DT Middle East & Africa No. 6, 2018

Dubai Health Authority bags two golden International Stevie Awards / Whole mouth extractions in children on the rise in the UK / Do it your way – with CEREC / Predictable implant impressions / PlanMill dentists to get even more choice / EVO.15 – The world's safest contra-angle, developed by Bien-Air / Oral care brand Beverly Hills Formula finish off a fantastic year in style / Seven keys to optimising interdisciplinary orthodontics / Predictable steps to Biomimetic Class IV restorations / Nd:YAG laser-assisted removal of instrument fragments / Mastering the implant digital workflow / News / Interview / Paediatric / News / Event / Poster Presentation / Endo Tribune Middle East & Africa Edition No. 6, 2018 / Lab Tribune Middle East & Africa Edition No. 6, 2018 / Hygiene Tribune Middle East & Africa Edition No. 6, 2018 / Implant Tribune Middle East & Africa Edition No. 6, 2018 / Ortho Tribune Middle East & Africa Edition No. 6, 2018

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www.dental-tribune.me

PUBLISHED IN DUBAI

November-December 2018 | No. 6, Vol. 8

ENDO TRIBUNE

LAB TRIBUNE

HYGIENE TRIBUNE

IMPLANT TRIBUNE

ORTHO TRIBUNE

Direct pulp capping as
a conservative procedure to
maintain pulp vitality

VITAPAN EXCELL:
For predictable, aesthetic and
functional results

We have an enormous
influence on children’s
overall health

Implants should only be inserted
when periodontal conditions
are stable

Self-Ligating Brackets.
A discussion of the pros, cons
and specifics

ÿA1-8

ÿB1-4

ÿC1-4

ÿD1-4

ÿE1-4

Dubai Health Authority bags two
golden International
Stevie
Awards
ENTAL RIBUNE

The Dubai Health Authority
(DHA)
won
two golden
International
Stevie Awards for their
The World’s
Dental
Newspaper
Middle
East & Africa Edition
innovative projects in the field of healthcare.

By Dubai Health Authority
The DHA won for two of its primary healthcare innovative projects: the implementation
of 3D printing technologies in dental care and
for their smart headache clinic, which uses telemedicine technology to conduct remote doctor consultations.
Dr Manal Taryam, CEO of the Primary Healthcare Sector at the DHA received the awards
on behalf of H. E. Humaid Al Qutami, Director
General of the DHA during the award ceremo-

ny, which was held in London, UK in the presence of notable decision makers and businessmen from around the world.
Commenting on the win, Al Qutami said this
achievement reflects the innovative environment of the UAE and Dubai in specific. This international recognition also reaffirms Dubai’s
pioneering role in the health sector and acts as
an incentive to all those working in the health
sector to continue on the path of providing
quality healthcare services using the latest
state-of-the-art technology.

Dr Manal Taryam (second from the left), CEO of DHS's Primary Healthcare Sector, collected the awards. There
were 3,900 other candidates and organisations from 74 countries in the running

Al Qutami stressed that winning this international award was possible due to the support
of His H.H. Sheikh Mohammed bin Rashid Al
Maktoum, Vice President and Prime Minister of the UAE and Ruler of Dubai. This is also
possible thanks to the support of H. H. Sheikh
Hamdan bin Mohammed bin Rashid Al Maktoum, Crown Prince of Dubai and Chairman
of the Executive Council and H.H Sheikh Hamdan bin Rashid Al Maktoum, Deputy Ruler of
Dubai, Minister of Finance and President of the
DHA.
He added that winning such a notable award
is a testimony to Dubai’s healthcare services,
which are based on the best international
standards and practices.
Dr Taryam on the other hand expressed her
happiness with the win, as the DHA won after competing against 3,900 other candidates
and organisations representing 74 countries
around the world.
She said the DHA won for its implementation
of 3D printing within dental care, which has
many benefits including: producing highly
accurate dental modules and casts at a shorter
time and reducing patients’ waiting time.
It also reduced multiple visits made by patients
to ensure accuracy of sizes as implementing 3D
technology increased the accuracy of dental
module’s color and size to 100 per cent.

