy smile.

Case presentation The patient is a Lebanese girl aged 15 years 2 months. She came with her mother seeking orthodontic treatment to improve her facial esthetics. They were both aware of the protrusion of the patient’s upper and lower incisors, and were bothered by her lips’ protrusion and as well as her lack of chin. They also had concerns about her open naso-labial angle and her gummy smile. They confirmed that these problems were hereditary, as most of the women in the family had the same familiar characteristics. The patient’s extraoral examination showed a small deviation of the nose to the right, with a tendency towards a long face syndrome. She presented a minor gummy smile posteriorly and anteriorly. Her profile was convex, with a retrusive chin and an open nasolabial angle [Fig. 1]. Intraorally, the upper midline was deviated 0.5 mm to the right while the lower midline was on. She had class I molars and class II canines on both sides with biprotrusive incisors, no crowding on both arches, and a curve of Spee of 1.5 mm on each side of the lower arch [Fig. 2]. The lateral cephalometric analysis confirmed the hyperdivergent growth pattern (FMA= 31°), as well as the lower incisor important proclination (FMIA= 47°; IMPA= 102°), and the upper incisor significant proclination (IFPA= 118°). It also indicated a skeletal class II relation (ANB= 6.5°) due to a retrognathic mandible (SNB= 76°), while the Z angle (58.5°) conveyed

a convex profile due predominantly to the proclined lower lip combined to the retrusive chin. The panoramic radiograph showed the presence of the wisdom teeth at the crown formation stage [Figs. 3, 4]. Treatment objectives - Correct the biprotrusive incisors and lips to get a more harmonious profile. - Maintain the naso-labial angle since it is already wide open and the retraction of the upper lip will aggravate it. - Improve the gummy smile. - Control the vertical dimension and achieve a counterclockwise rotation of the mandible and the chin to ameliorate the profile and the skeletal class II. Treatment alternatives Three treatment options were considered: 1: Extraction of the four first premolars with maximum anchorage to correct the biprotrusion with posterior miniscrews for vertical control and anchorage control with the risk of widening the naso-labial angle. 2: Extraction of the upper first premolars and lower second premolars, with a reciprocal space closure, inducing a molar mesial drifting and an incisor rabbiting. Miniscrews will be used for vertical control and gummy smile correction. 3: Extraction of the maxillary second premolars in order to get molar drifting combined to incisor retraction, and extraction of the mandibular first premolar for incisor repositioning. An orthognathic surgery for maxillary impaction and maybe protrusion, as well as a counterclockwise rotation of the mandible, will complete the orthodontic treatment. This will correct the lips protrusion, the open naso-labial angle, the gummy smile, the chin retrusion and the vertical problem. Option 2 was selected as it presented the best and less invasive mean for achieving our treatment objectives.


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Fig. 1: Pre-treatment facial photographs.

Fig. 2: Pre-treatment intra-oral photographs.

Fig. 3: Pre-treatment panoramic and lateral cephalometric radiographs.


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Fig. 4: Pre-treatment cephalometric analysis.

Treatment progress After extracting the four premolars, both arches were bonded using .022"x.028" Roth information brackets, with bands placed on the first and second molars. The arches were leveled using .016 Nickel-Titanium (NiTi) wires then .017x.025 NiTi, followed by .019x.025 Stainless Steel (SS) wires. In the maxillary arch, retraction of the cuspids was initiated at this stage, using power chain elastics from the second molars to the canines, then from the first molars to the canines to allow some molar mesialisation. In the mandibular arch, retraction of the cuspids and the first premolars was also initiated on the .019x.025 SS wire, using power chain elastics from the second molars to the canines. In the middle of the cuspids and premolars retraction, a .019x.025 SS closing wire was placed to obtain a reciprocal space closure. This closing wire helps protract the molars, while the incisors undergo a posterior rab-

biting. In the Roth brackets, the lower incisor torque is null, and the play existing between the 0.22x.028 bracket and the 0.19x.025 wire is sufficient to get a good rabbiting without torque control. Furthermore, the significant protrusion of the incisors contributes to creating a negative torque when the straight wire is introduced in the bracket slot, which helps the rabbiting procedure needed in this case [Fig. 5]. In the maxillary arch, when the cuspids were fully retracted, a .019x.025 closing loop wire was used to retract the upper incisors while creating rabbiting during space closure. Before the end of the anterior space closure, two miniscrews (Absoanchor, Dentos, Korea) were placed between the central and the lateral incisors in the maxillary arch. The miniscrews had a diameter of 1.3 mm and a length of 8 mm; they were placed in the alveolar bone as high as possible in the attached gingiva. The miniscrews were used to intrude the anterior incisors

while retracting them, for gummy smile correction. An intrusive step was placed in the arch between the laterals incisors and the canines in order to intrude the posterior segment for better vertical control and posterior gummy smile correction [Figs. 6, 7]. At the end of space closure, vertical elastics were used in the presence of miniscrews, for a very short period of time, to seat the occlusion. After 23 months of active treatment, fixed appliances and miniscrews were removed. Canine-to-canine lingual retainers were bonded to the maxillary and mandibular arches, and a removable retainer was placed on the upper arch as well. The patient was asked to wear her removable retainer full-time for one year and at night for as long as possible. She must consult a speech therapist to ascertain the stability of the final result. The patient was advised to come back for followups every 3 months to control wisdom teeth eruption.


