Dental News September 2015

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Dental News, Volume XXII, Number III, 2015

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Case-control Retrospective Study of Osteosarcoma Incidence in Fluoridated and Non-fluoridated Communities.

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Dr. Abdullatef M. Nureddin, Dr. Adel Mohamed Abdel-Azim, Dr. Mohamed Salah-Eldin Ayoub

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Dental News, Volume XXII, Number III, 2015

INTERNATIONAL CALENDAR

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w w w.dentalnews.com Volume XXII, Number III, 2015 EDITORIAL TEAM Alfred Naaman, Nada Naaman, Jihad Fakhoury, Dona Raad, Antoine Saadé, Lina Chamseddine, Tarek Kotob, Mohammed Rifai, Bilal Koleilat, Mohammad H. Al-Jammaz COORDINATOR Suha Nader ART DEPARTMENT Elie Hajj SUBSCRIPTION Micheline Assaf, Nariman Nehmeh ADVERTISING Josiane Younes PHOTOGRAPHY Albert Saykali TRANSLATION Gisèle Wakim, Marielle Khoury DIRECTOR Tony Dib ISSN 1026-261X

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

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FDI 2015 Annual World Dental Congress

September 22 - 25, 2015 Bangkok, THAILAND Email: info@fdiworldental.org Website: www.fdi2015bangkok.org

International orthodontic congress: WFO

September 27 - 30, 2015 London Website: www.wfo2015london.org

BIDM 2015 - The 25th Lebanese Dental Association Congress

October 8 - 10, 2015 at the BIEL, Beirut, LEBANON Website: www.bidm-lda.com

The International Team for Implantology Congress Middle East - ITI

October 15 - 16, 2015 Dead Sea, JORDAN Email: congressmiddleeast@iti.org Website: www.iti.org

4th International Conference of King Abdulaziz University Faculty of Dentistry

October 26 - 29, 2015 at the Jeddah Hilton, KSA Website: www.fdc.kau.edu.sa

PAEC 2015 - The 4th Pan Arab Endodontic Conference

October 29 - 31, 2015 Hamamet, TUNISIA Website: www.paec2015.org

WIOC 2015 - World Implant Orthodontic Conference

November 10 - 13, 2015 at the Intercontinental Hotel, Festival City, Dubai, UAE Email: wioc2015@mci-group.com Website: www.wioc2015.com

The Egyptian Dental Association Meeting

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SDS 2016 - The 26th Saudi Dental Society International Conference

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

February 2 - 4, 2016 at the Dubai International Convention & Exhibition Centre, Dubai, UAE Website: www.aeedc.com

Dental News, Volume XXII, Number III, 2015

12 Oral Pathology

Case-control Retrospective Study of Osteosarcoma Incidence in Fluoridated and Non-fluoridated Communities.

Abdullatef., A.M Nureddin BDS. PG-Diploma. MDSc. DDSc. Department of Oral Surgery, Oral Medicine and Oral Pathology. College of Dentistry. Tripoli University nureddinabdullatef@yahoo.com

Adel Mohamed Abdel-Azim.

Professor of oral pathology.

Faculty of dentistry-Ain-Shams University. Cairo-Egypt adelmam55@yahoo.com

Mohamed Salah-Eldin Ayoub Professor and Head of Oral Pathology Department.

Faculty of Dentistry Ain-Shams University.

Abstract There are conflicting data regarding the association between fluoride exposure in drinking water and the incidence of osteosarcoma in man and animals. However, fluoride exposure shows great variation between north-western region of Libya and Cairo-Egypt. In the north-western part of Libya, tap water is naturally fluoridated with a mean of about 1.38 ppm, while drinking water in Cairo is considered non-fluoridated with fluoride concentration of about 0.4 ppm Therefore, the aim of our study is to compare a match case-control retrospective analysis of lifetime fluoride exposure and the incidence of osteosarcoma in these two communities. 20 cases of osteosarcoma from each community were retrieved from the archives of General Pathology and Orthopedic Departments of Sabrath Tumour Institute, Tripoli Medical Center (Libya), Cairo National Cancer Institute and Ain-Shams Hospital (Egypt). Clinical data were also retrieved from archives of these departments with exclusion criteria of any radiation therapy, renal dialysis and incomplete residential history in the home country. Statistical analysis of variance as a pair-wise test was performed to evaluate the level of significance. The result showed 85% of osteosarcomas were diagnosed in patients aged between 10-30 years in naturally fluoridated community (Libya) in contrast to non-fluoridated community where 65% of osteosarcomas cases were diagnosed between ages 10-30 years. Furthermore, sex distribution showed 65% of cases were females in fluoridated community, and just 30% of cases were females. in non-fluoridated community. However, statistical analysis revealed no statistically significance difference among age distribution in fluoridat-

Dental News, Volume XXII, Number III, 2015

ed and non-fluoridated community (P value = 0.078), but there were a significance difference among sex distribution (P value = 0.028). It is concluded from this study that osteosarcoma affects females more than males in fluoridated community and more frequently seen between ages 10-30 year in fluoridated community.

Keywords Osteosarcoma, fluoride, case-control, retrospective, Libya, Egypt, age, sex, P-value test, naturally fluoridated, non-fluoridated, Sabrath Tumour Institute, Tripoli Medical Center, Cairo National Cancer Institute, Ain-Shams Hospital.

Introduction Osteosarcoma is the most common primary malignant bone tumor which represent a heterogenous group of tumors with different histological and clinical features as well as biological behavior and therapy.1 However, World Health Organization (WHO) listed several variants of osteosarcomas that differ in location, clinical behavior and level of cellular atypia. The conventional or classical osteosarcoma is the most frequent variant, which develops in the medullary region of the bone and can be subdivided in osteoblastic, chondroblastic and fibroblastic histological types, depending on the type of extra-cellular matrix produced by tumour cells.2 Osteosarcoma is largely a disease of young adults, where it most frequently occurs in the second decade with some 60% of patients under the age of 25 years. It appears that males are affected 1.5 to 2 times as frequently as females.3

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14 Oral Pathology The precise aetiology of OS remains unknown due to lack of understanding of the cell or origin, the absence of identifiable precursor lesions, and its marked genetic complexity at the time of presentation. Interestingly, several human genetic disorders, familial cancer syndromes such as LiFraumeni syndrome, history of trauma, Paget’s disease of bone, fibrous dysplasia, osteoblastoma, osteochondroma, radiation exposure and recently the high-fluoride level in drinking water are all linked to an increase risk of development of osteosarcoma.4,5,6,7,8,9 Furthermore, many recent studies have showed that most of OSs contain clonal chromosomal aberrations. The aberrations are complex, comprising an abundance of numerical and structural alterations.10 Since fluoride acts as an anabolic agent for bone cells and that its osteogenic properties are mediated primarily by an increase in osteoblastic proliferation, as well as most of the fluoride is deposited in actively mineralizing areas of bone11,12, cartilage13, and the mitogenic action of fluoride and genotoxicity action (ability of fluoride to induce chromosomal aberrations) was subsequently confirmed by a number of laboratories on bone cells of various species, including humans.14, 15, 16 Therefore, it is biologically plausible that widespread exposure to fluoride during critical periods of growth may play a role in the aetiology of OS, but still there are conflicting data regarding the association between fluoride exposure and the incidence of osteosarcoma.

Materials and methods This study is a retrospective hospital-based, matched case control study which evaluate lifetime exposure to fluoride from drinking water.

Patients were identified through the general pathology and orthopedic departments in 4 hospitals across the north-western region of Libya and Cairo-Egypt.

Exclusion criteria were any history of radiation therapy, history of renal dialysis and history of incomplete residence which conducted by telephone interview mainly with parents.

Fluoride level in drinking water was the first exposure of interest. In the north-western part of Libya, the main drinking water supply is the underground water which is naturally fluoridated.

Dental News, Volume XXII, Number III, 2015

Fluoride level in drinking water above the normal limit of that recommended by WHO 0.6-0.7 ppm (Khan & Chohan 2009). While in Cairo, the main drinking water supply is the Nile River which naturally has fluoride level below the normal limit that is recommended by WHO. However, in order to estimate the fluoride level in drinking water in both study areas. Water samples were collected from 20 sources of Governmental ground water supply from different places in the north-western region of Libya and two tap water samples from Cairo. All water samples from both countries were analyzed in the Institute of Oil Research in Tripoli. The fluoride concentration was determined on the unfiltered water samples using a Lanthanum Fluoride Ion Selective Electrode (Orion Mode 94-09).17 However, forty cases of osteosarcomas were included in this study. Twenty cases of osteosarcomas were identified through the orthopedic and general pathology departments of Sabrata Tumor Institute and Tripoli Medical Center in the North-western region of Libya between the years 1998 and 2008, which were used as the cases.

On the other hand, twenty cases of osteosarcomas were identified through the orthopedic and general pathology departments of Ain Shams Hospital and Cairo National Cancer Institute between the years 2006 and 2009 which were considered as controls.

All the forty cases were histologically diagnosed as osteosarcomas. In order to confirm the diagnosis of these cases included in this study. Two slides from each formalin-fixed embedded specimen of osteosarcoma were stained with Haematoxyline and eosin again and re-examined by two pathologists from Ain Shams University.

Medical records were collected from the archives of these Departments and relevant clinical data were retrieved including nationality, age and gender.

Data was collected and tabulated using Microsoft Excel 2003 and then statistically analyzed using SPSS version 15. Analysis of variance (ANOVA) will be performed and when it yielded a significant result, post-hoc Bonferroni test will be used as a pair-wise test. All statistical analysis will be performed at the significance.

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16 Oral Pathology Result I. Clinical Findings Age Distribution 17 out of 20 (85%) of Libyan osteosarcoma cases were diagnosed in patients with age range between 10-30 years. The remaining 3 cases (15%) were diagnosed in patients with age over 30 years. On the other hand, 13 cases out of 20 (65%) Egyptian osteosarcoma cases were diagnosed in patients with age range between 10-30 years while the remaining 7 cases (35%) were diagnosed in patients with age over 30 years (Table1).

When comparing the means and SD of age in Libyan cases (naturally fluoridated community) versus Egyptian cases (non-fluoridated community), statistical analysis revealed no statistically significant difference (P value =0.078) of age in Libyan cases (mean = 22.15) and those of Egyptian cases (mean = 29.6).

Table 2 showed the statistical results for comparison of mean age in both fluoridated and non-fluoridated communities.

Moreover, no osteosarcomas were observed un-

der the age of 10 years in fluoridated nor in nonfluoridated community while under 20 years of age, osteosarcoma appear to be more common in fluoridated area. In Libyan cases about 50% of osteosarcoma seen under this age but in Egyptian cases it was just 40%.

Sex Distribution 13 out of 20 cases (65%) of Libyan osteosarcoma cases were present in females. The remaining 7 cases (35%) were diagnosed in male patients. On the other hand, 14 out of 20 (70%) of Egyptian osteosarcoma cases were present in males, while the remaining 6 cases (30%) were seen in females patients (Table 3).