Other benefits include enhancing patients’
comfortability, storing all data electronically
and reducing the cost of making dental casts
and prosthetics
Implementing 3D printing in Dental care has
also increased the success rate of tooth transplants to 97 per cent.
Dr Taryam added that the DHA won the second
award for its headache clinic, which utalised
telemedicine and has been implemented in a
number of DHA facilities through the Robodoc
device, which greatly aided the implementation of remote consultation and helped reduce
the waiting time by 25 per cent.
According to a survey the implementation of
this clinic has also increased customer satisfaction to more than 90 per cent and increased
customer trust to 98 per cent.
The Stevie Awards are one of the world’s premier business awards. They were created in
2002 to honor and generate public recognition
of the achievements and positive contributions of organizations and working professionals worldwide.
There are seven Stevie Awards programmes,
each with its own focus and list of categories.

[2] =>

NEWS

IMPRINT
PUBLISHER/
CHIEF EXECUTIVE OFFICER
Torsten R. OEMUS
CHIEF FINANCIAL OFFICER
Dan WUNDERLICH

Whole mouth extractions
in children on the rise in the UK
By Dental Tribune UK
LONDON, UK: New data released by
the National Health Service (NHS)
has painted a bleak picture of the
state of oral health in children in the
UK, with 322 children under the age
of ten undergoing full dental extractions or full clearances in UK hospitals in the past 5 years. In response to
this data, dental experts have called
on local and national authorities to
do more to address preventable oral
disease.
According to the NHS’s figures, 75

children underwent full dental extractions in the period between
2017–2018, which is up from 54 children in 2012–2013. The British Dental
Association (BDA) warned that full
dental extractions are an extreme
sign of the epidemic of tooth decay
among children, particularly those
who come from disadvantaged backgrounds.
“It’s tragic whenever a dentist has to
perform a full clearance on a child,
but in many hospitals, it is simply
business as usual,” said Dr Mick Armstrong, Chair of the BDA.

“Tooth decay is wholly preventable,
but remains the number one reason
for admissions among young children. Sadly, these are just the most
extreme examples of an epidemic
that’s costing our NHS millions. The
sugar levy is progress, but must not
mark the end of government interest. Kids in England deserve a real
national effort to turn the tables on
decay,” Armstrong said.
Dr Max Davie of the Royal College of
Paediatrics and Child Health added
that “the leading cause of decay is
poor diet. With one in three children

DIRECTOR OF CONTENT
Claudia DUSCHEK
CLINICAL EDITORS
Nathalie SCHÜLLER
Magda WOJTKIEWICZ
EDITOR & SOCIAL MEDIA MANAGER
Monique MEHLER

obese by the time they leave primary
school, cases of tooth extraction are
likely to increase unless something is
done urgently to prevent it.”

EDITORS
Franziska BEIER
Brendan DAY
Kasper MUSSCHE
ASSISTANT EDITOR & VIDEO PRODUCER
Luke GRIBBLE

In response, NHS England stated that
“sugary food and drinks is driving
this unnecessary epidemic of extractions”.

COPY EDITOR
Ann-Katrin PAULICK
Sabrina RAAFF

“NHS England is working with the
dental profession, local authorities
and health providers on Starting
Well, a campaign to help children
improve their dental health.”

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Dr. Ninette BANDAY, UAE
Dr. Nabeel HUMOOD ALSABEEHA, UAE
Dr. Naif Almosa, KSA
Dr. Mohammad AL-OBAIDA, KSA
Dr. Meshari F. ALOTAIBI, KSA
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Dr. Mohammed AL-DARWISH, Qatar
Dr. Dobrina MOLLOVA, UAE
Dr. Ahmed KAZI, UAE
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©2018, Dental Tribune International GmbH.
All rights reserved. Dental Tribune
International makes every effort to report
clinical information and manufacturer’s
product news accurately, but cannot assume
responsibility for the validity of product
claims, or for typographical errors. The
publishers also do not assume responsibility
for product names or claims, or statements
made by advertisers. Opinions expressed by
authors are their own and may not reflect
those of Dental Tribune International.