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Fig. 5: Treatment progress with lower space closure and upper retraction of the cuspids.

Fig. 6: Treatment progress with upper space closure, upper intrusion using miniscrews and an upper intrusive posterior step between laterals and cuspids.

Fig. 7: Amount of intrusion using miniscrews with the upper intrusive posterior step.


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Fig. 8: Post-treatment facial photographs.

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Fig. 10: Smile changes before and after treatment. The patient is smiling and not laughing to the maximum.

Treatment result Treatment resulted in a facial esthetic improvement. The lips were retracted leading to a better harmonious profile. The patient did not show any significant mandibular growth; however, a forward and anterior movement of the chin was observed due to the vertical control. The minor gummy smile was also corrected using miniscrews and the teeth became more consonant with the smile line. Finally, the naso-labial angle was not altered, but was retained in its original dimen-

sion, in respect to the treatment objectives [Figs. 8, 9 and 10]. Intraorally, both upper and lower incisors were retracted and tipped backward while the molars on both arches encountered a mesial movement. Upper central incisors were intruded. Class I canine was achieved with normal overjet and overbite and good interdigitation between the dental arches. No interference was noted in the protrusion and laterality [Fig. 11]. The lateral cephalometric radiograph analysis confirmed the upper

incisor retraction as IFPA was reduced from 118° to 106° mainly by backward tipping, as well as the uprighting of the lower incisors (IMPA decreased from 102° to 92°). The skeletal Class II was improved mainly by a mandibular forward repositioning (ANB changed from 6.5° to 5°). While the maxillary position did not change (SNA= 82.5° before and after treatment) the mandible encountered a forward movement (SNB changed from 76° to 77.5°). The vertical dimension was controlled with a counterclockwise rotation of the mandible as FMA was reduced from


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Fig. 11: Post-treatment intra-oral photographs.

Fig. 12: Post-treatment panoramic and lateral cephalometric radiographs.

31째 to 29째, while the Z angle changed from 58.5째 to 68째 due to the counterclockwise rotation of the chin and to the retraction of the lips. The final panoramic radiograph showed the eruption of the third molars, an acceptable root parallelism and no root resorption [Figs. 12, 13]. The superimposed cephalometric tracings affirmed that the molars moved mesially while the upper incisors were uprighted and slightly intruded and the lower incisors were uprighted. Moreover, a forward and

upward movement of the chin was registered [Figs. 14, 15].

Discussion A successful orthodontic treatment relies on both the antero-posterior and the vertical positions of the maxillary incisors that are crucial for facial esthetics. In existing gummy smile cases, extractions for incisor retraction are not recommended since previous experiments have demonstrated that incisor retraction might lead to the

extrusion of the anterior segment, thus increasing the gummy smile [9]. In these cases, an intrusive force is usually applied in the anterior segment; however, this will create an extrusive force in the posterior segment during retraction of the incisors [13, 14]. Extrusive forces on the posterior segment can be detrimental, especially in hyperdivergent cases. Hence, reliable retraction mechanics that induce controlled intrusion and retraction in the anterior segment, without significant extrusion of the poste-


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Fig. 13: Post-treatment cephalometric analysis.

Fig. 14: Cephalometric tracing superimposition on SN at S.

Fig. 15: Maxillary superimposition on ENA-ENP at ENP and mandibular superimposition on MP at Me.


117 Orthodontie / 2UWKRQGRQWLFV rior segment, might be favored when dealing with vertical problems, such as a hyperdivergent face combined with a gummy smile. These mechanics include miniscrews anteriorly or posteriorly, or even both. In our case, we decided to use miniscrews anteriorly only, with intrusive steps posteriorly to counteract any extrusive movement that might occur in order to get a good vertical control. In the presence of a gummy smile, such the one presented, anterior titanium screws are usually placed in the dento-alveolar region between the central and lateral incisors, not only to control the extrusion movement, but also to intrude incisors and to correct the gummy smile. To achieve intrusion, the miniscrews should be placed as high as possible where the inter-root distance becomes wider, otherwise the screws might touch the roots during the intrusion and cause undesirable root resorption or screw failure [1517]. However, the miniscrews should not be placed higher than the attached gingiva, as the success rate of miniscrews implanted in the mucosa is lower than what it would have been if the miniscrews were implanted in the attached gingiva [17, 18]. Additionally, when placed in the oral mucosa, the miniscrews could be easily covered by this mucosa, causing inflammation [15]. In this hyperdivergent pattern, skeletal class II and dental biprotrusion case, extraction of the upper first premolars was considered in order to correct the incisors upper protrusion without anchorage control. In turn, the molars were supposed to have a mesial movement to help in closing the bite, and the incisors were supposed to have a controlled backward tipping in order not to have any changes in point A of the maxilla. We were very vigilant in trying to retract the upper incisors without torque control. This will correct the protrusion without retracting the alveolar bone that supports the upper lip, to insure, as much as pos-