Fisher’s exact test (one sided) revealed a significant difference among the sex distribution in Libyan and Egyptian cases (P value = 0.028).

The primary malignant tumour of bone (osteosarcoma) was more common in males than females and the reverse was true for Libyan.

Table 1. Age distribution of patients Cases

0-9 years

10-30 years

31 years and over

Mean

Total Number of Cases

Fluoridated Community (Libya)

0

17

3

22

20

Non-fluoridated community (Egypt)

0

13

7

30

20

Table 2. Mean and SD of patient’s age in fluoridated and non-fluoridated communities.

Nationality

Number of Cases

Mean

Std. Deviation

Std. Error of Mean

Fluoridated Community (Libya)

20

22.15

9.360

2.093

Non-fluoridated community (Egypt)

20

29.60

15.803

3.534

Dental News, Volume XXII, Number III, 2015

18 Oral Pathology Table 3. Sex distribution of the cases Nationality

Number of Males

Number of Females

Total

Fluoridated Community (Libya)

7

13

20

Non-fluoridated community (Egypt)

14

6

20

Table 4. Fluoride level in governmental water supply in both countries Sample

Range(Min-Max) (ppm)

Mean (ppm)

% Samples with Fconcentration more than 0.6 ppm

Total

Waters from north-west Libya

0.49 - 3.9

1.38

75.00%

20

Cairo waters

0.41 - 0.42

0.41.5

0.00%

2

II. Evaluation of fluoride level A. In drinking water A summary of the results of the fluoride analysis from the Libyan government underground water supply and Nile river waters is presented in Table 4.

The fluoride concentration in all 20 samples of government groundwater supply analyzed from Libyan north-western region ranges from 0.49 ppm to 3.9 ppm, with a mean of 1.38 ppm.

In comparison, Nile waters-Cairo have fluoride levels ranging from 0.41 to 0.42 ppm with a mean of 0.415 ppm. It is observed that on the average, the groundwater from Libyan region have a higher fluoride content than Nile river waters in Cairo. The world Health Organization (WHO) sets 0.6-0.7 ppm as the appropriate level of fluoride concentration in drinking water in tropical countries.18 It is also observed that about 75% of the ground water in Libyan north-west districts have fluoride concentrations greater than 0.6 ppm (Table 4), while in Cairo waters (the Nile river) is less than that of WHO recommended level.

Discussion The aetiology of osteosarcoma is largely unknown and evidence of risk factors is Dental News, Volume XXII, Number III, 2015

inconclusive with the only environmental agents known being ionizing radiation or other predisposing factors such as Paget’s disease of bone, fibrous dysplasia, Rothmund-Thomson syndrome, and Li-Fraumeni syndrome.4, 9, 19, 20, 21 However, the main source of fluoride to humans is drinking water, which is typically the largest single contribution to daily fluoride intake 22 and the appropriate level of fluoride concentration in drinking water for hot climate areas as recommended by WHO should be 0.6-0.7 ppm.18 Therefore, this study is conducted in two different countries, where there is a different fluoride concentration in drinking water to cast a light on the incidence of osteosarcoma in relation to the fluoride level in public water supply.

The north-western part of Libya is considered as naturally fluoridated community. It is estimated that the fluoride level in underground wells that represent the only main public source for drinking water ranges between 0.49 ppm and 3.9 ppm with a mean of 1.38. But on the other hand, the Cairo waters (Nile River) that represent the main source for drinking water for Egyptian community is non-fluoridated. The fluoride level is about 0.41 ppm.

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20 Oral Pathology Furthermore, fluoride appears to have the potential to initiate or promote cancers, particularly of the bone, but the evidence to date is tentative and mixed. Biologically, the link between fluorides in tap water and bone cancer in childhood period is highly plausible.6 Approximately 99 percent of ingested fluoride is deposited in the skeleton with about 50 percent of the daily ingested fluoride being deposited directly into bone.23 Fluoride is also confirmed as a mitogen agent in humans that increases the proliferation of osteoblasts.24, 25 Its uptake in bone increases during periods of rapid skeletal growth23, therefore, the effect of fluoride to cause bone cancer would be strongest during periods of rapid growth particularly in males.6 Furthermore, several studies have demonstrated fluoride to be genotoxic to mammalian cells that it induces DNA breaks and chromosomal aberration in bone -forming cells where osteosarcoma arises.26, 27, 28 There are conflicting data regarding the association between fluoride concentration in drinking water and the incidence of osteosarcoma in man and animals. Several studies showed positive relationship between fluoride in drinking water and osteosarcoma.6,7,29,30,31 In contrast, other studies found no association.32, 33, 34, 35, 36, 37 The result of this study demonstrated the fluoride concentration in drinking water in both communities (Libya and Egypt). In the north-western region of Libya, tap water samples were selected from different parts of the north-western costal region. The fluoride level in this region ranged between 0.49-3.9 ppm with a mean of 1.38 ppm, while in Egypt where the Nile River is the main source of drinking water, the fluoride level ranged between 0.41-0.42 ppm with a mean of 0.41.5 ppm.

The clinic-pathological data of this study showed that among the Libyan cases there were 20 cases of osteosarcoma occurred between 10-44 years of age with a mean age of 22 years. The incidence of this tumour under the age of 30 years was 85% and just 15% above 30 years of age.

The peak incidence (50%) of all cases of osteoDental News, Volume XXII, Number III, 2015

sarcoma occurred between 10-19 years.

Moreover. It is noted that females were most frequently affected than males in fluoridated community which accounts for about 65% of cases and of ratio of approximately 2:1 females to males. This result is consistent with the finding of (Ayala38, who stated that osteosarcoma was more common in females than males. This slight predominance could be attributed to the dimorphic sexual pattern of post-pubertal bone growth due to earlier adolescence growth spurt in girls.

The results of Egyptian cases where the fluoride in drinking water is at low concentration (0.410.42 ppm), all 20 cases of osteosarcoma occurred between ages 11-59 years with a mean age of 30 years. The incidence of osteosarcoma in this non-fluoridated community was 65% under 30 years of age and 40% under 20 years of age.

It is noted in this study in non-fluoridated community that the males were more frequently affected than females which accounts for about 65%. Of osteosarcoma cases with a ratio of approximately 2:1 males to females In general, this study revealed a significance difference in the pattern of age and sex distribution of osteosarcoma in fluoridated community compared to non-fluoridated community. This difference could be attributed to the effect of fluoride on osteoblastic activity which is sensitive to fluoride.

These results are in accordance with the findings of National Toxicology Program (NTP 2005), animal study which found equivocal evidence for correlation between fluoride in tap water and osteosarcoma for males but not for females29 and from two ecological studies that found an association for males but not for females less than twenty years of age.6, 7, 30, 31 Bassin’s study measured the risk of osteosacoma before age 20 years based on exposures to fluoride in drinking water during each year of age in childhood. The methodology employed is rigorous and fluoride levels in tap water for each study participant were confirmed for each year of exposure during childhood. The analysis shows significantly elevated risks of bone cancer

22 Oral Pathology in boys exposed to fluoridated water during a window of vulnerability, from ages five through ten, with a peak risk associated with exposure at seven years of age.

Several other case-control studies did not find a association between fluoride in drinking water and bone cancer.20, 32, 34, 35, 36, 39 The reason for the lack of agreement may be related to the bimodal age-incidence distribution of bone cancer.40 When there are two distinct peaks in an age-incidence distribution it has been suggested that two distinct sets of component causes should be considered36, included cases up to age forty years and age eighty-four years, respectively, and if fluoride exhibits a different effect according to the age specific distribution, detecting an effect would be unlikely.

However, a very recent published case-control study lends evidence that fluoride exposure may cause osteosarcoma and other types of bone cancer (Sandhu7 who found that the average serum fluoride level of osteosarcoma cases was twice as higher as the bone cancer cases and 3.5 times as higher than in the controls.

Our study demonstrated that the fluoride level in governmental water public supply in the northwestern costal region in Libya from 20 places was generally high, range between 0.49-3.9 ppm with a mean of 1.38 ppm as twice high as recommended by WHO.18 This natural fluoride level in drinking water is derived from the solvent action of water on rocks and soils of the earth’s crust. Fluoride concentration of natural waters therefore depends, among other findings, on the solubility of fluoride-containing mineral in the underground water and the porosity of the rocks and soil through which the water passes.41 Adding, the north-western coastal Libyan region geologically is surrounded by the known Naphosa mountain.

In Cairo the main source for drinking water is the Nile river through the governmental public water supply. The level of fluoride is low (0.41 ppm This study used drinking water as the main source for fluoride22, but there are limitations in which our estimation of fluoride in drinking water in Dental News, Volume XXII, Number III, 2015

all cases from both countries do not necessarily reflect actual consumption by patients. Fluoride exposure from other sources such as food, beverage, dental products, industrial fluoride, pesticides were not available. As mentioned before the exact aetiology of osteosarcoma is still unclear, therefore fluoride may not be the causative agent, instead there may be another factor in drinking water, diet, beverage, pesticides or industrial pollution correlated with the presence of fluoride such as radium.42 However, there are a few established environmental causes of osteosarcoma, such as radiation, certain chronic bone diseases, syndromes, genetic susceptibility and industrial and agricultural chemicals. Therefore, further research is required to confirm or refute this observation.

Conclusion In conclusion, this study provides support for the hypothesis that fluoride exposure in drinking water increases the risk development of osteosarcoma. The incidence of osteosarcoma is higher in Libyan cases under the age of 30 years and affects females more frequently than males in naturally fluoridated community.

Acknowledgement We would like to acknowledge the help of Pathology Departments of Sabrath Tumour Institute (Libya) and National Cancer Institute of Cairo in Egypt.

References 1. Antonescu, C. R. & Huvos, A. G. (2000). Low-grade osteogenic sarcoma arising in medullary and surface osseous locations., Am J Clin Pathol 114 Suppl : S90-103.

2. Murphey, M. D. (2007). World Health Organization classification of bone and soft tissue tumors: modifications and implications for radiologists., Semin Musculoskelet Radiol 11 : 201-214.

3. Benjamin, R. S. & Patel, S. R. (2010). Pediatric and adult osteosarcoma: comparisons and contrasts in presentation and therapy., Cancer Treat Res 152 : 355-363.

4. Hansen, M. R. & Moffat, J. C. (2003). Osteosarcoma of the Skull Base after Radiation Therapy in a Patient with McCune-Albright Syndrome: Case Report., Skull Base 13 : 79-83.

5. Hansen, M. F.; Seton, M. & Merchant, A. (2006). Osteosarcoma in Paget’s disease of bone., J Bone Miner Res 21 Suppl 2 : P58-P63.

6. Bassin, E. B.; Wypij, D.; Davis, R. B. & Mittleman, M. A. (2006). Age-specific fluoride exposure in drinking water and osteosarcoma (United States)., Cancer Causes Control 17 : 421-428.

