DT Middle East and Africa No. 3, 2016
News
/ Industry
/ Treatment planning: Retention of the natural dentition and the replacement of missing teeth
/ Bioactive materials support proactive dental care
/ Oral Health
/ Avulsion in Paediatric Dentistry: Management of a Double Dental Emergency in a Child
/ Advanced Restorative Techniques and the Full / Partial Mouth Reconstruction PART 3 : Treatment of severe wear cases
/ General Dentistry
/ Interview: “Technology leads to better dentistry”
/ Virtual reality simulation
/ News
/ Why Practice Management?
/ 11th CAD/CAM & Digital Dentistry International Conference
/ Hygiene Tribune Middle East & Africa Edition
/ Endo Tribune Middle East & Africa Edition
/ Lab Tribune Middle East & Africa Edition
/ Implant Tribune Middle East & Africa Edition
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DTMEA_No.3. Vol.6_DT.indd
L
NA
NT
AL FO
PR R T
O HE
FE
SS
IO
DE
www.dental-tribune.me
PUBLISHED IN DUBAI
May-June 2016 | No. 3, Vol. 6
HYGIENE TRIBUNE
ENDO TRIBUNE
LAB TRIBUNE
IMPLANT TRIBUNE
Poor dental health may
predict reduced ability to
leave one’s house
Getting to the 00.00
point
The story behind IPS POWER
Implant uncovery with
the Picasso diode laser
ÿInsertion
ÿInsertion
ÿInsertion
A time-saving procedure
to create natural esthetics
in posterior restorations
By Ivoclar Vivadent AG
A flowable bulk-fill composite
complements the existing Tetric NCeram Bulk Fill. For many years, the
universal composite Tetric N-Ceram
has been proven successful in restorative dentistry. As part of the
ongoing development of restorative
materials, a further innovation is
now launched on the market: Tetric
N-Flow Bulk Fill.
The new flowable composite complements the mouldable Tetric
N-Ceram Bulk Fill composite. In essence, Tetric N-Flow Bulk Fill is based
on the composition of Tetric N-Ceram Bulk Fill. The material is applied
as a bulk-fill base in Class I and Class
II restorations. Just like the existing
version, it can be light-cured in large
increments of up to four millimetres,
ÿPage 2
Ivoclar Vivadent AG Headquarters
ÿInsertion
[2] =>
DTMEA_No.3. Vol.6_DT.indd
2
nEWS
Dental Tribune Middle East & Africa Edition | 3/2016
◊Page 1
requiring only short light exposure
times. Excellent affinity to cavity
walls and self-levelling consistency
round off the benefits offered by this
volume replacement material. The
flowable version contains the same
Ivocerin light initiator, patented
shrinkage stress reliever and light
sensitivity filter like Tetric N-Ceram.
The light sensitivity filter extends
the working time under ambient
and operatory light.
Time savings of up to 55%
User studies have shown that clinicians can save up to 55% of the
time required for the incremental
technique if they use a bulk-fill material (with Tetric N-Flow and Tetric
N-Ceram).
Ivocerin light initiator and
Aessencio technology
nology. This technology causes the
translucency of the material to decrease from 28% to approx. 10% during polymerization. In combination
with the highly reactive patented
Ivocerin light initiator, the Aessencio
technology enables composite increments up to a thickness of 4 mm to
be cured, while at the same time a
low dentin-like translucency can be
maintained, allowing, among other
things, discoloured tooth structure
to be masked. This property makes
Tetric N-Flow Bulk Fill the ideal
companion for Tetric N-Ceram Bulk
Fill, which features an enamel-like
translucency. Tetric N-Flow Bulk Fill
should be covered with a load-bearing composite (e.g. Tetric N-Ceram
Bulk fill or Tetric N-Ceram). For restorations in deciduous teeth, the material can be applied without a capping
layer.
IMPRINT
GROUP EDITOR
Daniel ZIMMERMANN
newsroom@dental-tribune.com
Tel.: +44 161 223 1830
CLINICAL EDITOR
Magda WOJTKIEWICZ
ONLINE EDITOR
SOCIAL MEDIA MANAGER
Claudia DUSCHEK
EDITORIAL ASSISTANTS
Anne FAULMANN
Kristin HÜBNER
COPY EDITORS
Sabrina RAAFF
Hans MOTSCHMANN
PUBLISHER/PRESIDENT/CEO
New: Tetric N-Flow Bulk Fill
Tetric®, Ivocerin® and Aessencio® are
registered trademarks of Ivoclar Vivadent AG.
Another strength of the new composite lies in the Aessencio tech-
Torsten OEMUS
Contact Information
Ivoclar Vivadent AG
Bendererstrasse 2
9494 Schaan/Liechtenstein
Tel.: +423 235 35 35
Fax: +423 235 33 60
E-mail: info@ivoclarvivadent.com
www.ivoclarvivadent.com
CHIEF FINANCIAL OFFICER
Dan WUNDERLICH
CHIEF TECHNOLOGY OFFICER
Serban VERES
BUSINESS DEVELOPMENT MANAGER
Claudia SALWICZEK-MAJONEK
JUNIOR MANAGER BUSINESS
DEVELOPMENT
Sarah SCHUBERT
PROJECT MANAGER ONLINE
Tom CARVALHO
EVENT MANAGER
Lars HOFFMANN
KaVo PrimusTM 1058 Life
EDUCATION MANAGER
Christiane FERRET
Designed with passion.
Engineered with precision.
Built with perfection.
INTERNATIONAL PR & PROJECT
MANAGER
Marc CHALUPSKY
MARKETING & SALES SERVICES
Nicole ANDRÄ
EVENT SERVICES
Esther WODARSKI
Discover the new Primus 1058 Life
ACCOUNTING SERVICES
Karen HAMATSCHEK
Anja MAYWALD
Manuela HUNGER
MEDIA SALES MANAGERS
Matthias DIESSNER (Key Accounts)
Melissa BROWN (International)
Antje KAHNT (International)
Peter WITTECZEK (Asia Pacific)
Weridiana MAGESWKI (Latin America)
Maria KAISER (USA)
Hélène CARPENTIER (Europe)
Barbora SOLAROVA (Easten Europe)
EXECUTIVE PRODUCER
Gernot MEYER
ADVERTISING DISPOSITION
Marius MEZGER
DENTAL TRIBUNE INTERNATIONAL
Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 48 474 302
Fax: +49 341 48 474 173
www.dental-tribune.com
info@dental-tribune.com
DENTAL TRIBUNE ASIA PACIFIC LTD.
Room A, 20/F
Harvard Commercial Building
105–111 Thomson Road, Wanchai, HK
Tel.: +852 3113 6177
Fax: +852 3113 6199
Andreas Schweiger,
Director Research and Development
THE AMERICA, LLC
116 West 23rd Street, Ste. 500, New York
N.Y. 10011, USA
Tel.: +1 212 244 7181
Fax: +1 212 244 7185
The Primus 1058 has been the synonym for quality and
reliability in the dental world for over 15 years. Consequently, our development team has passionately designed
the new Primus 1058 Life around these core values
whilst adding a significant number of improvements and
innovations including:
• NEW intuitive dentist element
• NEW optimised ergonomics
• NEW contemporary design
• NEW AC chair motor
For More Information:
DENTAL TRIBUNE MEA EDITION
EDITORIAL BOARD
Dr. Aisha SULTAN ALSUWAIDI, UAE
Dr. Ninette BANDAY, UAE
Dr. Nabeel HUMOOD ALSABEEHA, UAE
Dr. Mohammad AL-OBAIDA, KSA
Dr. Meshari F. ALOTAIBI, KSA
Dr. Jasim M. AL-SAEEDI, Oman
Dr. Mohammed AL-DARWISH, Qatar
Prof. Khaled BALTO, KSA
Dr. Dobrina MOLLOVA, UAE
Dr. Munir SILWADI, UAE
Dr. Khaled ABOUSEADA, KSA
Dr. Rabih ABI NADER, UAE
Dr. George SANOOP, UAE
Dr. Olivier CARCUAC, UAE
Dr. Ehab Heikal, Egypt
Aiham FARRAH, CDT, UAE
Retty M. MATTHEW, UAE
PARTNERS
Emirates Dental Society
Saudi Dental Society
Lebanese Dental Association
Qatar Dental Society
Oman Dental Society
go.kavo.com/MEA
DIRECTOR OF mCME
Dr. Dobrina Mollova
mollova@dental-tribune.me
Tel.: +971 50 42 43072
DIRECTOR
Tzvetan Deyanov
deyanov@dental-tribune.me
Tel.: +971 55 11 28 581
DESIGNER
Kinga Romik
k.romik@dental-tribune.me
KaVo Dental GmbH · D 88400 Biberach/Riß · Telephone +49 7351 56-0 · Fax +49 7351 56-1488 · www.kavo.com
2305_TU-Anzeige_DE.indd 1
23/05/16 13:13
PRINTING HOUSE
Al Nisr Printing
P. O. Box 6519, Dubai, UAE
[3] =>
DTMEA_No.3. Vol.6_DT.indd
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[4] =>
DTMEA_No.3. Vol.6_DT.indd
4
news
Dental Tribune Middle East & Africa Edition | 3/2016
Direct Restorative in treating function
and aesthetics
By Dr. Jan van Lierop
Understanding
Do we always respect the true role of
the anterior dentition? Or do we get
caught up in the creation of beauty
to the disadvantage of function. In
this clinical case we show how the
understanding of the entire occlusal
complex is critical in establishing a
beautiful and stable long-term result. By first creating stable anterior
and canine guidance we can protect
the dentition and the restorations,
adding to long-term stability of both.
When faced with obvious aesthetic
shortcomings (as in Figure 1) we have
to guard against getting caught up in
the obvious. Often by looking closer
can we identify the true underlying
cause. Here the signs of abfraction,
loss of posterior support through
molar erosion and the lack of canine
guidance (Figure 2 and 3) had played
a critical role in the eventual wear
and chipping of the anterior teeth
(Figure 4), part of the initial aesthetic
complaint.
Function
Aesthetics
To establish a stable aesthetic result,
it is essential that we stabilize the
occlusion first. This was achieved by
systematically restoring the palatal
anatomy of the anterior teeth (Figure 5 and 6) using direct restoratives
(Filtek™ Supreme XTE A2B) in a single visit. This established critical anterior and canine guidance (Figure 7).
In a subsequent visit, only a few days
later, the lower posterior teeth were
restored to their original anatomy
(Filtek™ Supreme XTE A2B) thereby
creating total occlusal contact and
stability (Figure 8).
3 months after the occlusion had
been stabilized, anterior aesthetics
was created following a digitally designed plan (Figure 9). By transferring the digital plan to an analogue
model we could create stents to
guide in the aesthetic restoration
(Figure 10). By using Filtek™ Supreme XTE (shade A2D and A1E) in a
layering technique a beautiful result
was achieved (Figure 11 and 12). Realizing the ultimate goal of achieving
protective function and long-term
aesthetics.
Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Figure 7
Figure 8
Figure 9
Figure 10
Figure 11
Figure 12
Dr van Lierop
Dr Jean van Lierop
is a private practitioner in Hout
Bay Dental Studio clinic in Cape
Town, South Africa. After graduating from the University of Stellenbosch in
1999, Dr Jean van Lierop spent some time
in private practice in the Netherlands and
United Kingdom. He achieved his PDD in
Aesthetic dentistry at the University of
Western Cape (Cum Laude), and is completing an MSc in Restorative Dentistry at
the same University. He is also a visiting
lecturer at the University of the Western
Cape’s post graduate restorative department. His primary interest lays in the use
of direct restoratives, in particular their
use in the conservative treatment of dental erosion and tooth wear.
Filtek™ Supreme XTE Universal Restorative material name in MEA region is Filtek™ Z350XT Universal Restorative.
Professional development with
3MSM Health Care Academy
Science. Knowledge. Solutions. Dentistry in Practice.
International Expert Meeting, Warsaw, 3-4 May 2016
By 3M
Science in and around us
The Dentistry in Practice event held
in Warsaw in May, offered through
the 3MSM Health Care Academy, was
dedicated to all dentists seeking
practical tips to solve daily problems
in their practices. Throughout the
event participating international
dental practitioners had the opportunity to share their most successful
techniques and newest science that
allows dentists to overcome their
everyday challenges.
The International Science. Knowledge. Solutions. Expert Meeting in
Warsaw hosted 20 specialized sessions led by 20 experienced dental
professionals within Central Eastern
Europe and Middle East and Africa
Region. They explored and discussed
how science is driving evolutions in
dentistry and how it can be applied
to one’s daily work. The sessions
covered clinical cases and innovative
technologies that make it easier to
find solutions for better clinical outcomes as well as improve the safety,
health and comfort of the patient.
With easy access to the knowledge
exchanged by experts on
www.dentistryinpractice.com, we allow every dentist to become a part
of the conference directly from his
or her home or office. In a quick and
simple way, dentists can review videos of the Specialized Sessions that
were recorded during the Expert
Meeting in Warsaw online at any
time.
Knowledge for development
3M is connecting the specialist com-
munity to drive the exchange of
knowledge, clinical experience and
ideas that result in brilliant technological solutions. Our goal is to make
sure that our solutions have a real
impact on the everyday practice of
dentists and enable them to achieve
greater clinical success. Working
with patients is a real challenge and
responsibility, requiring constant
development and enhancements
towards modern, science-based solutions. This is why we created a dedicated website that allows dentists to
watch videos online and provides
the opportunity to obtain practical
tips with their utmost convenience
in mind. We want to be everyday
partners and advisors in your practice.
conference video materials, which
will be regularly uploaded on dentistryinpractice.com. 3M, aiming to be
partner in the daily work of dentists,
has developed this innovative and
convenient exchange of knowledge
to improve dental practices through
easy-to-apply solutions. This will
help specialists to continue their
education in a modern way, and to
share their learnings and experiences throughout the dental community.
With www.dentistryinpractice.com,
3M helps science to move out of the
laboratory and into daily practice for
optimal clinical outcomes and the
highest patient satisfaction.
Solutions for simplified and
better outcomes
Every dentist can be a part of the
3MTM conference, with access to its
content online. After registering, our
partner dentists will receive notifications every two weeks about new
Contact Information
Elena Golubeva
Marketing Manager
Oral Care Solutions Division CEEMEA
egolubeva@mmm.com
[5] =>
DTMEA_No.3. Vol.6_DT.indd
A beautiful smile
she can’t wait to share.
There are things in life worth sharing …
and now, her smile can be one of them.
Restore with beautifully strong
Filtek™ Z350 XT Universal Restorative—
and polish with the Sof-Lex™ Diamond
Polishing System. Together, they can
produce a diamond paste-like gloss with
the convenience of a rubberized system.
Oh, don’t be surprised if word of your
great work gets around … because she
shares everything she thinks is amazing.
www.3MGulf.com/espe
3M, ESPE, Filtek and Sof-Lex are trademarks of 3M or 3M Deutschland GmbH.
Used under license in Canada. © 3M 2016. All rights reserved.
Filtek™ Z350 XT Universal
Restorative polished with Sof-Lex™
Diamond Polishing System (left) vs.
TPH Spectra® Universal Composite
polished with Enhance® Finishing
System and PoGo® Polishing
System (right).
[6] =>
DTMEA_No.3. Vol.6_DT.indd
6
industry
Dental Tribune Middle East & Africa Edition | 3/2016
Light-curing nano-ceram composite
• Perfect aesthetics
• Highly biocompatible
• Low polymerisation shrinkage
• Universal for all cavity classes
• Comfortable handling, easy modellation
• Also available as a flowable version
Dental Material GmbH
24537 Neumünster / Germany
Tel.
+49 43 21 / 5 41 73
Fax
+49 43 21 / 5 19 08
eMail
info@promedica.de
Internet www.promedica.de
Will India be
the next big
dental market?
By DTI
HYDERABAD, India: The Indian dental care services market is estimated
to experience a double-digit growth
rate, reaching up to US$2.2 billion
(147 bn. Indian rupees) by 2020. According to Ken Research, India has
already witnessed a compound annual growth rate of 12 per cent for
the period of 2010 to 2015 as dental
awareness and disposable income
have increased. Taking into account
factors such as continued economic
growth and reforms, India might
have the potential to become the
largest market for dental products
and materials worldwide.
According to the Indian Dental Association, India’s population of 1.2
billion had access to 180,000 dentists, including 35,000 specialists,
in 2014. This number is projected to
grow to 300,000 by 2018. Around
5,000 dental laboratories and 300
dental institutes currently provide
basic and advanced oral health care.
Expected growth in the number of
dental chains will increase the share
of organised dental clinics across the
country. Although the vast majority of dental products are imported
from Germany, the US, Italy and Japan, foreign companies continue to
invest in India and establish production units.
Most importantly, patient demand
for better health care facilities has
increased. As a country without a
unified health care system, more
Indians are purchasing private oral
health insurance. A rising elderly
population, changing lifestyles, and
increased private and public health
care expenditure are additional factors for the growth of the dental care
market. Furthermore, dental companies are focusing on improving
dental services for tourists seeking
lower-cost treatment across India.
Ken Research recommends that
domestic companies focus on effective marketing strategies and attractive discounts. In addition, free
dental check-ups, dental outreach
programmes and mobile clinics
should improve the oral health care
situation in less-developed regions,
as substantial differences between
rural and urban areas regarding access to dental clinics remain. The
current dentist–population ratio
is reported to be 1:9,000 in urban
and 1:200,000 in rural areas. Many
Indian citizens, especially in poorer
areas, have yet to be educated about
preventative oral health care.
The publication, India dental care
service market outlook to 2020—Increasing awareness on oral care and
rising number of organized players
to foster future growth, is available
online at www.kenresearch.com. The
report covers various aspects, such as
market size, structure and segmentation, as well as the demographics of
domestic and foreign customers.
[7] =>
DTMEA_No.3. Vol.6_DT.indd
Dental Tribune Middle East & Africa Edition | 3/2016
7
InDuStry
Splyce ID: Designing
Bespoke Modern
Wonder Clinics - Part IV
(Circular Shapes)
By Menaka Ramakrishnan, India
Circles are congruous with infinity. The shape signifies interminable peace, balance and harmony. So
how does one incorporate this into a
Dental Clinic? Splyce Interior Design
ideated the most efficacious ways to
do this.
Four years ago Splyce Interior
Design conceptualized a clinic for
the same client in Dubai Healthcare
City. The relaxing aura and ambiance have gotten several laurels. The
Same Day Dental Clinic attributes
their triumph to impeccable service
and seamless interiors.
The specialty of Splyce is creating novel yet concrete designs, particularly clinics. The effective functionality of the space is imperative
followed by adding precise atmospheric elements. Dr. Costa, leading
dentist at the Same Day Dental Clinics, had entrusted Splyce with this
project before. Now, the clinic had
to be customized to dentist-clients
on Jumeirah Beach Road, Dubai. Dr.
Costa has been practicing since 1984,
therefore the space needed to reflect
his astounding qualifications and experience.
Ranjit Prasad, Creative Director
of Splyce, envisioned circular shapes
along with shades of white and grey
to be used within the clinic space.
The first facet of this is the flamboyant, circular ceiling crystal chandelier
that is placed right at the reception.
The very presence of this chandelier
fills the customer with tranquility.
Consequently all other areas of the
clinic branch out from this central
zone in an organic distribution. It’s
so important to feel relaxed at a dental clinic, principally before intricate
procedures. Splyce manages to set a
peaceful tone as soon as the customer sets foot into the clinic.
Circular clouds lights are placed
above each treatment chair in the
procedure rooms. These lights incite a visual of clouds. White circular
lights are also placed in strategic locations throughout the clinic such as
the waiting areas. Curvilinear pieces
of furniture are used in the reception
and meeting rooms. This comple-
ments the Zenlike sensation.
The
client
required superlative materials for
this project. As the
colour palette was
mainly white and
grey, the choices
were limited. The
colour white signifies sterility and cleanliness. Therefore the floor has been exclusively
built around this shade. Warmer tons
of white leather have been used for
the waiting and relaxation areas to
emulate cosiness. Solid surface resin
was chosen as the countertop material. The dental chairs also imitate
this leitmotif. Carpets were placed in
the meeting rooms and admin areas
to entice the reverberation of sound.
Natural light has been fruitfully
used as well, with large windows being placed in the meeting room and
waiting areas. Glass windows coupled with the colour white enlarges
the space. The aesthetic is analogous
to being in a premiere spa. The tech-
nology used is up-to-the-mark as
well, predominantly in the dental
laboratory space and treatment areas.
Splyce Interior Design has clearly demonstrated the evolution of
a run-of-the-mill dental clinic, into
a peaceful and specialized setting.
Dentist trips are no longer dreadful,
but manageable thanks to them.
Our goal is to integrate meaningful design into the space we create.
Every element in the space we create is placed to achieve something
significant, as is the case with Same
Day Dental Clinic. Watch this space
for further prodigious design inputs
by Splyce ID.
Splyce Interior Designs is a boutique agency driven to meet satisfactions of a clientele that know the value of good design and incorporated
that into their own philosophy. Splyce believes its reason d’être is creating stunning designs that exceeded
client expectations.
Splyce Interior Design LLC
Unit 124, 3rd floor
Oasis Centre, SZ Road
Dubai, UAE
T: +971 4 3806560
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[8] =>
DTMEA_No.3. Vol.6_DT.indd
8
mCME
Dental Tribune Middle East & Africa Edition | 3/2016
Treatment planning:
Retention of the natural
dentition and the replacement of missing teeth
CAPP designates this activity for 2 CE Credits
mCME articles in Dental tribune have been approved by:
HaaD as having educational content for 2 CME Credit Hours
DHa awarded this program for 2 CPD Credit Points
By Scott L. Doyle, DDS
Preservation of the natural dentition
is the primary goal of dentistry. Published surveys indicate that patients
generally value teeth and express a
desire to save their natural dentition
in favor of extraction whenever possible.1,2 Significant technological and
biological improvements have been
made in all disciplines of dentistry,
making long-term retention of natural teeth more attainable. Patients
entrust dental professionals to make
appropriate
recommendations
regarding the maintenance and
restoration of their oral health and
function. It is essential to employ an
evidence-based, interdisciplinary approach that addresses the interests
of the patient when determining the
best possible course of treatment.
In July 2014, the American Association of Endodontists, in collaboration with the American College of
Prosthodontists and the American
Academy of Periodontology, hosted
a two-day Joint Symposium titled
“Teeth for a Lifetime: Interdisciplinary Evidence for Clinical Success.”
Approximately 375 general dentists
and specialists assembled in Chicago
to focus on preserving the natural
dentition.
The educational program included
evidence-based presentations on
advanced regenerative techniques,
improvements in technology, minimally invasive restorative methods
and best practices for interdisciplinary treatment planning. Dr. Alan
Gluskin, chair of the 2014 Joint Symposium Planning Committee, concluded that the current evidence directs clinicians to consider saving the
natural dentition as the first option
when developing treatment plans.
Dental implants are one of the
most significant advancements in
contemporary dentistry. This innovation has had profound effects
on endodontic, periodontic and
prosthodontic treatment planning
for the rehabilitation of edentulous spaces and for teeth with an
unfavorable prognosis.3 Implantsupported restorations minimize
unnecessary preparation of intact
abutment teeth and allow fixed
prosthodontic replacement when
suitable abutments are absent. With
appropriate usage and case selection,
implant dentistry provides a viable
option for the replacement of missing teeth.4,5
There has been an increasing trend
toward replacing diseased teeth with
Fig. 3. A matched-case comparison of
survival rates after treatment with either a restored endodontically treated
tooth (n=196) or a restored singletooth implant (n=196) performed at
the same institution. J Endod 2006;31.
dental implants. Often, an inadequate or inappropriate indication for
tooth extraction has resulted in the
removal of teeth that may have been
salvageable.6 Teeth compromised by
pulpal or periodontal disease have
value and should not be extracted
without thoroughly evaluating restorability and potential retention
therapies.7
A recent systematic review published in the Journal of the American
Dental Association highlights a key
question: “Is the long-term survival
rate of dental implants comparable
to that of periodontally compromised natural teeth that are adequately treated and maintained?”8
Nineteen studies with a follow-up
period of at least 15 years were included in the analysis.
The results show that implant survival rates do not exceed those of
compromised but adequately treated and maintained teeth. These findings support other studies comparing long-term survival of implants
and natural teeth,9,10 providing an
important message: Periodontally
compromised teeth can be retained
with quality treatment and appropriate maintenance. Therefore, it
may be advisable to postpone implant consideration for the periodontitis-susceptible patient to fully
utilize and extend the capacity of the
natural dentition.11
Treatment planning options
A key focus of the Joint Symposium
involved treatment planning decisions regarding endodontic treatment and implant therapy. Should
a tooth with pulpal disease be retained with root canal treatment
and restoration, or be extracted and
replaced with an implant-supported
restoration? This assessment involves a challenging and complex
decision-making process that must
be customized to suit the patient’s
needs and desires.12-14 The topic has
received considerable attention in
the literature, the media and at dental continuing education courses.
Endodontic treatment and implant
therapy should not be viewed as
competing alternatives, rather as
complementary treatment options
for the appropriate patient situation
(Figs. 1a, b). Root canal treatment is indicated for restorable, periodontally
sound teeth with pulpal and/or apical pathosis. Endodontic treatment
on teeth with nonrestorable crowns
or teeth with severe periodontal conditions is contraindicated, and other
Fig. 4a. Pre-op image of tooth
#30 with previous endodontic
treatment and persistent apical
periodontitis. A dentist initially
recommended extraction and replacement of this tooth with an
implant. The patient requested a
second opinion from an endodontist who determined the tooth to
be treatable.
Fig. 1a. Pre-op image of tooth #19
with pulp necrosis and symptomatic apical periodontitis. The patient is interested in rehabilitation
of the edentulous space.
(Photos/Provided by American Association of Endodontists)
Fig. 1b. Three-year recall image.
The patient has benefited from
both root canal treatment and
implant therapy. Courtesy of Dr.
Tyler Peterson and the University
of Minnesota School of Dentistry.
Fig. 2a. Pre-op image of tooth #29. Fig. 2b. Two-year
Note lateral radiolucency and com- recall image reveals both excelplex canal anatomy.
lent endodontic
and restorative
treatment. Note
healing of lateral radiolucency.
favorable outcomes30
Courtesy of Dr. Joe
and positive patient
Petrino.
31
Table 1_Survival rates following initial nonsurgical root canal treatment.
(Table/Provided by American Association of Endodontists)
options such as implant placement
should be considered.15
When making treatment decisions,
the clinician should consider factors including outcome assessment,
local and systemic case-specific issues, costs, the patient’s desires and
needs, esthetics, potential adverse
outcomes and ethical factors.16
Outcome assessment:
Success and survival
Treatment outcomes play a key role
in the assessment of different treatment options. Patients often ask
whether a procedure is going to be
successful or not. This question can
be challenging for a clinician to answer due to the variety of reported
outcomes in the literature.17 There
are differences in the methodology
and criteria used to evaluate the outcomes for root canal treatment and
implant prosthetics, which makes
comparisons between success rates
difficult, if not impossible.18
Endodontic studies have historically
used “success” and “failure” as outcome measures and have focused on
a strict combination of radiographic
and clinical criteria.19 In contrast,
the implant literature has primarily reported “survival,”20, 21 i.e., the
implant is either present or absent.