sible, the stability of the naso-labial angle. As a matter of fact, the presence of biprotrusive lips that were bothering the patient, in combination with an open naso-labial angle, complicated the treatment. The key to the success in this case was the ability to correct the profile without altering the naso-labial angle, in addition to having a good vertical control. That is why the decision of low anchorage control was taken in the upper and lower arches; for this purpose, the miniscrews were placed in the anterior segment to intrude the incisor while retracting. The intrusive step placed between the anterior and the posterior segment provided a sufficient posterior vertical control while moving the molars forward. This vertical control led to a counterclockwise rotation of the mandible bringing the chin to a much better position. Moreover, the anterior positioned miniscrews helped in correcting the gummy smile and in achieving a more harmonious smile. It would have been desirable, in this case, to upright more the lower incisors, to align them more with the criteria of facial balance and harmony in high-angle patients established by Klontz [19]. Nevertheless, this uprighting would have been at the expense of the molar mesialisation. This molar mesialisation, along with the good vertical control, have helped in closing the bite, in addition to creating a posterior space for the third molars, consequently contributing to the achievement of a much less aggressive treatment of eight teeth extractions.

Conclusion Before the invention of miniscrews, the success rate of complicated clinical cases was mostly related to patient cooperation, and the treatment plans were sometimes very aggressive in terms of extractions or combined orthognathic surgery. Nowadays, with the use of miniscrews, the cases are becoming much more controllable. Nevertheless, a good diagnosis and

treatment planning should be established and followed in order to obtain a good balance between the different solutions, since sometimes solving a certain problem can aggravate another existing situation.


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References 1. <DR&/DL(&KDQJ-&KHQ,&KHQD<&RPSDULVRQRIWUHDWPHQW RXWFRPHVEHWZHHQVNHOHWDODQFKRUDJHDQGH[WUDRUDODQFKRUDJH LQDGXOWVZLWKPD[LOODU\GHQWRDOYHRODUSURWUXVLRQ$P-2UWKRG 'HQWRIDFLDO2UWKRS 2. &KDH -0 $ QHZ SURWRFRO RI 7ZHHG0HUULÃ&#x20AC;HOG GLUHFWLRQDO IRUFH WHFKQRORJ\ ZLWK PLFURLPSODQW DQFKRUDJH $P - 2UWKRG 'HQWRIDFLDO2UWKRS

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Médecine Orale / 2UDO0HGLFLQH

CONCOMITANT OCCURRENCE OF NEUROFIBROMATOSIS TYPE I AND LOBULAR CAPILLARY HEMANGIOMA IN THE ORAL CAVITY: A CASE REPORT Rakhi Issrani*

Abstract Neurofibromatosis type I is one of the most common autosomal dominant inherited disorders associated with deletion, insertion, or mutation in the NF-1 gene. Neurofibromas are the hallmark of the neurofibromatosis type I and usually appear during childhood or adolescence after the emergence of “café au lait” spots. Despite their occurrence in the head and neck region, neural sheath tumors are rarely seen in the oral cavity. Lobular capillary hemangioma is a histologic variant of pyogenic granuloma which is a common benign vascular lesion of the skin and mucosa. It is neither infective / purulent nor granulomatous as the name might suggest - rather a reactive enlargement that is an inflammatory response to local irritation. In the present study, we report a rare case of concomitant occurrence of neurofibromatosis type I and lobular capillary hemangioma in a fifteen-year-old Indian female who presented with a gingival overgrowth in her maxillary anterior region. The lesion was excised and histopathological report confirmed the diagnosis. To the best of our knowledge this is the first case in english literature where there was a parallel occurrence of neurofibromatosis type I and lobular capillary hemangioma in the oral cavity. Keywords: Neurofibromatosis type I – von Recklinghausen’s disease – lobular capillary hemangioma – pyogenic granuloma.