[3] =>

Dental Tribune Middle East & Africa Edition | 6/2018

INDUSTRY

Do it your way – with CEREC
CEREC is just what you need it to be

By Dentsply Sirona
Start your CEREC journey by discovering the digital solution and
workflow that best matches your
practice needs. For more than 30
years, CEREC has been synonymous with the creation of restorations in a single visit. We have
continuously
developed
and
improved CEREC to meet your
requirements and satisfy your patients’ demands. Today its capabilities extend far beyond single
restorations. The CEREC solution
spectrum now covers three key
areas: restorative, implantology
and orthodontics, both for chairside and clinic-to-laboratory
workflows – giving you the ideal
set-up for the future.
CEREC is a fully scalable system
that lets you start with taking digital impressions and evolve into
chairside CAD/CAM when you’re
ready. Taking a digital impression
is always your first step, no matter
which workflow you are following,
which is why our intraoral scanner, the CEREC Omnicam, can be
installed in the practice as a unit
to solely take impressions. From
there it is up to you to take the
next step. Sirona Connect allows a
simple and secure clinic-to-laboratory digital connection so you can
collaborate with well-established
partners if required, giving you
flexible treatment strategies. Or
you can take advantage of singlevisit dentistry and take your CEREC
journey chairside.
The full CEREC system includes a
digital scanner, milling unit and
furnace that allows you to fabricate anything from single-unit
crowns to multi-unit bridge frameworks, orthodontic aligners, and
custom implant abutments — all
in your practice.
CEREC is your partner every step
of the way. Be free to start your
digital workflow just the way you
want.

GATE

CEREC DESTINATION

Choose your destination
Start your CEREC journey by discovering the digital solution
and workflow that best matches your practice needs.
Taking a digital impression with the CEREC Omnicam is always
your first step, no matter which workflow you are following.
CEREC is a fully scalable system so from there it is up to you
to take the next step: scan the affected area and submit it to
your lab of choice for your restorative, orthodontic, or implant
procedures, or finish them chairside for single-visit solutions.

Conquer your future now at dentsplysirona.com/
dentsplysirona.com/CEREC

Do it your way – with CEREC
Dentsply Sirona
The Bay Gate Tower Dubai, UAE
Tel.: +971 4 523 0600
Web: www.dentsplysirona.com

[4] =>

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 6/2018

Predictable implant impressions
Using 3M Impregum Soft Quick Step Polyether impression material. Open Tray/Pick-up Technique
By Dr Izchak Barzilay, USA
A 31-year-old female patient presented for clinical recall evaluation after
not being seen for five years. Her initial treatment involved restoration
of a missing upper right lateral incisor with an osseointegrated external
hex implant of narrow diameter.
The restoration was designed to be
retrievable and had functioned well.
The patient had noticed over the
past six months that the crown no
longer seemed in place and appeared
to be rotated. On presentation, the
implant crown was firm and nonmobile. Radiographic assessment
(Fig. 1) showed an apparently well
integrated implant with bone levels
that had changed very little since initial restoration. After removal of the
crown and abutment, ISQ values and
clinical assessment suggested that
the implant was stable and healthy.
Examination suggested that there
was movement of the other teeth in
relation to the implant and the decision was made to fabricate a new restoration for this implant.
A pickup impression coping was
secured to the implant and seating
was verified (Fig. 2). This impression
coping is designed to stay in the im-

Fig. 1: Implant radiograph at recall appointment shows stable bone levels and a
secure restoration.

pression material when the impression is removed from the mouth.
The central screw of the impression
coping must exit the impression tray
while the impression is setting so one
can disengage the screw and then remove the impression. It was decided
that a 3M Directed Flow Impression
Tray would be used to make the impression. An appropriate sized tray
was chosen and tried in for fit.

hole in the base of the tray (Fig. 4) and
the impression tray was then tried in
the mouth to ensure that there was
clear access to the impression screw
(Fig. 5).

& 7). The syringe has not yet been activated. Blue rope wax is placed into
the end of the impression screw to
make sure that no impression material gets lodged in this area (Fig. 8).
This facilitates future screw retrieval
using an appropriate driver.

in the impression material and can
be seen inside the impression. An
implant lab analogue (replica) is then
connected to the impression coping
by positioning it onto the impression
coping and securing the impression
screw from the opposing end of the
tray (Fig. 14). The impression is now
ready to be poured.