Therefore, implant studies that solely evaluate survival as an outcome
measure will likely publish higher
success rates than endodontic studies that rely on biologic healing and
factors related to the entire restored
tooth. To establish more valid and
Fig. 4b. Four-year recall image
demonstrates apical healing following nonsurgical retreatment.
Accurate diagnosis prevented the
unnecessary treatment of tooth
#31. Courtesy of Dr. Martin Rogers.
less biased comparisons, the same
outcome measures should be used.
A more patient-centered measure is
to compare the outcome of survival,
which is considered to be an asymptomatic tooth/implant that is present and functioning in the patient’s
mouth.22,23
Multiple large-scale studies including millions of teeth have used
survival to assess the outcome following root canal treatment. An investigation using an insurance database of more than 1.4 million root
canal-treated teeth demonstrated
that 97 percent were retained within
an eight-year follow-up period.24
Other studies show similarly high
survival rates (Table 1).25,26 An epidemiological approach allows for the
assessment of tooth retention from
a large sample of patients experiencing actual care in private practices.
Systematic reviews27 and controlled
studies from academic settings complement the previous findings. Two
prospective trials each reported 95
percent survival rates at four years28
and four to six years29 for teeth after
initial root canal treatment.
Predictable tooth retention:
Nonsurgical root canal treatment and restoration
The majority of endodontic treatment is performed by general dentists with a high degree of success.26
For complex cases, referral to an endodontist with additional training
and expertise may result in more
Fig. 5a. Pre-op image of tooth #19 with pulp
necrosis and chronic apical abscess.
Fig. 5b. Two-year recall image demonstrates
excellent endodontic treatment and healing
of apical periodontitis. Courtesy of Dr. Deb
Knaup.
experiences.
Interdisciplinary care is important
for the management of endodontically treated teeth. The restorative
dentist plays a significant role in the
outcome by providing an appropriate and timely restoration.32 Root
canal treatment is not complete until the tooth is coronally sealed and
restored to function. Multiple studies have confirmed that a definitive
restoration has a significant impact
on survival.24,25,27,28,33 Therefore, the
likelihood of a favorable outcome increases with both skillful endodontic
care and prompt restorative treatment (Figs. 2a, b).34
Advancements in technology aid in
attaining high levels of tooth retention. The dental operating microscope, nickel-titanium instruments,
apex locators, enhanced irrigation
protocols and dentin preservation
strategies are examples of improvements that allow clinicians to predictably manage a greater range of
treatment options. Additionally,
cone-beam-computed tomography
facilitates more accurate diagnosis
and improved decision-making for
the management of endodontic
problems.35,36
Comparative studies: Endodontically treated teeth and
single-tooth implants
Large-scale systematic reviews have
addressed the relative survival rates
of endodontically treated teeth and
single-tooth implants. The Academy
of Osseointegration conducted a meta-analysis using 13 studies (approximately 23,000 teeth) on restored
endodontically treated teeth and
57 studies (approximately 12,000
implants) on single-tooth implants.
The outcome data demonstrated no
difference between the two groups
during any of the observation periods.37 Another systematic review
supported by the American Dental
Association compared the outcomes
of endodontically treated teeth with
those of a single-tooth implant-restored crown, fixed partial denture
and no treatment after extraction.
At 97 percent, the long-term survival rate was essentially the same
for implant and endodontic treatments. Both options were superior
to extraction and replacement of the
missing tooth with a fixed partial
ÿPage 9
[9] =>
DTMEA_No.3. Vol.6_DT.indd
9
mCME
Dental Tribune Middle East & Africa Edition | 3/2016
◊Page 8
Fig. 6a. Pre-op image. Tooth #14
was determined to have a vertical
root fracture of the MB root. The
patient expressed a strong desire
to retain the natural dentition but
also to rehabilitate the edentulous
space.
Fig. 6b. Two-year recall image.
Tooth #14 had retreatment and
resective surgery on the MB root.
Two dental implants have restored
the edentulous space. Courtesy of
Dr. Brian Barsness and the University of Minnesota School of Dentistry.
denture.38
Retrospective studies also have
compared the outcomes for the two
treatment options. A study conducted at the University of Minnesota
compared the outcomes of 196 restored endodontically treated teeth
with 196 matched single-tooth implants.39 Both groups had 94 percent
survival rates. The survival curves
for these two groups are provided in
Figure 3. Another investigation from
the University of Alabama provided
similar results.40
Based upon similar survival rates,
the decision to treat a compromised
tooth endodontically or replace it
with an implant must be based on
factors other than treatment outcome.37,41 Several factors influence
the decision-making process.42-44 The
following lists provide an overview
of case-specific factors that should be
considered in making this treatment
decision.
Systemic factors
• The list of potential risk factors for
peri-implantitis or implant failure is
extensive. It includes systemic disease, genetic traits, chronic drug or
alcohol consumption, smoking, periodontal disease, radiation therapy,
diabetes, osteoporosis, dental plaque
and poor oral hygiene.45
• There are few medical conditions
that directly affect endodontic treatment outcomes. Risk factors that
may be associated with decreased
survival of root canal-treated teeth
include smoking,46 diabetes,28,46 systemic steroid therapy28 and hypertension.47
• Patients taking antiangiogenic or
antiresorptive (i.e., bisphosphonates)
medications may have an increased
risk for developing medication-related osteonecrosis of the jaw. This may
affect treatment planning for both
implant and endodontic treatment.
• It is generally recommended to
wait for the completion of dental
and skeletal growth prior to implant
placement.48
Local factors
• Accurate diagnosis.
• Restorability assessment: removal
of caries/restorations; adequate ferrule.
• Strategic nature of the tooth as it
fits into the comprehensive restorative plan.
• Caries risk and oral hygiene.
• Periodontal assessment: tissue biotype, adequate biologic width.
• Presence of crack(s), root fracture(s),
resorption.
• Occlusion and parafunction.
• Teeth with less than two proximal
contacts and those serving as fixed
partial denture abutments may have
lower survival.27
• Need for adjunctive treatment
(crown lengthening, orthodontic
extrusion, sinus lift, bone graft, etc.),
which may impact financial cost and
time to function.
• Quantity and quality of bone.
• Proximity to anatomical structures
(maxillary sinus, inferior alveolar
nerve, etc.)
• Implant esthetics in the anterior region may be challenging.49
Fig. 7. Pre-op image.
In addition to systemic and local
factors, it is critical to include the
patient’s concerns during treatment planning. Common patientcentered factors include costs, treatment duration, satisfaction with
treatment and the potential for adverse outcomes.
Financial considerations can influence a patient’s decision when
weighing treatment options. The
availability of dental insurance may
also impact choices.50 Endodontic
treatment and restoration offer considerable economic advantages to
the patient.51-53 A benefit of root canal treatment is the short time frame
required to completely restore both
dental function and esthetics. In one
study of about 400 patients, the restored single-tooth implant showed
a longer average and median time to
function than similarly restored endodontically treated teeth. Additionally, the implant group had a higher
incidence of post-treatment complications requiring subsequent treatment interventions.39 This increased
post-operative care can impact patients in terms of additional visits,
lost wages and unforeseen costs.
Clinicians should consider the patient’s preferences, which are often
related to function, comfort and esthetics. Tooth loss is associated with
an impaired quality of life,54 and
surveyed patients express a clear
desire to save their natural dentition whenever possible.2 Large-scale
surveys of post-endodontic patients
have demonstrated that endodontic treatment not only preserves
the natural tooth, but also significantly improves patients’ quality
of life.55 More than 97 percent of patients report being satisfied with
their endodontic treatment.31 If an
implant is used to restore an edentulous space, a similarly high percentage of patients have a positive
experience with implant therapy.56
Furthermore, comparative studies
demonstrate that patients report a
high degree of satisfaction with the
overall experience following both
procedures.2,15
Despite high survival rates, both
endodontically treated teeth and
implants are susceptible to complications. Nonrestorable caries, prosthetic failures, periodontal disease,
crown/root fractures and specific
endodontic factors are examples of
complications following root canal
treatment.57 Complications associated with implants and related prostheses include: surgical, implant loss,
bone loss, peri-implant soft-tissue,
mechanical and esthetic/phonetic.58 A retrospective study directly
compared the rates of additional
interventions related to complications. Implant cases had a substantially higher need for subsequent
intervention and maintenance visits
than endodontically treated teeth.40
However, a more recent prospective
study suggests that patients from
both groups have minimal complications at one-year follow-up.15
Endodontic retreatment options
The consequences of failure and
subsequent treatment differ be-
Fig. 8. Root-end filling with MTA.
tween endodontics and implants.
Endodontic failure can usually be
addressed successfully by retreatment, microsurgery or by extraction
and potential implant placement.
Intervention after implant failure
may vary from minimal restorative
repairs to multiple corrective surgeries and/or the use of a different prosthesis.59
Nonsurgical retreatment, or revision,
is often the first choice to address
post-treatment apical periodontitis,60,61 provided that the tooth is
suitable for further restoration and
that the restoration will have a good
long-term prognosis (Figs 4a, b).62
Current best evidence indicates that
the survival of nonsurgical retreatment is similar to that of primary
treatment, and that the two treatments share similar prognostic factors.63 Two studies specifically evaluated survival following retreatment.
An epidemiological study using an
insurance database of 4,744 retreated
teeth reported an 89 percent survival
rate at five years64 and a prospective
trial of 858 retreated teeth reported
a 95 percent survival at four years.28
Modern techniques and rationale
contribute to excellent potential
outcomes for retreatment. An important factor when considering
retreatment is the ability to identify and address the etiology of posttreatment disease.63 Primary sources
of nonhealing are persistent intracanal microorganisms or ingress of
microorganisms following treatment. If the etiology of the problem
is deemed correctable via an orthograde approach, retreatment is often
the first choice. If not, a surgical approach may be the more predictable
option.65
Contemporary endodontic microsurgery has undergone significant
technological and procedural advancements.66,67 Recently performed
studies suggest that microsurgical
techniques using biocompatible
root-end filling materials provide
significant improvements over traditional methods. A meta-analysis
showed contemporary microsurgical techniques to have a significantly
improved outcome (94 percent)
compared to older techniques and
instruments (59 percent).68 A recent
systematic review investigating current microsurgery found survival
rates of 94 percent at two to four
years and 88 percent at four to six
years, indicating that teeth treated
with endodontic microsurgery
tended to be lost at low rates over
the time studied.69 Microsurgery,
with appropriate case selection, is a
predictable procedure for teeth that
may have been considered for extraction in the past.
Ethics and interdisciplinary
consultation
Clinicians are ethically bound to
inform patients of all reasonable
treatment options, explain the risks
and benefits involved with the available treatment options, and obtain
informed consent before initiating
treatment. This information should
be conveyed in an impartial manner.1 Patients value participation in
the decision-making process and
should be encouraged to exercise
autonomy by communicating their
preferences.70 Clinical treatment decisions regarding either endodontic
Fig. 9. Post-op image.
treatment or tooth extraction with
implant therapy must always be
made in the best interest of the patient using the best, most current
evidence.
Should it be necessary, experts from
the dental team may need to be
called upon to assist the clinician
in rendering the highest quality
of care (Figs. 5a, b). The standard of
care must be applied equally to all
clinicians, generalists and specialists
alike. The AAE’s Endodontic Case Difficulty Assessment Form and Guidelines provides valuable information
to aid the clinician in case selection
and determining whether to treat
or refer. Patients are deserving of the
best possible outcome for each case.
Interdisciplinary communication
and collaboration during treatment
planning maximize this likelihood.
Specialists and restorative dentists
should be viewed as partners in the
treatment planning team. Endodontists are uniquely positioned to evaluate the restorability and prognostic
longevity of teeth and recommend
whether to attempt natural tooth
preservation or consider extraction
and replacement with an implant.71
Likewise, the endodontist should be
well-versed in implant treatment
planning to assist patients and referring colleagues in making an informed choice regarding all replacement options.72,73
If a tooth has a questionable prognosis, the endodontic specialist becomes an indispensable part of the
treatment planning team. The endodontist has experience with various
treatment options that have potential to preserve the natural dentition.
Consultation regarding a questionable tooth is often in the patient’s best
interest prior to considering extraction. If the prognosis of a restorable
tooth is categorized as questionable
or unfavorable in multiple areas of
evaluation, extraction should be
considered after appropriate consultation with all relevant specialists.
Only then is the decision to extract
an informed choice. Extraction is an
irreversible treatment, but if necessary, dental implants provide an
excellent option to replace missing
teeth (Figs. 6a, b).
Case report
A case report (Figs. 7-10) demonstrates an alternative treatment option for a patient to save a natural
tooth. A 70-year-old female presented to an endodontist’s office with a
complaint of persistent pain to biting. Tooth #31 had a history of root
canal treatment and coronal restoration. A thorough examination,
including CBCT, led to the diagnosis
of previously treated tooth #31 with
symptomatic apical periodontitis.
A detailed explanation of the risks
and benefits associated with all treatment options was presented. The
patient expressed a strong desire
to save her tooth and consented to
intentional replantation. Tooth #31
was atraumatically extracted and
continuously hydrated with Hanks’
Balanced Salt Solution. No cracks or
fractures were visible. Apical microsurgery was performed extraorally.
The root end was resected, ultrasonically prepared and filled with mineral trioxide aggregate. The tooth
was replanted. The patient remains
asymptomatic and very satisfied
Fig. 10. Seven-month recall image.
with her treatment.
A recent systematic review and meta-analysis revealed a mean survival
rate of 88 percent for intentional replantation.* With careful case selection, intentional replantation may
allow for a reasonable, cost-effective
treatment option for teeth that
do not heal following endodontic
treatment. Clinicians are advised to
explore all options before recommending extraction. Referral to an
endodontist can aid in the retention
of a compromised tooth.
Conclusion
Patients are living longer; therefore,
preservation of the natural dentition
is more important than ever. Helping patients maintain their “Teeth
for a Lifetime” is the fundamental
goal of dentistry and often aligns
with the desires of the patient. A wide
range of endodontic procedures result in a high level of tooth retention
and patient satisfaction. Large-scale
studies provide strong support that
the restored endodontically treated
tooth offers a highly predictable,
long-term approach to preserving
“nature’s implant” — a tooth with an
intact periodontal ligament.
Thus, excellent endodontic treatment followed by an immediate restoration of equal quality promises
to give patients service and function
while maintaining their esthetics for
years. The results of multiple studies
indicate that the high survival rates
for the natural tooth are similar to
those reported for the restored single-tooth implant.
Therefore, clinicians must consider
additional factors when making
treatment planning decisions, all of
which must be in the best interest of
the patient. Endodontic treatment
and implant therapy should not be
viewed as competing alternatives,
rather as complementary treatment
options for the appropriate patient
situation.
This article originally appeared in
ENDODONTICS: Colleagues for Excellence, Spring 2015. Reprinted with
permission from the American Association of Endodontists, ©2015. The
AAE clinical newsletter is available at
www.aae.org/colleagues.
A complete list of references is available from the publisher, and also at
www.aae.org/colleagues.
Case report contributed by Dr. Robert S. Roda.
Scott L. Doyle,
DDS, MS. He currently
practices
with Metropolitan
Endodontics
in
Minneapolis and
serves as an associate clinical professor for the Division
of Endodontics at
the University of Minnesota. Doyle is a
diplomate of the American Board of Endodontics. He is a past president of the
Minnesota Association of Endodontists,
chair of the AAE Continuing Education
Committee and serves as a reviewer for
the Journal of Endodontics. Doyle has
written multiple articles in scientific
journals, as well as a chapter on the “Endodontic Applications of CBCT” in an upcoming textbook.
[10] =>
DTMEA_No.3. Vol.6_DT.indd
10
mCME
Dental Tribune Middle East & Africa Edition | 3/2016
Bioactive materials support
proactive dental care
CAPP designates this activity for 2 CE Credits
mCME articles in Dental tribune have been approved by:
HaaD as having educational content for 2 CME Credit Hours
DHa awarded this program for 2 CPD Credit Points
By John C. Comisi, DDS, MAGD
Resin bonding of the human dentition has become a “standard” in the
United States and Canada. There are
more than 80 different bonding systems on the market today. We have
seen them evolve through multiple
generations in an attempt to “simplify” the bonding process. Yet, as
these agents have simplified, many
in our profession have seen many
challenges arise.
A significant number of reports in
the literature have been showing
that the “immediate bonding effectiveness of contemporary adhesives
are quite favorable, regardless of
the approach used [however] in the
long term, the bonding effectiveness of some adhesives drops dramatically.”1 The hydrophillicity that
both etch-and-rinse and self-etch
bonding agents offer initially in the
dentin-bonding process becomes a
significant disadvantage in terms of
longterm durability.2
It is this hydrophillicity of simplified
adhesive systems combined with
other operator-induced challenges
that contribute to these failures.
Tay, Carvalho, Pashley, et al. have
reported repeatedly in the literature
of this problem.3,4 They continue to
report that these bonding agents do
not coagulate the plasma proteins
in the dentinal fluid enough to reduce this permeability. The fluid
droplets contribute to the incompatibility of these simplified adhesives
and dual-/auto-cured composites
in direct restorations and the use of
Fig. 4
Fig. 5
Fig. 6
Fig. 8
resin cements for luting of indirect
restorations.
The term “water-tree” formation
has been coined to describe this
process, which originated from the
tree-like deterioration patterns that
were found within polyethylene insulation of underground electrical
cables. It is now being applied to the
water blisters formed by the transfer
of dentinal fluid across the dentinbonding interface. These “water blisters ... act as stress raisers and form
initial flaws that cause subsequent
catastrophic failure along the adhesivecomposite interfaces.”4
The previously mentioned plasma
proteins are released by the dentin
when subjected to acids and cause
hydrolytic and enzymatic breakdown of the dentin and resin bonding agent interface.5 These enzymes
are called matrix metalloproteinases
(MMPs).
Currently, there are only three
methods of reducing these MMPs:
2 percent chlorhexidine solutions
that are used prior to application of
bonding agents; etchants containing
benzalkonium chloride, otherwise
known as BAC (i.e., Bisco’s Uni-etch
products); and polyvinylphosphonic-acid-producing products (glass
ionomer and resin-modified glass
ionomers).
Due to the short efficacy of these
chlorhexidine solutions being used
before bonding, this methodology
has come into question as of late.6
Etchants with BAC have been shown
to be valuable in the reduction of
MMPs and should be considered in
Fig. 7
Fig. 9
Fig. 11
Fig. 10
Fig. 12
all bonding processes.7 However,
the most intriguing methodology
of reducing MMPs
and remineralizing tooth structure
is with the use of
glass ionomer cements (GIC) and
resin-modified
glass
ionomers
(RMGIC).
Glass ionomers Fig. 1
and resin-modified glass ionomers
Glass ionomer cements have long
been used as a direct restorative material. Their early formulations made
the material difficult to handle, and
the breakdown of the material made
it an undesirable solution in dental
restoration. However, these materials, especially in today’s formulations and pre-encapsulated presentations, have many properties that
make them very important in the
restorative process.
The work at companies such as SDI
North America (Riva product line),
GC America (Fuji product line) and
VOCO (Iono product line) have continued to make great strides in improving these products for easier
and longer-lasting use of GIC and
RMGIC products.
First, these materials are bioactive,
and up until recently, they were the
only materials with this property;
that is they have the capacity to interact with living tissue or systems.
Glass ionomers release and recharge
with ions from the oral cavity.
This transfer of calcium phosphate,
fluoride, strontium and other minerals into the tooth structure helps
the dentition deal with the constant
assault of the acidic nature of day-today ingestion of food and beverages
and encourages remineralization;
and the incorporation of phosphorous into the acid in today’s GICs creates polyvinylphosphonic acid.8
This property of GICs makes them a
major agent in the reduction of MMP
formation, and thereby minimizing
if not eliminating the collagen breakdown commonly found in many
resin-dentin bonding procedures.9
Second, they bond and ultimately
form a union with the dentition by
chemically fusing to the tooth.
The combination of the polyacrylic
acid and the calcium fluoroalumino
silicate glass typically found in GICs
reacts with the tooth surface, which
releases calcium and phosphate ions
that then combine into the surface
layer of the GIC and forms an intermediate layer called the “interdiffusion zone.”10
No resin bonding agents are required due to this chemical fusing to
the tooth structure. This ion release
helps inhibit plaque formation and
provides an acid buffering capability
that helps to create a neutralization
effect intraorally. In addition, these
GICs have very good marginal integrity with better cavity-sealing properties, have better internal adaption
and resistance to microleakage over
extended periods of time, have no
Fig. 2
free monomers, can be bulk filled
and offer excellent biocompatibility.11
Another important consideration is
that GICs are moisture-loving materials, which makes them very sensible for use in the intraoral cavity.
The transfer of dentinal fluid from
the tooth to the GIC essentially creates a “self-toughening mechanism
of glass ionomer based materials…
serves to deflect or blunt any cracks
that attempt to propagate through
the matrix [and] … plays an adjunctive role by obliterating porosities
[which] delay the growth of inherent
cracks in the GIC under loading.”4
The intermediate layer of the GIC
provides flexibility during functional loading and acts as a stress absorber at the interface of the restoration
and the tooth.12
Resin-modified glass ionomers
(RMGIC), which are a hybrid of traditional glass ionomer cements with a
small addition of light-curing resin,
exhibit properties intermediate of
the two materials.13 This material has
been shown to have properties similar to GIC, but with better esthetics
and immediate light cure. RMGICs
have been shown to undergo slight
internal fracturing from polymerization shrinkage, yet have an inherent
ability to renew broken bonds and
reshape to enforce new forms.12
Application of RMGIC to all cut dentin in Class II composite restorations
has been shown to “significantly reduce micro-leakage along (the) axial
wall” of the restoration,14 and helps
prevent bacterial invasion of the
restored tooth. RMGIC biomaterials
are multifunctional molecules that
can adhere to both tooth structure
and composite resin, thus providing an improved sealing ability by
chemical or micromechanical adhesion to enamel, dentin, cementum
and composite resin.
They, like GICs, can be bulk filled to
reduce the amount of composite
necessary to restore the cavity preparation and act as dentin substitutes
in the restoration.15
The use of GIC and RMGIC in the
restoration of posterior Class V restorations and conservative Class I
restorations provides many benefits.
They are easy to place and reasonably forgiving, even in a slightly moist
environment. They should be placed
in a moist but not wet environment,
so familiarity with technique is imperative as it is with all dental restorations.
I will often use Riva SC (SDI) or Fuji 9
Fig. 3
GP Extra (GC America) in posterior
Class I and V restorations (Figs. 1–7).
Polishing and shaping of the materials must be done with water spray
and fine/ultra fine composite finishing burs and polishers so as not to
destroy the surface of the material
(Fig. 8).
The use of RMGIC products, such as
Riva LC or Fuji II LC, is great in bicuspid and anterior Class V restorations,
especially in high caries prone patients (Figs. 9–12).
Class II restorations, however, have
always presented a challenge to the
clinician. If the operator wanted to
use GIC or RMGIC, there was no easy
way to do this that appeared to provide satisfactory results. It is with
this in mind that the “sandwich technique” was developed.
It was thought that using the properties of GIC to bond to the tooth and
then applying resin-bonding agents
and composite to the set GIC could
help reduce sensitivity and bond
failures typically seen in many resinbonded composite (RBC) techniques.
Typically, the GIC is placed in the
preparation, allowed to set, cut back
to ideal form and then bonded to
with an RBC technique. However, the
inability of RBCs to adhere to the set
GIC often creates many failures. The
materials by themselves are incompatible over the long term.
The modified sandwich technique
evolved as a means to overcome this
problem. Placing RMGIC over set GIC
— and then adding a RBC to that —
provided a better solution, but was as
laborious and time consuming to do,
as is the sandwich technique.
The ‘Co-Cure Technique’
In 2006, an article was published16
that, in my opinion, has revolutionized the way I approach direct
posterior restorations and direct
restorations as a whole. The article
presented a radical approach to direct posterior restorations, called the
Co-Cure Technique. This technique is
defined as the simultaneous photopolymerization of two different light
activated materials that involves
“the sequential layering of GIC,
RMGIC and composite resin prior
to photo-polymerization and before the initial set of the GIC [which]
enables an efficient single-visit placement of a [direct] restoration …”16
In the Co-Cure Technique, the composite restoration does not require a
ÿPage 11
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◊Page 10
bonding agent because the bonding
agent is essentially the RMGIC. The
RMGIC acts as the interface between
the GIC and the com-posite material. It combines the GIC, RMGIC and
composite in a way to form what can
best be described as a “monolithic
biomimetic restoration.”
This restoration is an “open sandwich” type of sandwich technique.
That is, the GIC component is exposed to the oral environment (Fig.
13) at the gingival portion of the restoration. It is quickly and efficiently
accomplished and has significantly
reduced postoperative sensitivity compared with typical direct RBC
techniques. I have been placing these
types of direct posterior restorations
since 2008. They have become the
cornerstone of my practice.
Technique procedure (Fig. 14)
After placement of an appropriate
dental matrix, the technique incorporates the use of 37 percent phosphoric acid to prepare the tooth for
restoration. The acid is essentially
“flooded” into the preparation in
a similar manner to doing a “totaletch” RBC. It is, however, washed off
after five seconds of placement.
The tooth is then dried but not desiccated. The area remains slightly
moist because the GIC that will be
placed next is hydrophilic.
Fill the preparation with the triturated GIC material up to the level of
the DEJ, then immediately place the
triturated RMGIC in a very thin layer
to cover the GIC and walls of the
preparation. Finally, place the composite over the previous materials
to slightly overfill the preparation.
With a large round burnisher dipped
in an unfilled resin material (i.e., Riva
Coat by SDI or G-Coat by GC), wipe
away the excess GIC and composite
restoration material to create your
margins and prevent ditching and
white lines.
The occlusal table of the restoration
can then be compressed gently with
a plastic occlusal matrix by either
having the patient bite or by the
operator pressing gently with his
thumb or forefinger to improve the
coalescence of the three materials.
This can help reduce the time in-
volved in creating the final occlusion
of the restoration by creating a functional occlusal table.
The restoration is then cured for 30
to 40 seconds with an LED curing
light that generates at least 1,500
mw/cm2. Appropriate light output
is critical for all direct cured restorations, and assurance that appropriate output is provided by the curing
light is needed for complete cure of
any direct restoration.
The restoration is evaluated for complete cure and then a layer of an unfilled resin is placed on the exposed
GIC/RMGIC/composite
complex
and cured for an additional 10 seconds. The matrix band is removed
and the restoration is trimmed and
polished as any typical RBC restoration would be.