* Ass. Prof. Oral Medicine, India dr.rakhi.issrani00@gmail.com

Résumé La neurofibromatose de type I est l’un des troubles autosomiques dominants héréditaires les plus courants, associé à la suppression, insertion ou mutation dans le gène NF- 1. Les neurofibromes caractérisent la neurofibromatose de type I ; ils apparaissent généralement pendant l’enfance ou l’adolescence après la survenue des tâches « café au lait». Malgré leur occurence dans la région de la tête et du cou, les tumeurs des gaines nerveuses sont rarement observées dans la cavité buccale. L’hémangiome capillaire lobulaire est une variante histologique des granulomes pyogènes. C’est une lésion vasculaire bénigne de la peau et des muqueuses. Il n’est ni infectieux / purulent ni granulomateux comme son nom l’indique - plutôt un élargissement qui est une réponse inflammatoire à une irritation locale. Dans la présente étude, nous rapportons un cas rare de neurofibromatose de type I et d’hémangiome capillaire lobulaire chez une fille de 15 ans qui s’est présentée avec une hypertrophie gingivale au niveau de la région maxillaire antérieure. La lésion a été excisée et le rapport histo-pathologique a confirmé le diagnostic. Mots-clés: neurofibromatose de type I – maladie de Von Recklinghausen – hémangiome capillaire lobulaire – granulome pyogène.


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Introduction The term “neurofibromatosis” refers to a group of genetic disorders that primarily affect the cell growth of neural tissues [1]. Neurofibromatosis is now recognized to consist of two distinct variants that differ from each other genetically, microscopically, and clinically. Neurofibromatosis type I (NF-I) is an autosomal dominantly inherited disease, associated with the mutation of NF-1 gene, a tumor suppressor gene located on chromosome 17q11.2. It is a common neurocristopathy, with an estimated incidence of 1 in 3,000 live births; almost 50% of NF-I patients have family history of the disease. Neurofibromatosis type II (NF-II) is a much more uncommon manifestation that probably results from a structural defect in chromosome 22 [2]. The frequency of oral manifestations is debated in the literature. Some authors report a frequency of 4-7% of cases [2], whereas others suggest that these manifestations are present in up to 72% of cases [3]. The neurofibroma associated with NF-1 usually runs an indolent course but sometimes can undergo malignant transformation and in such cases can be fatal [1]. Pyogenic granuloma (PG) is a common inflammatory tumor-like growth seen in the oral cavity as a mucosal reaction response to irritation, trauma or hormonal imbalances and is considered to be non-neoplastic in nature [4]. The peak prevalence is in teenagers and young adults, with a female predilection. In the oral cavity, PGs commonly occur on the gingiva owing to the presence of chronic irritation by the calculus or foreign material in the gingival sulcus [5]. Clinically these lesions usually present as single nodule or sessile papule with smooth or lobulated surface and are red, elevated and usually ulcerated. They may also develop rapidly, reach full size and then remain static for a time and later become fibrotic [6].

Histologically, PGs are of two types namely lobular capillary hemangioma (LCH) and non lobular capillary hemangioma (non-LCH). Surgical excision is the most common treatment of these lesions [7]. In the present study, we report a rare case of concomitant occurrence of NF-I and LCH in a fifteen-year-old Indian female who presented with a gingival overgrowth in her maxillary anterior region. To the best of our knowledge this is the first case in english literature where there was a parallel occurrence of NF-I and LCH in the oral cavity.

Case Report A fifteen-year-old Indian female patient presented with a complaint of a slowly growing painless mass in the upper front region of the jaw since six months. Clinical history and physical examination findings The patient was suffering from excessive gingival bleeding during meals for the last six months, accompanied by gingival enlargement in the maxillary anterior region. A short time after the bleeding has started, she discovered, in the same region, a reddish mass that has been increasing in size gradually. Patient gave a history of disturbed mastication and phonation in the last five months; she was suffering from fever during the last 8 days. On general examination, the patient was poorly built and nourished. No pallor, icterus, cyanosis, clubbing, pedal edema or lymphadenopathy was noticed. The physical examination revealed flat nose and frontal bossing (Fig. 1). Multiple cutaneous nodules and “café au lait” pigmentations of varying sizes were seen distributed on the entire body, extensively involving the neck, chest and back regions; they were present since childhood (Figs. 2a and 2b). A diffuse reddish macular lesion was present on the left arm extending from shoulder to the palm (Fig. 3). The

Fig. 1:Extra-oral photograph of the patient UHYHDOLQJÁDWQRVHDQGIURQWDOERVVLQJ

family history revealed that her father, sister and brother had similar nodules on their bodies. On comprehensive intraoral examination, a solitary exophytic, non-ulcerated mass measuring approximately 5 × 4 cm in size was observed on the maxillary anterior region, attached to the marginal gingiva, interproximally between the maxillary central incisors and covering their entire crowns. The lesion presented as a lobulated mass extending buccally into the buccal vestibule and palatally till the rugae region (Fig. 4). The growth was sessile, irregular in shape with a smooth surface and normal in color except at the marginal gingiva in relation to the maxillary left central incisor where it appeared erythematous. No surface ulceration or secondary infection was noted. Another sessile irregular mass, measuring about 1 × 0.5 cm was present interdentally in relation to the maxillary right premolars on the palatal gingival surface (Fig. 5).