7. Sandhu, R.; Lal, H.; Kundu, Z. S. & Kharb, S. (2009). Serum Fluoride and Sialic Acid Levels in Osteosarcoma., Biol Trace Elem Res .

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8. Gupta, S. K.; Gupta, R. C. & Gupta, A. B. (2009). Is there a need of extra fluoride in children?, Indian Pediatr 46 : 755-759.

9. Gorlick, R. & Khanna, C. (2010). Osteosarcoma., J Bone Miner Res 25 : 683-691.

10. Atiye, J.; Wolf, M.; Kaur, S.; Monni, O.; Böhling, T.; Kivioja, A.; Tas, E.; Serra, M.; Tarkkanen, M. & Knuutila, S. (2005). Gene amplifications in osteosarcoma-CGH microarray analysis., Genes Chromosomes Cancer 42 : 158-163.

11. Farley, J. R.; Wergedal, J. E. & Baylink, D. J. (1983). Fluoride directly stimulates proliferation and alkaline phosphatase activity of bone-forming cells., Science 222 : 330-332.

12. Grynpas, M. D. (1990). Fluoride effects on bone crystals., J Bone Miner Res 5 Suppl 1 : S169-S175.

13. de Carvalho, J. G.; Cestari, T. M.; de Oliveira, R. C. & Buzalaf, M. A. R. (2008).

Fluoride effects on ectopic bone formation in young and old rats., Methods Find Exp Clin Pharmacol 30 : 287-294.

14. Burgener, D.; Bonjour, J. P. & Caverzasio, J. (1995). Fluoride increases tyrosine kinase activity in osteoblast-like cells: regulatory role for the stimulation of cell proliferation and Pi transport across the plasma membrane., J Bone Miner Res 10 : 164-171.

15. Mihashi, M. & Tsutsui, T. (1996). Clastogenic activity of sodium fluoride to rat vertebral body-derived cells in culture., Mutat Res 368 : 7-13.

16. Kleinsasser, N. H.; Weissacher, H.; Wallner, B. C.; Kastenbauer, E. R. & Harréus, U. A. (2001). [Cytotoxicity and genotoxicity of fluorides in human mucosa and lymphocytes], Laryngorhinootologie 80 : 187-190.

17. Orion Research 1983. Instruction Manual : Fluoride Electrode Model 94-09, Orion Res. Cambridge USA. 18. Khan, N. B. & Chohan, A. N. (2009). Accuracy of bottled drinking water label content., Environ Monit Assess 19. Huvos, A. G. (1986). Osteogenic sarcoma of bones and soft tissues in older persons.

A clinicopathologic analysis of 117 patients older than 60 years., Cancer 57 : 14421449.

20. Cheng, Y.-S. L.; Wright, J. M.; Walstad, W. R. & Finn, M. D. (2002). Osteosarcoma arising in Paget’s disease of the mandible., Oral Oncol 38 : 785-792.

21. Avigad, S.; Peleg, D.; Barel, D.; Benyaminy, H.; Ben-Baruch, N.; Taub, E.; Shohat, M.; Goshen, Y.; Cohen, I. J.; Yaniv, I. & Zaizov, R. (2004). Prenatal diagnosis in LiFraumeni syndrome., J Pediatr Hematol Oncol 26 : 541-545.

22. Dhar, V. & Bhatnagar, M. (2009). Physiology and toxicity of fluoride., Indian J Dent Res 20 : 350-355.

23. Whitford, G. M. (1999). Fluoride metabolism and excretion in children., J Public Health Dent 59 : 224-228.

24. Gruber, H. E. & Baylink, D. J. (1991). The effects of fluoride on bone., Clin Orthop Relat Res : 264-277.188.

25. Kleerekoper, M. (1996). Fluoride and the skeleton., Crit Rev Clin Lab Sci 33 : 139161.

26. Hayashi, N. & Tsutsui, T. (1993). Cell cycle dependence of cytotoxicity and clastogenicity induced by treatment of synchronized human diploid fibroblasts with sodium fluoride., Mutat Res 290 : 293-302.

27. Kishi, K. & Ishida, T. (1993). Clastogenic activity of sodium fluoride in great ape cells., Mutat Res 301 : 183-188.

28. Zeiger, E.; Shelby, M. D. & Witt, K. L. (1993). Genetic toxicity of fluoride., Environ Mol Mutagen 21 : 309-318.

29. Bucher, J.R. Hejtmancik, M.R (1991). Results and Conclusions of the National Toxicology Program’s Rodent Carcinogenicity Studies with Sodium Fluoride. Int. J. Cancer 48 (5), 733-737.

30. Hoover, R. N.; McKay, F. W. & Fraumeni, J. F. (1976). Fluoridated drinking water and the occurrence of cancer., J Natl Cancer Inst 57 : 757-768.

31. Cohen PD (1992). A Brief Report on the Association of Drinking Water Fluoridation and the Incidence of Osteosarcoma among Young Males. Trenton, NJ: New Jersey Department of Health. Environmental Health Service.

32. Hrudey, S. E.; Soskolne, C. L.; Berkel, J. & Fincham, S. (1990). Drinking water fluoridation and osteosarcoma., Can J Public Health 81 : 415-416.

33. Maurer, J. K.; Cheng, M. C.; Boysen, B. G. & Anderson, R. L. (1990). Two-year carcinogenicity study of sodium fluoride in rats., J Natl Cancer Inst 82 : 1118-1126.

34. McGuire SM. (1991). Is there a link between fluoridated water and osteosarcoma. J Am Dent Assoc. 122:39-45.

35. Freni SC. Gaylor DW. (1992). International Trends in the Incidence of Bone Cancer are not Related to Drinking Water Fluoridation. Cancer 70: 611-8.

36. Moss, M. E.; Kanarek, M. S.; Anderson, H. A.; Hanrahan, L. P. & Remington, P. L. (1995). Osteosarcoma, seasonality, and environmental factors in Wisconsin, 19791989., Arch Environ Health 50 : 235-241.

37. Gelberg, K.H. Fitzgerald, E.F. (1995). Fluoride exposure and Childhood osteosarcoma: a case-control study . Am. J. Public Health . 85(12), 1678-1683.

38. Ayala, A.G. Ro, J.Y. Raymond, A.K.(1989). Small Cell osteosarcoma. ClinicPathological Study of 27 Cases. Cancer 64(10), 2162-2173.

39. Operskalski, E. A.; Preston-Martin, S.; Henderson, B. E. & Visscher, B. R. (1987). A case-control study of osteosarcoma in young persons., Am J Epidemiol 126 : 118-126.

40. Dorfman, H. D. & Czerniak, B. (1995). Bone cancers., Cancer 75 : 203-210.

41. Smith, G. E. (1988). Is fluoride a mutagen?, Sci Total Environ 68 : 79-96.

42. Reddy, D. R. (2009). Neurology of endemic skeletal fluorosis., Neurol India 57 : 7-12.

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46 18 26 Orthodontics

CA Clear Aligner Clinical Protocol, and Why it is as it is Pablo Echarri, DDS echarri@centroladent.com Martín Pedernera, DDS

Abstract In this article, biological basis of CA® CLEARALIGNER clinical protocol is explained.

Key Words

activation of them, means the increase of the treatment time.

Biological bases of CA® CLEAR-ALIGNER Protocol

CA® CLEAR-ALIGNER, clinical protocol.

Introduction Removable or fixed orthodontic treatments are based on the insertion of the appliances and their periodical activation. It should be always started with a very mild activation and then the appliance should be progressively reactivated so the movement can be effective.

In this way, removable appliances should be activated through their screws, arches, springs, etc., and fixed appliances require replacement of the arches, elastic chains, etc. so the treatment progresses adequately.

In all cases, failure in the use of removable appliances and debonding of fixed appliances (treatment interruption), or failure in periodical

CA® CLEAR-ALIGNER protocol is based on sequential aligners carried out over the impressions, and plaster casts carried out each 4 weeks. One “step” of treatment includes a plaster cast set-up, 3 aligners (CA®-soft, CA®medium, CA®-hard) pressure moulded over this plaster cast set-up, and a report on movements carried out in the set-up. It corresponds to one month of treatment.

The treatment starts when the diagnosis is finished. The impressions are taken, and a 0.5 mm dental movement is carried out in the plaster cast set-up. Over this plaster cast, 3 CA® CLEAR-ALIGNERS of 3 different thicknesses are pressure moulded (Figs. 1 and 2).

Fig 1

Fig 1: CA®-soft, CA®-medium, CA®-hard aligners.

Fig 2

Fig 2: Thickness of the CA® CLEAR ALIGNER in inches and in millimetres.

Dental News, Volume XXII, Number III, 2015

- CA®-soft, a 0.5 mm aligner.

- CA®-medium, a 0.625 mm aligner.

- CA®-hard, a 0.75 mm aligner.

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28 Orthodontics The patient should use CA速-soft during the first week; CA速-medium, during the second week, and CA速-hard, during the third week. After the third week, the patient should go to the clinic so the new impressions can be taken. He will use a CA速-hard during the fourth week while the new step is prepared in the laboratory.

In the first step of treatment, a 0.5 mm movement of the tooth is carried out. An inclination of the tooth is searched for inside the periodontal space (Fig. 3). A vasodilation is Fig 3

Fig 3: Scheme of the biological reaction in the first step of the treatment.

Fig 1

Fig 4: Scheme of the biological reaction of the following steps of the treatment..

Dental News, Volume XXII, Number III, 2015

carried out, as well as the increase of osteoblasts and osteoclasts, which enables the treatment with these aligners. Clinically, dental movement will not be observed.

In the following steps, a 1 mm movement is carried out in the set-up (Fig. 4). This activation produces pressure zones and traction zones in periodontal ligament. In pressure zones, bony resorption is produced, and the tooth moves in this direction. In traction zones of ligament, bony apposition is started, and it is much slower.

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If the patient doesn’t use enough the CA® CLEAR-ALIGNER (17 hours per day) the tooth returns to the initial position and it also might present the mobility because the bony resorption has been produced, but not bony apposition in the opposite zone.

If a patient doesn’t come to the clinic so the new impressions can be taken and the new step carried out, and he continues using the same CA® CLEAR-ALIGNER, the tooth will remain in that position, but the density of osteoblasts and osteoclasts is reduced. In this way, when the treatment is re-activated, it won’t be possible to continue with 1 mm movements in the set-up, but it will be necessary to start again with the 0.5 mm movement, which means the delay of the treatment (Fig. 5).

Fig 5

Fig 5: Scheme of the biological reaction when there’s no activation.

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Therefore, it is very important to motivate the patient to use the CA® CLEAR-ALIGNER 17 hours per day, and to make sure they come regularly to the activation appointments, so the treatment time or number of CA® CLEAR-ALIGNERS is not increased.

ITENA

32 Orthodontics Fig 6

Fig 6: CA® RETENTION.

When treatment objectives are achieved, the patient should use a 1 mm thick aligner, CA® RETENTION (Fig. 6). CA® RETENTION is formed over the final plaster cast, without any dental movement.