I have found that an entire threesurface posterior restoration can
be accomplished in less then three
minutes once the matrix has been
placed. Typically, finishing the restoration can also be done in less then
three minutes. This makes the direct
posterior restoration quite efficient
and beneficial to the clinician and
the patient because we are providing
a restoration that will help enhance
healing of the dentition and reduce
recurrent decay and restorative failure.
Nanotechnology in dental
materials
Nanotechnology involves the production of functional materials and
structures in the range of 0.1 o 100
nanometers by various physical or
chemical methods. Today, the development of nanotechnology has
become one of the most highly energized disciplines in science and technology because it can stimulate the
creation of many new materials with
previously unimagined applications
and properties.
Several studies17,18 have shown that
the inclusion of these types of nanofillers and nano-fibers into the dental
materials (dental composites and
bonding agents) can improve the
physical properties by increasing the
strength, polishability, wear resistance, esthetics and bond strengths in
many dental applications.
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Fig. 13
Fig. 14
Fig. 16
Fig. 17
It is also envisioned that the incorporation and utilization of these nanoparticles in the form of nanorods,
nanofibers, nanospheres, nanotubes
and ormocers (organically modified
ceramics) into dental restorative and
bonding agents can create more biomimetic (life-like) restorations. This
will not only enable these materials
to mimic the physical characteristics
of the tooth structure, but will also be
able to facilitate the remineralization
of that structure.
As Saunders states in his conclusion,
“such nanorestorative biomaterials
could very credibly be the next transformative clinical leap” in restorative
dentistry.
Giomers
In that vein, an exciting advancement in bioactive materials is the
development of giomer products
(Shofu Dental, Beautifil II, and Beautifil Flow Plus).
These giomers are resin-based composites that contain pre-reacted glass
ionomer particles (S-PRG).
These particles are made of fluorosilicate glass reacted with polyacrylic
acid (just like a GIC), just before being
incorporated into the resin. This creates a new type of bioactive material.
These giomer products display properties in a manner similar to GICs19:
They release ions and recharge with
ions from the oral cavity, inhibit
plaque formation and neutralize and
buffer the acids of the mouth.20
No other composite material has this
property to date. I use these giomers
instead of traditional nano-hybrid
composites in my restorations
because of these properties. They
complete the entire biomimetic and
bioactive nature of all the co-cure
procedures that I create.
The Beautifil Flow Plus product line
has also expanded the way that I create restorations due to their unique
viscosities. These materials can be
stacked (Fig. 15) and used in a restorative process I call the “modified resin
cone technique” (Fig. 16).
They can also be applied to create
direct composite veneers that can
be easily placed, sculpted and highly
polished (Fig 17). Easy placement,
the ability to stack and maintain
position and shape, plus their bioactive nature, make these materials a
“game changer.”
Resin-modified,
bonding agents
Fig. 15
light-cured
Another advancement that I have
been working with is a product that
is a resin-modified, light-cured bonding agent (SDI, North America: Riva
Bond LC). This product is a specially
formulated liquid RMGIC that can
be used to bond composite restorations in the traditional sense, used in
traditional sandwich and modified
sandwich techniques and, of course,
used in the Co-Cure Technique. This
concept is especially appealing in
light of the research that indicates
RMGICs provide quite good marginal seal when used as a bonding agent
on cut dentin surfaces.14 I especially
like to use it with the Co-Cure Technique and when doing anterior restorations. Using this technique I am
able to get a completely biomimetic,
bioactive restoration in both situations because of the bioactive nature
of the materials used.
The technique for use of this RMGIC
bonding agent with composite is as
follows:
1) Etch with 37 percent phosphoric
acid for five seconds.
2) Wash and dry but do not desiccate.
3) Triturate and apply the RMGIC
bonding agent with a micro-brush
and cure for 20 seconds.
4) Place composite to fill the preparation and cure as appropriate.
When I use this material in the CoCure Technique, I just substitute it
for the traditional RMGIC material
that I would have used otherwise.
Resin-modified calcium silicates
Another recent interesting product
release is from Bisco and is called
TheraCal™ LC. This light-cured bioactive material is used to seal and
protect the dentin-pulp complex. It
is the first of a new class of internal
pulpal protectant materials known
as resinmodified calcium silicates
(RMCS).
It acts as a pulp capping and liner
material. Calcium hydroxide (CH)
has been the “gold” standard for pulp
capping for many years. However, it
has always had difficulties in use as a
liner under RBC adhesives.
In fact, despite their frequent use, the
success of CH based therapies is only
30 to 50 percent.21
It has also been shown that traditional resinbased light-cured liners
have been cytotoxic to cultured odontoblast-like cells, while light-cured
resinbased MTA cements presented
the lowest cytopathic effects.22 Based
on this, the creation of light-cured
RMCS is a logical step in developing a
solution for direct pulpal protection.
Calcium has been shown to be crucial to the formation of apatite, dentin bridge formation and re-apatite
potential of affected dentin. Additionally, alkalinity also seems to be
contributory toward this goal. This
combination in the RMCS material
appears to form good, hard and thick
dentin bridges and stimulates dentin pulp cells to turn into odotoblastic dentin cells.23
This type of material represents a
promising new direction in direct
pulp-capping clinical procedures
with its ability to form apatite and
further contribute to the formation
of new dentin.
Conclusion
It is my belief that using bioactive
materials in the provision of care for
my patients has been paramount to
the success of the care I have been
providing. In this way, I have provided ways to heal the dentition, enhance the restoration and improve
the health of my patients.
I believe we are on the threshold of
further bioactive material advancements and that learning and incorporating these restorative materials
into the day-to-day provision of care
will continue to help our patients,
our practices and our profession.
References
1. J. De Munck, K. Van Landuyt, M.
Peumans, A. Poitevin, P Lambrechts,
M. Braem, and B. Van Meerbeek. A
Critical Review of the Durability of
Adhesion to Tooth Tissue: Methods
and Results. J. Dent Res 84(2):118–132,
2005.
2. C. M. Amaral, DDS, MS, PhD; A. K. B.
Bedran-Russo, DDS, MS, PhD; L. A. F.
Pimenta, DDS, MS, PhD; M. S. Shinohara, DDS, MS; M. C. G. Erhardt, DDS,
MS, PhD. Effect of long-term water
storage on etch-and-rinse and selfetching resin-dentin bond strengths.
General Dentistry, May–June 2008 ,
Volume 56 , Issue 4, pp. 372–377.
3. Tay, Carvalho, & Pashley: Water
movement across bonded dentin —
too much of a good thing? J. Appl.
Oral Sci. vol.12, no. spe Bauru 2004.
The full list of references is availlable
from the publisher.
John C. Comisi,
DDS, MAGD, has
been in private
practice in Ithaca,
N.Y., since 1983.
He is a graduate
of Northwestern
University Dental
School and received his Bachelor of Science in biology at Fordham University.
He is a member of the American Dental
Association and its tripartite organizations, the Academy of General Dentistry,
the American Equilibration Society, the
International and American Association
of Dental Research, a research associate
at New York University Dental School
and an editorial board member of Dental Products Shopper Magazine. Comisi
is a Master of the Academy of General
Dentistry, and holds fellowships in the
Academy of Dentistry International, the
American College of Dentistry, the Pierre
Fauchard Academy and the International
College of Dentistry. He may be contacted
at jcomisi@jcomisi.com.
[12] =>
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Dental Tribune Middle East & Africa Edition | 3/2016
FDI expert conference:
Oral health for ageing populations
By DTI
fessional dental care; however, owing to limited availability or inaccessibility, the use of oral health services
is markedly low among older people.
LUCERNE, Switzerland: From 3 to 5
May, the FDI World Dental Federation held a three-day conference on
Oral Health for Ageing Populations
(OHAP) in Lucerne. The invite-only
conference focused on the theme of
“Life-long oral health: A fundamental human right”. A total of 20 experts from around the globe, including the World Health Organization
(WHO), gathered to discuss strategies
to address the growing burden of
oral disease and prevent tooth loss in
elderly populations.
After the World Congress in March
2015, themed “Dental care and oral
health for healthy longevity in an
aging society”, which was held by
WHO and the Japan Dental Association in Tokyo in Japan, the OHAP
initiative was launched by the FDI in
collaboration with GC International,
the global branch of dental products
manufacturer GC, in order to ensure
oral health challenges are addressed
in broader disease policies for ageing
populations.
At the meeting, FDI President Dr
GC Chairman Makoto Nakao highlighted, “In countries like Japan,
30 per cent of the population are
already over 60 years old, it is now
low- and middle-income countries
that are experiencing the biggest
change and GC is committed to
working with FDI and through its
network of more than 200 national
dental associations to address this issue on a global level and affect positive change for the millions of people suffering unnecessarily from oral
disease, when they could be enjoying
active healthy ageing.”
From left: Dr Hiroshi Ogawa (WHO), Dr Patrick Hescot (FDI), Dr Beat Wäckerle (Swiss Dental Association), Makoto
Nakao (GC) (Photograph: Gilberto Lontro/FDI)
Patrick Hescot stated, “It is a great
achievement that populations are
living longer thanks to advances
made in the fields of medicine, technology, public health and policy. But
it is our role as dentists to ensure that
people not only live longer lives but
healthier ones too, free of oral disease, which plays a fundamental role
in securing a person’s overall health
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and wellbeing. Oral health is often
a neglected area of healthy ageing,
which is why this conference is so
important to try and reset the balance.”
Dr Beat Wäckerle, President of the
Swiss Dental Association and local
conference host added, “Avoiding
tooth loss is crucial for healthy ageing. Yet, the complete loss of natural teeth is highly prevalent among
older people all over the world, with
severe dental caries and advanced
periodontal disease being the major
causes. We must take urgent action
and put preventative strategies in
place.”
Although tooth loss is declining in
many high-income countries, and
older people are increasingly preserving their teeth in a functional
condition, the latest figures from
WHO indicate that the prevalence of
oral disease is increasing in low- and
middle-income countries. Most oral
diseases and conditions require pro-
Outcomes from the recent meeting
in Lucerne will be presented at the
FDI Annual World Dental Congress,
which will take place in Poznań in Poland from 7 to 10 September. In addition, strategies on combatting oral
disease in ageing populations will be
launched at the event.
According to the Global Burden of
Disease Study, oral disease affects
3.9 billion people worldwide and untreated dental caries affects almost
half of the world’s population (44 per
cent), making it the most prevalent
of all the 291 conditions investigated
in the study.
Poor dental health can affect both
psychological and physiological
health, leading to a significantly
reduced quality of life. In addition
to functional problems, poor oral
health and dental problems can result in inflammation of the gingivae
and a poor-quality monotonous diet,
all of which increase the risk of malnutrition. The FDI stressed that this
problem will only worsen if urgent
action is not taken. WHO estimates
that the proportion of the world’s
population over the age of 60 will
nearly double from 12 to 22 per cent
between 2015 and 2050.
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Twenty experts from around the globe attended the conference
in Lucerne.
[13] =>
DTMEA_No.3. Vol.6_DT.indd
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oraL HEaLtH
Dental Tribune Middle East & Africa Edition | 3/2016
Daily cleaning between your teeth matters
By Jordan
Effective removal of interproximal
plaque is not achieved by a toothbrush alone. Dentists recommend
that you floss daily, but very few
people do this on a regular basis. Interdental brushes can be an attractive alternative to flossing and are
a proven effective tool for reducing
interproximal plaque. There are a
number of different factors that
need to be considered when choosing the right interdental brush, for
example size, shape, the user’s manual dexterity and motivational level.
The smallest size is best for those
users who have healthy gums and
small interproximal spaces. This is
generally a good alternative for first
time users. Daily use of an interdental brush gives results, especially in
comparison to simply brushing.
Studies show that most of us
(up to 90%) will experience some
form of mild gum disease (gingivitis). Early symptoms of gum disease
can be detected by inflamed gum
tissue. This is caused by the bacteria
in dental plaque. If the bacteria is not
brushed away, it may form tartar
and can eventually result in a cavity.
As many as 30% of cavities are between our teeth. Statistics show that
the population is aging and growing, and many of these people are
keeping their own teeth. The good
news is that gingivitis is reversible
and preventable with daily brushing
and cleaning between your teeth. A
tooth has five surfaces that you need
to clean thoroughly in order to get
the best cleaning results. An international study, showed that brushing
with an interdental brush removes
more plaque than brushing with a
toothbrush alone. The study showed
a positive significant difference using an interdental brush with respect
to plaque scores, bleeding scores
and probing pocket depth. The majority of the studies also showed a
positive significant difference in the
plaque index scores when using an
interdental brush compared to using
dental floss.
Motivation is a key element in
succeeding with making interproximal cleaning part of the daily “brushing” session. Studies have found that
the ease of use of a product does
affect one's motivation. The majority of the test study individuals preferred using interdental brushes to
floss. They found them simpler to
handle, using only one hand, and felt
that interdental brushes were more
time efficient.
The advice is to look for an interdental brush that has a sturdy but
compact handle so that the users get
a good and comfortable grip. Shorter
handles give the user more control
as the position of the thumb/finger
grip is closer to the point of contact.
A non-slip grip also helps controlled
movement. It is important that the
user is able to navigate easily in the
mouth, reaching the back molars.
We found the highest usage of interdental brushes among consumers
between the ages of 40-49. 6 out of
10 of these use interdental brushes
on average 3-7 times a week.
proximal Brushes in a Randomised
Split Mouth Trial Incorporating an
Assessment of Subgingival Plaque.
Noorlin I, Watts TL. Oral Health Prev
Dent 2007; 5: 13-18.
4. ADA.org
5. Statistics, Norway 2011
6. See footnote 2
7. The efficacy of interdental brushes
on plaque and parameters of periodontal inflammation: a systematic
review. Slot DE, Van der Weijden FA.
Department of Periodontology,
Academic Centre for Dentistry Am-
sterdam (ACTA), Amsterdam, The
Netherlands. Dörfer CE. Clinic for
Conservative Dentistry and Periodontology,
Christian-AlbrechtsUniversität, Kiel, Germany Int J Dent
Hygiene 6, 2008; 253–264.
8. Study: (5)Perceptor Quantitiative
survey, Sweden, 2014
9. Statistics, Norway 2011
10. Chronic Diseases and Health Promotion. Centers for Disease Control
and Prevention. 13 Aug. 2012. Web. 15
Sept. 2013.
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References
1. Statistics, Norway 2011
2. Comparison between manual and
mechanical methods of interproximal hygiene. Schmage P, Platzer U,
Nergiz I. Quintessence International
Volume 30, Number 8, 1999
3. A Comparison of the Efficacy and
Ease of Use of Dental Floss and Inter-
prevention.KerrDental.eu
[14] =>
DTMEA_No.3. Vol.6_DT.indd
14
oraL HEaLtH
Dental Tribune Middle East & Africa Edition | 3/2016
Interview: “The future of dentistry
is digital and focused on prevention”
an interview with ueli Breitschmid, CEo of Curaden
By Marc Chalupsky, DTI
laxis techniques. We use the latest
technologies and modern cleaning
techniques; in short, the right mechanical plaque control. Of course,
the seminars are open to those dental staff with years of experience too.
There are always new ways to brush
teeth and gaps properly.
Swiss dental company Curaden is
one of the few businesses in the industry that adopt a holistic approach
to dentistry. The company combines
high-quality dental products, pioneering training systems and prophylaxis concepts for long-term oral
health. In this interview, CEO Ueli
Breitschmid talks about new ways
and knowledge in dentistry and optimal preventive care as key to good
oral health.
Dental Tribune: Mr Breitschmid,
Curaden aims to offer more than just
dental care products. You advocate
comprehensive training in the field of
dental prevention. Why is this issue so
important?
Ueli Breitschmid: Curaden is the
only company that, in addition to
manufacturing products, provides
patients with the necessary knowledge and skills, in cooperation with
trained instructors, to take control
of their oral health themselves. We
have developed our knowledge and
products with the aim of teeth remaining healthy for a lifetime. Our
corporate philosophy combines the
innovative CURAPROX products, our
dental educational system iTOP and
the practical Prevention-One plan.
Our goal is to reduce the prevalence
of gingivitis, periodontitis and tooth
loss. Therefore, we support comprehensive soft-tissue prophylaxis. Finally, gingival problems are still the
most common cause of poor oral
health. We support prophylaxis to
this end with our great interdental
toothbrushes, our iTOP seminars
and other services.
In any oral health discussion, it is always important to look at the combination of a high-quality product and
the trained application thereof. The
product alone without a trained user
changes little or nothing. Therefore,
80 per cent of people in developed
countries have gingival diseases; because nobody has shown them proper oral hygiene. Only a well-trained
person can motivate and instruct
someone else.
How can control and continued motivation be achieved?
Patients and dentists should follow
a regular schedule concerning both
treatment and training. Today’s approach of one or two dental visits
annually is no longer appropriate.
Going to the dentist or the dental
How long is the iTOP programme?
The iTOP programme is structured
consecutively. We offer multi-day
seminars for both beginners and
advanced participants, as well as for
prospective iTOP trainers. Our recall
seminars enhance knowledge and
provide additional motivation. iTOP
also teaches communication strategies. Communication with the patient and within the team too are key
to dental health. A further advantage
of iTOP is the global coverage of our
educational programme. Whether in
Europe, Asia or North America, dental staff can benefit from the comprehensive solutions of our iTOP
training.
Ueli Breitschmid, CEO of Curaden: "It is always important to look at the combination of a high-quality product and the
trained application." (Photograph: Curaden AG)
hygienist should not be an annual
event, but more frequent. Just think
how often we enjoy a beauty treatment or a pleasant massage. White
and well-kept teeth are part of the
modern concept of body awareness,
much like a trip to the fitness centre.
A world famous example of achieving control and continued motivation is Martina Hingis. Hingis, who
was once tennis’s youngest-ever
number one champion, is our new
global ambassador promoting a new
level in oral healthcare. Over the next
three years, the 35-year-old Swiss will
be making some major appearances
for our brands. And I would also like
to mention KU64, one of the largest
dental practices in Germany. Over
20 motivated dentists are working
seven days a week and use the latest
CURAPROX products. Besides that,
KU64 offers massage therapy, manicure and pedicure and much more.
This is the modern concept of body
awareness.
So, does this mean that most oral
health problems can be solved
through regular prophylaxis?
Dental prophylaxis is only one aspect of oral health. It seems much
“Our goal is to reduce
the prevalence of
gingivitis, periodontitis
and tooth loss.”
more important to consider dental
training. For years, leading dentists
and dental companies have been
in favour of a change in dental education. Preventive dental therapy
should hold at least the same position as restorative dentistry. Every
dentist knows how little is taught
in dental schools about prevention.
There are long-established and financially attractive prevention concepts
for the entire office staff, including
Prevention-One. Today’s digital solutions offer a painless and quick
prophylactic therapy. The future of
dentistry is digital and focused on
prevention, and the dentist of the future as a preventive physician is responsible for patients’ overall health.
So you envision dentists and doctors
working more closely?
Dentistry and medicine will certainly continue to move closer together,
as the interaction between the oral
tissue and other organs is now better
understood. Slowly but surely, dentists will be recognised for their role
in medicine. They are the gatekeepers of health, because the mouth represents the basis of almost all chronic
diseases. In time, dentists will measure blood pressure and take saliva
samples or blood samples. It will
become possible to decrease the
prevalence of chronic diseases, including cancer, Alzheimer’s disease,
cardiovascular disease and diabetes,
through better oral health. At the
same time, medicine of the future
will be able to detect signs of gingivitis or periodontitis.
Mr Breitschmid, you focus on holistic
oral health prevention rather than restoration. What concepts does Curaden
offer in this regard?
We focus on optimal prophylaxis for
patients and dental professionals.
Individually trained oral prevention
(iTOP) is our internationally wellknown educational system. For this
purpose, we have been working together with established dentist Dr Jiri
Sedelmayer. He has revolutionised
the approach to teaching, motivation and control of individual prophylaxis for long-term dental health.
This approach includes regular training, the proper tools and a good dose
of motivation. First, we begin with
the dental professionals, who pass
their new knowledge and skills directly to patients. All our iTOP seminars are supervised by independent
dentists and dental hygienists who
have completed the training themselves.
iTOP addresses one of the major issues in every dental practice: how
to motivate and instruct patients to
brush perfectly, with good outcomes.
Through iTOP, we offer individual
training with regular monitoring
and correction of the learnt prophy-
I would like to recommend our iTOP
workshop on 23 June in Basel in Switzerland to all dental hygienists. This
is being held as part of the 2016 International Symposium on Dental Hygiene. We have invited top speakers
from Ireland, South Africa, Canada
and Switzerland to talk about their
experiences with iTOP in their respective fields and how it has helped
them to achieve sustainable oral
health in their patients.
With iTOP for students, Curaden is targeting students and young dentists.
Why does Curaden place so much
importance on the early training of
students?
First, students should maintain their
teeth for perfect oral health; only
then can they treat their patients.
The dentist and patient should always have the regular care of their
own teeth with good toothbrushes,
toothpaste and interdental brushes
in common. This allows the aspiring
dentist to become familiar with how
the damage to be repaired arose.
Early on, we convey the principle of
touch to teach—the proof is in the
pudding.
How can dental professionals better
apply your iTOP concept for the benefit of the patient and practice?
We offer them a financially attractive
service package for the long-term
dental health of their patients, called
Prevention-One. Prevention-One is
our innovative treatment approach
to prophylaxis services. The plan includes regular dental cleaning and
dental procedures, as well as our
CURAPROX products. We believe
strongly that Prevention-One represents the future of dentistry.
No matter the product, whether
Prevention-One or CURAPROX, we
strive to be accessible to patients. In
2015, we founded the first Curaden
clinic, in the heart of London. The
practice offers top facilities and, of
course, all the products and concepts
of Curaden.
Thank you very much for the interview.
[15] =>
DTMEA_No.3. Vol.6_DT.indd
Dental Tribune Middle East & Africa Edition | 3/2016
15
PaEDIatrIC
Avulsion in Paediatric Dentistry: Management
of a Double Dental Emergency in a Child
By Dr Ghada Hussain & Dr Iyad Hussein, UAE
Introduction
General dental practitioners and
paediatric dentists face real dental
emergencies that effect children, especially dental trauma. Avulsion is
considered, in terms of severity, the
worst of all dento-alveolar injuries.
This is when the tooth is completely
displaced out of its socket and the
socket is found empty or filled with
a blood coagulum. We report a case
that describes the management of
an avulsed maxillary central incisor
(21) in a fit and healthy 8-year-old
boy, accompanied by a lower lip laceration. The management of 21 took
place up over a period of 12 months.
Case Report
An 8-year old child presented to the
department of paediatric dentistry
at the Hamdan Bin Mohammed College of Dental Medicine (HBMCDM)
at the Mohammed Bin Rashid University (MBRU) in Dubai Healthcare
City. He allegedly fell off a climbing
wall, and knocked out his upper left
maxillary incisor (tooth # 21) and cut
his lower lip (Figures 1 and 2). This occurred at 14:15 hours at school, and
the school nurse called the patient’s
mother at 14:20 hours. The patient’s
mother asked the nurse to find the
tooth and put it in milk. The tooth’s
“dry time” was thus around 10 minutes. The patient attended with both
his mother and aunt, to our specialist clinic at 14:55 hours.
The tooth was presented in a milk
container (Figure 3) and the tooth’s
“wet time” was 50 minutes. By the
time, the tooth was replanted, the
tooth’s total “dry and wet time”
or Extra-Alveolar Time (EAT) was
around 60 minutes.
Upon history taking, the child had
fallen on a gravelled playground,
with no loss of consciousness (LOC),
nausea, vomiting or disorientation.
He was responsive, alert, and otherwise fit and well with no known allergies. There were no safeguarding
concerns. His dental history revealed
that he was an irregular attendee,
with no history of dental treatment
under local anaesthesia (LA) but he
had a history of avulsed primary
tooth when he was two years old and
had multiple primary teeth extractions under general anaesthesia (GA)
four years ago.
Extra oral examination
• No TMJ, alveolar or facial bone fractures detected.
• Lower lip through- and-through
ragged laceration of the lower lip
(Figure 1).
• Class 2 skeletal profile.
Intraoral Examination
• 21: empty socket with coagulum.
• Laceration of the buccal gingiva
near 21.
• Incisor relationship Class 2 Division
1 (OJ= 10mm). Mum informed us of
her son having proclined incisors
prior to the injury.
Figure 1: Initial presentation. 21 was avulsed
and its socket appeared empty. There was a laceration of the lower lip
16 55 54 53 12 11
46 85 83 42 41
-- 22 63 64 65 26
31 32 73 75 36
Radiographic examination
Periapical views of the upper maxillary incisors were obtained to rule
out any root fractures (See Figures
4 a & b) revealed immature roots
of teeth # 12, 11, 22, no root fractures
and an inverted supernumerary
apical to 11 and an empty socket of
21. There was no need for soft tissue
radiographs as no tooth fragments
were missing and the tooth was accounted for.
Diagnostic summary
• 21 avulsed with immature root.
• Concussion 12, 11, 22.
• Through-and through lower lip laceration involving the vermilion.
• Inverted conical supernumerary/
mesiodens $.
• Behaviour: Mildly anxious at initial presentation, very cooperative
through the treatment visit.
Aims and objectives of treatment
• Management of acute traumatic injury and replant the avulsed 21
• Suture the lacerated lip.
• Monitor the vitality and periodontal healing of 21.
• Preserve 21 in the short and medium term aiming to maintain the
bone level in the long term.
• Inform patient and parents about
the poor long-term prognosis of 21
Figure 2: Palatal view of 21 socket. Notice the
coagulum filled socket
Treatment Plan
After the patient’s initial assessment, we administered LA to his upper anterior
sextant and lower lip. During this
time, both the tooth and socket were
gently irrigated with physiological
saline. 21 was found to have an immature root and open apex. (Figures
5 a & b).
Within the hour, tooth 21 was gently
replanted into the socket (Figure 6)
and a flexible 0.5mm wire/composite passive splint of teeth #12, 11, 21,
22 was secured (Figure 7). We sutured
the lacerated lower lip in multiple
layers (mucosa, deep and superficial) using Vicryl® (Sizes 40 and 60)
resorbable fine sutures (Figure 8 and
9). This took place after thorough debridement of the wound with physiological saline. Care was taken to assure alignment of the lip’s vermilion
involved in the laceration.
The patient was advised to maintain
a soft diet, and analgesics (Paracetamol 500mg PRN) and antibiotics
(Amoxicillin 250mg TDS for 5 days)
were prescribed. Chlorexidine gluconate 0.2% 10 mls BD mouth rinse
was advised. After discussing the
short and long- term consequences,
a follow up appointment was arranged in a week, and the patient was
discharged. We advised the patient
to attend his general medical practitioner (GMP) to obtain a Tetanus
booster injection straight after the
appointment.