121 Médecine Orale / 2UDO0HGLFLQH

a

b

Fig. 2a and 2b: Multiple cutaneous nodules and “café au lait” pigmentations seen on the entire body, extensively involving the neck, chest and back regions.

Fig. 3: A diffuse reddish macular lesion was present on the left arm extending from shoulder to the palm.

On palpation, the two masses were soft and oedematous, tender with profuse bleeding on provocation. Based on the history and clinical examination, a provisional diagnosis of pyogenic granuloma was given. The other pathologic entities included in the differential diagnosis were soft tissue fibroma and peripheral giant cell granuloma. Among other dental findings, we observed a supernumerary tooth in relation to teeth #12 and 13, bilateral peg laterals, moderate supragingival calculus, bleeding on probing and localized gingival enlargement in mandibular anterior region. Complete blood examination and urine analysis were advised. The laboratory investigations of blood and urine were within normal limits; this permitted us to rule out any leukemic enlargement, diabetes mellitus and hyperparathyroidism. The patient was referred for dermatological and ophthalmological opi-

Fig. 4: Preoperative intraoral view showing a sessile and lobulated mass extending into the buccal vestibule and the palate covering almost the entire coronal part of the maxillary incisors.

Fig. 5: A sessile irregular mass present interdentally in relation to maxillary right premolars.


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­SURSRVG XQFDV_&DVH5HSRUW nions. Lisch nodules were noted on eye examination by the ophthalmologist. The patient underwent radiographic examination that included a maxillary occlusal and a panoramic radiograph. Radiographic findings The maxillary occlusal radiograph revealed a soft tissue shadow in the maxillary anterior region covering almost the entire coronal part of the maxillary central incisors (Fig. 6). Diastema in the same region could also be appreciated. The panoramic radiograph revealed widening of mandibular canals, enlarged mental foramen, deepening of sigmoid notch and shortening of ramus suggestive of neurofibromatosis (Fig. 7).

Fig. 6: Maxillary occlusal radiograph revealing a soft tissue shadow in the maxillary anterior region covering almost the entire crowns of the maxillary central incisors.

Surgical findings The patient underwent surgical removal of the mass under local anaesthesia; the gingival specimen was sent for histopathological examination. The healing was uneventful (Fig. 8). Histologic findings The histopathologic examination revealed stroma comprised of numerous budding blood vessels and endothelial lined blood vessels of varying sizes which appeared to be interconnected. The endothelial cells were round to oval with few showing hyperchromasia and few showed vesicular nuclei. The stroma comprised of loose to dense bundles of collagen fibres with plump to spindle shaped fibroblasts and fibrosis. Patchy distributions of dense inflammatory infiltrate were seen, predominantly consisted of lymphocytes and plasma cells along with neutrophils. Areas of dystrophic calcification were also noted (Fig. 9). Histopathological features were suggestive of lobular capillary hemangioma.

Discussion Neurofibromatosis is a disorder that includes two distinct variants

Fig. 7: Panoramic radiograph revealing widening of mandibular canals, enlarged mental foramen, deepening of sigmoid notch and shortening of ramus on the right side.

which differ from each other genetically, histologically and clinically and have been designated as NF-I and NF-II. NF-1, often known as von Recklinghausen’s disease (VRD) is one of the most common autosomal dominant inherited disorders associated with deletion, insertion, or mutation in the NF-1 gene, a tumor suppressor gene located on chromosome 17q11.2 with an incidence of 1 in 3,000. NF-II, also known as central neurofibromatosis, accounts for an extremely small percentage of the total cases of neurofibromatosis [2]. Despite the advances of molecular biology, the diagnoses of NF-I and NF-II are still based on clinical crite-

ria. The National Institutes of Health Consensus Development Conference has suggested clinical criteria diagnosis of NF-I and NF-II [8]. Diagnosis of NF-I: 1. Six or more “café au lait” macules with the greatest diameter over 5 mm in pre-pubertal individuals and over 15 mm in greatest diameter in post-pubertal individuals. 2. Two or more neurofibromas of any type or one plexiform neurofibroma. 3. Freckling in the axillary or inguinal regions (Crowe´s sign). 4. Optic gliomas.


123 MĂŠdecine Orale / 2UDO0HGLFLQH

Fig. 8: Treatment outcome after excising the lesion.