Fig 8

This appliance keeps the tooth in the final position and periodontal ligament traction in the zones in which the bony apposition is needed (Fig. 7).

The patient should use CA® RETENTION at least 6 months, but fixed permanent retention is recommended to avoid the relapse. The stability is achieved when the alveolar bone remodelling is finished (Fig. 8). If the use of CA® RETENTION is not sufficient, the relapse will take place (Fig. 9).

During the active phase of the treatment, other types of CA® CLEAR-ALIGNER which increase the treatment effectiveness can be used.

Fig 8: Remodelling of alveolar bone at the end of the treatment.

Fig 9

Fig 7

Fig 7: Scheme of the biological reaction to CA® RETENTION Dental News, Volume XXII, Number III, 2015

Fig 9: Relapse due to the lack of CA® RETENTION use.

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34 Orthodontics CA® Bubbles When a plaster cast set-up is carried out in the laboratory, the aligners CA®-soft, CA®-medium and CA®-hard are carried out, but CA® Bubbles can also be made (Fig. 10) so when the patient can use it during the fourth week and achieve greater movement.

Fig 10

Fig 10: CA® Bubbles scheme.

CA® Bubbles Activable When a plaster cast set-up is carried out in the laboratory, the aligners CA®-soft, CA®-medium and CA®-hard are carried out, but before the CA®-hard is pressure moulded, a space can be created in the direction of the movement of the tooth (Fig. 11), so the clinician can create an activation bubble in the clinic using the CA®-Tip 1 Pliers when impressions are taken for the next step.

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Fig 11: CA® Bubbles Activable scheme.

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36 Orthodontics Fig 12

Fig 12: CA Forced extrusion scheme. ®

Fig 13

CA® Forced extrusion To achieve an effective extrusion movement, CA® POWER GRIP will be used, bonded on the tooth, 2 buttons in CA® CLEAR-ALIGNER and extrusion elastics, as it is shown on the scheme of the figure 12. It is activated by changing the elastics 3 to 4 times per day. The CA® CLEARALIGNER is carried out in a such a way that when the necessary extrusion is finished, the tooth stops to extrude.

CA® Forced intrusion CA Forced intrusion (Fig. 13) has buttons for anchorage of the intrusion elastics and it is activated by changing the elastics 3 to 4 times a day. The CA® CLEAR-ALIGNER is carried out in a such a way that when the necessary intrusion is finished, the tooth stops to intrude.

CA® Buttons To adjust midline or overjet, upper and lower CA® CLEAR-ALIGNER can be used with intermaxillary elastics (Fig. 14). It is activated by changing the elastics 3 to 4 times a day.

Fig 13: CA® Forced intrusion scheme.

Fig 14

CA® Expansion Screw During the expansion phase, CA®-hard can be used with the expansion screw Vector 40 (Fig.15). These appliances are activated by a screw turn each 3-4 days.

Conclusions

Fig 14: CA® Buttons scheme.

Fig 15

It is very important to maintain the rhythm of activations to complete the treatment within the planned time. It is important to make sure patients come to control appointments by organizing a “reminder system”, as well as a system to motivate the patient in using, cleaning and taking care of the CA® CLEAR-ALIGNER, so the treatment can be completely effective.

Bibliography Echarri P. Clear Aligner. 1st Ed. Madrid (Spain):Ripano Médica; 2012

Fig 15: CA® Expansion screw scheme.

Dental News, Volume XXII, Number III, 2015

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38 Restorative Dentistry

Er:YAG Laser and Recurrent Caries.

A review.

Cendrella Assaf, DESS, DU – Monitor

Emilie Mouchantaf, DESS, DU – Assistant Head of Clinic emiliemchantaf@hotmail.com

Assad Nasser, DESS, DU – Monitor

Fadi Honein, DESS, DU – Chief Head of Clinic

Department of Conservative and Aesthetic Dentistry, Lebanese University, Beirut, Lebanon

Abstract Purpose: To investigate the correlation between the application of Er-YAG laser prior to any composite restoration and the occurrence of recurrent caries.

Methods: A review based on the literature search in PubMed was performed.

Results: based on the synthesis of the reviewed literature, different topics concerning the Er-YAG effects, characteristics, as well as dental tissues changes are discussed and recommendations are revisited.

Keywords: Thermo mechanical excavation, chromophore, microleakage, marginal integrity, bond strength, recurrent caries, pulpal tolerance, cohesive, and adhesive failures.

Introduction Dental laser is the latest modern innovation of the 20th century. It offers an alternative to high speed drill, reducing patient’s discomfort and fear.

At present, Erbium lasers are the only hard tissue laser wavelengths available commercially.

Their main chromophore is water, and they are well absorbed in carbonated hydroxyapatite, a component of natural tooth structure and bone.1 These inherent absorption qualities allow erbium lasers to ablate tooth and bone. Indeed, they are unique in that they are the only lasers that can cut both hard and soft tissues. Two different wavelengths of Erbium lasers have been commercialized: Er,Cr:YSGG and Er:YAG, this review will focus on Er:YAG laser.

The use of the erbium yttrium aluminum garnet (Er:YAG) laser to remove carious tissue and prepare cavities started at the end of the 1980s

Dental News, Volume XXII, Number III, 2015

in a study by Hibst and Keller. Later, this type of laser was approved by the US Food and Drug Administration in 1997 for use on hard tissues.

Lately, many studies focused on investigating the efficiency of Er:YAG to remove carious lesion.1,2,3 Secondary caries (recurrent caries) is a primary carious lesion of tooth at the margin of an existing restoration; they usually occur years after composite or other kinds of restorations were performed.

This lesion has been widely considered as the most important and common reason for restoration replacement. It may occur in two parts: an outer lesion, formed on the surface of the tooth as a result of primary attack, and a wall lesion formed as a result of diffusion of bacteria, fluids or hydrogen ions between the restorations and the cavity walls.2 Recurrent caries are induced by marginal microleakage of the restoration; so improved marginal integrity and adaptation of the resincavity interface are essential for the prevention of such caries.2, 4 Do the changes in the surface texture of enamel and dentine induced by laser affect the microleakage of adhesive restorative material and result in preventing recurrent caries?

Discussion The Effect of Er:YAG on dental structures: The mechanism of dental hard tissues removal by laser is called “thermo-mechanical process”, “photo thermal fragmentation” or “ablation”.

The energy delivered by Er:YAG laser with a wavelength of 2.94 μm has one of the highest absorption in water, and a high affinity for hydroxyapatites. During irradiation, water heats and evaporates resulting in a high pressure of steam that causes a micro-explosion of dental tissues below its melting point.3

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

40 Restorative Dentistry Vaporization of water within mineral substrate causes the surrounding material to literally explode away in a popping sound which is more preferable to patients than the whirring of dental drill. Many studies have demonstrated that water cooling is required to reduce the increase in pulpal temperature and improve the ablation rate during cavity preparation; this is to avoid odontoblastic alterations and inflammatory response in the pulp chamber beneath the preparation.5 Generally, cavity preparation using Er:YAG laser takes more time compared to rotary cutting instruments. Its advantages include low noise and vibration eliminating, in most cases, the need for local analgesia.6 Clinical studies, however, suggested that the application of the Er:YAG laser system was a more comfortable alternative or adjunctive method compared to conventional mechanical cavity preparation.7 Erbium laser is slower in cutting through enamel than dentine. This is due to the fact that there is more water in dentine than enamel and more water in carious dentine as well; so the ablation of each of these tissues occurs at a varying rate.

Erbium lasers are able to cut hard dental tissues with efficacy and depth that corresponds to the increasing power setting and use of water spray.8 At enamel level: During cavity preparation, ablation of sound enamel by Er:YAG laser promotes cavities with rough enamel margins, irregular and rugged walls, a chalky surface, and a depth that depends on the energy density and pulse width.9 Micromorphology of the Er:YAG laser-treated enamel depicts a retentive pattern similar to acid etched enamel while anatomical features of enamel rods are preserved.10 (Fig1) Consequently, preparation by Er:YAG laser at suitable output energy showed the better marginal integrity of resin composite restorations compared to a rotary cutting instrument.

Occlusal and cervical cavosurface angles were significantly different when the energy was increased: It is essential for the dentist to be aware of the alteration produced in the cavity form and cavosurface angles by the variation of energy in order to ensure selection of Dental News, Volume XXII, Number III, 2015

Fig 1

Fig 1: Enamel surface etched with Er:YAG laser. Irregular areas on the surface due to tissue removal and intact area can be observed. (SEMĂ—500-A and Ă—2000-B).

The arrows shows untreated enamel surface within the irradiated area. (21)

appropriate laser parameters for the desired cavity preparations.11, 12 Most of the studies available on microleakage and marginal adaptation used Er:YAG with high energies over 300 mJ. These energies induce subsurface damages into enamel. It is thus not surprising that many publications reported poor marginal adaptation with a high degree of microleakage, and that acid etching following Er:YAG with a low energy -used for finishing the enamel- gave much better results.12, 10 As soon as low energies were used for cavity preparation, microleakage of lased and bur treated cavities was not significantly different.

Some studies using dye penetration even presented less microleakage regarding lased cavities.

The problem is that the preparation with low energies requires a very long treatment time compromising the use of Er:YAG laser in the routine clinical setup. In comparison with classical bur treatment, it is necessary to smoothen cavity surfaces and margins, after efficient cavity preparation, with low energy settings; though when combined with acid etching as adequate finishing methods it has shown to improve marginal adaptation with less presence of microleakage.13, 14 At dentin level: Dentin surfaces irradiated by Er:YAG laser were irregular, scaly, or flaky and dentinal tubules were opened without smear layer, cracked or melted; whereas protrusion of peritubular dentin was revealed due to its less amount of water compared with intertubular dentin.(Fig2) Irregularities promoted by laser irradiation vary according to the energy density applied.6, 9 Also it is reported that these lasers can fulfill the

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42 Restorative Dentistry requirement of minimal invasive dentistry due to the possibility of maximum conservation of sound tissue structure during caries removal and that of the surface decontamination of affected dentin.9 Er-YAG laser is turned off when significant changes on fluorescence are detected during caries removal, established by a cut-off value indicating that all decayed tissue was removed.9, 15 However, this technique hasn’t altered composition and microhardness of dentin tissue.

Three layers were observed in the sub-surface: a superficial less decalcified layer; an intermediate most decalcified layer, and a deep normal shade layer. Er:YAG laser irradiation affected acid resistance sub-surface dentin.8 Bond strength of self-etching systems to dentin was not affected by any Er:YAG laser irradiation settings, but the etch and rinse systems showed the lowest bond strength on laser-irradiated dentin. The reasons for the decrease in bond strength to laser-irradiated dentin are related to the alteration of the acid resistance of dentin and the deficient diffusion of adhesive monomers within the denatured fibrils.

In other words, laser irradiation can form different organic and inorganic compounds which in term show different levels of acid solubility.

A well-defined hybrid layer was not noticed when Etch and rinse was bonded to laser irradiated dentin regardless of laser irradiation parameter used.