A second trauma within two
hours
Within two hours of leaving our clinic, the patient suffered another trauma affecting the injured area. This
happened at the GMP receptionist’s
office. As the receptionist was asking the patient’s mother where her
son was, she pointed to him (he was
standing behind her) and accidently
hit her son in the mouth. There was
no LOC, nausea, vomiting or disorientation. This caused the GMP concern so she sent the patient back to
us for a reassessment. To our surprise, the patient showed up in our
clinic (at 18:20 hours) with renewed
bleeding from his mouth (Figure 10
a & b).
After obtaining a new history and
carrying out an assessment, the
wound was debrided. The splint and
sutures were examined and were
found to be intact. Although the
splint was slightly mobile (Grade 1), it
was securely bonded to the teeth. No
new radiographs were indicated. The
patient and family were reassured
and the above advice was re-iterated.
They went back to the GMP for the
ÿPage 16
Figure 3: Storage medium of 21 was milk. The
“wet time” was 50 minutes
Figures 4 (a & b). Empy socket of 21 due to its
avulsion. Notice the immature apices of 12, 11
and 22. In addition there was a supernumerary
tooth/mesiodens
Figure 5 (a & b). Avulsed 21 with open apex was irrigated with saline as soon as the patient arrived
to the clinic. Notice the tooth was held without touching the root to preserve the PDL tissue
Figure 8. Suturing of the lower lip laceration in
three layers using fine resorbable sutures (Vicryl® Sizes 40 and 60).
and the available definitive future treatment options.
• No missing fragments of teeth.
• Teeth present (FDI):
Figure 9. Immediate post suturing. Notice the
wound margins had been aligned so the vermilion was continuous.
Figure 6: Tooth 21 was replanted gently into the
socket after giving LA. This took place 60 minutes after the injury
Figure 7. A passive composite and wire splint
involved # 12 to 22. The lip was yet unsutured.
Figure 10 (a & b): The clinical appearance following a second trauma incident that happened within two hours of fitting the dental splint.
[16] =>
DTMEA_No.3. Vol.6_DT.indd
16
PaEDIatrIC
Dental Tribune Middle East & Africa Edition | 3/2016
◊Page 15
Figure 12: Healing of the lip one month post-op.
Some oedema and scarring were noted
planned Tetanus booster.
Figure 11: A peripical radiograph
taken one week post-op showed the
correct positioning of the replanted
tooth. Note the open apex.
Trauma follow-up appointment (one-week post op)
The aim of the visit was to review 12,
11, 21, 22 and to assess soft tissue healing. The patient had no complaint
whatsoever. Observations revealed
a slight mobility of 21 and good healing lower lip and buccal gingiva of
Figure 13: One-month post op after removal of the
splint. The tooth was responsive to EC & EPT.
21 with good oral hygiene but some
visible plaque on 22. The splint was
intact. We obtained a periapical radiograph of 21, which showed it to be
in a favourable position (see Figure
11) with a large wide-open apex.
At this appointment, and in the subsequent appointments (1, 3, 6, 9 and
12 months post-op) we completed a
“Dental Trauma Stamp” (see Table 1
Figure 14: One year follow up. The patient and parent were
pleased with the aesthetic result. 21 was vital and positively
responsive to EC & EPT. The tooth was non mobile and produced a metallic sound indicative of ankylosis.
for an example) which included assessment for mobility, tooth colour
(direct and transillumination), tenderness to percussion (TTP), sinus
presence, swelling presence, percussion sound, electric pulp tester (EPT),
ethyl chloride (EC) and radiographic
assessment. The latter was essential
to assess for apical pathology, root
resorption (internal and external), arrested/continued root development,
pulp obliteration and replacement
resorption/ankylosis. The dental
trauma stamp was repeated at every
visit. It helps in assessing periodontal
ligament (PDL) and pulpal healing.
Trauma follow-up appointment (one-month post op)
The healing of the lip appeared
satisfactory (Figure 12). We gently
removed the dental splint (Figure
13) and a new dental trauma stamp
was completed. Tooth 21 was +ve to
EC & EPT suggesting possible revascularization, although this was not
absolute.
Subsequent appointments
(at 3, 6, 9 and 12 months post
op)
Healing of the lip and periodontal
soft tissues continued satisfactorily
and the patient and mother were
happy with the aesthetically pleasing result (one year follow up- see
Figures 14, 15 & 16). A mouth guard
was made to prevent further dental
injuries to the same area. Dental caries was treated appropriately.
However the dental trauma stamp
revealed that tooth 21, despite remaining vital (+ve to EC and EPT),
non-discloured and asymptomatic,
became ankylosed. At 3 months, a decision whether to initiate root canal
treatment or not was debated, but
no intervention was decided upon,
as the tests suggested its vitality.
The tooth was non -mobile and was
producing a “crack plate metallic”
sound on percussion. At 6 months,
radiographically, there was evidence
of replacement resorption (Figure 17
a, b & c). This worsened at 12 months.
This tooth will inevitably be lost.
Discussion
Traumatic dental injuries are common, with between 6-34% of children aged 8-15 experiencing damage
to their permanent teeth1. Over ¾ of
all traumatic oral injuries occur in
childhood, and in the United Kingdom, the proportion of 12 and 15 year
olds with any traumatic damage was
recently found to be 12% and 10%
respectively2. Traumatised teeth can
have a significant clinical, aesthetic
and social impact on a child as an individual. Treatment of traumatised
teeth usually requires extensive
management, carrying a burden for
the patient as well carers and health
authorities in the long term. Avulsion is the complete displacement of
tooth out of its socket and the socket
is found empty or filled with a blood
coagulum3. Avulsion accounts for
between 0.5 to 3% of dento-alveolar
trauma to permanent teeth4. About
90% of replanted avulsed teeth will
undergo ankylosis1.
ÿPage 17
[17] =>
DTMEA_No.3. Vol.6_DT.indd
17
PaEDIatrIC
Dental Tribune Middle East & Africa Edition | 3/2016
◊Page 16
Figure 15: Palatal view of 21 one year on. Notice the
excellent gingival healing.
Figure 16: Lip healing one year on showed excellent
soft tissue healing and an aesthetically good outcome following the suturing of the lip.
Figure 17 (a, b and c): Post op radiographs taken at 3, 6 and 12 months. They show lack
of PDL some pulpal obliteration and replacement resorption.
age of 18 years)
Tooth No (FDI)
12
11
21
22
Diagnosis
concussion
concussion
avulsed
concussion
Colour
✓
✓
✓
✓
Transillumination
✓
✓
✓
✓
TTP
+
+
++
+
Sinus
-
-
-
-
Swelling
-
-
-
-
Mobility
n/a
n/a
slight
n/a
Percussion sound
n/a
n/a
n/a
n/a
Ethyl Chloride
+ve
+ve
-ve
+ve
Electric Pulp Tester
-ve
+ve
-ve
-ve
Radiographs
✓
✓
✓
✓
Apical path
-
-
-
-
External Inflammatory / Root Resorption
-
-
-
-
Summary and conclusion
Internal Inflammatory / Root Resorption
-
-
-
-
Replacement. Resorption /ankylosis
-
-
-
-
Arrested root development
-
-
-
-
Obliteration
-
-
-
-
21 was avulsed with a lip laceration.
The tooth was replanted, splinted
and the lip was sutured. The tooth
suffered another trauma after
two hours. Radiographic findings
showed signs of replacement resorption from 6 months post trauma.
Clinically, 21 responded positively to
EPT and EC tests, no other sign of inflammation. Decoronation (removal
of the crown and retention if the root
with surgical coverage) will be implemented. The lip healed favourably.
The patient and his parents were
warned about the poor long-term
prognosis of 21 and alternative long
treatment options were discussed.
Table 1. Example of the “dental trauma stamp”. This was taken at one week post op.
According to British Society of
Paediatric Dentistry (BSPD) guidelines1, factors to take into account
in avulsed teeth are dry time (DT)
and total extra alveolar time (EAT).
In cases with less than 30 minutes
DT and less than 90 minutes EAT,
when stored in appropriate storage
medium, replantation without disturbing the PDL is recommended
plus splinting with flexible wire for
7-14 days. This case falls under this
condition where the DT was 10 minutes and EAT was 60 minutes. There
is limited evidence regarding the
benefit of systemic antibiotics on
pulp healing. Prescription should be
governed by clinical judgment. After evaluation of this patient’s type
of trauma with the associated soft
tissue injury and contamination,
an antibiotic was prescribed as per
International Association of Dental
Trauma (IADT) guidelines3. The GMP
gave a tetanus booster due to the environmental contamination of the
tooth. For immature teeth like this
case, no endodontic treatment was
electively recommended due to an
open apex, favorable DT and EAT, as
we were hoping for continued tooth
growth and 21 with pulpal regeneration. However we must not forget
that the tooth was traumatised for
a second time with two hours, thus
this may have had an impact on the
reduction of its prognosis. The tooth
was carefully monitored to assess
pulpal regeneration or necrosis. The
tooth remained vital, however, it
underwent ankylosis. Therefore, its
prognosis was deemed poor, and its
loss was expected. In children and
adolescents ankylosis is frequently
associated with infraposition5. Decoronation may be necessary later
when infraposition (>1mm) compared to its counterpart is seen5. The
outlined options, in the long term, to
replace 21 are highlighted below.
Long term treatment plan
and future considerations
Tooth 21 future treatment options
available will:
- Decoronation: Removal of the
crown and retention of the root.
- Extraction and partial removable
denture
- Extraction and resin bonded bridge
- Auto-transplantation of a premolar
(if crowding occurs)
- Osseo-integrated implant (after the
As he was a very active boy and loves
playing football, and due to his dental history where he had a repeated
history of trauma in the same tooth,
in addition to his Class 2 Division
1 malocclusion with an overjet of
10mm, a custom fit mouth guard
was fabricated to be worn while engaging in any contact sports. Overjet
correction will be needed. The patient was referred for an orthodontic
and restorative opinion for planning
of multidisciplinary treatment options.
References
1. Day, FP & Gregg TA. UK National
Clinical Guidelines in Paediatric
Dentistry. Treatment of avulsed permanent teeth in children, (British
Society of Paediatric Dentistry BSPD
Avulsion Guidelines). www.bspd.org.
uk. 2012.
2. Children’s Dental Health Survey
2013. Executive Summary: England,
Wales and Northern Ireland.
3. Dental Trauma Guide [Internet].
2016 [cited 6 April 2016]. Available
from: www.dentaltraumaguide.com
4. Andreasen, JO, Andreasen, F & Andersson, L. Textbook and Colour Atlas of Traumatic Injuries of the Teeth,
4th edition, Blackwell Munksgaard.
2007.
5. International Association of Dental Traumatology. Dental Trauma
Guidelines, 2012
Dr Ghada Hussain
BDS (Dublin), BA
(Dublin)
Postgraduate
Resident in Paediatric Dentistry,
Hamdan Bin
Mohammed
College of Dental
Medicine
Mohamed Bin Rashid University of
Medical and Healthcare Sciences
Email: ghada.hussain@mbru ac.ae
Dr Iyad Hussein
DDS (Damas),
MDentSci
(Leeds), GDC Stat.
Exam (London),
MFDSRCPS(Glasg)
Clinical Assistant.
Professor in Paediatric Dentistry
UK Specialist in Paediatric Dentistry
Hamdan Bin Mohammed College of
Dental Medicine
Mohamed Bin Rashid University of Medical and Healthcare Sciences
Email: iyad.hussein@mbru.ac.ae
EFP societies celebrate biggest-ever
European Day of Periodontology
By DTI
MADRID, Spain: For the third time,
the European Federation of Periodontology (EFP) celebrated the European Day of Periodontology on 12
May. The event has grown immensely since its launch in 2014, with 20
national societies of periodontology
across Europe taking part this year.
The EFP-affiliated bodies organised
a wide range of activities, including television and radio interviews,
awareness actions in public spaces,
and free periodontal screenings at
universities and dental surgeries.
With this year’s slogan, “Healthy
gums for a better life”, the EFP and
its affiliated societies aimed to raise
awareness of gingival disease and
its links to other diseases, such as
diabetes and cardiovascular disease.
In order to support this goal, the EFP
launched a media campaign, including posters, press releases, images
and a new visual identity, also providing its members with information material for the event.
According to the EFP, at least 20 national societies joined yesterday’s
celebration by organising numerous
events across Europe. The countries
that took part were Austria, Azerbaijan, Belgium, Croatia, Finland, France,
Germany, Greece, Ireland, Israel, Italy, Lithuania, the Netherlands, Portugal, Romania, Spain, Switzerland,
Turkey, Ukraine and the UK.
The Belgian Society of Periodontology invited all dentists in the country to dedicate 12 May to periodontal
screening. Moreover, it created a mini-site in French and Dutch with useful information on gingival health
for dentists and patients, and a list
of all 200 dental practitioners taking
part in the massive free screening
across the country.
The Société Française de Parodontologie et d’Implantologie Orale, the
French society of periodontology
and oral implantology, organised
a multidisciplinary event together
with endocrinologists, cardiologists
and gynaecologists with the aim of
educating and raising awareness
about the link between periodontal
and systemic health.
The Ukrainian Society of Periodontists organised a day of periodontal
check-ups at the Shupyk National
Medical Academy of Postgraduate
Education in Kiev. Patients had the
opportunity to learn about different periodontal treatment options,
as well as strategies to improve their
gingival health, including dental
hygiene and lifestyle recommendations, particularly for young patients.
“Our association has been encouraging dentists and medical doctors
to play their part in the treatment
and diagnosis of periodontitis and
to raise public awareness of periodontitis and its link to systemic
health and general wellbeing,” said
Daiva Gelažienė, EFP delegate of the
Draugija Periodontologų Lietuvos,
the Lithuanian periodontal association. Among other activities, the
society conducted events related
to gingival health at schools in Vilnius, with about 200 children participating in a game of comparing
their knowledge about and skills in
keeping their mouths and bodies
healthy. “The EFP’s communication
tools have been very helpful,” noted
Gelažienė. “We are very happy to be a
part of this excellent initiative.”
[18] =>
DTMEA_No.3. Vol.6_DT.indd
18
restorative
Dental Tribune Middle East & Africa Edition | 3/2016
Advanced Restorative Techniques
and the Full / Partial Mouth Reconstruction
PART 3 : Treatment of severe wear cases
In part three, Dr Paul Tipton describes the diagnostic work required for the full mouth reconstruction
at an increased vertical dimension.
By Prof. Paul Tipton, UK
Prosthodontists are often called
upon to reconstruct the occlusion in
patients with severe wear. There may
be a multitude of issues to address
in such cases, including attrition,
abrasion, and erosion – all of which
contribute to uneven wear and compensatory eruption throughout the
arches. There may also be incisal
wear and/or interproximal wear
and, as a result, the occlusal plane
may need leveling and lengthening
for enhanced aesthetics and to allow
correction and control of the occlusal
relationship.
The aesthetic and functional requirements include a decision of the occlusal scheme to be used (part two)
followed by determination of the
incisal edge positions at rest, the occlusal plane, vertical dimension to
work to anterior guidance, lip support etc. All this is achieved by the
diagnostic wax-up. This article describes the diagnostic work required
for the full mouth reconstruction at
an increased vertical dimension.
Treatment planning
All comprehensive treatment planning should begin with an occlusal
aesthetic evaluation. Evaluation of
the face is essential in determining
the ideal aesthetic orientation of the
teeth from both a horizontal and
vertical perspective. The horizontal
reference planes will help the clinician align the occlusal plane and the
soft tissue levels along with other
related aesthetic determinants. The
horizontal reference planes should
be evaluated from two perspectives:
the frontal and the sagittal.
The frontal perspective is assessed
by having the patient look out into
the horizon and choosing the ideally
leveled plane. The most commonly
used horizontal reference planes
include inter-pupillary line and
inter-commissural line (Figure 1).
Intra-oral photographs are also key
at this stage (Figures 2-4). The following steps are essential to fulfilling the
correct diagnosis.
Step 1: Mounted study casts
This is achieved by taking accurate
alginate impressions of upper and
lower jaws in rim-lock trays, facebow recording and jaw registration
around RAP. The technician can now
mount the study casts in a semi-adjustable articulator (Figures 5-8).
the degree of over-eruption of either
arch can be assessed (Figures 9-10)
and casts adjusted (Figures 11-12).
Step 2: Vertical dimension
Step 3: Lower incisal edge position
The first treatment planning decision is what vertical dimension to
work at (part five). This can be established by the use of a wax squash bite
placed into the patient’s mouth. As
the patient is manipulated into RAP
the lower teeth indent the wax bite.
This can be removed, chilled in iced
water and replaced as the patient
and clinician now assess profile and
facial aesthetics. In this way changes
in vertical dimension can be transferred early to the technician on the
articulated casts and the initial new
occlusal plane assessed via an elastic
band (Figures 7-8). Once mounted,
The incisal edge position, incisal
plane and occlusal plane are the
three most important aesthetic determinants in the development of
the treatment plan. These determinants enable the clinician to transfer
information throughout the treatment, and are related in specific
ways to other aesthetic criteria. The
first step in determining the position
of the teeth is evaluation of the lower
incisal edge position with the lips
at rest (Figure 13). Tooth exposure is
ÿPage 22
Figure 1: Pre-op smile showing inter-commissure line
Figure 2: Patient in ICP
Figure 3: View of upper teeth
Figure 4: View of lower teeth
Figure 5: Mounted study casts
Figure 6: Upper study cast showing degree of wear
Figure 7: Mounted study cast showing rubber band indicating
approx occlusal plane – right hand side
Figure 8: Left hand side
Figure 9: Study cast showing amount of over-eruption of upper
teeth – right hand side
Figure 10: Left hand side
Figure 11: Upper occlusal plane adjusted – right hand side
Figure 12: Left hand side
[19] =>
DTMEA_No.3. Vol.6_DT.indd
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[20] =>
DTMEA_No.3. Vol.6_DT.indd
Introducing
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and phosphate bone regeneration technology1 to help relieve the pain
of your patients’ dentine hypersensitivity.
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exposed dentine and within dentine tubules2–6
Protects patients from the pain of future sensitivity: The robust layer
firmly binds to dentine6,7 and is resistant to daily oral challenges3,8,9,10
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References: 1. Greenspan DC. J Clin Dent 2010; 21(Spec Iss): 61–65. 2. LaTorre G, Greenspan DC. J Clin Dent 2010; 21(3): 72-76. 3. Burwell A et al. J Clin Dent 2010; 21(Spec Iss):
66–71. 4. West NX et al. J Clin Dent 2011; 22(Spec Iss): 82-89. 5. Earl J et al. J Clin Dent 2011; 22(Spec Iss): 62-67. 6. Efflandt SE et al. J Mater Sci Mater Med 2002; 26(6): 557-565. 7.
Zhong JP et al. The kinetics of bioactive ceramics part VII: Binding of collagen to hydroxyapatite and bioactive glass. In Bioceramics 7, (eds) OH Andersson, R-P Happonen, A Yli-Urpo,
Butterworth-Heinemann, London, pp61–66. 8. Parkinson C et al. J Clin Dent 2011; 22(Spec Issue): 74-81. 9. Earl J et al. J Clin Dent 2011; 22(Spec Iss): 68-73. 10. Wang Z et al. J Dent
2010; 38: 400−410. Prepared December 2011, Z-11-516.
[21] =>
DTMEA_No.3. Vol.6_DT.indd
[22] =>
DTMEA_No.3. Vol.6_DT.indd
22
restorative
Dental Tribune Middle East & Africa Edition | 3/2016
◊Page 18
considered to be in the 0mm to 3mm
range dependent on age. To achieve
the correct position the edges of the
lower anterior teeth need to be shortened or lengthened by either removing stone or adding wax. For example, if crown lengthening is indicated
on teeth that were previously ideally
proportioned, the incisal edge length
can be reduced. Establishing the correct amount of lower tooth exposure
dependent upon the age of the patient at rest should be the goal. Once
the final lower incisal edge position
is determined, the lower occlusal
plane is evaluated.
Step 4: Curve of Spee
For this the PMS method is used to
establish the anatomically average
curves of Spee and Monson, of the radius of a 4” circle. This is done using
a Boyles plane analyser (Figure 14).
For this three reference points are required. One has already been established and that is the position of the
lower incisal edge position as per the
aesthetic requirements of the patient
dependent upon age. The amount of
wax added to the lower incisors or
amount of stone removed from the
lower incisors on the mounted study
casts is established by using the lip
as the reference plane and calculating where the lower incisal edges are
and where they should be. This new
level is transferred to the technician
so that his starting point for the waxup is the two lower incisors. The two
posterior reference points are the
retro-molar pads (Figure 15), which
have been shown not to change during life/tooth loss etc. There is a certain amount of flexibility when establishing these two reference points
as being half-way and two-thirds of
the way up the retro-molar pads.
The lower occlusal plane is established by the Boyles plane analyser
resting on the waxed-up or adjusted
lower incisors and the two posterior
reference points on the retro-molar
pads. Any over-erupted teeth are
ground down and any teeth not
touching are waxed-up to the analyser. This creates the ideal lower occlusal plane (Figures 16-18). The lower
incisal plane should be leveled to the
chosen horizontal reference plane
(the inter-commissural line, interpupillary line etc), and evaluated
from the frontal perspective while
the patient is smiling. The next step
is to evaluate the occlusal plane from
a sagittal view of the patient’s smile.
Step 5: Upper incisal edge position
Next, the upper incisal edge position
should be established. This is done by
aesthetics and phonetics, especially
the ‘F’ and ‘V’ sounds to establish the
labio-lingual position. Aesthetically,
the incisal edge position is evaluated in relationship to the upper lip
at rest. Age is again used as a guide
and it is common that the range of
incisal edge show may be between
1mm and 5mm. The horizontal anterior planes, inter-pupillary line and
inter-commissural lines are again
used to establish the correct positions. The midline position of the
upper incisors can be taken from
several anatomical landmarks such
as the facial midline, nasal midline,
lip midline etc. Studies suggest the
closest anatomical landmark is the
most important – i.e. the midline of
the upper lip. Technicians and clinicians should also realise the extent
to which they can change midlines
without reverting to root canal therapy – approximately 1.5mm to 2mm
depending upon the size of the teeth.
However, special tooth preparation
techniques (beveling the interproximal margin one side) are required to
allow for this change. Even then soft
tissue problems may occur as the
gingival zeniths will move.
Step 6: Establishing anterior
guidance
Any space between the lower incisal
edges and the palatal aspects of the
upper anterior teeth is now closed
by waxing the palatal aspects of the
upper palatal aspect down to contact
the lower incisal edges to gain an incisal and canine stop in the intercuspal positions (Figure 19). Adequate
anterior guidance is a complex function directly related to the form of
the teeth, and thus to the vertical
and horizontal overlap of the incisors and canines. Anterior guidance
is influenced by the proprioception
of those teeth, which provides feedback to the masticatory muscles and
influences the entire masticatory
system. Unlike the posterior determinants, such as the slope of the
articular eminence, the vertical and
horizontal overlap of the anterior
teeth are – to variable degrees – ame-
nable to modification. However, any
modifications of the anterior teeth
must satisfy not only the aesthetics
and phonetics, but also the overall
function. If the disclusive angle is too
steep, temporomandibular joint or
muscular discomfort may result.
Step 7: Maxillary occlusal surfaces
Once the mandibular teeth are ideal
in shape and form, wax is added to
the maxillary posterior occlusal surfaces to occlude against the mandibular occlusal surfaces in the correct
relationship. Correct occlusal shape
and form and ridge and groove direction, depth of fossae and height of
cusps are now established at the set
vertical dimension dependent upon
the choice of articulator, facebow
and articulator setting devise; check
bite, cadrax, pantograph (Figures 2022).
Step 8: Refine the occlusion
The occlusal surfaces can be corrected to perfect the occlusal relationship and to idealise the aesthetic
ÿPage 24
Figure 13: Lips at rest
Figure 16: Lower arch waxed up to correct curve of Spee and
Monson using the boyles plane analyser - right hand side
Figure 19: Wax-up of upper model showing contour and shape of palatal aspects
Figure 14: Boyles plane analyser
Figure 15: Lower study cast showing retro molar pads
Figure 17: Front
Figure 18: Left hand side
Figure 20: Wax-up completed – right hand side
Figure 21: Front
Figure 22: Left hand side
Figure 24: Final smile close up
Figure 23: Final facial view
Figure 25: Pre-restorative smile
Figure 26: Pre-restorative smile – close up of the smile
[23] =>
DTMEA_No.3. Vol.6_DT.indd
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Ayad et al. 2009b,
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*
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Baseline
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Control with
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Control 2
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References:
BY DENTISTS
1. Cummins D. J Clin Dent 2009; 20 (Spec Iss): 1 – 9
2. Ayad F et al. J Clin Dent 2009; 20 (Spec Iss): 115 – 122
3. Petrou I et al. J Clin Dent 2009; 20 (Spec Iss): 23 – 31
BRAND RECOMMENDED
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[24] =>
DTMEA_No.3. Vol.6_DT.indd
24
restorative
Dental Tribune Middle East & Africa Edition | 3/2016
◊Page 22
Figure 27: Intra-oral ICP view
Figure 28: View of lower arch
Figure 29: Lower study cast
Figure 30: Mounted study casts at new increased vertical dimension
Figure 31: Anterior tooth preps
Figure 32: Silver dies model
Figure 33: Restorations on the silver dies model
Figure 34: Final completed view in ICP
so that the diagnostic waxing, prep guides and
prototypes were produced.
Acknowledgements
Reconstruction then followed along established
guidelines of initially an occlusion splint to establish the correct RAP prior to starting tooth
preparation procedures. All teeth were initially
prototyped starting with upper and lower anteriors then one side followed by another side
over a period of three visits during one week.
Figure 36: Final smile
Figure 35: Final completed view of lower arch
contours by the further addition or subtraction
of wax. The final contours of the central incisors
should be determined first, followed by the lateral incisors and canines, since the symmetry of
these teeth is not as critical as the central incisors.
Step 9: Restoration
The final restorations can be seen in Figures 23
and 24. The step-by-step procedures in the restoration will be discussed during the next case
study.
Case study
Mr O was referred to me from Birmingham
for a full mouth reconstruction (Figures 25-26).
On examination there was marked amounts
of wear present and loss of vertical dimension
(Figures 27-28). Mounted study casts were taken
and the vertical dimension – to which the final
restorations were to be fabricated – assessed as
per the previous discussion (Figures 29-30). The
diagnostics and treatment planning protocols
discussed in this paper were used to establish
the ideal aesthetic and functional end result
Once the prototypes had been in place for a
period of time to establish the correct occlusion, function and aesthetics and the patient
was comfortable, sections of prototypes were
removed, definitive preps, impressions, occlusal records and facebow were taken and final
restorations fabricated and fitted. Again, upper
and lower anterior crowns were fabricated and
fitted first to establish and copy (via a custommade incisal guidance table) the established
anterior guidance (Figures 31-33). This was followed by one side then another in the same
way. The final result can be seen in Figures 34,
35 and 36. Finally, a post-restorative splint was
made for night-time use.