5. Two or more Lisch nodules (iris harmartomas). 6. A distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudoarthrosis. 7. A first-degree relative (parent, sibling, or offspring) with NF-I diagnosis. All these manifestations may not be present; the diagnosis is established if the patient has two or more of the above-mentioned features. Diagnosis of NF-II: 1. Bilateral masses of the eighth cranial nerve seen with appropriate imaging techniques (e.g., CT or MRI) 2. One relative in first-degree with NF- II and either: a) Unilateral mass of the eighth cranial nerve, or b) Two of the followings: t/FVSPGJCSPNB t.FOJOHJPNB t(MJPNB t4DIXBOOPNB

Fig. 9: A histologic slide showing the characteristic features of lobular capillary hemangioma.

Despite their occurrence in the t +VWFOJMF QPTUFSJPS TVCDBQTVMBS head and neck region, neural sheath lenticular opacity. The criteria are met by an indivi- tumors are rarely seen in the oral cavity with only 4% to 7% of patients affected dual who satisfies condition 1 or 2. by neurofibromatosis displaying oral Neurofibromas are the hallmark manifestations. Oral localized neurofibromas of the NF-I and usually appear during childhood or adolescence after the present as discrete nodules of noremergence of â&#x20AC;&#x153;cafĂŠ au laitâ&#x20AC;? spots. Our mal color. Oral radiographic findings patient had multiple neurofibromas unique to NF include lengthening, of the skin and â&#x20AC;&#x153;cafĂŠ au laitâ&#x20AC;? spots. narrowing and rarefaction of coronoid Neurofibromas occur either as spo- and articular process, deepening of radic solitary nodules unrelated to sigmoid notch, enlarged mandibular any apparent syndrome or as solitary, canal, mandibular foramen and mental multiple or numerous lesions in indi- foramen. Other findings are shortening of the ramus, notching of the infeviduals with NF-I. Neurofibroma presents most com- rior border of the mandible and even monly as a cutaneous nodule (loca- asymmetrically developed maxillary lized cutaneous neurofibroma) and sinus [2]. In our case, widening of the less often as a circumscribed mass in mandibular canal, an enlarged mental a peripheral nerve (localized intraneu- foramen, deepening of the sigmoid ral neurofibroma) or as a plexiform notch and shortening of the ramus enlargement of a plexus or major nerve were present. The partial or total surgical removal trunk. All ages and both sexes are affected in NF-I [2]. The present case of tumors can be performed to solve is reported in a fifteen-year-old Indian aesthetic and functional problems, but it is preferable to wait till the end of female. growth to reduce the risk of re-occur-


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­SURSRVG XQFDV_&DVH5HSRUW rence. To date there is no indication that surgery favours malignant degeneration. NF-I may be considered as a familial cancer predisposition syndrome and the patients with NF-I need to be assessed periodically to rule out any malignant change [9]. Fortunately, there were no signs of recurrence or other manifestations of NF-I during the one year follow-up period of our patient. The most common vascular proliferation of the oral mucosa is the PG. The first case was reported by Hullihen (1844) [10] and the term “pyogenic granuloma” or “granuloma pyogenicum” was coined by Hartzell (1904) [11]. It is a reactive tumor-like growth of the oral cavity or skin that is considered to be non-neoplastic in nature, resulted from reaction of tissue growth in response to various stimuli such as low grade chronic irritation, trauma, hormonal imbalances or iatrogenic stimulations in dental practice like guided tissue regeneration [4, 12]. Gingival irritation and inflammation that result from poor oral hygiene, dental plaque and calculus, over-hanging restorations, trauma to a primary tooth or aberrant tooth development may be the precipitating factors in many cases especially for extragingival PGs [13]. It is possible that micro-ulceration caused by these irritants allows the ingress into the gingival connective tissue of low virulent oral microflora. In the oral cavity pyogenic granulomas show a striking predilection for the gingiva and the interdental papillae, especially in the maxillary anterior region, the facial aspect being the most common site as in our case; less commonly it can occur on the lips, tongue, buccal mucosa, palate [14]. Clinically the lesion is elevated, pedunculated or sessile, with smooth surface, sometimes lobulated and warty surface which is usually hemorrhagic and compressible as in the present case. It may develop as dumb-bell-shaped masses which can commonly show ulcerations covered with yellow fibrinous membrane [12]. The size of the lesion usually ranges between 0.5-2cm and they may