This tray was chosen for several reasons:
• It fits well into the patient’s arch
• It needs no adhesive
• It is secure and rigid
• It is easily adjustable
• The tray has the unique feature
of incorporating a palatal reservoir
so that when used, the excess impression material that escapes out
the distal portion of the tray can be
scooped up with a mirror and housed
within this area thereby keeping the
mouth clear and creating a more gag
free impression.

The impression material chosen for
this situation was a polyether-based
material. This material was chosen
for a several reasons:
• Polyether is inherently hydrophilic.
With the mouth always being wet,
this is a good choice in impression
materials for all intraoral applications.
• Polyether is rigid enough to support
an implant impression coping without distortion or movement.
• It is easily injected through an impression syringe in either a monophase or dual phase technique.
• It is easily poured in the lab using
many stone formulations.
• It is accurate and can be poured
multiple times if needed.
• It has multiple setting times to
choose from.

A marking medium was placed on
the top surface of the implant impression screw and this marking was
transferred to the inside of the tray
by seating the tray intraorally (Fig.
3). An acrylic bur was used to create a

A monophase technique was chosen
since a medium body material shows
ideal characteristics in terms of rigidity and detail capture. A 3M Intra-oral
Syringe is loaded directly from the
50ml cartridge and set aside (Figs. 6

Fig. 2: A pickup impression coping has
been secured to the implant. Note the
central screw which extends out of the
implant impression sleeve.

Fig. 3: The 3M Directed Flow Impression
Tray has been chosen for its strength and
handling characteristics. Note the palatal
reservoir.

Fig. 4: An acrylic bur is being used to cut a
hole in the tray to access the impression
screw.

Fig. 5: The 3M Directed Flow Impression
Tray is being tried in the mouth to make
sure that the impression screw is accessible.

Fig 8: Wax is placed on the impression
screw to obturate the driver receptacle.

Fig. 9: The 3M Intra-oral Syringe is activated and must be bled before using for
final impression.

Fig. 10: Inject impression material around
the impression coping while the dental
assistant is loading the 3M Directed Flow
Impression Tray using the 3M Pentamix 3
Automatic Mixing Unit.

Fig. 11: The 3M Directed Flow Impression Tray has been loaded and is seated
intraorally. Note the extrusion of impression material in the area of the impression
coping.

Fig. 13: The impression has been removed
from the mouth and is ready for inspection.

Fig. 14: Place an implant lab analog into
impression coping and secure with the
screw. The impression is now ready to be
sent to the dental laboratory for pour up
and crown fabrication. Note the incredible detail and accuracy seen in the 3M
Impregum Soft Polyether Impression Material.

The area of interest is dried using
compressed air and isolated. The impression syringe is activated, and an
initial amount of impression material is “bled” from the impression syringe tip (Fig. 9). Impression material
is then syringed around the impression coping and the neighbouring
teeth. While this is being done, the
impression tray is loaded with the
same medium body (monophase)
polyether material that is dispensed
from a 3M Pentamix 3 Automatic
Mixing Unit (Figure 10). Once loaded, the tray is seated to place so that
the impression coping screw can be
visualized protruding though the
impression tray (Fig. 11). The area is
wiped away over the impression
screw and the tray is held in place for
the setting time prescribed by the
manufacturer. Once the impression
is set, the impression screw is unscrewed (Fig. 12) and the impression
is removed from the mouth (Fig. 13).
The impression coping is picked up

The new prosthesis is now in place
and had addressed the malposition
issues that were initially evident
when the patient presented for treatment (Fig. 15).
About the Author
Dr. Izchak Barzilay, , D.D.S., Cert. Prostho.,
M.S., F.R.C.D.(C), received his DDS from the
University of Toronto in 1983, a Certificate in Prosthodontics from the Eastman
Dental Center in Rochester, NY in 1986,
and a MS from the University of Rochester
in 1991. He is currently Head of the Division of Prosthodontics and Restorative
Dentistry at Mt. Sinai Hospital in Toronto,
Ontario.
To learn more 3M Impregum Polyether
Impression Material please visit:
www.3Mae.ae (Gulf countries)
www.3m.com.sa (Saudi Arabia)
To request Pentamix ‘Test Drive’or visit of 3M
specialist please contact us at:
3MOralCareGulf@mmm.com

Fig. 6: A 3M Intra-oral Syringe is ready to
be loaded with 3M Impregum Soft Polyether Impression Material.