The author would like to thank the following for
their help:
- Dr Ibrahim Hussain, BDS, M.Med.Sci.Implantology – implant surgeon
- Dr Andrew Watson, BDS, MSc, specialist in endodontics
- Mr Bradley Moore – dental technician, ADS
Laboratory, Harrogate.
Professor Paul Tipton BDS,
MSc, DGDP RCS (UK)
DENTAL SURGEON
Visiting Professor of Restorative
and Cosmetic Dentistry, City of
London Dental School
www.colds.co.uk
SPECIALIST IN PROSTHODONTICS
www.drpaultipton.co.uk
T Clinic @ Manchester , London | www.tclinic.co.uk
TIPTON TRAINING Ltd
www.tiptontraining.co.uk | www.bard.uk.com
President of the British Academy of
Restorative Dentistry (BARD)
[25] =>
DTMEA_No.3. Vol.6_DT.indd
[26] =>
DTMEA_No.3. Vol.6_DT.indd
26
gEnEraL DEntIStry
Dental Tribune Middle East & Africa Edition | 3/2016
Minimally invasive preparation treatment
By Dr Alina Lazar, Germany
In this case, the patient – a 26-yearold female – approached the practice
after finding us on the internet. She
had already visited three other dentists for a consultation with her main
complaints being crowding and
dental erosion of her anterior teeth.
Part of the problem was that she had
Pre treatment facial view
Pre treatment uppers
wize+™ arch evaluation software
calculations revealed that 2.7mm
of space would need to be created
before the IAS Inman Aligner treatment could begin.
upper anteriors, a fixed retainer was
bonded from 13 to 23.
Following professional tooth cleaning, the expander was fitted and the
patient instructed to wear it for 22
hours a day and to adjust the appliance once every three days by one
turn. Over the course of the expander treatment, parts of the fan screw
were removed. Firstly from 13 and 23
and eventually it was removed from
11, 21 and finally 12. After six weeks
and a new Spacewize+™ calculation,
the amount of expansion needed
had been reduced to 1.8mm.
To further improve the aesthetics of
the patient’s smile, anaxGUM from
anaxDENT – a gingiva-coloured
composite for the aesthetic reconstruction of the gingiva – was applied
to 41 and 31. At this time the patient
also had a filling (class five) and performed home bleaching with Opalescence® PF 10%, which was followed
by the use of Relief Oral Care Gel to
reduce the sensitivity caused by the
whitening treatment. An individual
vacuum-formed template was cre-
Pre treatment retracted view
IAS Inman Aligner appliance
Digital Smile Design and
Bleaching
to monitor the development of the
treatment process. It was very rewarding to see the patient become
emotional as she realised the changes that were being achieved.
Once the digital smile design analysis and mock-up were complete, only
the finishing touches were left. The
initial part of this was crown lengthening to 14, 15, 22, 24 and 25, which
took place at the same time as the
preparation. Shortly after, non-preparation veneers were placed on 14, 15,
24 and 25 and veneers were placed on
11, 13, 21, 22 and 23. Additionally, a partial crown was bonded
on 12 and an IPS e.max
Press from Ivoclar Vi-
Pre treatment anterior
practice. Although finishing with
composite contouring or veneers depends on the case that is presented,
the most important element is to
work as minimally invasively as the
case allows. Indeed, I have found that
when the above mentioned steps are
carried out in the same way as this
particular case study, a very satisfying result can be achieved.
References
Majewski RF. Adolescent caries: a
discussion on diet and other factors,
including soft drink consumption. J
Mich Dent Assoc. 2001;83(2):32–34.
i
Pre Treament smile view
Pre treatment upper occlusal
Digital smile design
Pre treatment retracted
Digital Smile Design phase 2
Post straightening occlusal view
Post alignment treatment
Smile Design face proportions
Digital Smile Design
Facial shot with digital design
Mock up
been drinking more than one litre of
sugary drinks, such as cola and juice,
every day – one of the leading causes
of dental caries and enamel erosion.
Expander and IAS Inman
Aligner Treatment
The first step needed to achieve the
intended outcome was to complete
a full orthodontic treatment. As the
patient wanted an effective, safe and
minimally invasive solution to anterior alignment, she opted for the IAS
Inman Aligner. Although the initial
examination showed no abnormalities, the model analysis and Space-
Mock up
After that, the patient was shown
how to use and remove the IAS Inman Aligner appliance and was instructed to wear this for 20 hours a
day. During this treatment process
predictive proximal reduction (PPR)
was carried out on the distal palatal
aspect of 12 and 21, mesially distally
and labially on 22. Interproximal
reduction (IPR) was also performed
progressively every three weeks
throughout the course of the IAS Inman Aligner treatment. Once the desired outcome was achieved on the
Mock up
ated to help guide tooth preparation.
Essentially, the digital smile design
allowed me to create a virtual mockup, which was applied to a plaster
model, and ultimately improved the
effectiveness of treatment planning.
Veneers, Non-Prep Veneers
and Crown Lengthening
The next step was to complete a
mock-up using a self-curing composite material –CS C&B shade BL3
from Ivoclar Vivadent. It was at this
point that photographs were taken
Transformation
vadent was used on the incisors – the
MT Ingots chosen were A1 and were
modified using both the cut-back
and layering techniques.
Outcome
After the expansion, anterior alignment, bleaching, digital smile design
and finishing treatments, the process was complete and both the patient and I were very happy with the
final results.
Ultimately, incorporating smile design is important to the ethos of my
Dr Alina Lazar has been practising dentistry since 1994 and founded ‘Praxis Dr.
Alina Lazar’ in Germany in 2001. She completed further qualifications to become a
Specialist in Aesthetic Dentistry in 2012
and a certified provider of the IAS Inman
Aligner in 2013. Alina also completed the
IAS Advanced training course in 2014 to
develop her knowledge and skills in anterior alignment.
[27] =>
DTMEA_No.3. Vol.6_DT.indd
Dental Tribune Middle East & Africa Edition | 3/2016
The IAS Inman Aligner course is part of the IAS Academy
pathway of training for GDPs. The course is now
a continuum and 2 cases must be submitted and evaluated
on completion for website listing.
The power of this
For more information on the IAS Inman Aligner
and upcoming training courses, please visit
www.inmanaligner.com or call 0845 366 5477
Inman Aligner
Academy Certification
Courses in GCC
By Dental Tribune MEA/CAPPmea
The Inman Aligner is the perfect solution for
crowding or protrusion of the front teeth. It
is really fast, very safe and great value. With
the patented Inman Aligner, your front teeth
can be gently guided to an ideal position in a
matter of weeks. Most cases complete in 6-18
weeks and because it's removable you can
take it out to fit with your lifestyle (inmanaligner.com).
How does it work?
The Inman Aligner corrects teeth position using Nickel Titanium coil springs that power
two aligner bows which set the teeth to their
desired position. These bows gently oppose
each other, the inner one pushes forwards,
while the outer bow pulls back on the front
teeth.
After the Certification course the participants will understand case selection and
implantation for the Inman Aligner orthodontic appliance along with the concept of
progressive smile to provide minimally invasive cosmetic dentistry. At the end of the day
delegates will be listed as an Inman Aligner
Certified User.
Packed into this
The next "The New Concept of Alignment,
Bleaching and Bonding (Inman Aligner)" Certification course available will take place
in Jumeirah Beach Hotel, Dubai, UAE during
the 8th Dental Facial Cosmetic Int'l Conference on 06 November 2016.
For more information on available courses
in GCC visit www.cappmea.com website and
at the same time book your spot for the next
course.
How long does the treatment take?
For relative cases, the Inman Aligner treatment is usually much faster than other orthodontic techniques. Most cases are completed within 6–18 weeks.
Because we’re not born
with robotic arms
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[28] =>
DTMEA_No.3. Vol.6_DT.indd
28
interview
Dental Tribune Middle East & Africa Edition | 3/2016
Interview:
“Technology leads to better dentistry”
By Dental Tribune MEA/CAPPmea
During the 11th CAD/CAM & Digital
Dentistry Int’l Conference, which
recently took place on 06-07 May
2016 at Jumeirah Beach Hotel in
Dubai, Dental Tribune MEA had the
pleasure of interviewing several international experts about the latest
dental technologies. The organizer,
CAPP, had gathered together an impressive scientific lineup consisting
of renowned international speakers,
so we managed to ask the same questions to some of them. Let’s compare
their different opinions.
Dental Tribune MEA/CAPPmea: Have
digital solutions changed the way
dentists are performing nowadays?
Dr. Eduardo Mahn, Chile: In my opinion, the answer is both yes and no.
Certain methods work much better now, especially with the help
of digital dentistry and CAD/CAM
technologies, as these have become
standardized protocols whilst other
methods remain unchanged due to
technological and mechanical re-
analytic tools that offer us more than
just CAD/CAM dentistry. This is what
makes it more valuable. I believe digital solutions have not revolutionized but evolutionized dentistry. It is
an ongoing process.
they receive immediate feedback
and that’s what makes them better
dentists. It is not about the technology itself, but the technology leads
to the fact that dentists have become
better.
Asst. Prof. Dr. Cagdas Kislaoglu, Turkey: Digital solutions help us in every
way. They allow us to work faster
and more efficiently, and give us the
ability to foresee everything. Digital
technologies have become an important part of our daily life and this
trend will continue to grow in the
future. In my opinion, every dentist
will have to use digital dental solutions sooner rather than later.
What part does CAD/CAM and digital
dentistry play in the development of
dental specialties?
Dr. Eduardo Mahn, Chile: I believe it is
an important one. Nowaways, CAD/
CAM is playing a new role in many
processes and many specialties: not
only in prosthodontics or restorative
dentistry, but also in orthodontics,
implantology and surgery.
Dr. Michael Dieter, Switzerland: Yes,
digital technologies have definitely
had a great impact on dentistry. I
first came into contact with digital
dentistry in 1998 when I became
very fascinated by CAD/CAM systems that had just been launched
at the time. Now, eight years later,
the technology has already been
tested through real life situations
“... you have this ability
to predict where you are
going to go, to control
things”
strictions. Digital solutions have not
necessarily improved the way dentists work directly. We all still need
to perform a lot of the steps by ourselves anyway, for example we are
the ones who prepare the teeth we
need to cement using restorations
made by CAD/CAM machines.
Prof. Jan-Frederik Güth, Germany:
Digital solutions have not changed
the principles of dentistry. They have
more to do with the way we work as
dentists, bringing more predictability and analyzing 3D datasets, using
Dr. Jan Paulics, Denmark
- those restorations have been in
the patients’ mouths for years thus
providing us valuable test results. A
lot of dentists struggle to do tooth
preparations correctly. For instance,
they have used technologies such
as metal based restorations for a certain period of time and now all of the
sudden they want to use ceramic restorations, so, when performing the
preparations, they do not have immediate feedback. They have taken
impressions and the dental technician has to deal with the end result.
However, when they take a scan,
Dr. Jan Paulics, Denmark: Actually, if
you view dentistry from a new perspective, not seeing the clinic and
the dentist as separate, but seeing
everything combined in a complete
workflow. So instead of simply taking the patient in and taking care of
them, you start at the beginning by
digitizing everything. When someone comes into the clinic we first
scan the patient, then we sit together
and go through everything that is
happening in their mouth. From
there on, we can plan the treatment
together. In this way the patient is
fully involved and there is no need to
sell any treatment to them - they will
be the ones to ask for it instead.
Prof. Jihad Abdallah, Lebanon: Well,
digital dentistry was something I
had been looking for that I found in
CBCT. I thought it would be great to
use in the field of implant dentistry.
When the patient comes into the office and you have a CBCT machine,
you can easily find the data you need
to plan and execute the case. Sometimes you need to do CBCT during
surgical planning in very complex
cases. Only when we received the
CBCT machine in the office, did we
understand the power of digital dentistry. The technology also allowed
me to take it a step further by acquiring an intraoral camera and a milling
machine.
Do you think that digital dentistry is
the future of dentistry?
Prof. Jan-Frederik Güth, Germany: Absolutely. What is happening at the
moment is that we have what I call
‘different island solutions’ in digital
Asst. Prof. Dr. Cagdas Kislaoglu, Turkey
Dr. Eduardo Mahn, Chile
Prof. Jan-Frederik Güth, Germany
dentistry: intraoral scanning, face
scanning, digital articulators, everything is now connected together so
we can put bridges between all those
islands. This is where development
takes part. If one day this connection
happens to become complete, digital
dentistry will make even more sense
because its value will increase.
Prof. Jihad Abdallah, Lebanon: Yes, the
development of digital dentistry will
give more prospects for different inoffice treatments and dentists will
be able to offer better treatments to
their patients.
Michele Temperani, CDT, Italy: Technology is a good thing and it’s some-
Dr. Michael Dieter, DDS, Switzerland
thing that can’t be stopped. Eventually, most of the work will be done
by machines but the handicraft of
dental technicians will always be
the best. What might happen is that
dental technicians would do high
quality work using their own hands,
which would come to be considered
of the highest value and probably
not many people would be able to
afford it.
What are the advantages of digital
dentistry?
Dr. Eduardo Mahn, Chile: The main
advantage of digital dentistry is
that machines are accurate and can
ÿPage 30
Dr. Tif Qureshi, UK
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Dental Tribune Middle East & Africa Edition | 3/2016
◊Page 28
Michele Temperani, CDT, Italy
do repeated work. For example, if
you need to redo a crown because it
broke, you can keep the same prep,
press “Play” and you receive exactly
terior guidance, canine lateral guidance and we can make sure that the
patients are functioning not only as
well but potentially even better after
the orthodontic treatment. The digital step forward we have had in orthodontics has been enormous. The
other thing we are able to do with
digital dentistry is that we can actually start to preview the shape of required teeth. Sometimes it is hard to
understand but when you have teeth
that are crooked they tend to be wide
and bulbous. When teeth have been
straightened and put in the full arch
they need to be slightly arrowed and
having seen this digitally all upfront,
dentists have much better guidance
how to shape correctly to get a much
better result.
Prof. Jihad Abdallah, Lebanon
the same crown.
ability to predict where you are going to go, to control things. So, the
orthodontists could be very easy to
lose control of the inclusion if you
Dr. Tif Qureshi, UK: The advantage of
digital dentistry is that you have the
weren’t able to see where the teeth
were going to move to. When we
know where the teeth are going to
move to we can then plan our an-
Are there any limitations of digital
dentistry?
Dr. Eduardo Mahn, Chile: Machines
still do not complete the entire work
process. They can create a crown but
you still need to polish it, glace it and
give it definition. The software and
the database of patients’ teeth do
not automatically create a beautiful
smile so there is still the need of a human touch.
Prof. Jan-Frederik Güth, Germany: I
think they vary, depending on the individual system you use and whether it is open or closed. For example,
full arch intraoral scans are still very
dependent on how you scan them
and whether you need powder or
not. We must be aware of the specific
technology and look for treatment
concepts to use with it.
PRINT
L
DIGITA N
TIO
EDUCA
EVENTS
Dr. Tif Qureshi, UK: Yes, definitely,
there should be limitations in orthodontics. Something that’s very
important and that we teach is to
make sure that GP dentists start at
first with very limited cases. They
should be primarily working in the
anterior teeth only. If the teeth require movement in the back of the
mouth, that should be treated by an
orthodontist, unless the dentist has a
huge matter of experience. So, with
Inman Aligner and Clear Aligner and
with everything we teach in the IAS
Academy, we are making sure that
the dentists are focusing on the front
region and only treating minor tooth
movement, if at all.
.
The DTI publishing group is composed of the world’s leading
dental trade publishers that reach more than 650,000 dentists
in more than 90 countries.
Dr. Michael Dieter, Switzerland: Frankly, I do not see any limitations in general. Currently, the question is rather
how many dentists are using digital
technology specifically when they
need to go into a big investment. This
applies for both dentists and dental
technicians. The fact that there are
different systems, open and closed,
can be seen a limitation. In my opinion, the bigger problem are the investments. Also, the systems should
be a little bit adjusted so that dentists
can work with different software and
hardware manufacturers.
CAPP
Mobile: +971 50 2793711
Telephone: +971 4 3616174
FAX: +971 4 3686883
E-mail: events@cappmea.com
Web: www.cappmea.com
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31
cad/cam
Virtual reality simulation
Indications and perspectives for the technology in the field of dental education
By Dr Susan Bridges, Suzanne Perry
& Prof. Michael Burrow, Hong Kong
& Australia
Virtual reality (VR) simulationinevitably conjures up images of futuristic technology, imaginary worlds
or complex robotic devices. What it
may not initially suggest is the use
of virtual technology as a means of
training dental students and den-
tists, facilitating the development of
skills in a safe and relaxed environment.
An increase in demand for simulation units over the last ten to 10 years
has indicated growing interest from
dental schools, suggesting a certain
confidence that simulation systems
have potential as a recognised form
of dental skills training in the future.
Using technology inspired primarily
from the flight simulation industry,
dental simulators are now able to
create an environment in which users can practise clinical procedures,
such as restorative dentistry, endodontics, periodontal assessment,
implant placement and even dental
extractions.
These systems are a far cry from the
first phantom head simulator created in the early 1900s that attempt-
ed to represent the oral cavity with
a relatively primitive set of upper
and lower dental casts mounted on
a metal pole (Fig. 1). Although phantom head systems are now the mainstay for undergraduate training,
educationalists are becoming more
aware of the additional benefits of
ÿPage 32
Data security: How not to become
the next Ashley Madison
sider if you are using a commercial
e-mail provider to liaise with your
patients, and determine whether
your website communication tools
and feedback portals are compliant
and if not ensure your designated
data policy controller addresses this
as a priority. Here in the UK, the ICO
can issue monetary penalty notices,
requiring organisations to pay up
to £500,000 for serious breaches of
By Naz Haque, UK
At the heart of the relationship between a dentist and a patient lies
trust and respect. Recent events,
such as the Sony or, more currently,
the Ashley Madison breach, have
brought to public awareness the importance of securing one’s data.
Data security and governance
is a very tricky area. I must make
it clear I am not a lawyer, but I am
a highly experienced information
technology professional with a good
understanding of data protection
and other relevant legislation. All interpretations provided here are my
own.
Even if a dental practice has not
embraced the digital age and all records and correspondence are ink
and paper based, the practice still has
a number of responsibilities regarding data security. As dental practices
collect patient details, they must
register with the Information Commissioner’s Office (ICO) here in the
UK. Dental records must be stored
safely and securely for a number of
years (up to six years for the National
Health Service; NHS) and kept for a
maximum of 30 years (Department
of Health). Records must also be
disposed of in a policed manner to
avoid fines.
What about dental practices
who have embraced digital? Data is
accessed in two situations, storage
and movement, the same as physical records are. This also means that
there are the two situations in which
data can be compromised in the
digital world. Dental practices have
an obligation to ensure patient data
is backed up, recoverable (in case
of disasters), secure and protected.
This applies during both storage and
movement. If you are using one of
the popular industry patient management systems, such as EXACT
(Software of Excellence), it should
have features to support this in
place; liaise with your account manager to verify this.
The next area of concern then is
movement of data. This can be via email, online referral tools or portals,
feedback platforms or devices, and
your website. E-mail is not a secure
medium, and communication with
patients about their medical history
or medical circumstances using this
platform raises potential issues. The
service provider you use for your
e-mail could also be inadvertently
making you breach data security
rules. For example, if you are using
one of the popular US-based organisations for e-mail, such as AOL, Hotmail and Gmail, and liaise with your
patients via this e-mail platform, you
have to consider where the e-mails
are being stored; most likely on servers outside your own country.
The UK’s Data Protection Act
states that “personal data shall not be
transferred to a country or territory
outside the EEA (European Economic
Area) unless that country or territory ensures an adequate level of
protection for the rights and freedoms of data subjects in relation to
the processing of personal data.” As
a dental practice, you should recon-
the DPA occurring on or after 6 April
2010. Clients at Dental Focus expect
us to take care of online compliance
and provide guidance on keeping up
to date and resolving these issues.
Make sure your data is secured and
protected before it is too late.
This article was published in CAD/
CAM International Magazine No.4,
2015
Fig. 1. A sketch of an early phantom head
simulator.
Naz Haque, aka „The Scientist“, is Operations Manager at Dental Focus. He has a
background in mobile and network computing, and has experience supporting a
wide range of blue-chip brands, from Apple to Xerox. As an expert in search engine
optimisation, Naz is passionate about
helping clients develop strategies to enhance their brand and increase the return
on investment from their dental practice
websites. He can be contacted at naz@
dentalfocus.com.
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Dental Tribune Middle East & Africa Edition | 3/2016
◊Page 31
Dr Susan Bridges
is an associate
professor at
the Faculty of
Education at the
University of Hong
Kong in China. She
can be contacted
at sbridges@
hku.hk
3D Glasses
Viewing screen
Display screen
Dental
handpiece
input device
Foot pedal
Fig. 2. The Simodont Dental Trainer (Moog) haptic VR simulator.
VR simulation, such as the ability to
repeat the same task many times,
providing real-time feedback leading
to a reduction in supervision, and
the benefits of students being able
to practise in their free time without laboratory supervisors. Other
benefits of VR simulators include
the reduction of consumable costs
incurred with plastic teeth and the
elimination of water system management issues, reducing the possibility of water-borne infections such
as Legionella.
Undoubtedly, the initial cost of the
VR simulators is a major deterrent
and, with additional concerns regarding possible lack of realism to
the clinical situation, it is natural that
many suggest the need for more evidence-based research prior to committing to such an investment.
In the limited literature on VR dental
simulation, studies have been mixed
but, in general, are positive about
the use of the technology for dental
training.
Research has shown that procedural
learning on VR simulators may be
more effective than with the traditional phantom head and may reduce the number of staff—student
interactions without a reduction in
the quality of the practical work.
In contrast, other research has shown
that dental performance may be no
better using VR simulation and that
some students prefer their training
to be on phantom heads. Naturally,
further research will be needed to
establish the effectiveness of the
technology.
What are haptics?
The addition of haptics to VR technology creates a dimension of sensory feedback for the user. The word
itself originates from the Greek work
haptikos, which means “to touch or
grasp”. There are many examples of
haptic simulation in modern-day
technology, such as in gaming and
the vibration component of a mobile phone. The aim of haptics in
many cases, and especially simulation, is to improve the realism of the
virtual experience. In dentistry, for
example, when carrying out a cavity
preparation on a haptic VR simulator, there is a difference in hardness
felt when cutting from enamel to
dentine, and if the pulp is damaged
an instant loss of resistance occurs,
producing a realistic sensation of
drilling through the roof of the pulp
chamber (Figs. 2 & 3).
Naturally, the important question is,
does the addition of haptic technology really make a difference when
learning using VR simulation? To answer this, we have to delve into surgical research for which a stronger evidence base exists, specifically in the
area of laparoscopy. A review of the
use of haptics in surgery suggested
that the addition of haptics to simulation can reduce surgical errors and
is especially beneficial in the early
Fig. 3. An image of a cut tooth from the Simodont haptic VR simulator.
stages of learning a new skill task.1
Other studies have shown that the
addition of haptics may improve
overall performance of surgical skills
and may be beneficial when a trainee
is first exposed to a clinical situation.
In dentistry, small-scale studies of
haptic VR simulators suggest that
they are at least as good as phantom
heads in training undergraduates.
haptic VR simulation is proving an
interesting development, offering
encouraging prospects for the future
skills-based training of dentists. The
evidence is limited, however, so, prior to commending this technology
as the mainstay of training in dental
undergraduate curricula, there is a
compelling need to expand the current research base.
The future of VR simulation
in dentistry
This article was published in CAD/
CAM International Magazine No.2,
2015
Currently, exciting research involving the universities of Hong Kong
and Melbourne is looking into gaining solid evidence concerning the
use of haptic VR simulation in the
dental undergraduate curriculum.
By utilising neuroimaging techniques, identification of the traits an
expert usually displays can occur,
which in turn can be built into training pathways to enhance the effectiveness of procedural learning.
Initial findings have suggested that
distinct differences may be apparent
in the brains of dental experts and
novices during a simulated clinical
task when using a dental haptic VR
simulator. Further work in this area
is to be carried out, with additional
investigation into the positioning of
haptic VR simulation within a curriculum and considering its effectiveness compared with traditional
phantom head training techniques.
Already it can be seen that the area of
VR in dentistry and especially that of
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For more information visit www.invisaligngcc.com
Prof. Michael
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Biomaterials at
the Melbourne
Dental School at
the University
of Melbourne in
Australia. He can
be contacted
at mfburrow@
unimelb.edu.au
Study finds fundamental misconceptions
about dental implants
among patients
By DTI
HONG KONG, China: Investigating
patients’ knowledge and perceptions
regarding implant therapy, a Chinese study has found that an alarming number of participants had inaccurate and unrealistic expectations
Science in Every Smile
INVISALIGN®
Suzanne Perry
is a PhD candidate
at the Faculty of
Education at the
University of Hong
Kong. She can
be contacted at
subygee@yahoo.
co.uk
about dental implants. Moreover,
the study determined that only 18
per cent felt confident about the information they had about the treatment.
In the study, the researchers
investigated preoperative information levels, perceptions and expectations regarding implant therapy via
a questionnaire. Responses from 277
patients were obtained during 2014
and 2015 in three different locations
in China (Hong Kong, Sichuan and
Jiangsu).
The analyses established that
about one-third of the participants
had mistaken assumptions about
dental implants. According to the researchers, common misconceptions
were that dental implants require
less care than natural dentition, implant treatment is appropriate for all
patients with missing teeth, dental
implants last longer than natural
dentition, and there are no risks or
complications with implant treatment.
Overall, younger respondents (<
45) and those with higher education
(bachelor’s and postgraduate degrees) tended to have more realistic
perceptions and lower expectations
of the treatment outcome.
When asked about their level of
knowledge, 63 per cent of the participants said that they were generally
informed about implants, but only
18 per cent felt confident about the
information they had.
The study, titled “What do patients expect from treatment with
dental implants? Perceptions, expectations and misconceptions: A
multicenter study”, was published
online ahead of print on 23 March in
the Clinical Oral Implants Research
journal.
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news
Dental Tribune Middle East & Africa Edition | 3/2016
Dentsply Sirona
Instruments
Introduces Online
Knowledge Sharing
Platform for Laser
Dentistry
The Sirona Laser Platform is the ideal one-stop resource for dentists for basic information on how they work to
clinical case reports, discussion forums, and training and e-learning offerings.
By Dentsply Sirona
Dental lasers are an easy way to provide dentists and their patients with
greater comfort and more treatment
options. The range of application
possibilities has been considerably
improved as a result of blue laser
technology – an opportunity to increase the popularity of laser dentistry. In order to promote knowledge
sharing in laser dentistry, Dentsply
Sirona introduced the first international online platform.
at the same time, created greater
awareness of laser dentistry. The international “Sirona Laser Platform”
from Dentsply Sirona, which was introduced at the beginning of March,
is meant to acquaint dentists with
the different areas of laser dentistry
in a lively way. Dentists who wish to
take advantage of this opportunity
can receive free access to the knowledge-sharing platform of the global
market and technology leader in the
dental industry via the link http://
www.sirona.com/en/sirolaser.