grow at an alarming rate reaching that size in just 4-7 days [15]. The colour ranges from deep red, reddish purple to pink depending on its duration and vascularity of the lesion. The lesion is painless and soft in consistency; although older lesions tend to become more collagenized and firm. Differential diagnosis of PG includes parulis, peripheral giant cell granuloma, peripheral ossifying fibroma, hemangioma, peripheral fibroma, leiomyoma, hemangioendothelioma, hemangiopericytoma, bacillary angiomatosis, Kaposi’s sarcoma, metastatic tumor, post extraction granuloma and pregnancy tumor [12]. Depending on its rate of proliferation and vascularity, there are 2 histological variants of pyogenic granuloma called LCH and non-LCH. Clinically, LCH PG occurs more frequently (66.4%) as sessile lesion whereas non-LCH PG occurs as pedunculated (77%). LCH usually presents as a spontaneous, painless, bleeding mass. The lobular area of the LCH PG contained a greater number of blood vessels with small luminal diameter than did the central area of non-LCH PG. In the central area of non-LCH PG a significantly greater number of vessels with perivascular mesenchymal cells nonreactive for alpha-smooth muscle actin and muscle-specific actin was present than in the lobular area of LCH PG [7]. Although PG can be diagnosed clinically with considerable accuracy, radiographic and histopathological investigations help confirming the diagnosis. Radiographs are advised to rule out bony destructions suggestive of malignancy or to identify a foreign body [13]. The treatment of pyogenic granuloma depends on the severity of the symptoms in the lesion. If it is small, painless and free of bleeding, clinical observation and follow-up are advised. If the lesions are huge, surgical excision and removal of causative irritants are among the treatment choice. There is relatively high rate of recurrence (about 15%) after simple excision. Other conventional surgical modali-

ties for the treatment of pyogenic granuloma reported are cryosurgery in the form of either liquid nitrogen spray or a cryoprobe. Nd: YAG, CO2 and flash lamp pulsed dye lasers have also been used for the treatment of oral pyogenic granuloma [12, 13, 16].

Conclusion Occasionally, oral manifestations may provide the opportunity to diagnose NF. A thorough examination and trained eye will provide the opportunity to diagnose NF. Therefore, the oral diagnostician should be made aware of the oral manifestations of the NF which will help in timely diagnosis and treatment of this disorder. Although PG is a non-neoplastic lesion of the oral cavity, it is important to the dentist because of its associated gingival vascular features and complications in the form of impaired nutrition and oral hygiene, increased accumulation of plaque and microorganisms and increased susceptibility to oral infections, which can affect the systemic health of the individual. Good oral hygiene, maintenance and regular follow- up can prevent recurrence of such lesions.


125 Médecine Orale / 2UDO0HGLFLQH

References 1. 0DKLMD -DQDUGKDQDQ 6 5DNHVK 5% 9LQRG .XPDU ,QWUDRUDO SUHVHQWDWLRQ RI PXOWLSOH PDOLJQDQW SHULSKHUDO QHUYH VKHDWK WXPRUVDVVRFLDWHGZLWKQHXURÃ&#x20AC;EURPDWRVLV-2UDO0D[LOORIDF 3DWKRO-DQ$SU  ² 2. Geist JR, Gander DL, Stefanac SJ. Oral manifestations of QHXURÃ&#x20AC;EURPDWRVLVW\SHV,DQG,,2UDO6XUJ2UDO0HG2UDO3DWKRO 0DU   3. 6KDSLUR 6' $EUDPRYLWFK . 9DQ 'LV 0/ 6NRF]\ODV /- /DQJODLV53-RUJHQVRQ5-HWDO1HXURÃ&#x20AC;EURPDWRVLV2UDODQG UDGLRJUDSKLF PDQLIHVWDWLRQV 2UDO 6XUJ 2UDO 0HG 2UDO 3DWKRO   *UHHQEHUJ 06 *OLFN 0   %XUNHWW·V 2UDO 0HGLFLQH 'LDJQRVLV DQG 7UHDWPHQW VW LQ  %& 'HFNHU +DPLOWRQ Canada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Ã&#x20AC;EURPDWRVLVDQGQHXURÃ&#x20AC;EURPDWRVLV -$0$ 9. 0XEHHQ .KDQ 1HHUD 2KUL 2UDO PDQLIHVWDWLRQV RI W\SH , QHXURÃ&#x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SCIENTIFIC INTERNATIONAL MEETINGS 2014 CONGRÉS SCIENTIFIQUES INTERNATIONAUX 2014

Africa countries Australia Europe countries Far East countries Middle East & Arab countries North America countries South America countries

Event

Date

Location

Website

Hawaii Dental Convention

16 - 17 January

Honolulu, Hawaii, USA

www.hawaiidentalassociation.net

Comprehensive Review of Pediatric Dentistry

24 - 26 January

Austin, Texas, USA

www.aapd.org

CIOSP 32nd Sao Paulo International 30 JanuaryDental Meeting 02 February

Sao Paulo, Brazil

www.apcd.org.br

AEEDC

04 - 06 February

Dubai, UAE

American Academy of Dental Group Practice – 41st Annual Conference & Exhibition

06 - 09 February

Las Vegas, USA

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European Federation of Periodontology 1st EFP Master Clinic