For self-etching systems, TEM figures showed that adhesive layers on irradiated dentin were consistently bonded to dentin without the presence of gaps or debonding areas. The adherence of the composite resin bonded to the Er:YAG laser-irradiated dentin using selfetching adhesive systems appeared equal or lower to those obtained for a bur-cutting dentin surface16,17 At pulp level: Neither odontoblastic alterations have been noticed nor inflammatory response in pulp chamber beneath the preparation observed.

Histopathological studies in animals and humans have shown that pulpal tissues underlying deep cavity preparations realized with an erbium Dental News, Volume XXII, Number III, 2015

Fig 2

Fig 2: Left panel: scanning electron photograph showing the dentin surface treated with EDTAC. Magnification:1000X. Right panel: scanning electron photograph showing the dentin surface treated with Er:YAG laser. Arrows indicate the presence f micro-retention and absence of smear layer. Magnification: 1000X. (22)

laser do not undergo pathological changes.

Utilization of rats teeth have shown that fibroblast proliferation is observed sooner and more frequently in the specimens treated with the Er:YAG laser than those prepared with the high-speed drill.

Because the tissue is not vaporized completely but only disintegrated into fragments, radiant energy is converted efficiently into ablation that alters morphological structure of the tissue. No evidence of a melting process that might lead to considerable heat damage of the surrounding tissues.3, 5, 15 Relevance of microleakage to secondary caries: Microleakage refers to clinically undetectable leakage between cavity wall and filling. It has been also considered as a potential predictor of secondary caries and has caused serious concern to many researchers.

Absence of a seal at restoration margins permits entry of oral bacteria and fluids, which can result in postoperative sensitivity, adverse pulpal responses, and recurrent caries. There is a twoway interaction; the potential for leakage is influenced not only by the surface texture of the prepared tissues, but also by the composition and physical properties of restorative materials

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44 Restorative Dentistry applied to it. Laser-induced changes in surface texture of enamel and dentine could potentially affect microleakage of adhesive restorative materials.9

With Er:YAG laser, SBS is low due to: 1. Absence of smear layer 2. Denatured sub-surface = less strong collagen fibers 3. Hybrid layer thickness = 5 to 6 microns with the self-etch adhesives.

In vitro shear bond strength (SBS) to dentin with self etching adhesives (3 firms: I Bond, Kulzer/ Xeno 3, Dentsply/ Clearfil SE Bond, Kuraray) Er:YAG laser

Bur

Mean shear bond strength

I Bond

6,44 +/- 2,28

9,37+/- 3,49

Mean shear bond strength

Xeno 3 Clearfil SE Bond

8,92+/- 2,96 9,63+/- 3,28

9,76+/- 3,49 13,87+/-5,25

Adhesive failure

I Bond Xeno 3

20% 30%

10% 20%

Adhesive failure Cohesive failure

Clearfil SE Bond I Bond

30% 0%

5% 0%

Cohesive failure Cohesive failure

Xeno 3 Clearfil SE Bond

5% 5%

10% 30%

Mixed failure Mixed failure

I Bond Xeno 3

80% 65%

90% 70%

Mixed failure

Clearfil SE Bond

65%

65%

Mean shear bond strength Adhesive failure

Comparative study between laser irradiation and burs (conventional) on dental tissues Reference: (17, 18, 19) Laser

Burs

Required time(sec)

95,51 +/- 2,21

15,32+/- 2,35

Temperature rise(ËšC)

2,1 +/- 1,2

1,9 +/- 1,35

Quantities in weight Ca and P (%)

Ca 36,28 +/- 3,35 P 17,55 +/- 3,2

Ca 29,35 +/- 25 P 14,55 +/- 2,27

Ratio Ca/P

No Change 2,06

No Change 2,02

Light microscopic observation

Rough irregular surface, absence of cracks nor carbonization

Well delimited cavity, clear margins, smooth cavity floor

SEM observation

Scaly irregular surface No smear layer Dentinal tubules opened Intertubular dentin more ablated than peritubular

Resistance to artificial secondary caries

MARKED

Dental News, Volume XXII, Number III, 2015

Flat appearance Presence of smear layer Dentinal tubules plugged

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Conclusion The use of laser irradiation in operative dentistry has several advantages such as a more conservative cavity design, a significant decrease of enamel solubility, which play a significant role in the prevention of recurrent caries.

Moreover, laser ablation provides more comfort to the patient due to the absence of vibration and a lower pain sensation.

On the other hand, the major drawback related to the use of Er:YAG laser in operative dentistry is the relatively long time needed for cavity preparation. Time required for a complete excavation is, in general, twice compared to that with rotary instruments. Therefore, they can be complementary to the rotary instruments, mainly on the dentin.

At dentin level, absence of smear layer is very often mentioned as an advantage of laser irradiation of tooth surfaces, in particular for bonding procedure but it has been reported that laser may change composition and conformation of the dentin’s organic matrix, which may impair adhesive penetration and facilitate collagen degradation particularly when it comes to etch and rinse systems since they are based on only micromechanical interaction with dentin.6, 10 Dental News, Volume XXII, Number III, 2015

Nanoleakage pattern of self-etching systems was not changed by irradiation and storage in water.

Irradiation with an Er:YAG laser with different parameters did not form a well-defined hybrid layer when etch-and-rinse adhesive was used, whereas for self-etching systems, TEM figures showed that adhesive layers were consistently bonded to irradiated dentin, without the presence of gaps or debonding areas.20 High energies (over 300mJ) can induce subsurface damages into enamel inducing poor marginal adaptation with a high degree of microleakage.

Low energies may require longer working time, but on the other hand, microleakage significantly decreased to become equal or even less then in bur treated cavities.

However it seems to be necessary, the same as after classical bur treatment, to smoothen the cavity surfaces and margins with acid etching in order to improve marginal adaptation.13 Next step can be a specific laser optimized adhesive systems and restorative materials, to improve marginal integrity.

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2. Shinoki T, Kato J, Otsuki M, Tagami J. Effect

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Dental Health, News, Volume XXII, Number III, 2015

Er:YAG Asian Pac J Dent 2011;

of cavity preparation with

laser on marginal integrity of resin composite restorations.

11:19-25.

3. Bader C, Krejci I. Indications and limitations of Er:YAG laser applications in dentistry. Am J Dent 2006 Jun; 19(3):178-186.

4. Giuriato JB, Freitas PM, Nagase DY, Oda M. In vitro evaluation of microleackage in class V restorations after cavity preparation with high speed diamond bur, ultrasonic tip or laser. Clin Lab Res Dent 2014; 20(1):39-45.

5. Raucci-Neto W, Raquel Dos Santos C, Augusto De Lima F, Pécora JD, Bachmann L, Palma-Dibb RG. Thermal effects and morphological aspects of varying Er YAG laser energy on demineralized dentin removal: an in vitro study. Lasers Med Sci 2014 Apr 23.

6. Arbabzadeh F, Birang E, Nazem R, Abbasian M, Koosha F, and Birang R, A Comparative Study on Micro Hardness and Structural Changes of Dentin Floor Cavity Prepared by Er: YAG Laser Irradiation and Mechanical Bur. J Dent (Shiraz). Jun 2013; 14(2): 73–77.

7. Chimello DT, Serra MC, Rodrigues-Júnior AL, Pécora JD, Corona SA. Influence of Er:YAG laser on microhardness of enamel adjacent to restorations submitted to cariogenic challenge in situ. Photomed Laser Surg 2008 Aug; 26(4):379-385.

8. He Z, Otsuki M, Sadr A, Tagami J. Acid resistance of dentin after erbium:yttriumaluminum-garnet laser irradiation. Lasers Med Sci 2009 Jul; 24(4):507-513.

9. Mjör IA, Toffenetti F. Secondary caries: a literature review with case reports.

Quintessence Int 2000 Mar; 31(3):165-179.

10. Pires PT, Ferreira JC, Oliveira SA, Azevedo AF, Dias WR, Melo PR. Shear bond strength and SEM morphology evaluation of different dental adhesives to enamel prepared with ER:YAG laser. Contemp Clin Dent. 2013 Jan; 4(1): 20–26.

11. Giusti JS, Santos-Pinto L, Lizarelli RF, Bagnato VS. Cavosurface Angle Patterns of Er: YAG Laser Cavity Preparations in Primary Teeth. J Oral Laser Applications 2004; 4:23-27.

12. Altan AB, Baysal A, Berkkan A, Göktolga-Akin EG. Effects of Er:YAG Laser Irradiation and Topical Fluoride Application on Inhibition of Enamel Demineralization.

Turk J Orthod 2013; 26:30-35.

13. Margolis FS. The erbium laser: the “Star Wars” of dentistry. Alpha Omegan 2006; 99(3):128-131.

14. Iaria G, Parker S. Clinical Considerations for the Use of Er:YAG Lasers in Restorative Dentistry. J Laser Dent 2008; 16(2):58-68.

15. Shahabi S, Chiniforush N, Juybanpoor N. Morphological Changes of Human Dentin after Erbium-Doped Yttrium Aluminium Garnet(Er:YAG) and Carbon Dioxide(CO2) Laser Irradiation and Acid-etch Technique: An scanning electron microscopic (SEM) Evaluation. J Lasers Med Sci 2013 Jan; 4(1):48-52.

16. Brulat N, Rocca JP, Leforestier E, Fiorucci G, Nammour S, Bertrand MF. Shear bond strength of self-etching adhesive systems to Er:YAG-laser-prepared dentin. Lasers Med Sci 2009 Jan; 24(1):53–57.

17. Koliniotou-Koumpia E, Kouros P, Zafiriadis L, Koumpia E, Dionysopoulos P, Karagiannis V. Bonding of adhesives to Er:YAG laser-treated dentin. Eur J Dent. 2012 Jan; 6(1):16–23.

18. Hossain M, Nakamura Y, Tamaki Y, Yamada Y, Murakami Y, Matsumoto K. Atomic analysis and knoop hardness measurement of the cavity floor prepared by Er,Cr:YSGG laser irradiation in vitro. J Oral Rehabil 2003 May; 30(5):515-521.

19. Dixit V, Dixit M, Hegde V, Sathe S, Jadhav S. Clinical evaluation of conventional and laser tooth preparation using visual analogue scale. J Dent Lasers 2013; 7:27-29.

20. De Oliveira MT, Reis AF, Arrais CA, Cavalcanti AN, Aranha AC, de Paula Eduardo C, Giannini M. Analysis of the interfacial micromorphology and bond strength of adhesive systems to Er:YAG laser-irradiated dentin. Lasers Med Sci 2013 Jul; 28(4):1069-1076.

21. Sasaki LH, Lobo PD, Moriyama Y, Watanabe IS, Villaverde AB, Tanaka CS, Moriyama EH, Brugnera A Jr. Tensile bond strength and SEM analysis of enamel etched with Er-YAG laser and phosphoric acid: a comparative study in vitro. Braz Dent J. 2008; 19:57-61.