Bensheim/Salzburg: The development of blue laser technology has
vastly increased the possible applications of diode lasers in dentistry and,
The information available on the
platform is very diverse and encompasses the various types of lasers in
the market, the differences between
diode and traditional lasers and how
they work. Images and videos are
also used to illustrate the different
application areas of dental lasers. Experience reports on the new SIROLaser Blue, clinical case examples and
the possibility to view upcoming
training courses on specific products all complement the range of
information offered.
Additionally, a corresponding forum
is included in this platform as well.
This gives participants a place to exchange knowledge and information
on all things related to laser dentistry
with other colleagues. Whether it be
difficulties, treatment approaches
or everyday tips, the community is
Ideal dose
for 2 arches
G
UG
ABLE SYRIN
G
ES
PL
HIGH TECHNOLOGY
FOR DENTAL BLEACHING
Pre-dosed Hydrogen
Peroxide and thickener
8 times
mixing only
www.dme-medical.com
Tel: +971 6 5308055
welcome to openly discuss all dentalrelated experiences with lasers.
Blue lasers are especially well-suited
for surgical procedures
Lasers were introduced about 50
years ago and have been used in dentistry since the mid 1990s, especially
the diode laser. The SIROLaser Blue is
one of the newly developed diode lasers. The Blue laser light, with a wavelength of 445 nm, is mainly indicated
for soft tissue surgery because of the
superior absorption properties and
excellent cutting performance; however, it is also used in implantology
and prosthetics. This allows dentists
to offer their patients virtually painfree treatment. With two additional
wavelengths, the SIROLaser Blue
covers the complete treatment spectrum of diode lasers: a red laser light
(660 nm) for biostimulation, low
level laser treatments and an infrared laser light (970 nm) for reducing
bacteria in endodontics and periodontics as well as for the treatment
of aphthae and herpes.
Dentsply Sirona
Sirona Straße 1
5071 Wals bei Salzburg, Austria
T +43 (0) 662 2450-588
F +43 (0) 662 2450-540
www.dentsplysirona.com
[35] =>
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nEWS
35
New sugar tax could
save South Africa
billions in health care
costs, experts say
especially harmful to the teeth, since
they tend to be very acidic, which
makes the teeth particularly vulnerable to both dental decay and tooth
erosion.
By DTI
JOHANNESBURG, South Africa: Calculations by the University of the
Witwatersrand suggest that South
Africa’s sugar-sweetened beverages
tax, which is underway and proposed for implementation in April
2017, could save the country R10 billion (€560 million) in expenditure
related to treating Type 2 diabetes
over the next 20 years. The fiscal
initiative, which was introduced by
Finance Minister Pravin Gordhan in
his national budget speech in February, is an effort to help reduce excessive sugar intake and curb obesity in
the country.
Although Gordhan said that the
sugar tax will be implemented in
April next year, he has not yet said
how high the levy will be. With the
measure, South Africa will follow
countries such as Denmark, Finland,
France, Hungary, Ireland, Mexico
and Norway, which all tax sugarsweetened drinks already.
“Treasury will need to decide on
the tax rate and what qualifies to be
taxed,” remarked Aviva Tugendhaft,
Deputy Director of PRICELESS SA
at the university’s School of Public
Health. The research programme
is one of 26 representatives of the
Public Health Community of South
Africa that submitted a letter to
treasury endorsing the tax plans in
April. “The government may decide
to institute a flat rate on all beverages, as has been done in Mexico, or
consider taxing the caloric content of
the drinks,” she said.
Both financial and health benefits resulting from the levy on beverages with added sugar, including soft
drinks, fruit juices, energy drinks and
vitamin waters, could be extensive,
a 2015 study by Wits University has
shown. If the tax is implemented at
20 per cent, Wits researchers calculated savings of R10 billion in costs
for hospitalisations and medication related to treating rising cases
of Type 2 diabetes. Moreover, the
analysts estimated that the tax could
prevent obesity in about 280,000
young adults.
South Africa has the highest
obesity rate in sub-Saharan Africa.
According to figures from the World
Health Organization, 26.8 per cent of
South Africans were obese in 2014.
Just last year, the country’s health
department released its national
strategy on the prevention and control of the condition. It stated that
fiscal measures were the most costeffective ways to combat rising obesity compared with measures such
as food labelling, advertising regulations or media campaigns.
Aside from increasing the risk
for obesity, various studies have confirmed the direct relation between
the intake of dietary sugars and dental caries. Soft drinks and juices are
South Africa’s Finance Minister Pravin Gordhan proposed introducing a tax on sugar-sweetened beverages as of
April 2017 in the national budget speech in February. (Photograph: feelphotoz/pixabay)
[36] =>
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news
Dental Tribune Middle East & Africa Edition | 3/2016
CAPP launches new long-term “Associate Fellowship”
and “Diploma” CME programs in Dubai
By Dental Tribune MEA/CAPPmea
DUBAI, UAE: The Centre for Advanced Professional Practices (CAPPmea) has launched two new
long-term programs for continuing dental education starting in Dubai coming September 2016.
The programs are in partnership with the American Academy of Clinical Orthodontics (AACD) and
British Academy of Restorative Dentistry (BARD)
respectively.
Practical Clinical Orthodontics –
Associate Fellowship with AACD
The Associate Fellowship Program targets General
Practitioners focusing on Clinical Orthodontics
and consists of five six-day modules spread over
the course of one year. The program is accredited
by the American Academy of Clinical Orthodontics (AACO) which will award 210 CME and an
Associate Fellowship to successful participants.
ADA C.E.R.P and local accreditations in the United
Arab Emirates will also be made available through
Dubai Health Authority (DHA) and Health Authority Abu Dhabi (HAAD).
A number of activities including lectures, live
demonstrations, hands-on sessions and group
discussions will allow participating dentists to
gain knowledge and practice new skills fundamental to contemporary orthodontic practice.
The program is based on in-depth
clinical experience and practical
knowledge of various orthodontic
treatment procedures ranging from
diagnosis to finishing and detailing,
relevant to the management of basic
clinical situations. Participants will
also benefit from well-documented
case studies offering a detailed stepby-step approach to treatment planning. The course aims to give participants a deeper understanding of the
biological and mechanical principles
of tooth movement through various
appliances and protocols thus contributing to a more complete appreciation of the science and art of contemporary orthodontic treatment.
The course focuses on “individualized diagnosis, and customized treatment mechanics and care” in order
to carefully match and optimize all
aspects of patient care. After all, it all
boils down to helping clinicians treat
their patients with better results.
The program will be conducted
by Dr. Dubravko Pavlin, Dr. Brent
Calleghari, Dr. Bradley Pierson, Dr.
Bryan Jennings, Dr. Ryan Reyes and
Dr. Doug Jensen all from the United
States of America.
Restorative & Aesthetic Dentistry Course – Diploma with
British Academy of Restorative Dentistry
CAPP-Tipton Dental Academy is
launching the Restorative & Aesthetic Dentistry Diploma course in
Dubai, starting on September 15th,
2016. The two-year program will
award successful participants 210
CME, accredited by the American
Dental Association, Dubai Health
Authority and Health Authority Abu
Dhabi and a further diploma upon
completion and successful passing
of the exams.
The program is divided into two
parts. During the first year of study
participants will be able to participate in 4 modules over a total of 15
days,
Obtaining 105 CME. Upon successful
completion, participants will receive
a Certificate in Restorative Dentistry
from the British Academy of Restorative Dentistry (BARD).
Holders of the certificate will be qualified to resume their study for Year 2
Diploma. Part 2 is also grouped into 4
modules spanning 15 days, leading to
a Diploma in Restorative & Aesthetic
Dentistry from BARD after passing
exams which include several parts
including submission of 5 clinical
cases.
Each of the two year-long course
comprises of a series of lectures,
practical’s on phantom-heads,
seminars and webinars, aiming to
teach dentists to apply scientifically
proven restorative and aesthetic
techniques in order to achieve great
results. After the courses, clinicians
will also gain more confidence in
taking on more complex cases and
ultimately find better job prospects,
increase their income and transition
into successful private practices. The
unique program has been very successful for over 20 years with Professor Paul Tipton in the United Kingdom and can be seen as a pathway
to a further MClinDent with City of
London Dental School (CoLDS) or an
MSc with Manchester University.
The program is taught by some of
the most experienced, knowledgeable and passionate lecturers, whose
enthusiastic approach aims to inspire participants to improve their
skills and become more confident
in their daily practice including the
likes of: Prof. Paul A. Tipton, Prof. Edward Lynch, Prof. Göran Urde, Prof.
James Prichard, Dr. Geoffrey Sharpe,
Dr. James Russell, Dr. Julian Caplan,
Dr. Adam Toft and Mr. Jonathan Parkinson.
CAPP-Tipton Dental Academy has
prepared special registration packages for delegates willing to take on
the diploma challenge including a
promotion for everyone who recommends the courses to their friend/
colleague.
Registration for the programs in
Practical Clinical Orthodontics and
in Restorative & Aesthetic Dentistry
are now available on www.cappmea.
com/capptipton and www.cappmea.
com/ortho
[37] =>
DTMEA_No.3. Vol.6_DT.indd
37
news
Dental Tribune Middle East & Africa Edition | 3/2016
Bristol researchers
receive funding for
super-chlorhexidine
“We’re very excited about
Pertinax’s potential.”
Dr Michele Barbour (Photograph: Bhagesh Sachania, University of Bristol)
By DTI
BRISTOL, UK: A University of Bristol
spin-off has been awarded almost £1
million to bring a new technology to
the market that could help to fight
infections in the mouth and body.
An enhanced form of chlorhexidine,
the substance, named Pertinax, is
said to offer improved properties
compared with those of the original
substance.
Overall, Pertinax Pharma has received around £900,000 from
southern England technology investor Mercia Fund Management, Innovate UK (through its Aid for Start-Ups
scheme) and an unnamed private investor. The company’s founder and
chief scientific officer, Dr Michele
Barbour, who is also a senior lecturer
in biomaterials at the university’s
School of Oral and Dental Sciences,
said that the company will focus on
the development of applications in
dentistry first, where the technology
already has relevance to a number of
areas. Further uses in medicine will
follow in time.
Trusted market leader since 1967.
“We’re very excited about Pertinax’s
potential,” she said.
Representing some International major companies such as:
A proven antimicrobial agent, chlorhexidine has been used in a wide
range of products and treatment
processes to prevent and treat bacterial infections. Since it is a new
formulation of the substance, Pertinax is reported to possess the same
antibacterial properties, but without
some of the shortcomings of the
original formulation, such as short
efficacy time. Possible future applications are its use in cements to
reduce the failure rates of dental fillings, for example.
“With a strong management team
and innovative product, Pertinax
Pharma has the potential to take its
product from dental tool to a musthave anti-infective across a wide
range of industries, from veterinary
care, to cosmetics and even home
appliances,” Investment Manager
at Mercia Fund Management Dr
Brijesh Roy commented.
Mercia Fund Management recently
provided funding for another oral
health care-related project by the
University of Manchester.
ABU DHABI SHOWROOM
TEL. (02) 673 0790
FAX. (02) 673 1995
SHARJAH INDUSTRIAL AREA OFFICE
TEL. (06) 535 5575
FAX. (06) 5350839
SHARJAH BUHAIRAH SHOWROOM
TEL. (06) 555 3922
FAX. (06) 555 1300
[38] =>
DTMEA_No.3. Vol.6_DT.indd
38
practice management
Dental Tribune Middle East & Africa Edition | 3/2016
Why Practice Management?
By Dr. Ehab Heikal, Egypt
Historically, dentistry has been a
closely regulated field in terms of
management, marketing and business ethics. Dentists were educated
to achieve one goal—clinical excellence. The notion of marketing a clinic, selling services or even discussing
ideal business models and profitability simply were not (and in the majority of Universities, is still not) part
of the curriculum, as some dentists
felt these concepts somehow detracted from the professionalism of
the industry.
As a dentist, I understand and appreciate that some dentists find a focus
on dental management, marketing
or business efficiency to be contrary
to achieving clinical excellence.
However, in today’s world, I believe
clinical excellence and an efficiently
operated business only complement
rather than contradict one another.
Practice management and
quality of patient care
One point of view to consider is
that failing to operate a clinic efficiently or not consistently providing outstanding customer service
can detract from a dentist’s ability to
provide excellent clinical care and a
positive patient experience.
A clinic that is disorganized or chaotic, for example, does not provide
proper focus on the patient. A dentist who is constantly interrupted to
solve managerial problems or "put
out fires" is distracted from providing clinical excellence and cannot
completely concentrate on patient
care. Inefficiencies in a clinic will
lead to scheduling confusion, which
often causes chaos, rushing and frustration for the doctor and patient.
I believe clinical excellence and an
efficiently operated business only
complement rather than contradict
one another.
Clinics operating in a fast-paced, disorganized environment often fail to
provide patients with a comprehensive oral examination. In many instances, the dentist spends less than
five minutes examining a patient,
and the focus is on identifying active
caries, soft-tissue disease or restorative work that is obvious and in need
of repair. Rarely in this disorganized
environment does time allow the
dentist to focus on reaching optimal
oral health through innovative and
comprehensive clinical and elective
services.
Clinics that lack a sufficient profit
margin will be unable to invest in
new technologies, invest in continuing education or use the best
products and materials. Dental clinics, like hospitals, are faced with the
ever-increasing cost of technology.
The addition of items such as practice management software and
digital radiography systems require
that certain levels of cash flow and
profitability be maintained to afford
a technology investment. In time,
a clinic that does not invest in new
technologies, materials and services
fails to offer its patients the highest
level of care.
Inefficiencies in a clinic are com-
pounded by the fact that approximately 5 percent of patients are noshows or last-minute cancellations
each year. Close to 30 percent of
patients are overdue for periodontal
maintenance (Not mentioning oral
cancer screenings that is rarely done,
if ever done!!). These numbers only
grow. This does not detract from, but
rather enhances, clinical care.
But, does implementing Practice
Management make us focus only
on profits and the money side of our
clinic?
“I believe clinical
excellence and
an efficiently operated
business only complement
rather than contradict one
another. ”
illustrate further why clinics must
have systems in place to provide
comprehensive diagnosis and treatment to all patients, as well as effective care for overall excellence in oral
health treatment.
What these examples also indicate is
that efficient management systems
and follow-up procedures allow
practices to track and interact better
with patients, ultimately providing
these patients with the opportunity
for excellence in dentistry. The goal
of efficient dental management is
to help dentists and their staff teams
achieve their personal and professional goals by providing a solid
business foundation from which to
Balancing quality care and
ethics
In no way am I suggesting that a total focus on money at the expense
of the best interests of patients is
the proper way to practice dentistry.
Practice management is a very broad
field that covers hundreds of different subjects, and only one of these is
practice profitability. A comprehensive practice management program
also must consider the enjoyment of
the dentist, satisfaction and training
of the staff, level of stress in the clinic,
investment in clinic upgrades, cash
flow to move or expand an office if
necessary, efficiency in record keeping, patient flow and scheduling,
proper care of emergency patients,
patient financial arrangements,
treatment, presentation and case acceptance, technology investments,
continuing education and more.
But those who lump critical practice
management issues into one category and proclaim they detract from
clinical care rather than enhance it
misunderstand the very purpose of
better practice management: excellence in all areas of the practice.
Efficient practice management is
about much more than profitability.
It is about educating and motivating patients to achieve optimum
oral health by incorporating the
best business methodologies and
systems into the management of all
clinic operations.
Effective practice management cannot be accomplished without gaining the overwhelming satisfaction
and trust of every patient. This can
be achieved only through excellence
of care and by achieving the high
professional standards that dentistry
currently demands.
Dr. Ehab Heikal
BDS, FICD, MBA, DBA.
Practice Management
consultant. He can be
contacted at:
eheikal@gmail.com
[39] =>
DTMEA_No.3. Vol.6_DT.indd
COLGATE TOTAL
®
PROVIDES PROTECTION*
TO 100% OF THE
MOUTH’S SURFACES1
O Regular toothpastes† only protect the hard tissue, which
is 20% of the mouth2
O The remaining 80% of the mouth is the tongue, cheeks,
and gums, which can provide a bacteria reservoir for plaque
biofilm recolonization
WHY SETTLE FOR 20% WHEN YOU CAN
OFFER PATIENTS PROTECTION TO 100%
OF THE MOUTH’S SURFACES?
*In addition to fluoride for cavity protection, Colgate Total® provides 12-hour antibacterial protection
for teeth, tongue, cheeks, and gums.
†
Defined as non-antibacterial fluoride toothpaste.
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.
[40] =>
DTMEA_No.3. Vol.6_DT.indd
[41] =>
DTMEA_No.3. Vol.6_DT.indd
Ov
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11 CAD/CAM & Digital Dentistry
International Conference
th
06-07 May 2016
Jumeirah Beach Hotel, Dubai, UAE
www.dental-tribune.me
Published in Dubai
Show Edition
Dubai Dental Week
gathered 2128
professionals from
all over the world
Participants during the scientific session at the 11th CAD/CAM & Digital Dentistry Int’l Conference
By Dental Tribune MEA/CAPPmea
DUBAI, UAE: This year’s 11th CAD/
CAM & Digital Dentistry International Conference, which took place
from May 04-09 at the Jumeirah
Beach Hotel in Dubai, can boast a
great record of international dental
attendance. Catering to the scientific and business needs of dental
specialists, the nearly week-long forum gathered a total of 2,128 professionals from across the world. The
conference is considered the most
important industry event in the region, and the organizers – the Centre
for Advanced Professional Practices
(CAPPmea) and the Emirates Dental
Society had prepared an impressive
line-up of top lecturers and a number of accompanying events.
The conference was an incredible
opportunity for dental teams to obtain up-to-date professional and
scientific information through a series of innovative presentations and
hands-on courses covering a variety
of multidisciplinary topics in digital
dentistry and continuing dental education.
This year the agenda offered a wide
variety of top quality scientific sessions, lectures and panel discussions by industry leading experts in
dentistry and dental technologies,
a great deal of hands-on courses, as
well as networking opportunities
with leading dental providers, dis-
tributors and experts from all over
the world.
The renowned international speakers who took part in the 11th CAD/
CAM & Digital Dentistry International Conference 2016 were Prof.
Jan-Frederik Güth (Germany), Dr.
Michael Dieter (Switzerland), Asst.
Prof. Dr. Cagdas Kislaoglu (Turkey),
Prof. Jihad Abdallah (Lebanon), Asst.
Prof. Joseph Sabbagh (Lebanon), Dr.
Mario J. Besek (Switzerland), CDT
Vanik Kaufmann-Jinoian (Switzerland), Dr. Kiril Dinov (Bulgaria), Dr.
Guillaume Jouanny (France), Dr. Jan
Paulics (Denmark), Dr. Tif Qureshi
(UK) and Dr. Eduardo Mahn (Chile).
They discussed current issues in digital dentistry, aesthetics, prosthetics,
implantology, restorative dentistry,
endodontics, etc.
The panel discussions following
the sessions proved a useful way to
trigger an exchange of viewpoints
among experts with the audience
and further increase the participants’ understanding of the subject
at hand.
With the constant increase in demand for hands-on approach, CAPP
partnered with several international
key opinion leaders and industry
partners to offer a total of 15 handson courses spread over six days. The
limited enrollment allowed participants the maximum opportunity
to practice the skills in a hands-on
format.
Among the events that took place
parallel with the 11th CAD/CAM &
Digital Dentistry Conference were
the Dental Technician International
Meeting and the traditional industry
exhibition.
The Dental Technician International
Meeting was attended by over 200
international dental technicians,
clinical dental technicians, laboratory owners and other visitors. The
meeting focused on the hottest topics of interest not only for technicians and lab owners, but also for the
entire dental technology profession.
The panel of speakers included some
of the industry’s most respected
experts: Vanik Kaufmann (Switzerland), Michele Temperani (Italy),
Aiham Farah (Syria), John Philipp
(Canada), Christopher Adamus (Denmark), Yamen Chaban (Germany),
Maffei Simone (Italy) and Clemens
Schwerin (Germany). Dental technicians also had a chance to attend a
number of trainings titled ‘Round
Table Clinic Trainings’, during which
they had a chance to ask their questions and immediately receive valuable insight from the presenters
while practicing hands-on.
The top leader manufacturers generously sponsored the conference
to contribute for the developing of
these advanced technologies. The exhibition taking place during the conference days was designed to showcase the sponsors’ latest CAD/CAM
Panel discussion during the scientific session at the 11th CAD/CAM & Digital Dentistry Int’l Conference
Participants during the 11th CAD/CAM & Digital Dentistry Int’l Conference
Round Table Clinic Trainings during Dental technician Int’l Meeting 2016
& digital technologies, materials and
techniques, as well as promote innovative ideas and services. The exhibition provided great business opportunities for all parties – delegates,
visitors and trade representatives.
The 11th CAD/CAM & Digital Dentistry International Conference
welcomed dentists, providers and
experts from 35 countries in Europe,
Asia, Africa, Australia and the Americas. The organizers, CAPP and Emirates Dental Society re-established
the reputation of the conference as
the industry’s leading international
scientific event and proved its increasing popularity. In the words of
Dr. Aisha Sultan, who opened the
11th CAD/CAM & Digital Dentistry
International Conference, the forum
is ‘a gateway to knowledge acquisition so that all dental professionals
may follow the latest developments
in dental world’.
For more information about the
conference and upcoming scientific
events in the MEA region, visit cappmea.com.
CAPP
Mobile: +971 50 2793711
Telephone: +971 4 3616174
FAX: +971 4 3686883
E-mail: events@cappmea.com
Web: www.cappmea.com
[42] =>
DTMEA_No.3. Vol.6_DT.indd
11th CAD/CAM & Digital Dentistry International Conference
06-07 MAY 2016 · Jumeirah Beach Hotel, Dubai, UAE
2
10th CAD/CAM
Dental Technician Int’l Meeting
Delegates during DTIM
Ivoclar Vivadent - Crystal Sponsor
Dentsply Sirona - Platinum Sponsor
DeguDent - Official Sponsor
ZirkonZahn - Official Sponsor
Dr. Aisha Sultan Alsuwaidi, President
of Emirates Dental Society, MOH, UAE
GSK - Silver Sponsor
MESA - Official Sponsor
Asst. Prof. Dr. Cagdas Kislaoglu, Turkey
Michele Temperani, CDT, Italy
Planmeca - Gold Sponsor
Mac International - Gold Sponsor
New Al Farwaniya - Gold Sponsor
Round Table Trainings during DTIM
The Scientific Session at
the 11th CAD/CAM & Digital Dentistry
Conference in Dubai
Delegates during the scientific sessions
Hands-on courses
Exhibition
Hands-on courses
Exhibition
Delegates
Dr. Eduardo Mahn, Chile
CAPP thanks all sponsors, delegates, speakers & exhibitors!
SPONSORS
[43] =>
DTMEA_No.3. Vol.6_DT.indd
www.dental-tribune.me
Published in Dubai
May-June 2016 | No. 3, Vol. 6
Poor dental health may
predict reduced ability to
leave one’s house
By DTI
SENDAI, Japan: Researchers in Japan
have investigated the association
between poor dental health and being housebound in the elderly, and
found that having fewer teeth and
no dentures were associated with
future risk of being homebound,
especially in people aged 65–74. The
findings may have important implications for interventions that promote dental health and denture use
to prevent older people from becoming confined to their homes.
The longitudinal cohort study used
data of 2,035 men and 2,355 women
aged 65 and over who responded
to two postal surveys conducted in
2006 and 2010 and were not homebound, defined as leaving their
home less than once weekly, at baseline. After the four-year study period,
324 (7.4 per cent) of the respondents
were housebound.
With regard to dental status, the
researchers found that, overall, participants with fewer teeth were twice
as likely to be confined to the house
than those with more teeth were. Almost 10 per cent of the homebound
respondents had fewer than 20 teeth
and no dentures, about 9 per cent
had fewer than 20 teeth and dentures, and about 4 per cent had 20 or
more teeth.
However, such a significant association between being homebound and dental health was not
observed in participants aged 75
and over.
According to the researchers,
A study has found that poor dental health may be linked to future risk of being homebound.
several possible pathways may
(Photograph: pixabay/stevepb)
link dental health and being
bound to one’s home. For example, dental health, including loss The researchers concluded that fu- their risk of becoming housebound
of teeth, affects food choice and nu- ture intervention studies focused on in the future.
tritional intake, conversation, and improving dental health in order to
facial attractiveness. Therefore, poor prevent older persons in the Japa- The study, titled “Does poor dental
dental health could negatively influ- nese population being homebound health predict becoming homeence social activities, leading indi- are required to verify the findings. bound among older Japanese?”, was
viduals to isolate themselves from They suggested that improving the published online in 30 April in the
others. Being housebound in itself is rate of denture use among older peo- BMC Oral Health journal.
a barrier to access to dental care.
ple with fewer teeth could reduce
Testing toothpastes, toothbrushes
Improving dental hygiene products through virtual brushing
By DTUS
Designing toothpastes and toothbrushes is a time-consuming process
involving the production and testing
of numerous samples. Using a new
type of simulation, various parameters such as bristle shape and abrasive particle size can be modified
with just a click. This enables manufacturers to improve the quality of
new dental care products and bring
them to market more quickly.
When we wake up in the morning,
there is a fur-like coating on our
teeth: this is a biological film that
forms overnight. Over time, this can
lead to the development of caries —
which is why it is critical that we remove this “rug” using a toothbrush.
There is a large selection of dental
hygiene products on the market, including brushes whose bristles are
rounded, pointed, hard, and soft.
There are also brushes with bristles
of varying lengths. Until now, to determine which ones clean the most
thoroughly while doing as little damage to the tooth enamel as possible,
manufacturers have had to conduct
experiments. This was also the case
when selecting the right abrasive
particles to be used in toothpastes.
Various toothpaste formulations
had to be mixed and then tested on
artificial tooth enamel models — a
laborious task. Another drawback to
Freiburg, Germany. “With our procedure, manufacturers of dental hygiene products can determine the
cleaning effectiveness of each individual parameter in a fast, economical and reliable manner,” says IWM
scientist Dr. Christian Nutto. “Unlike
in real-world experiments, the individual parameters in the simulation
can be easily modified — be it the
size, shape and quantity of abrasive
particles in a toothpaste, or the material from which they are made, or the
shape and elasticity of the bristles.”
Simulated tooth brushing
Simulation of pressure distribution in suspensions of varying viscosities with
spherical abrasive particles as a toothbrush bristle rubs against tooth enamel:
The more viscous toothpaste suspension leads to greater abrasion on enamel.