07 - 08 February

Paris, France

www.efpmasterclinic.com

Chicago Dental Society 149th Chicago Midwinter Meeting

20 - 22 February

Chicago, USA

www.cds.org

67th Indian Dental Conference

21 - 23 February

Kolkata, India

www.ida.org.in

Academy of Laser Dentistry 2014 21th Annual Meeting

27 February - 01 March

Arizona, USA

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Contemporary Sedation of Children for the Dental Practice: Enteral and Parenteral Techniques

27 February - 01 March

Los Angeles, USA

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Dentistry Show 2014

28 February 01 March

Birmingham, England

www.thedentistryshow.co.uk

Management of Pediatric Sedation Emergencies: A Simulation Course

01 - 02 March

Los Angeles, USA

www.aapd.org

Academy of Osseointegration (AO)29th Annual Meeting

06 - 08 March

Seattle, WA, USA

www.osseo.org

3DFLÀF'HQWDO&RQIHUHQFH

06 - 08 March

Vancouver, BC, Canada

www.pdconf.com

Dental South China

06 - 09 March

Guangzhou, China

www.dentalsouthchina.com

Expodental 2014 International Dental Equipment, Supplies and Services Show

13 - 15 March

Madrid, Spain

www.expodental.ifema.es

www.aeedc.com


127 Mémento/5HPLQGHU

Event

Date

Location

Website

ADEA 2014 American Dental Educational Association Annual Meeting

15 - 18 March

San Antonio, Texas, USA

www.adea.org

43rd Annual Meeting & Exhibition of the AADR

19 - 22 March

Charlotte, NC, USA

www.iadr.org

Australian Dental Industry Asscociation

21 -23 March

Sydney, Australia

www.adx.org.au

2014 AAE/AAP/ACP Joint Symposium

19 - 20 July

Chicago, USA

www.perio.org

Scandefa

02 - 04 April

Copenhagen, Denmark

www.scandefa.dk

12th Istanbul Oral and Dental Health Apparatus and Equipment Exhibition-IDEX 2014

03 - 06 April

Istanbul, Turkey

www.cnrexpo.com

IDEM Singapur

04 - 06 April

Singapur

www.idem-singapore.com

The 2014 British Dental Conference and Exhibition

10 - 12 April

Manchester, England

www.conference.bda.org

Special Care Dentistry Association – 26th Annual Meeting

10 - 13 April

Chicago, USA

www.scdaonline.org

AAP 2014 Spring Conference

25 - 26 April

Chicago, USA

www.perio.org

American Association of Orthodontists - Annual Session

25 - 29 April

New Orleans, USA

www.aaomembers.org

ITI World Symposium 2014

24 - 26 April

Geneva, Switzerland

www.iti.org

American Association of Endodontists - Annual Session

30 April -03 May

Washington DC, USA

www.aae.org

American Academy of Cosmetic 'HQWLVWU\$QQXDO6FLHQWLÀF Session

30 April -03 May

Orlando, USA

www.aacd.com

American Academy of Pediatric Dentistry– 67th Annual Session

22 - 25 May

Boston, USA

www.aapd.org

Sinodental

09 – 12 June

Peking, China

www.cnc.sinodent.com.cn


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Event

Date

Location

Website

7KHWK$VLD3DFLÀF'HQWDO Congress -APDC Dental Expo

17 – 19 June

Dubai, UAE

www.apdentalcongress.org

American Dental Hygienists’ Association (ADHA) – 91st Annual Session

18 - 24 June

Las Vegas, USA

www.adha.org

Advancing Excellence in Healthcare 2014

19 - 20 June

Glasgow, United Kingdom www.aeh2014.rcp.sg

92nd General Session & Exhibition of the IADR

25 - 28 June

Cape Town, South Africa

www.iadr.com

European organisation for caries research (ORCA) - 61st ORCA Congress

02 - 05 July

Greifswald, Germany

www.orca-caries-research.org

2014 AAE/AAP/ACP Joint Symposium

19 - 20 July

Chicago, USA

www.perio.org

AAOMS 96th Annual Meeting 6FLHQWLÀF6HVVLRQVDQG([KLELWLRQ

08 - 13 September

Honolulu, Hawaii

www.aaoms.org

IADR Pan European Region Meeting

10 - 13 September

Dubrovnik, Croatia

www.iadr.org

FDI World Dental Congress

11 – 14 September

New Dehli, India

www.fdiworldental.org

10th IADR World Congress on Preventive Dentistry (WCPD)

09 - 12 October

Budapest, Hungary

www.aadronline.org

American Dental Association- ADA 155nd Annual Session

09 - 12 October

San Antonio , Texas, USA

www.ada.org

Dentech Shanghai

22 - 25 October

Shanghai, China

www.dentech.com


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