22. Pécora JD, Cussioli AL, Guerisoli DM, Marchesan MA, Sousa-Neto MD, Brugnera Junior A. Evaluation of Er-YAG laser and EDTAC on dentin adhesion of six endodontic sealers. Braz Dent J. 2001; 12:27-30.

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50 Implant Dentistry

Cement-free Implant Retention

Dr. George Freedman DDS, FAACD, FIADFE, FACD epdot@rogers.com

Randy Kwon DT

Implants are very predictable, both in terms of maxillary and mandibular osseointegration and as functional and esthetic dental restorations.

They tend to have very high rates of success, and are suitable for most patients. Their widespread, routine use in dentistry over the last 20-30 years has established implants as a mainstream modality. Most importantly, patients are now generally more aware of this restorative opportunity, and are increasingly choosing implant-borne restorations in the place of fixed bridges and/or removable appliances.

Some practitioners elect to perform both the surgical and the restorative procedural components that comprise the total implant treatment.

Most professional, however, tend to gravitate towards one or the other of these treatment areas. Specialty practice licensure limitations in some jurisdictions contribute to the separation of treatment interests and responsibilities.

Periodontists, oral surgeons and endodontists generally prefer the surgical elements of implant therapy, readying the hard tissue recipient site for the implant, and then placing the implant in the bone.

General practitioners, while they typically take the responsibility of overseeing the total implant case, are more likely to be tasked with the pretreatment planning and the post-surgical restorative aspects of the implant sequence. These responsibilities include: 1. Pre-treatment positioning and angular alignment of the implants, essential in the development of the functional and esthetic parameters that guarantee a successful case (computergenerated guides and surgical stents are used to communicate this data between the surgical, restorative and laboratory team members), 2. Impression-taking from the abutment phase to the final restorative phase,

Dental News, Volume XXII, Number III, 2015

3. Occlusal and esthetic adjustment of the labfabricated implant prosthesis, 4. Attachment of the prosthesis to the implant(s) by one of several means, and, 5. Maintenance and repair of the implant restoration.

This last responsibility, including maintenance and repair, is commonly underestimated. This task, by default, falls to the restorative implant provider, typically the general practitioner who provides ongoing clinical services to the patient.

Implants are appliances that are in continuous function in patients’ mouths over extended periods of time, years and decades. They are subject to the significant functional and parafunctional forces that are generated by the muscles of mastication acting upon materials of varying hardness as they are chewed. Considering the mechanical loads on un-splinted implant molar crown restorations, the mechanical strength of many types of screw-retained implant-abutment connections is too low.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 On the other hand, the 6º conical connection found in MIS C1 implants (MoreDent/More Group, Melbourne, Australia) provides an exceptionally strong, gap-free, subgingival tapered connection that relies on surface-tosurface metal friction at the fixture/abutment interface for retention.16 (Fig 1) The friction grip relationship eliminates micro movement between the abutment and the implant, eradicating microbial colonization at the interface, and reducing bone loss at the crestal level.17 A 6-position cone index within the C1 connection assists in the correct orientation during abutment insertion.

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52 Implant Dentistry Fig 1

Occasionally, masticatory and accidental forces can cause damage to the carefully constructed restorations. The titanium of the implants and the metals utilized for the restorative infrastructures are so strong that they are rarely affected; porcelain, on the other hand, can chip or fracture, bridge metals can fatigue or require unit additions, and retention screws can loosen. In the MIS C1 system, the fixation screw between the abutment and the implant does not provide all the retention: the conical C1 connection is rotationally stable and positionally-oriented, and offers the greatest possible security against screws loosening and breaking.18 There are several methods commonly used to fix implant restorations to osseointegrated implants. The most commonly used approaches to fixating a crown on an implant are: Screw retention The crown is fixed to the abutment, or directly to the underlying implant, with a screw. Additional rotational stabilization such as manufactured or milled hexing may be required. After the screw is appropriately tightened, the screw head is protected by cotton, and the insertion access hole is restored to occlusion with composite. This makes it possible, in case the need arises (due to ceramic fracture or screw loosening), to access the retention screw. The composite is carefully removed to the cotton layer without damaging the screw head. The cotton that covers the head of the retention screw is picked out, exposing the retention screw. The crown can then be removed for laboratory repair or screw tightenDental News, Volume XXII, Number III, 2015

ing. This approach permits the implant crown or bridge to be totally retrievable. The location of the occlusal access hole is often rather unasthetic, and is difficult to adapt to patient acceptability with composite.

Cement retention The most common approach (often selected for esthetic reasons) has been to cement the crown onto the implant abutment with a theoretically retrievable temporary or provisional cement.

The fundamental concept of this technique is that the crown is removable from the abutment simply by breaking the seal of the provisional cement between the crown and the abutment at the margin. While provisional cements allow the somewhat flexible acrylic and bis-acryl dental provisionals to be separated rather easily from natural abutments (within the first few weeks or months after placement), the precision-fit, metal-to-metal crown-abutment implant interfaces are far more gap-free and retentive. These factors contribute to a much greater retention than would be normally expected from a provisional cement. Furthermore, there is ample evidence to indicate that provisional cements mature to the properties of permanent cements over the span of several months.

Thus, the provisionally cemented implant crown can become effectively irretrievable within 3-12 months after placement. This is a major clinical problem for the practitioner in cases where the esthetic ceramic covering of the crown or bridge fractures is compromised, the abutment or bridge requires an addition due to the further

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54 Implant Dentistry loss of natural dentition, or the implant retention screw suffers loosening that simply needs to be retightened. If the crown cannot be removed from the implant abutment easily (particularly difficult in situations where the retention screw has loosened), without damaging the abutment or compromising the integrity of the underlying implant in the bone, the practitioner is forced to cut the crown off the abutment. It is not likely that the sectioned crown is salvageable; thus, it cannot be repaired adequately for reinsertion, and must be remade.

There are additional risks in cutting off an implant-borne crown to consider. The metal-tometal crown-abutment interface consists of a very thin and often virtually invisible layer of temporary cement. It is easy to inadvertently cross this line during the high-speed crown removal process. Thus, sectioning will, in addition to destroying the crown, often damage the screw retained abutment as well. These risks are even greater where the retention screw has loosened and the drill bit does not have a secure purchase on the wobbling implant crown assembly.

The question of financial liability is an important consideration. Once an implant-borne crown is sectioned off, it (and all too often, the abutment) must be re-fabricated to restore the patient’s dentition. Who should assume part or all of the financial liabilities that arise from the process: removal, re-fabrication, and re-insertion? Is it the patient, the dentist, the laboratory technician, or the manufacturer? And at what point in time after the original insertion of the prosthesis does the “normal use and wear” make the replacement procedure the patient’s financial responsibility?

Setscrew retention A well-established engineering concept is available for implant restorations, offering a clinical solution that eliminates all of the above risks and potential liabilities. The setscrew is a totally retrievable mechanism for affixing the implantborne crown to the abutment. It is a high-precision system that is manufactured entirely at the dental laboratory, requiring no additional chairside time or steps. The process adds somewhat to the laboratory cost but significantly reduces Dental News, Volume XXII, Number III, 2015

clinical chairtime during the insertion phase; the greatest benefits occur in situations where implant-borne crowns/bridges must be removed.

Removing the setscrew is very simple, very fast, and very easy, and the implant prosthesis is released within seconds at no risk to the osseointegrated implant and no discomfort to the patient. The setscrew does not become more difficult to remove with time, and the anatomy of the head is so shallow that no supplementary restorative coverage is required.

The implant bears the occlusal masticatory loads, and lateral forces are transferred at the abutment-implant interface by one of the following: a conical-index anatomy (MIS C1), a retention screw plus hex, or a retention screw alone. A precision-fit implant crown relying on a conical metal-to-metal interface does not require very much retentive strength. The small, horizontally-inserted setscrew only needs to prevent the vertical movement of the crown on the abutment, and is not exposed to high stress.

During the insertion, it also provides the practitioner with a defined registration for the crown, both rotationally and inciso-gingivally.

The only additional pre-planning required is to ensure that the placement of the setscrew access does not compromise the patient’s esthetics and that the direction of entry allows adequate clearance for the driver and the practitioner’s fingers in the patient’s mouth during insertion.

56 Implant Dentistry Case 1 The implant has osseointegrated and the soft tissue is ideally shaped for the restoration. (Fig 2) After transfer impressions and electronic shade taking (plus custom in-lab color adjustment), the dental laboratory (Progenic Dental Laboratory, Oakville ON, Canada) returned the custom abutment, crown, and setscrew assembly. These are viewed on the model from the buccal (Fig 3), occlusal (Fig 4), and lingual (Fig 5) The driver is used to disassemble the lingual attachment on the model and to establish the screw access angulation. (Fig 6) The abutment is viewed from the lingual, indicating the milled setscrew entry path (Fig 7).

The transitional abutment has maintained the anatomy and the gingival health of the tissue surrounding the implant (Fig 8). The abutment is positioned and secured with the fixation screw (Fig 9). The indexed conical taper of the precision-fitting abutment provides a rotationally stable and gap-free attachment to the implant. The crown is tried in to verify mesio-distal positioning, occlusal clearance, soft tissue relations, and esthetics. The incisogingival positioning of the crown is verified from the lingual by the alignment of the crown setscrew access with the abutment setscrew hole (Fig 10).

The setscrew is carefully positioned on the driver (Fig 11) and the crown is fixed onto the abutment (Fig 12). A close up view indicates the required angulation of the driver both mesiodistally and inciso-gingivally, an orientation that was predetermined on the model (refer to Fig 6).

Fig 3

Fig 4

Fig 5

Fig 6

Fig 2

Fig 7

Dental News, Volume XXII, Number III, 2015

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References: 1. Fine DH, Sreenivasan PK, McKiernan M, et al. J Clin Periodontol. 2012;39:1056-1064. 2. Collins LMC, Dawes C. J Dent Res. 1987;66:1300-1302.

58 Implant Dentistry Fig 8

The tightened setscrew leaves a small space towards the gingival (Fig 13). While food may sometimes settle in this location in between brushings, it is not likely that this debris will have any effect on the exposed smooth metal surfaces.

The setscrew allows the crown to be removed, for any reason whatsoever, in a matter of seconds. The patient’s smile shows the implant-borne crown in place (Fig 14) and close-up (Fig 15).

Fig 13

Fig 9

Fig 10 Fig 14

Fig 11

Fig 15

Fig 12

Dental News, Volume XXII, Number III, 2015

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60 Implant Dentistry Fig 16

Fig 17

Fig 18

Case 2

Conclusion

The “provisionally” cemented implant crown was loose but impossible to separate from the abutment, and the entire crown assembly was mobile during the removal process. The original implant abutment was damaged when the loosened crown was sectioned (Fig 16). The new abutment required an innovative laboratory approach (Fig 17) to create a suitable site for the setscrew and to maintain adequate ceramic space for esthetics (Progenic Dental Laboratory, Oakville ON, Canada). The positioning of the abutment bucco-lingually (Fig 18) and mesio-distally (Fig 19) are dependent upon the less than ideal arch form. The custom abutment is fixed on the implant (Fig 20), and the crown is placed on the abutment and secured with a setscrew (Fig 21). The lingual view demonstrates the non-traditional positioning of the crown margins and the setscrew to offer the patient a long-term restoration. (Fig 22)

Setscrew retention provides the practitioner with the option of a restoration that is totally retrievable within seconds. Pre-planning the location of the setscrew access allows uncompromised functional and esthetic results. The required collaboration between the dentist and the laboratory technician is simple and straightforward. Setscrew retained implant restorations make the practice of implant dentistry better, faster, and easier.