Fig. 1: Lower viscosity (1 mPas). Fig. 2: Higher viscosity (20 mPas). Left-side images show pressure distribution in the suspension (a deeper red indicates higher pressure). Right-side images show stress input against the tooth enamel by
abrasive particles (a deeper red indicates greater abrasion). Images/Provided
by Fraunhofer IWM
this approach is that the brush, paste
and enamel can be analyzed only as a
complete system, which means that
manufacturers have a difficult time
determining which effects observed
in these experiments are derived
from which of the various parameters.
Help has arrived in the form of a new
type of simulation developed by researchers at the Fraunhofer Institute
for Mechanics of Materials IWM in
Researchers can increase the scope
of the experiments far beyond what
is possible in real-world testing, and
that makes a noticeable difference
in the quality of the products. What
effects do the shape and stiffness
of the bristles have when brushing? How do the different abrasives
or toothpaste viscosity affect the
enamel, and how do they affect their
intended target, the biofilm on the
teeth? Simulation testing can deliver
reliable answers to questions such as
these, and it does so long before the
manufacturer ever mixes the toothpaste.
Nutto relies on SimPARTIX® simulation software developed at the
IWM, which uses the Smoothed
Particle Hydrodynamics (SPH) particle simulation method. “We specify
Simulation of interaction between a toothbrush bristle and a suspension with spherical
abrasive particles.
characteristics for the abrasive particles such as density, shape and fill
factor,” he says. Even parameters for
the tooth enamel are included. The
virtual toothbrush bristle is then
rubbed over the tooth enamel, with
the simulation providing data on
how the scrubbing particles interact
with the elastic bristle. It also calculates cleaning effectiveness, as well
as the aggressiveness of the abrasives against the tooth enamel. Here,
the team from the Powder Technology, Fluid Dynamics group can vary
the speed at which the bristles pass
across the enamel as well as their
pressing force. The SimPARTIX team,
together with the Fraunhofer Institute for Algorithms and Scientific
Computing SCAI, designed an additional software tool to integrate the
particle simulation into standardized simulation programs.
But do the findings correspond to reality? The comparative experiments
ÿPage 2
[44] =>
DTMEA_No.3. Vol.6_DT.indd
2
hygiene tribune
Dental Tribune Middle East & Africa Edition | 3/2016
Tennis legend Martina
Hingis becomes Curaden
ambassador
By DTI
KRIENS, Switzerland: Curaden has
health care and promote Curaden’s
CURAPROX, swiss smile and megasmile brands.
named international tennis star
Martina Hingis its global ambassador. As part of the collaboration, Hingis, who became the youngest Grand
Slam champion of all time in 1996
and the youngest world No. 1 in 1997,
will help raise awareness about oral
Over the next three years, 35-yearold Hingis will make several major
appearances in her role as global
ambassador for Curaden and
CURAPROX at and alongside her
sporting commitments as the cur-
rent leading women’s doubles player, including teaming up with Swiss
tennis professional Roger Federer
at the Olympics in Rio de Janeiro in
Brazil.
Ueli Breitschmid, owner and CEO
of Curaden, said: “Martina Hingis is
our perfect match—she’s the ideal
fit for our company, which operates
in over 60 countries. That’s because
she’s a mature and credible ambassador who’s famous all over the world.
She’s an exceptionally talented
sportswoman with a strong personality and great self-reliance who will
help us spread the word about our
modern kind of oral health care in
the best possible way. Together, we
want to be the names on everyone’s
lips in the future.”
Curaden offers over 120 products
under the CURAPROX dental brand,
which is sold in 60 countries. Its oral
hygiene products are developed and
manufactured in partnership with
researchers, teachers and practitioners. Based in Kriens near Lucerne,
Curaden employs some 300 staff
across the world. In 2015, the company generated sales in excess of
CHF130 million (€118 million) and
manufactured over 28 million toothbrushes.
◊Page 1
M Y DA I L Y R IT UAL
Martina Hingis and her CS 5460.
Better health, higher success.
TOOTHBRUSHING.
IT’S A SERIOUS GAME.
MAKE IT A FUN ONE.
CS 5460
www.curaprox.com
VISIT AND WIN.
were conducted by Dr. Andreas
Kiesow and his staff at the Fraunhofer Institute for Microstructure
of Materials and Systems IMWS in
Halle as well as the MikroTribologie
Centrum µTC in Karlsruhe. In the
tests, a brush bristle was placed in a
fastener and brushed at a constant
speed across an artificial tooth enamel model onto which toothpaste had
been applied. It was concluded that
the simulation can precisely predict
how the toothpaste and bristles will
affect the tooth enamel. At a later
stage, it will also be able to predict
the effectiveness of the toothpaste
and brush at removing the biofilm
from teeth.
Abrasive particles are a key component of toothpastes and serve to mechanically remove plaque from the
teeth. But a good toothpaste should
not be overly abrasive, as over the
years the friction can damage the
enamel, which does not regenerate.
Furthermore, this damaging effect
is far more pronounced on the soft
dentine. For this reason, the representative body for dentists in Germany recommends that patients
with exposed root surfaces choose a
toothpaste with a low abrasive effect.
About Fraunhofer
Fraunhofer identifies itself as Europe’s largest application-oriented
research organization. Its research
efforts are geared to people’s needs:
health, security, communication,
energy and the environment. The
company designs products, and it
improves methods and techniques.
(Source: Fraunhofer)
[45] =>
DTMEA_No.3. Vol.6_DT.indd
PATIENT SENSITIVITY
CAN BE GONE
IN SECONDS.
BEFORE
Open tubules
AFTER
Closed tubules in
60 SECONDS
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
et al. J Clin
Dent. 2009;20(4):115-122.
RECOMMENDED
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www.colgateprofessional.com
[46] =>
DTMEA_No.3. Vol.6_DT.indd
4
hygiene tribune
Dental Tribune Middle East & Africa Edition | 3/2016
Company introduces world’s first smart
floss dispenser
By DTI
PALO ALTO, Calif., USA: For prevention of dental disease, the American
Dental Association recommends
flossing at least once a day to help
remove plaque from interproximal
areas that cannot be reached with a
toothbrush. However, only a quarter
of people use dental floss on a regu-
lar basis. In order to address this issue
and improve oral health care, a U.S.
company has now introduced floss
time, a novel smart floss dispenser.
The patent-pending floss time can
easily be mounted to the bathroom
mirror or wall and automatically
dispenses 18 in. of floss at the push
of a button. After floss has been dispensed, the device starts a 90-second
flossing timer in the form of blueglowing quadrants that move clockwise around the circular light ring,
indicating how long the user should
floss each quadrant of his or her
mouth. Upon completion, floss|time
will light up with a blue smile. If not
used daily, an orange frown or reminder light cues the user that it is
time to floss again.
The device has a single- and dualuser mode and can thus be shared by
two people. It can also be individualized using animal snap-ons to make
flossing more appealing to children.
According to the inventors, the floss in the new device lasts for one year of daily flossing. (Photograph: floss|time)
The use of dental floss is generally
recommended in addition to daily
toothbrushing. Insufficient flossing has been associated with an increased risk of caries and periodontal
disease, which have been linked to
other serious health problems, including cardiovascular disease and
diabetes.
Floss time was created by a team of
designers, Ph.D.s and engineers. In
addition to the device’s functional
properties, the team paid great attention to its esthetic aspects, such
as elegant LED lightning. They believe that their invention will help
establish long-term flossing habits.
The group is currently raising money for the manufacture of floss|time
through the Kickstarter funding
platform, which will help finance the
first production run.
The funding initiative at Kickstarter
ends on Dec. 12 at 4 p.m. (CET).
More information about the dispenser can be found at www.flosstime.com.
Dental caries treatment
may prevent pneumonia in Parkinson’s patients
By DTI
KAOHSIUNG, Taiwan/KUALA LUMPUR, Malaysia: Pneumonia is a
common condition in patients with
Parkinson’s disease. A new study
that explored risk factors for pneumonia development has now found
that patients treated for dental caries had a reduced risk of pneumonia
compared with patients who had not
been treated.
The study included 2,001 participants newly diagnosed with Parkinson’s disease between 2000 and
2009. Over a mean follow-up period
of about six years, 19 per cent of the
patients were hospitalised for pneumonia. With regard to oral health
status, the researchers observed
that dental diseases were among
the most common co-morbidities.
About 48 per cent of the patients in
the study had dental caries and over
44 per cent periodontitis. Moreover,
the data analysis showed that the
incidence of pneumonia in patients
who had received treatment for
dental caries was lower. They thus
concluded that maintenance of good
oral hygiene and control of oral biofilm formation reduce the number
of potential respiratory pathogens,
thereby lowering the risk of pneumonia, especially in elderly men.
The researchers found that older patients, males in particular, patients
living in the northern, southern and
eastern regions of Taiwan, and patients with lower income had a higher risk of developing pneumonia.
For example, over 60 per cent of the
participants who developed pneumonia were men. Of the patients
hospitalised for pneumonia, about
95 per cent had a monthly income of
less than NT$30,000 (US$928).
The study, titled “Risk factors for
pneumonia among patients with
Parkinson’s disease: A Taiwan nationwide population-based study”,
was published on 27 April in the Neuropsychiatric Disease and Treatment
journal.
Smiles in London, York and Liverpool rated best
By DTI
LONDON, UK: Brits may not like to
show their smiles very often, according to research, but when it comes to
ranking them, most consider Londoners, Yorkers and Liverpudlians
to have the nicest smiles. All three
cities scored highest in a recent poll
commissioned by the Oral Health
Foundation as part of National Smile
Month.
Overall, the foundation asked 2,000
Brits where they thought the best
smiles in Britain are, out of 45 of
the country’s most populous urban
areas. While the capital and the two
northern cities came out top, smiles
in Salford, Wolverhampton and Lichfield were rated significantly lower.
from the truth,” remarked Chief
Executive of the Oral Health Foundation Dr Nigel Carter, OBE, on the
poll. “It shows that quantity is not
always related to quality and when
London residents do choose to smile
their grins are showing the rest of the
country the way forward.”
“London may have a reputation for
being a place that is very short on
smiles but this couldn’t be further
The survey findings were released
on the first day of National Smile
Month, the UK’s largest and long-
est running charity campaign initiative. Celebrated this year for the
40th time and held until 16 June,
it is aimed at increasing awareness
of the importance of oral health by
highlighting key messages, such as
the benefits of regular toothbrushing and visiting a dentist in order
to develop and maintain a healthy
mouth.
Thousands of individuals and or-
ganisations take part in the initiative
every year.
“A simple smile can make others
around you feel at ease. It is highly
contagious and plays such an important role in our lives that we should
make our oral health top priority,”
Carter added. “It is an incredibly powerful tool and worth remembering it
is one we all possess.”
[47] =>
DTMEA_No.3. Vol.6_DT.indd
Dental Tribune Middle East & Africa Edition | 3/2016
hygiene tribune
Presence of certain
oral bacteria
may indicate
increased pancreatic
cancer risk
Assessment of bacterial changes in the mouth could be used to determine individual risk of developing pancreatic
cancer. (Photograph: pixabay/stevpb)
By DTI
NEW YORK, USA: Researchers have
found that the risk of developing
pancreatic cancer is associated with
specific bacteria in the mouth. They
hope that the findings could enable earlier and more precise treatment of the disease, which is one of
the most common causes of cancer
death in both men and women and
results in more than 40,000 deaths
annually in the U.S. alone.
Other studies have shown that pancreatic cancer patients are susceptible to periodontal disease, cavities and poor oral health in general.
Therefore, the research team at the
NYU Langone Medical Center set out
to search for direct links between the
makeup of bacteria driving oral disease and subsequent development
of pancreatic cancer.
The researchers compared bacterial contents in mouthwash samples
from 361 American men and women
who had developed pancreatic cancer with samples from 371 people of
matched age, sex and ethnic origin
who did not. They found that men
and women whose oral microbiome
included Porphyromonas gingivalis,
a major contributor to periodontal
disease, had an overall 59 percent
greater risk of developing pancreatic
cancer than those whose microbiome did not contain the bacterium.
Similarly, people with oral microbiomes containing Aggregatibacter
actinomycetemcomitans, which has
been associated with severe periodontitis, were at least 50 percent
more likely overall to develop the
disease.
“Our study offers the first direct
evidence that specific changes in the
oral microbiome represent a likely
risk factor for pancreatic cancer
along with older age, male gender,
smoking, African-American race, and
a family history of the disease,” said
senior investigator and epidemiologist Dr. Jiyoung Ahn.
In another study published last
month, Ahn and her colleagues
showed that cigarette smoking was
linked to dramatic, although reversible, changes in the amount and mix
of bacteria in the oral microbiome.
However, she cautioned that further research is needed to determine
whether there is any cause-and-effect relationship, or how or whether
such smoking-related changes alter
the immune system or otherwise
trigger cancer-causing activities in
the pancreas.
The findings were first presented on
April 19 at the annual meeting of the
American Association for Cancer Research in New Orleans.
5
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www.dental-tribune.me
PUBLISHED IN DUBAI
May-June 2016 | No. 3, Vol. 6
ENDO TRIBUNE
FKG Dentaire SA expands its range of 3D instruments
with the introduction of the XP-endo® Finisher R
The World’s Endodontic Newspaper Middle East & Africa Edition
By FKG
FKG Dentaire SA continues it’s
marketing of innovative instruments, after the introduction of the
revolutionary XP-endo® Finisher
in 2015. The range of instruments
designed for 3D cleaning of the root
canal is now enriched by the XP-endo® Finisher R (XP-FR), targeting the
removal of filling material.
Made of a unique and highly
flexible NiTi alloy that can expand
100 fold compared to standard instruments, XP-FR reaches areas of
the canal walls impossible to reach
with traditional files.
After initial filling material is removed, regardless of the instrumentation technique used, residual material is always present particularly
in curved or oval canals.
Like with the XP-endo® Finisher
the exclusive FKG MaxWire™ alloy
(Martensite-Austenite) gives to the
instrument the ability to expand
and contract so as to contact difficult
to reach areas, especially in curvedand oval-shaped canals.
With its ISO 30 diameter, the XPFR is slightly stiffer than the XP-endo® Finisher enabling it to eliminate
Gutta-percha and sealer.
Moreover, the XP-FR features
unparalleled resistance to cyclic fatigue, due to its small core size and
zero taper. The instrument is easy
to use and intended for all dentists
keen to enhance the long-term success of their retreatment procedures.
The XP-FR is available in sizes 21
and 25 mm, packed in a sterile blister
of 3 instruments.
XP-FR L21 - ISO 30 (M Phase)
XP-FR L21 - ISO 30 (A Phase)
FKG MaxWire
S1.XB0.00.0AE.FK - XP-endo Finisher R, ISO 30, 21 mm, Sterile
XP-FR L25 - ISO 30 (M Phase)
Contact Information
FKG Dentaire SA
Crêt-du-Locle 4
CH-2304 La Chaux-de-Fonds
Switzerland
T. +41 32 924 2244
info@fkg.ch
www.fkg.ch
XP-FR L25 - ISO 30 (A Phase)
S1.XB0.00.0AD.FK - XP-endo Finisher R, ISO 30, 25 mm, Sterile
The XP-FR is available in sizes 21 and 25 mm. Packed in a sterile blister of 3 instruments.
3D generation_
Long-term success
for your endodontic treatments
FKG Dentaire SA
www.fkg.ch
[52] =>
DTMEA_No.3. Vol.6_DT.indd
2
endo tribune
Dental Tribune Middle East & Africa Edition | 3/2016
Getting to the 00.00 point
By Prof. Philippe Sleiman, Lebanon
Anatomy and nature still teach us
on a daily basis. Root canal treatment, while it is becoming a routine
procedure, surprises and sometimes
bad cases still occur. In this article, I
will present two unusual case reports
from my own practice.
Case 1
The first is a clinical case that in my
experience posed rather a challenge.
The patient was referred to my office
suffering from paraesthesia of his
lower lip on the one side after a root
canal treatment had been performed
on his mandibular second molar.
The preoperative radiograph (Fig.
1), which was sent by his dentist,
showed a well-performed root canal
treatment that did not explain the
clinical manifestations, but looking
closely at the apical part one could
observe that the obturation material lay in proximity to the apex of
the mandibular canal. Immediate
retreatment was required. Unfortunately, the material that had been
used was the plastic carrier Thermafil (DENTSPLY), and it was extending into the nerve, causing the inflammation, and the inflammation
was causing pressure on the nerve.
The Thermafil was removed from
the canals—never an easy thing to
do—using K3XF files (Sybron -Endo;
Fig. 2) and without any solvent in
order to avoid any more damage to
the nerve in case of leakage. I set the
Elements Adaptive Motor (Kerr Endodontics; Fig. 3) to K3XF mode, first
using a 25.06 file in the softened part
of the gutta-percha with the System
B plugger. I was very careful not to
push the carrier further inside the
nerve and not to damage the plastic
carrier and lose the grip. The second
file used was the 25.04 K3XF to remove more gutta-percha and to liberate the carrier.
The instrument was used to hold the
Fig 7
carrier and to remove it from the canal (Fig. 4). Once the Thermafil had
been removed and the exact working length had been determined using the Apex ID apex locator (Axis,
SybronEndo, Fig. 5), the canals were
shaped following the SM sequence
in TF Adaptive mode to the working
length, and I used the EndoVac irrigation system (SybronEndo, Fig. 6) with
cold physiological saline in order to
reduce the inflammation by cooling
down the roots. All of the canals were
irrigated with the cold saline for at
least 20 minutes. The reason I used
this technique was to immediately
lower the in flammation inside the
mandibular canal, which is not well
innervated. Reducing the inflammation inside and around the nerve can
take a while and I needed to lower it
as soon as possible. The canals were
kept empty with a cotton pellet inside the access cavity and a hermetic
seal on top. I asked immediately for
a CT scan (i-CAT, Imaging Sciences
International) to be taken in order
to study the case. To my surprise, I
found that the position of the mandibular canal was different from the
contralateral one and that it was in
contact with the apex of the second
molar where the root canal treatment was performed (Fig. 7).
sealer at the end too. Carefully adjusted master cones were placed
inside the canals with a very tight
tug back. The correct amount
of sealer was applied in order
to avoid any excess and gentle
warm obturation was performed
with the Elements Obturation
Unit (SybronEndo). The integrity
of the obturation was checked
with a CBCT scan (Figs. 9 & 10).
Six months later, a conventional
radiograph was performed (Fig.
Fig 1
Fig 2
Fig 3
Fig 4
The patient was prescribed antiinflammatories and kept under observation. Several days later, his lip
was normal in function, but there
was still some of loss of sensibility.
Thirty days postoperatively, another
CT scan was taken (Fig. 8) in order to
check the inflammation inside the
nerve itself, but during this time we
continued to irrigate the canals with
cold physiological saline at intervals
of three days.
Until the patient reported the slow
return of sensitivity, I decided to
seal the canals, and it was for me
the moment of truth, since I knew
that I needed to seal the canals to the
00.00 point and place a small puff of
Fig 8
Fig 5
Fig 6
11) in order to follow up on the case;
the patient was doing very well with
a completely functional and sensitive lip. The final radiograph showed
a sealed root canal space and none of
the sealer inside the mandibular canal remained. The conclusion of this
case is that we will never know the
reason for such a difference in the
position of the mandibular canal between the right and left of the mandible, and that we need to respect
the 00.00 point of the length of the
roots—nothing more and nothing
less. And the most important conclusion is that nature and the human
body have a truly amazing healing
power once the cause of inflammation has been eliminated.
Case 2
In the second clinical case, the patient presented at the office with
problems biting on his molar, with a
fistula on the buccal side of his mandibular first molar. The preoperative
radiograph showed an acceptable
root canal treatment performed in
accordance with recommendations
(Fig. 12).
Studying the radiographs in detail,
we could obviously see that something was not right in the apical area
of the mesial canals. A closer look
indicated some kind of pathology
Fig 9
Fig 10
in the coronal part of the distal canal
and possibly a cervical resorption or
an internal resorption that might explain the fistula in this area.
Again K3XF files were used to retreat
the case, with the proper irrigation
technique using the Endo Vac. A
50.04 file or the ML3 file in TF Adaptive mode was used to shape the last
3 mm of the canals. Adequate master cones were prepared with a very
strong tug back placed 0.5 mm short
of the working length.
My choice was the Elements Obturation Unit in order to perform the
sealing of the root canal system. The
choice of the plugger was made, selecting the largest plugger to reach
5 mm from working length in each
canal, in order to generate hydraulic
pressure and to seal in 3-D during the
down-pack or the first wave of obturation. Manual pluggers were also
adjusted to reach 5 mm and 10 mm
from the working length. Medium
viscosity was chosen for the cartridge with a large opening and the
extruder was set to two arrows or fast
injection. The sealer was placed on
the cones and inserted into all four
ÿPage 3
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DTMEA_No.3. Vol.6_DT.indd
Dental Tribune Middle East & Africa Edition | 3/2016
3
endo tribune
◊Page 2
formed by the endodontist to complete the root canal treatment, but it
should be concluded with a hermetic
seal on top of it.
The article was published in Roots
Magazine 1/2016
Fig 11
canals, the first wave of condensation was performed in the canals one after another, and
the manual plugger that reached 5 mm from
working length was used thereafter in order
to control the apical plug. Sealer was placed
inside the canal, the preheated cartridge was
inserted very slowly with no pressure applied
on the needle, since it should reach 7 mm
Irrigatys
By DTI
With endodontic treatment, there is
the risk of superinfection. The French
laboratory ITENA Clinical claims to
have solved this problem with its
revolutionary Irrigatys handpiece.
This two-in-one device is used for
both irrigation and agitation of the
cleaning solution inside the root canal. To achieve this, the laboratory
put a perforated metal tip at the top
of the handpiece to deliver the cleaning solution in an oscillating movement.
A removable tank allows the root canal to be treated successively using
sodium hypo chlorite and EDTA. The
irrigation line directs the cleaning solution through the metal tip.
The patented technology, achieved
after six years of research, optimises
the results of a very complex procedure, according to the company.
Ambidextrous, light and flexible, the
device has excellent ergonomics,
providing intuitive handling. Irrigatys recharges on a charging station
that can be fixed to the chair.
Irrigatys is available with all of its accessories in a starter kit. The metal
tips are available in two sizes, 17 mm
and 21 mm, to cover all clinical cases.
Fig 12
from the working length, 5 mm was injected
into each canal, manual pluggers were used to
condense this part and final filling of the root
canal system was performed, also followed by
hand plugging. The hydraulic force generated
with this technique is sufficient to seal lateral
and accessory canals and, of course, the resorption in the distal canal that appeared in
Fig 13
the final postoperative radiograph (Fig. 13).
The root canal system has a very complex
anatomy and this is not often apparent on
radiographs. Performing a partial root canal
treatment and placing one cone is not the
gold standard in root canal treatment. Sealing the root canal system is the final step per-
Prof. Philippe Sleiman
Advance American Dental Center
Abu Dhabi and Dubai, UAE
profsleiman@gmail.com
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DTMEA_No.3. Vol.6_DT.indd
www.dental-tribune.me
Published in Dubai
May-June 2016 | No. 3, Vol. 6
The story behind IPS POWER
By Aiham Farah, Syria
IPS e.max® Ceram The versatile layering ceramic is optimally coordinated with the materials of the IPS
e.max System. Matching the shade
when using different framework
materials is clearly facilitated by the
universal layering diagram and the
precise shade coordination. After
all, the veneering ceramic is the key
to highly esthetic results within the
IPS e.max System – both on lithium
disilicate (LS2) and zirconium oxide (ZrO2) – particularly for the adaptation to the natural model. The
unique combination of translucen-
cy, brightness, and opalescence leads
to natural light scattering and a balanced relationship between brightness and chroma. (Fig. 2)
balanced relation between brightness and chroma results in the exact match with the respective shade
guide. (Fig. 2)
At the beginning of the all-ceramic
era, both lithium disilicate and zirconium oxide were only available
with medium or high opacity. These
opaquer framework structures reflect a lot of light, which increases
the brightness of the fabricated restoration. The conventional IPS e.max
Ceram Dentin and Incisal (Fig. 3) materials are exactly adjusted to this effect and are thus optimally suitable
for use on opaque substructures. The
Frequently Asked Questions
Why POWER dentin & Incisal initially
developed?
Mainly because of two factors that
raised over the past few years; (Fig. 4)
1st- The continuous development of
more translucent all-ceramic framework materials.
2nd- the general trend of patients’
desire of brighter restorations in the
overall.
Figure 2: Combination of different frames (bridge Zirconia zenostar & 2 veneer
e.max press) All layered by IPS e.max Ceram
ÿPage 2
Figure 4
Figure 1
Figure 5
LIFELIKE ESTHETICS –
EFFICIENTLY PRESSED
Figure 3
Figure 6 & 7: A comparison between the e.max ceram & e.max ceram POWER after 1st and 2nd firing
IPS e.max PRESS MULTI
®
THE WORLD’S FIRST POLYCHROMATIC PRESS INGOT
Figure 8
• Monolithic LS2 restorations showing a lifelike shade progression
amic
all cer need
u
all yo
• Exceptional combination of strength, esthetics and efficiency
• For crowns, veneers and hybrid abutment crowns
• Coordinated with high-precision Programat press furnaces
• Maximum cost effectiveness in the press technique
www.ivoclarvivadent.com
Ivoclar Vivadent AG
Figure 9
A shade comparison between IPS the e.max ceram Incisal (I)& IPS e.max ceram POWER Incisal (PI)
Bendererstrasse 2 | 9494 Schaan | Liechtenstein
Tel.: +423 235 35 35 | Fax: +423 235 33 60
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2
lab tribune
Dental Tribune Middle East & Africa Edition | 3/2016
◊Page 1
Case Report in Pictures
Figure 10: Discolored grayish stump, and bright natural adjacent
central BL4.
How does it affect restorations?
With the modern translucent substructures less light would
reflect, what reduces the brightness of the fabricated restora-
Figure 11: Using IPS e.max Ceram Power Dentin BL4 & Power BL
incisal to build up the central, was imperative to help counteract
the grayish effect, and match the level of brightness exist in the
natural symmetrical central, IPS e.max Press MO0 frame was
used, and bleach XL try-in material from VarioLink II was also
used to do the try in before cementation.
tion. To counteract this effect, IPS e.max Ceram “Power Dentin”
and“Power Incisal” materials were developed (Fig. 5).
Where is IPS Power Dentin from Deep Dentin?
Deep Dentin is basically developed to enhance the Chroma dimension of a shade, and subsequently increases opacity and value of the
ceramic restoration, whereas Power
Dentin is developed to enhance the
Value dimension of a shade in the
first place, and indirectly and slightly
increase the chroma of a ceramic restoration.
register for
FREE
Figure 12: Picture was taken right after cementation, it shows
the matching in all shade dimensions and especially Value.