Fig 20

Fig 19

Fig 21

Fig 22

Dental News, Volume XXII, Number III, 2015

Dr. George Freedman is a founder and past president of the American Academy of Cosmetic Dentistry, a co-founder of the Canadian Academy for Esthetic Dentistry and a Diplomate of the American Board of Aesthetic Dentistry. He is a Visiting Professor at the MClinDent programme in Restorative and Cosmetic Dentistry, BPP University in London. His most recent textbook, “Contemporary Esthetic Dentistry” is published

by Elsevier. Dr Freedman is the author or coauthor of 12 textbooks, more than 700 dental articles, and numerous webinars and CDs and is a Team Member of REALITY. Dr Freedman was recently awarded the Irwin Smigel Prize in Aesthetic Dentistry presented by NYU College of Dentistry. He lectures internationally on dental esthetics, adhesion, desensitization, composites, impression materials and porcelain veneers. A graduate of McGill University in Montreal, Dr. Freedman is a Regent and Fellow of the International Academy for Dental Facial Esthetics and maintains a private practice limited to Esthetic Dentistry in Toronto, Canada.

Randy Kwon achieved his Ontario College Advanced Diploma in Dental Technology from George Brown College in 2007. This early in his young career, Randy Kwon has become the head of the implant department and leading gold and CAD/CAM technician at Progenic Dental Lab, where he has trained and worked since 2004. He keeps his industry knowledge up with regular enrollment in accredited implant, esthetic and functional courses across North America.

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62 Implant Dentistry

References 1. Mollersten L, Lockowandt P, Linden LA. Comparison of strength and failure mode of seven implant systems: an invitro test, J Prosthet Dent. 1997;78:582–591 2. Ekfeldt A, Carlsson G, Borjesson G. Clinical evaluation of single-tooth restorations supported by osseointegrated implants: a retrospective study. Int J Oral Maxillofac Implants. 1994; 9:179 3. Henry PJ, Laney WR, Jemt T, et al. Osseointegrated implants for single-tooth replacement: aprospective 5-year multicenter study. Int J Oral Maxillofac Implants, 1996; 11:450 4. Rangert B. Mechanical and biomechanical guidelines for the use of Branemark System—general principles, Aust Prosthodont J. 1993;7:39 5. Rangert B, Mech E, Krogh P, Langer B, Van Roekel N. Bending overload and implant fracture: a retrospective clinical analysis, Int J Oral Maxillofac Implants. 1995; 10:326 6. Mehl C, Harder S, Wolfart M, Kern M, Wolfart S. Retrievability of implant-retained crowns following cementation. Clin Oral Implants Res. 2008 Dec; 19 (12):1304-11 7. Chaar MS, Att W, Strub JR. Prosthetic outcome of cementretained implant-supported fixed dental restorations: a systematic review. J Oral Rehabil. 2011 March 12. doi: 10.1111/j.13652842.2011.02209.x. [Epub ahead of print] 8. Preiskel HW, Tsolka P. Cement- and screw-retained implant-supported prostheses: up to 10 years of follow-up of a new design. Int J Oral Maxillofac Implants. 2004 Jan-Feb; 19(1):87-91 9. Al-Omari WM, Shadid R, Abu-Naba’a L, El Masoud B. Porcelain fracture resistance of screw-retained, cement-retained, and

screw-cement-retained implant-supported metal ceramic posterior

crowns. J Prosthodont. 2010 Jun; 19(4):263-73. Epub 2010 Jan 29 10. Satterthwaite J, Rickman L. Retrieval of a fractured abutment screw thread from an implant: a case report. Br Dent J. 2008 Feb 23; 204(4):177-80 11. Pan YH, Lin CK. The effect of luting agents on the retention of dental implant-supported crowns. Chang Gung Med J. 2005 Jun; 28(6):403-10 12. Torrado E, Ercoli C, Al Mardini M, Graser GN, Tallents RH, Cordaro L. A comparison of the porcelain fracture resistance of screw-retained and cement-retained implant-supported metal-ceramic crowns. J Prosthet Dent. 2004 Jun; 91(6):532-7 13. Khraisat A, Hashimoto A, Nomura S, Miyakawa O. Effect of lateral cyclic loading on abutment screw loosening of an external hexagon implant system.

Prosthet Dent. 2004 Apr; 91(4):326-34 14. Michalakis KX, Pissiotis AL, Hirayama H. Cement failure loads of 4 provisional luting agents used for the cementation of implantsupported fixed partial dentures. Int J Oral Maxilllofac Implants.

2000 Jul-Aug; 15(4):545-9 15. Singer A, Serfaty V. Cement-retained implant-supported fixed partial dentures: A 6-month to 3-year follow-up. Int J Oral Maxillofac Implants. 1996 Sep-Oct; 11(5)645-9 16. Nentwig GH. The Ankylos Implant System: Concept and Clinical Application, Journal of Oral Implantology 2004; 30(3) 171177 17. Weigl P. New Prosthetic Features of the Ankylos Implant System, Journal of Oral Implantology 2004; 30(3) 178-188 18. Romanos GE, Nentwig GH. Single molar replacement with a progressive thread design implant system: a retrospective clinical report, Int J Oral Maxillofac Implants, 2000; 15:831–836.

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64 Restorative Dentistry

Dental Composite Curing System Apparatus and Method Dr. Mohammad Al Rifai

Shrinkage and stress is a common issue in the field of composite restorations. Dentists face this issue daily across the world, and no effective solution to address this problem has been reached yet. The idea behind this invention was to solve this problem and to minimize the unfavorable shrinkage and stress in the composite restorations. My research was done as a development and a contribution to the continuous efforts to solve this issue and improve dental outcomes.

Inventor: Dr Mohammad Al Rifai This invention will be a revolution in the field of dental composite restorations as it will change the prevailed principles and modify the current rules of composite application significantly.

With the techniques used in this research, any composite material that has inferior properties concerning stress or shrinkage will behave as an ideal composite restorative material. These results were achieved through decreasing the shrinkage, and stress up to 70% for the same materials currently used by dentists. This motivated me to publish my invention.

The idea was to reduce the negative effects of stress and shrinkage of composite polymerization.

The research and development departments in manufactories and universities tried to get the minimal negative effects of composite shrinkage throughout many ways like: 1. As resin is the main reason for shrinkage in composite they tried improving the quality of the resin matrix and tried to reduce its quantity in the composite mix.

2. Development of the curing light device (light source) by increasing the power of the light up to 1,600 mw/cm2, and increasing the range of the light wave length from 300 to 500 nm, or using

Dental News, Volume XXII, Number III, 2015

soft start technique and changing the direction of the light beams from straight to angled beam (conic shape) 3. In addition to the above, other techniques were used but with a minimal impact in reducing the negative effects of the composite shrinkage, such as using perforated plates with different shapes but unfortunately these techniques were not successful and failed.

Based on all of the above, we will explain the difference between this invention and other procedures.

Here are some introductory explanations: 1. The light beams in all light cure devices are divergent and have a conic form 2. During composite polymerization, unfavorable shrinkage and stress appears 3. Stress is the force produced from the shrinkage of the restoration connected to the edges of tooth’s walls at the same time the adhesion to the walls is greater than the shrinkage force (adverse effect). The stress power always concentrates at the corners of any shape like a triangle or rectangle unlike the circular shape.

4. Using the perforated plate is to divide the curing process in the restoration to cured and uncured areas, so the uncured areas will slightly expand and compensate the shrinkage generated by cured areas, and the benefits from this division is that the stress and shrinkage are allocated to many areas in the restoration and are not concentrated in the edges of the restoration. When the restoration gets cured without perforated plate, shrinkage and stress will pull the restoration to the center and the tooth’s walls will prevent this action. (fig 1.1 -1.2)

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66 Restorative Dentistry The first experiment with the perforated plate was not successful and we tried to find the reasons for the failure. The problem using the perforated plate is that large parts of the restoration cured or the whole restoration cured (Keeping in mind that the transformation from the plastic state to hardness takes 3 to 5 seconds). The reasons for failure were: Lack of closed space between the holes of the perforated plate to prevent the light beam from reaching the restoration so there were not enough uncured masses between the cured areas. And since the light beams diverge from the source this will increase the cured area and might cure the whole restoration. (fig 2)

Fig 1.1

Fig 1.2

To solve this issue I came up with the idea of leaving 1mm of closed space between the holes, and the diameter of the holes is also 1mm. Why 1mm and not more or less?

The main concept is trying to find the best combination that allows the highest number possible of perforations and achieve the highest number of both cured and non cured areas in the composite restoration (i.e. the smallest size of perforations and the smallest distance between the perforations) I tried several combinations of both perforation size and separating distance, and found the following : I. Perforations of 0.5 mm in diameter, did not allow sufficient amount of curing light to pass through the perforated plate and thus was not able to induce the desired curing effect in the composite.

II. Perforations of 1 mmin diameter, allowed enough amount of curing light to pass through the perforated plate ( I recorded 400 m watt/ cm2 out of a source of 1100 m watt/cm2) and was able to induce the desired curing process in the composite.

III. Perforations of more than 1 mm were not desirable, mainly for two reasons: 1- This will reduce the number of perforations possible which contradicts with the general concept.

Dental News, Volume XXII, Number III, 2015

Fig 2

2- In dental practice there are restorations of 1.52 mm in size. Which means that a perforation of 1.5 mm or 2 mm in diameter has the potential of covering the total surface of the restoration and cause the curing in the whole restoration which is what we are essentially trying to avoid.

IV. Perforations of 1 mm diameter and the holes 0.5 mm apart. I found that the light beams passing through the perforated plate (the plate must not exceed 0.5 mm in thickness to reduce the attenuation of the curing light power) have almost reunited on the restoration surface after passing through the plate (due to the divergent

68 Restorative Dentistry pattern of the light beams passing through the plate) and caused the curing effect on almost the whole restoration mass.

V. Perforations of 1 mm diameter and holes 1 mm apart. This combination allowed for enough light power to pass through with suitable separations, and achieved the desired result of both cured and non cured areas of the composite restoration.

VI. Perforations of 1 mm and 1.5 - 2 mm apart were not suitable for reasons very similar to the reasons that lead to the rejection of 1.5-2 mm perforations above.

In conclusion I have found a plate of 1 mm in diameter perforations and holes 1 mm apart to be the best combination that allows for enough curing light power to pass through the perforated plate, and achieve the desired curing process.

And why circular holes?