– education everywhere
and anytime
– live and interactive webinars
– more than 1,000 archived courses
– a focused discussion forum
– free membership
– no travel costs
– no time away from the practice
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– ADA CERP-recognized
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ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providersof continuing dental education.
ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.
What is the change needed on the layering diagram after POWER?
no change is required on the familiar
layering diagram, Power dentin is additional optional layer, just like Deep
dentin, but deep dentin enhance
the chroma, while Power dentin enhance the value, so it can be:
1- either placed bucckly as an intermediate layer between the frame
and the Dentin layer, and especially
in the cervical third where build up
ceramic at its maximum thickness.
2- or used instead of Dentin, for complete body build up.
In what case scenarios IPS POWER is
recommended? (Fig. 6,7)
1- patient cases when translucent
frameworks are used, Like Zenostar
(T or MT) zirconium oxide (ZrO2), or
lithium disilicate (LS2) IPS e.max (LT
or HT)
2- patient cases when natural teeth
clearly exhibit greater brightness.
3- patient cases when we have a thick
space bucckly, or extremely thin
space bucckly, to layer on with IPS
e.max Ceram.
4- patient cases when natural teeth
which need to be shade-matched exhibit high fluracense, what’s visually
interpreted as higher value effect .
5- patient cases when Bleach colors
of final restoration is required, Power
bleach dentin & Incisal range exhibit
higher value and subsequently higher bleach color stability.
6- patient cases when more lightfrom the inside out- required for the
restorations, knowing that intraoral
is a dark cavity, and slightly brighter
restorations are always recommended to compensate the lack of light
inside the mouth where restorations
will end up after cementation. fig
7- patient cases when stumps (prepared tooth) are not vital and exhibit
discoloration
What are the delivery forms of IPS
Power?
IPS e.max Ceram Power Dentin (PD)
materials are available in all A – D
shades and 4 Bleach BL shades. The
IPS e.max Ceram Power Incisal materials are available in 4 shades. Note in
(Fig. 8,9) a comparison in few shades
and incisals between before/after IPS
Power.
Contact Information
Ivoclar Vivadent AG
Bendererstrasse 2
9494 Schaan/Liechtenstein
Tel.: +423 235 35 35
E-mail: info@ivoclarvivadent.com
www.ivoclarvivadent.com
[57] =>
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lab tribune
Dental Tribune Middle East & Africa Edition | 3/2016
DAC UNIVERSAL: 10 Years of
Maximum Hygienic Safety
For 10 years, Dentsply Sirona Instruments has satisfied the most stringent hygiene requirements imposed on dental practices with the DAC UNIVERSAL combination autoclave. Now, the addition of the new FLEX lid extends the requirements
profile for the device and closes the hygiene gap in mechanical reprocessing.
By DentsplySirona
Bensheim/Salzburg: After acquiring the hygiene division of Danish company Nitram 10 years ago,
Dentsply Sirona continued developing the DAC UNIVERSAL combination autoclave to create a reprocessing device with validation processes
for handpieces in dentistry. By 2006,
the Robert Koch Institute (RKI) recommended that medical devices
be reprocessed only with suitable,
validated procedures to prevent infection. This prompted Dentsply Sirona Instruments to document the
autoclave’s reprocessing procedures
so that the technical and hygienic
operation of the device, as well as
its processes, can be tested and validated. As a result, dentists and their
teams can practice safe dentistry.
“The technology of our DAC UNIVERSAL complies with the most
stringent requirements, so we can
offer dentists greater legal certainty,”
says Eric Berndt, hygiene product
manager at Dentsply Sirona Instruments, referring to the tougher demands for compliance with hygiene
guidelines imposed by the health
authorities. Simultaneously, the capacities of practice teams and the
space they have in many reprocessing rooms are limited; therefore, the
equipment required for mechanical
reprocessing should be simple, effective, safe and usable with verifiable
results for many different instruments.
syringes. The STANDARD lid can be
used for cleaning, maintaining and
sterilizing up to six wrapped handpieces, or a wire basket makes it possible to reprocess solid instruments
such as probes, mirrors or curettes.
The ultrasonic tips are reprocessed
together with their associated torque
wrenches and undergo a closed, fully
automated hygiene cycle so that
sources of error are excluded.
Various adapters also make it
possible to reprocess instruments
from other manufacturers in the
DAC UNIVERSAL. Yet another advantage is the graphical user interface
that enables simple, intuitive operation. The current status is shown
Experience new freedom in your lab processes breaking the chains of
former dependencies with inLab and the new 5 axis milling and grinding
unit inLab MC X5. Open for all restoration data, combining the largest
material range and the possibility to machine both wet and dry disks
and blocks – for no limitations to your production. Enjoy every day.
With Sirona.
INLABMCX5.COM
DAC UNIVERSAL FLEX lid
in the LCD display throughout the
hygiene cycle. All-important reprocessing parameters and confirmation of successful completion of the
program can be documented after
the cycle ends.
inLab MC X5:
DENTAL LAB
FREEDOM OF CHOICE.
Unsurpassed hygienic safety
with the DAC UNIVERSAL
Compared with other reprocessing methods, the DAC UNIVERSAL
offers not only process safety but
significant time advantages as well,
because it is the only device on the
market that can clean, lubricate
and sterilize up to six turbines, and
straight and contra-angle handpieces in 16 minutes. Using this device,
instruments are quickly ready for
use again, which lowers the dentist’s
investment cost in handpieces. Additionally, no chemical additives are
used during the cleaning process,
which is beneficial for the working
life of the instruments.
For IDS 2015, Dentsply Sirona Instruments expanded the reprocessing capabilities of the combination
autoclave to include more instruments. With the new FLEX lid on the
DAC UNIVERSAL, the device can now
be used for internal and external
cleaning, thermal disinfection of ultrasonic tips and handpieces as well
as the nozzles of multifunctional
DAC UNIVERSAL can be used for reprocessing many different instruments
simply by replacing the Standard lid with the FLEX lid
[58] =>
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www.dental-tribune.me
Published in Dubai
May-June 2016 | No. 3, Vol. 6
Implant uncovery with the Picasso
diode laser
By Gregori M. Kurtzman, DDS,
MAGD, DICOI, DADIA
Introduction
Dental implants are placed either
utilizing a 1-stage approach (healing
abutment placed at implant placement) or a 2-stage approach (implant
is covered by soft tissue at time of
placement) and modification of the
soft tissue to expose the implant fully may be required. When the prosthetic phase is initiated, soft tissue to
either removed to uncover the implants or reshape the gingival margin for better esthetics which can be
accomplished by several methods. A
cutting instrument, (ie. Scalpel or tissue punch1) has been the traditional
approach to incise through the soft
tissue to the underlying implant.
The result is a bleeding edge that can
interfere with impressions if they
are to be taken at the same appointment. Additionally, post-operative
sensitivity has been reported and
can result from the fresh cut edge.
Typically a delay of 2 weeks or longer
is required before impressions can
be taken so that bleeding doesn’t
hamper the accuracy of how the soft
tissue is captured.
An alternative to the blade, electro
surgery has been offered as it can
cauterize the cut edges and decrease
post-operative bleeding. Yet, this
presents with two negatives outcomes to their use in and around
dental implants. Electro surgery requires a circuit be formed between
the monopolar tip intraorally and
the surgical unit with a grounding
plate placed on the patient a distance
Figure 2: Comparison of the depth of
affected cells with an electrosurgery
unit and a diode laser
from the oral cavity. When the current is activated it flows between
the electro surgery tip through the
soft tissue to the grounding plate,
completing the circuit with the metallic implant conducting the current along the path.2 Temperature
increases have been reported that
when exceeding a threshold of 10 degrees C at the osseous interface with
the implant may lead to bone loss
and possible de-integration of the
implant. A general recommendation
is to avoid electro surgery units in
and around dental implants.
As electro surgery affects cell layers
deep to the surface (deeper penetrating), combined with the temperature increase tissue shrinkage is often reported. 3 Necessitating a delay
between uncovery and impressions
to allow the cut edge of gingival tissue to stabilize is required so that the
gingival margin captured is stable
when the prosthetics is returned for
insertion.
Increasing diode lasers are being utilized in dental practices both due to
lower costs to implement this technology then the more expensive
CO2 and ND:YAG lasers and the wide
range of effective treatment afforded
by these devices. Diode lasers, such as
the Picasso (AMD Lasers, Indianapolis, IN, www.amdlasers.com) (Figure
1) provide adequate power to modify
soft tissue in and around the dental
implant for uncovery or alteration
Figure 3: Tissue reaction upon contact with an initiated diode laser
tip demonstrating the effect as one
moves away from the tip
Figure 5: When minimal keratinized gingiva is
present, the diode laser is utilized to make an
incision distal-mesially and the tissue is spread
conserving all of the attached gingiva present.
of the gingival margin to improve
the esthetics. Additionally, these operate within the temperature range
recommended so that the negative
effects associated with electro surgery do not occur to the bone around
the implant.4 Coagulation can also be
controlled combined with the lack of
tissue shrinkage following use of the
diode laser allowing impressions to
be taken at the time of uncovery. As
the diode laser affects fewer cell layers, tissue response does not involve
an inflammatory response that can
lead to tissue shrinkage during the
healing period the first few weeks after treatment.5-9 (Figure 2)
Utilization of the diode laser
Diode lasers are primarily used in a
contact application when cutting or
coagulation is required.10 The diode
laser tip is used in either an initiated
state or an uninitiated state. Initiated
refers to the tip of the diode laser
which has been coated with a blocking material. This allows energy from
the diode when activated, to heat the
tip causing cell ablation (vaporization) at the contact point with cutting resulting.11 The light energy in
the coated tip is converted into heat
by refraction of the blocking material on the diodes tip creating a “hot
tip”. This secondary thermal effect
of the heated tip allows cutting or
incising of the soft tissue. An area of
carbonization at the border of the
vaporization results. Coagulation occurs in the tissue bordering this zone
of carbonization as a result of contact
with the overheated tip rather than
by the laser energy itself. (Figure 3)
Bacterial decontamination can be
accomplished with an initiated diode tip which is useful in treatment
of peri-implantitis on the implants
surface or within the periodontal
sulcus/pocket around implants and
natural teeth.
Initiation of the tip is accomplished
with the diode set at 0.5 watts and
touched to a piece of blue articulating paper (Bausch Ref BK05) and the
laser is activated for 1 second. This is
repeated 6-8 times contacting different areas of the tip so that when finished the entire tip and 3-4mm of the
sides has been marked with the articulating paper. It is recommended
to avoid articulating ribbon as it will
ignite and is ineffective in initiating
the tip. A properly initiated tip will
glow orange when the foot pedal is
depressed.12 The tip should be wiped
with a piece of dry gauze to remove
debris periodically as it is being utilized to maintain efficiency. When
cutting fibrous tissue it may be necessary to reinitiate the tip during the
procedure when the tip appears to
not be cutting well.
Cutting efficiency is related to wattage. The higher the wattage, the
faster the soft tissue is vaporized.
But a greater zone of unwanted lateral thermal damage may result. It
is advised to use the lowest wattage
to accomplish the task to avoid the
risk of thermal damage within the
adjacent tissue. The assistant during
usage of the diode laser uses the HVE
near the site to remove any odors
and periodically can spray water on
the site to aid in cooling the tissue.
This also minimizes thermal issues
Figure 1: Picasso Diode Laser (AMD Lasers)
which improves initial healing. To
remove the soft tissue covering the
implants cover screw or reshape the
tissue for esthetics a setting of 0.8-1.0
watts in a continuous mode is usually sufficient. A 400 micron diode tip
(orange) is utilized for oral and periodontal surgical applications. The
300 micron tip (purple) is designed
for periodontal applications such
as Laser Assisted Periodontal Treatment (LAPT).
Beyond the carbonization zone, an
area of hemostasis (coagulation)
occurs. Typically sites treated with
the diode laser will demonstrate little to no bleeding depending on the
condition of the tissue prior to treatment. Tissue that is hemorrhagic
will require longer contact with the
diode laser to achieve coagulation
and may ooze due to the inflammation present prior to laser treatment.
The coagulation affects and lack of
post treatment tissue shrinkage allow immediate implant impressions
should that be desired
The laser also creates an area of biostimulation adjacent to the coagulation area.
Tissues and cells following irradiation with a diode laser, have a
ÿPage 2
Figure 4: Implant to be uncovered (A) presents with two options depending on width of attached gingiva available.
Wide band of attached gingiva will remain after removal of tissue over cover screw, the diode is utilized in a spiral pattern starting at center until fully exposed (B). Narrow band of attached gingiva present, an elliptical cut is made with the
diode and tissue is pushed buccally and lingually to preserve the attached gingiva (C).
Figure 6. Buccal view of the anterior maxilla
demonstrating preservation of the papilla due
to the provisional bridge.
Figure 7. Occlusal view of the anterior maxilla
demonstrating preservation of the papilla due
to the provisional bridge.
Figure 8. Picasso diode laser removing soft tissue to uncover the implants cover screws.
[60] =>
DTMEA_No.3. Vol.6_DT.indd
2
IMPLANT TRIBUNE
Figure 9. Uncovery of the implants and healing screws exposed.
biostimulatory effect that provides
faster or more favorable wound
healing, compared to tissue treated
with a scalpel or electrosurgical unit.
The laser irradiation stimulates the
proliferation of mesenchymal stem
cells without DNA alterations in the
affected cells.13 Thus, wound healing
is enhanced and soft tissue at the
cut edges demonstrates faster healing then when treated with a scalpel
or other methods by stimulation of
gingival fibroblasts inducing growth
factors.14, 15 It has been reported that
biostimulation via the diode laser
also has a positive effect on bone
cells and can be stimulatory to the
bone cells at the crest around the
implant.16, 17 Compared to conventional methods tissue healing as well
as postoperative sensitivity was less
with the diode laser then with other
methods. 18
Implant Uncovery technical
considerations
The width of attached gingiva remaining will dictate the best method
for implant uncovery. (Figure 4A)
Figure 10. Healing abutments placed into the implants.
When a wide band of attached gingiva is present and a sufficient amount
(3mm or greater) will be present after
uncovery on both the buccal and lingual then the diode laser is activated
and inserted at the center of the site
and worked in a spiral pattern outward until the entire cover screw
is exposed. (Figure 4B) A curette or
other instrument may be necessary
to loosen the tissue over the cover
screw as the periosteum during
implant healing becomes adherent
to the titanium cover screw. Sites
that present with a narrow width
of attached gingiva of 3-5mm at the
crests center will require some conservation of the remaining attached
gingiva. In this clinical situation, the
diode is utilized to remove an elliptical piece of soft tissue over the cover
screw and then the tissue is pushed
buccally and lingually to preserve
the attached gingiva. (Figure 4C) If
less attached gingiva is present on
either side of the center of the crest
then the practitioner will need to
preserve all of the attached gingiva
present and a conventional flap is
recommended to be able to position
the tissue in a more apical direction.
When this is necessary incisions can
be made with the diode laser as an
alternative to a scalpel. (Figure 5)
Case report
A 30 year old female patient presented with severely malposed maxillary
central incisors tipped facially and
a desire for esthetic improvement.
A CBCT was taken and noted minimal bone was present over the facial
of the central incisors. Options for
treatment were presented to the patient which included: orthodontics
to correct esthetics or extraction of
the central incisors, placement of implants at these sites and restorations
on the anterior teeth. The patient indicated that she did not wish to pursue a orthodontic treatment option
due to the time involved.
The patient presented for surgery
and the central incisors were atraumatically extracted under local anesthetic. The adjacent teeth were
prepared for crowns, which would
support a provisional bridge during the healing/integration period.
THE NINTH ANNUAL AMERICAN ACADEMY OF IMPLANT DENTISTRY
MaxiCourse®- UAE 2016 – 2017 Starts August 30
A UNIQUE OPPORTUNITY
DENTAL IMPLANTOLOGY
In Fulfillment of the Educational Requirement for the Examination
for Associate Fellow Membership for the American Academy
The Faculty are as follows:
Dr. Shankar Iyer, USA
Director, AAID Maxi Course®UAE
Diplomate AAID
Clinical Assistant Professor,Rutgers School
of Dental Medicine.
Dr. Ninette Banday, UAE
Co-Director AAID Maxicourse- Abu Dhabi, UAE
Academic Associate Fellow AAID
Dr. Amit Vora, USA
Diplomate of the American Board of
Periodontology
Professor (partime) ,JFK Hospital and the Veteran
Affairs (V.A.) Hospital
Dr. Jaime Lozada, USA
Director of the Graduate Program in Implant
Dentistry
Fellow, American Academy of Implant Dentistry
Dr. William Locante, USA
Diplomate of ABOI
Fellow of American Academy of Implant Dentistry
Dr. Robert Horowitz, USA
Dr. Stuart Orton-Jones, UK
Dr. Frank LaMar, USA
Fellow, American Academy of Implant Dentistry
Diplomate, American Board of Oral Implantology
Founder Member, The Pankey Association
Member, Alabama Implant Study Group
Director, The Stuart Orton-Jones Institute
Dr. John Minichetti, USA
Dr. Robert Miller, USA
Diplomat, American Board of Oral Implantology
Honored Fellow, American Academy of Implant
Dentistry
Dr. Robert Schroering, USA
Board Certified by the American Board of Oral
Implantology/Implant Dentistry
Honored Fellow American Academy of Implant
Dentistry
Board Certified by the American Board of Oral
Implantology
Fellow, American Academy of Implant Dentistry
Dr. Philip Tardeu, France
Dr. Kim Gowey, USA
Dr. Natalie Wong, Canada
Past President – AAID
Diplomate ABOI
Founder and Author, Computer Guided
Implantology and the Safe System.
Diplomate, American Board of Oral Implantology
Fellow, American Academy of Implant Dentistry
Dr.Burnee Dunson, USA
Fellow, American Academy of Implant Dentistry
Diplomate ABOI
Dr. Ahmed Ibrahim Osman UAE
Director of Implant Center, University of Sharjah.
Assistant Director of University Dental Hospital.
Dr. Irfan Kanchwala, India
Implant Fellowship ( UMDNJ, USA)
Diplomate , American Board of Prosthodontics
Dr. Jason Kim, USA
Diplomate of ABOI
Diplomate American Board of Periodontology
Clinical Assistant Professor New York University
Eighth Annual Program Accredition by Health Authority Abu Dhabi for 252.75 CME Hours.
Accredition for the Ninth Annual Program under process both with DHA & HAAD.
Program Includes placement of 10 Implants with all surgical and
prosthetic components, all materials for hands – on workshop and
lecture handouts plus one complete surgical instrument Kit.
MaxiCourse ® Advantage:
300 hours of comprehensive lectures, live surgeries,
demonstration and hands-on sessions.
In depth review of surgical and prosthetic protocols.
Sessions stretch across 10 months in 5 modules of 6 days.
Each session is always inclusive of a weekend.
Over 15 speakers from the International Community who are
amongst the most distinguished names in implantology will
teach the curriculum.
Certificate of completion awarded by the American Academy
of Implant Dentistry.
Non commercial, non sponsored course covering a wide
spectrum of implant types and system.
Hands-on patient treatment under direct AAID faculty
supervision.
Membership for AAID awarded for 2016 – 2017
Dates:
Module 1
Module 2
Module 3
Module 4
Module 5
Dental Tribune Middle East & Africa Edition | 3/2016
August 30th – September 4th 2016
November 3rd – 8th 2016
February 2nd – 7th 2017
April 26th – May 1st 2017
Dates to be announced
Registration :
Pre-Registration is Mandatory as it is a limited Participation Program.
For further information and registration details visit website: www.maxicourseasia.com or e-mail
Dr. Ninette Banday, Coordinator AAID-MaxiCourse UAE at drnbanday@yahoo.com
Figure 11. Removal of the healing abutments at 2 weeks post
uncovery demonstrating a lack of inflammation of the modified
soft tissue.
A 4mm wide 24 degree Co-Axis implant (Keystone Dental, Burlington,
MA) was placed into the osteotomy
at each central incisor orienting the
prosthetic axis to a vertical position
while the implants body followed
the trajectory of the premaxilla. A
healing screw was placed and osseous graft material (NovaBone, Jacksonville, FL) placed on the facial to
thicken the resulting bone. The soft
tissue was closed with resorbable
PGA sutures. A stent created over
the wax-up of the study models that
had been modified was filled with an
auto-cure provisional resin (Perfectemp 10, DenMat, Lompoc, CA) and
seated over the anterior and allowed
to set. Upon setting the stent with
provisional was removed intraorally
and trimmed and polished. The material at the implant sites was shaped
to a bullet shape to assist in forming
an emergence profile in the soft tissue and preserve the papilla’s.
Six months post implant placement
the provisional bridge was removed
and preservation of the papilla’s was
confirmed with a natural emergence
profile within soft tissue. (Figure 6, 7)
Local anesthetic was administered.
The Picasso diode laser was set at
2.5 watts in continuous mode with
an initiated tip and at the center
of the depression in the soft tissue
above the implants cover screw and
moved in a circular motion moving
outward until the entire cover screw
was exposed. (Figure 8) The process
cuts the desired soft tissue and coagulates any bleeding from the cut
edges. This was then repeated on
the second implant. (Figure 9) Open
tray implant impression abutments
were placed into the implants and
seating verified radiographically. An
impression of the maxillary arch was
taken utilizing Aquasil heavy body
VPS (Caulk, Milford, DE) in a Mira Advanced Implant tray (Hager Worldwide, Hickory, NC) and Aquasil Ultra
syringed around the preparations
and implant abutment heads. Healing abutments were placed into the
implants. (Figure 10) The previously
placed provisional bridge was tried
in and modified at the pontics to allow the bridge to fully seat over the
healing abutments and luted with
a provisional cement (Fuji Temp LT,
GC America, Alsip, IL).
Two weeks later the prosthetics returned from the lab (DenMat Labs,
Lompoc, CA) and the provisional
bridge was removed. The healing
abutments were removed and the
soft tissue demonstrated a lack of inflammation and a good periodontal
health where it had been modified
by the diode laser. (Figure 11) Ceramic crowns were tried in on teeth 7, 10
and 11 and the screw retained zirconia based implant crowns inserted.
A radiograph was taken verifying fit
of the implant prosthetics. A torque
wrench was utilized to tighten the
fixation screws on the implants to 30
Ncm and the ceramic crowns were
luted with Panavia SA resin cement
(Kuraray, NY, NY). Occlusion was
checked and adjusted where needed.
Conclusion:
Diode lasers are a useful adjunct to
soft tissue modification to uncover
dental implants or esthetically recontour the gingival margin. They
provide better safety then electro
surgery maintaining a temperature
profile within the safety zone of
bone and do not cause tissue shrinkage that can affect the esthetic outcome. As the diodes tip provides
simultaneous cutting and coagulation (hemostasis) a clear advantage
to the use of a scalpel or tissue punch
immediate impressions can be accomplished without site bleeding affecting the accuracy of the capture of
the soft tissue contours and position.
References
1. Zetz MR, Quereshy FA.: Singlestage implant surgery using a tissue
punch. J Oral Maxillofac Surg. 2000
Apr;58(4):456-7.
2. Wilcox CW, Wilwerding TM, Watson P, Morris JT.: Use of electro surgery and lasers in the presence of
dental implants. Int J Oral Maxillofac
Implants. 2001 Jul-Aug;16(4):578-82.
3. Goharkhay, K., Moritz, A., WilderSmith, P., Schoop, U., Kluger, W., Jakolitsch, S., & Sperr, W. (1999, June).
Effects on Oral Soft Tissue Produced
by a Diode Laser in Vitro. Lasers in
Surgery and Medicine, 401–406.
4. Gherlone, EF. Maiorana C Grrani,
.RF. Ciacaglini, R. Cattoni F. The use
of an 980-nm Diode and 1064·nm
Nd:YAG Liaser for Gingival Retraction in Fixed Prosthsis/ Oral Laser
Applications 2004; 4:183-190
The full list of references is available
from the publisher.
Dr. Kurtzman
He is in private
general practice
in Silver Spring,
Maryland and a
former Assistant
Clinical Professor
at University of
Maryland and a
former AAID Im-
plant Maxi-Course.
He is aslo assistant program director at
Howard University College of Dentistry.
He has lectured internationally on the
topics of Restorative dentistry, Endodontics and Implant surgery and prosthetics,
removable and fixed prosthetics, Periodontics and has over 460 published articles. He has earned Fellowship in the AGD,
ACD, ICOI, Pierre Fauchard, ADI, Mastership in the AGD and ICOI and Diplomat
status in the ICOI and American Dental
Implant Association (ADIA). Dr. Kurtzman
has been honored to be included in the
“Top Leaders in Continuing Education” by
Dentistry Today annually since 2006 and
was featured on their June 2012 cover. He
can be reached at dr_kurtzman@maryland-implants.com
[61] =>
DTMEA_No.3. Vol.6_DT.indd
Dental Tribune Middle East & Africa Edition | 3/2016
implant tribune
Study finds fundamental misconceptions
about dental implants among patients
Although dental implants are gaining increasing popularity, patients’ are
often insufficiently informed and their perceptions unrealistic, a study has
found. (Photograph: AnnaMoskvina/Fotolia)
By DTI
HONG KONG, China: Investigating
patients’ knowledge and perceptions
regarding implant therapy, a Chinese study has found that an alarming number of participants had inaccurate and unrealistic expectations
about dental implants. Moreover,
the study determined that only 18
per cent felt confident about the information they had about the treatment.
In the study, the researchers investigated preoperative information
levels, perceptions and expectations
regarding implant therapy via a
questionnaire. Responses from 277
patients were obtained during 2014
and 2015 in three different locations
in China (Hong Kong, Sichuan and
Jiangsu).
The analyses established that about
one-third of the participants had
mistaken assumptions about dental
implants. According to the researchers, common misconceptions were
that dental implants require less
care than natural dentition, implant
treatment is appropriate for all patients with missing teeth, dental
implants last longer than natural
dentition, and there are no risks or
complications with implant treatment.
Overall, younger respondents (< 45)
and those with higher education
(bachelor’s and postgraduate degrees) tended to have more realistic
perceptions and lower expectations
of the treatment outcome.
When asked about their level of
knowledge, 63 per cent of the participants said that they were generally
informed about implants, but only
18 per cent felt confident about the
information they had.
The study, titled “What do patients
expect from treatment with dental
implants? Perceptions, expectations
and misconceptions: A multicenter
study”, was published online ahead
of print on 23 March in the Clinical
Oral Implants Research journal.
3
[62] =>
DTMEA_No.3. Vol.6_DT.indd
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/ Advanced Restorative Techniques and the Full / Partial Mouth Reconstruction PART 3 : Treatment of severe wear cases
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/ Interview: “Technology leads to better dentistry”
/ Virtual reality simulation
/ News
/ Why Practice Management?
/ 11th CAD/CAM & Digital Dentistry International Conference
/ Hygiene Tribune Middle East & Africa Edition
/ Endo Tribune Middle East & Africa Edition
/ Lab Tribune Middle East & Africa Edition
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