My experiments indicate that this form will result in minimal shrinkage effects in comparison to other suggested geometrical forms. Furthermore, circular holes do not contain any angles (in contrast to the other suggested shapes of parallel lines or grid). And since it’s well known in the field that stress points are usually formed in the corners. This will result in minimal stress points formation in the restoration after polymerization.

Based on the above and after the experiments, I should get a cylinder or cone shaped curing in the restoration using a perforated plate with circular holes, but I got different result, I got random shapes with a bigger volume than expected and it was big enough to fuse with the next cured blocks. The reason for getting random and bigger shapes is the vibration in the doctor’s hand during the curing process, and due to this vibration there is a change in the light beam direction coming from the light source into the holes and this will cure areas in the restoration under the covered areas between the circular holes and curing this unwanted areas caused a bigger and random masses of cured composite.

Dental News, Volume XXII, Number III, 2015

To solve this issue and mitigate the vibration in doctor’s hand I found that we should fix the light source with the perforated plate and the tooth all together, and for this I designed a special handle to solve the vibration in the doctor’s hand and this handle has other advantages also (fig 3, 4.1, 4.2)

Fig 3

70 Restorative Dentistry Fig 4: A simple illustration of the handle 1. Flexible metal ring.

2. Fiber glass tube end of the light curing device.

3. Metal holder joining with the ring and the plate.

4. Perforated plate.

5. Leg of the holder designed to stand on the side of the tooth.

6. The passing light beam through the plate.

Fig 4.1

Fig 4.2

In this new design, the plate was carried independently to fix it on the tooth and put the light source over it.

In this pattern, the plate can be fixed under the light curing device directly by the flexible metal ring (1), then the device and the plate can be fixed on the tooth. This provides ease in treatment, and good stability of the plate over the tooth. So, the light beam doesn’t suffer from shaking during the curing process.

The plate can be fixed by a flexible ring that allows the head of the fiber glass tube to be inserted into the ring (1), and the ring is not closed.

It allows a simple expansion in dimensions. This makes the ring suitable with a large number of devices as in figure 4.

The ring allows moving the plate and the holder in different directions around the axis of the tube of the curing device, where the leg of the holder (5) can stand on different walls of the tooth (lingual, Buccal).

After using the handle with the perforated plate, we got acceptable results where the dimensions and the shapes of cured restoration had conical shapes, and didn’t fuse with each other.

Dental News, Volume XXII, Number III, 2015

Some details of the suggested design: 1. 0.5 mm thickness of the perforated plate is optimal, because if the plate was thicker, (1 mm thickness) will reduce the light beams passing through the holes and this will reduce the cured area significantly.

And if the plate is thinner than 0.5 mm, this will allow larger light beams to pass through holes and will increase the cured areas significantly.

2. The design of the handle is allowing the plate to rotate 360 degrees around the tube of the light cure device, which will give the doctor the ability to use the plate over any surface of the tooth, upper, lower, right or left tooth.

3. The design allows minimal distance between the light source, plate and tooth surface.

4. It is easy to produce the device commercially with low cost and with the ability to get sterilized (since it is made of stainless steel) 5. The shape of the part of the handle to be fixed on the tooth surface is curved allowing high stability on the tooth surface.

Dr. Mohammad Abdulkarim Al Rifai D.D.S Al Mamzar, P.O. Box 91190 Dubai, UAE E mail : drmr@usclinic.net Mobile: +971 52 869 5212 Telephone: +971 4 250 2471 Website: www.usclinic.net Personal Information: • Born in Damascus-Syria in 1976.

• Married and I have three adorable children.

• I have a valid UAE residence

Education: • Graduated from The Faculty of Dentistry- Albaath University in Hama- Syria, in the year 2000.

• I have a registered invention from the Director of United States of America Patent and Trademark office . In composite restoration field.

• A Registered dentist in the Ministry of Health-Syria and the Syria Dental Association-Daraa branch-Daraa -Syria since the year 2000.

• I have License from Dubai Health Authority since 2013 Working experience: • Working in Unique Smile Clinic from 2013 up to present as G.P. Dentist and Medical Director.

• I have been practicing dentistry in my private clinic in Daraa-Syria since the year 2000 until 2012 • I have a registered invention from the Director of United States Patent and Trademark office . In composite restoration field.

• I have advanced experience in the field of operative and cosmetic restorations and the field of Endodontic and Prosthesis.

• I am working with Focus Dental as a scientific support for Ivoclar Vivadent since 2004.

• I am working with NEAR EAST MEDICALS as a scientific support for BRASSELER. KOMET since 2006.

• CERTIFIED by the International Center for Dental Education (ICDE)-IVOCLAR VIVADENT. Schaan, Switzerland. In modern aesthetic and restorative dentistry in the year 2006 -2015 • Lecturer for VOCO scientific support in Syria 2009-2010.

72

UQUDENT Announces the Graduation of its First Batch of Dentists www.dentistry.uqu.edu.sa

Dean Mohamed Beyari Celebrating the Graduation of the First Batch of Dentists at UQU

The Faculty of Dentistry at the University of Umm Al-Qura presented a ceremony for the first graduates of the college on the 26th of May, 2015. Among the presence was the College Dean Dr. Mohammed Beyari, the Dean of the Medical Faculty at AL-Leeth Dr. Faris Altaf, the Head of the Dental Department of King Faisal Hospital in Makkah, Dr. Ayman Mandoura and the Head of the Dental Center of Al Noor Specialist Hospital, Dr. Firas Alim. As well as the College Vice Deans, the Head of Departments, the Faculty Staff and the Demonstrators. The event took place at the Dental Teaching Hospital building.

The ceremony opened by a welcoming talk from one of the graduating students Mr Eissa Al-Ghamdi who spoke on behalf of his graduating colleagues. He thanked UQUDENT the “Honored Place & Honored Education�, where they enjoyed every minute of it.

The following talk was presented by the Dean Dr. Mohammed Beyari where he expressed his delightfulness about the graduation of his sons and daughters of the first batch. He showed his excitement about them honored by joining the field of employment and be part of it and contribute with what they have learned.

Then Dr. Beyari explained how, the Faculty of Dentistry at the University of Umm Al-Qura, was keen and adamant from the start to be within the distinctive colleges with a high level of professionalism and performance. He also assured that the high standard and excellence, will continue to graduate more dentists to contribute in the service of humanity.

Then the Dean of the college honored the graduates and the talented students as well as the faculty members. The students also presented a gift to their Dean and had some photographs taken with him.

Dental News, Volume XXII, Number III, 2015

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with Colgate® Sensitive Pro-Relief™ Toothpaste*

COLGATE® SENSITIVE PRO-RELIEF™ WITH PRO-ARGIN™ TECHNOLOGY PROVIDES INSTANT AND LONG-LASTING RELIEF. Extensive scientific research has shown that Colgate® Sensitive Pro-Relief™ protects against the triggers and causes of sensitivity, and is proven to occlude dentin tubules in 60 seconds.* Finally, a way to quickly improve your patients’ satisfaction and comfort.

YOUR PARTNER IN ORAL HEALTH www.colgateprofessional.com *When toothpaste is directly applied to each sensitive tooth for 60 seconds.

Ayad F, Ayad N, Delgado E, et al. J Clin Dent. 2009;20(4):115-122.

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RECOMMENDED BRAND RECOMMENDED 1 BRAND

BY DENTISTS

BY DENTISTS

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NEW! The Cavex Bite&White ABC Masterkit Cavex has developed the ABC-Whitening-System accumulated in the Cavex Bite&White ABC Masterkit, where the AB&C stand for “Activate,” “Brighten,” and “Condition.” Following these 3 simple steps, Cavex ensures a highly effective, safe and above all – a pain free whitening treatment. How does it work?

Activation is the first step and is done with Cavex Bite&White StainLess. This refreshing paste has two functions. It has an exceptional ability to remove surface stains and plaque allowing the whitening product to be in direct contact with the enamel surface. Cavex Bite&White StainLess also has the amazing ability to raise the pH of the mouth whereby creating the perfect environment for a whitening treatment to work best.

Brightening is done by Cavex Bite&White, a proven, effective and above all safe whitening gel with 16% carbamide peroxide (equal to 6% hydrogen peroxide). The addition of sodium fluoride helps to reinforce the enamel while potassium nitrate helps avoid any potential sensitivity. Cavex Bite&White only needs 1 hour treatments to be effective -- there is no necessity to keep it in the mouth longer. This avoids enamel from drying out, which can also cause sensitivity.

Conditioning is done with Cavex Bite&White ExSense. Cavex Bite&White ExSense offers fast and long-lasting relief from sensitive teeth thanks to a revolutionary blend of hydroxyapatite and a ‘hydro-dispersing gel.’ The unique properties of the hydro-dispersing clay ensures accelerated dispersion that helps boost the hydroxyapatite penetration. Thanks to the synergetic composition of Cavex Bite&White ExSense, the hydroxyapatite penetrates deep into the tubules and micro-cracks in the enamel. This means that the areas causing sensitivity are completely sealed off, while at the same time, a process of crystallization helps to restore micro-hardness and accelerates the re-mineralization process.

Website: www.biteandwhite.com

Essentia™ from GC

Open the door to simplification - Just follow your intuition GC is proud to introduce its new composite Essentia™, a paradigm shift in layering composites.

Essentia breaks free from the conventions with a unique shade system. The new concept is bold and straightforward: seven shades to solve all clinical cases. The system is very intuitive which will simplify the daily work of clinicians.

Essentia simplifies the shade selection with six main restorative options. For the anterior cases, it will be 4 options based on the age of the patient: Bleach/Junior, young, adult and senior. For the posterior, you can select between an easy duo layering technique or a simple mono-shade using the Universal.

Furthermore, Essentia features optimal handling and optical properties in all situations. The dentin is made soft for an easy sculpting and displays an excellent shade adaptation. The enamel is slightly more compact and guarantees an excellent gloss. The Universal shade is packable for an easy application in the posterior area. The Masking Liner is injectable and very opaque which is perfect for deep discoloured cavities.

Finally, the aesthetics is secured by a simplified polishing procedure. The Enamel formulation secures a prefect surface in only few polishing steps. This gloss is retained thanks to the use of ultra-fine fillers.

Website: www.gceurope.com Dental News, Volume XXII, Number III, 2015

Dental News, Volume XXII, Number III, 2015

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

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

SEM images of denture surface. *In vitro single species biofilm after 5 minutes soak References: 1. Glass RT et al. J Prosthet Dent. 2010; 103(6): 384-389.

2. GSK Data on File, Lux R. 2012.

Arenco Tower, Media City, Dubai, U.A.E. Tel: +971 4 3769555, Fax: +971 3928549 P.O.Box 23816.

For full information about the product, please refer to the product pack.

For reporting any Adverse Event/Side Effect related to GSK product please contact us on contactus-me@gsk.com.

Date of preparation: June 2014, CHSAU/CHPLD/0008/14c We value your feedback Saudi Arabia: 8008447012 All Gulf and Near East countries: +973 16500404

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