Fig. 7: The 3M Intra-oral Syringe is loaded
from the hand-held gun but not yet activated.

Fig. 12: Once the 3M Impregum Soft Polyether Impression Material has set, use an
implant driver to unscrew the impression
screw. Remove the 3M Directed Flow Impression Tray.

Fig. 15a and 15b: Final insertion of implant crown 12

[5] =>

[6] =>

6

INDUSTRY

Dental Tribune Middle East & Africa Edition | 6/2018

PlanMill dentists to get even more choice
The range of materials for PlanMill has been extended to include Tetric CAD and IPS e.max ZirCAD

By Ivoclar Vivadent AG
The Tetric CAD composite blocks
and the IPS e.max ZirCAD zirconium
oxide materials have now been released for use with the PlanMill milling units (Planmeca). This provides
practitioners with even more opportunities to produce high-quality
restorations at chairside. In addition,
three new shades have been added
to the range of Telio CAD cross-linked
PMMA blocks.
Tetric CAD is an aesthetic composite
block designed for the efficient production of single-unit restorations.
Due to the pronounced chameleon
effect of the material, restorations
made of Tetric CAD optically blend
into the existing tooth structure to
generate a natural aesthetic integration. The block is easy to use and efficient to process: restorations can
be milled and polished quickly and
then seated using an adhesive technique. The new composite blocks are
available in an MT and HT level of

translucency, in five and four shades
respectively and in sizes I12 and C14.

Extended range of shades for
Telio CAD

Zirconium oxide for thin wall
thicknesses

Shades B3, C2 and D2 have been added to the range of Telio CAD blocks
for PlanMill. As a result, the crosslinked PMMA blocks are now available in nine LT shades (BL3, A1, A2, A3,
A3.5, B1, in addition to the three new
shades) and in two different block
sizes (B40L and B55).

IPS e.max ZirCAD LT (low translucency) is a monolithic zirconium
oxide block designed for crowns and
3-unit bridges. The material allows
posterior crowns to be designed in
a reduced wall thickness of 0.6 mm
and anterior crowns in a reduced
thickness of 0.4 mm due to its high
mechanical strength of 1,200 MPa(a)
and high fracture toughness of 5.1
MPa1/2(b). The reduced thicknesses
increase the translucency of the restorations and benefit the esthetic
outcome. A fluorescent effect can be
achieved with IPS e.max CAD Crystall./Glaze Fluo. The restorations are
placed using either a conventional
cementation technique or a self-adhesive resin cement, such as SpeedCEM Plus. Sintering is carried out in
the Programat CS4 furnace. The LT
blocks are available in the shades BL,
A1-3, B1-2 as well as in C2 and D2.

All you need for restorations
in a single visit
Ivoclar Vivadent offers a treatment
concept that empowers practitioners to restore the dentition of their
patients in a single visit. In addition
to the blocks and cementation materials, the range includes coordinated
materials for the entire restorative
workflow starting from the OptraGate lip and cheek retractor to luting
materials and oral care products.
IPS e.max, Tetric, Telio, Programat,
SpeedCEM and OptraGate are registered trademarks of Ivoclar Vivadent
AG.

AD

THE CLINICALLY PROVEN
SOLUTION FOR ALL YOUR
CAD/CAM NEEDS

IPS e.max CAD

THE LEADING CAD/CAM LITHIUM DISILICATE CERAMIC
• Monolithic single-tooth restorations and 3-unit bridges
• Efficiently produced hybrid abutments and hybrid abutments crowns
• High strength veneering structures; also for multi-unit bridges (CAD-on)
• Manufacturing in-house or via authorized milling partner network
• Clinically tested cementation with Multilink® Automix

amic
all cer need
u
all yo

www.ivoclarvivadent.com
Ivoclar Vivadent AG

Bendererstr. 2 | 9494 Schaan | Liechtenstein | Tel.: +423 235 35 35 | Fax: +423 235 33 60

Dentists using PlanMill can now benefit from an even larger range of Ivoclar Vivadent
materials to produce their restorations

a) typical mean value of flexural
strength, R&D Ivoclar Vivadent AG,
Schaan/Liechtenstein
b) R&D Ivoclar Vivadent AG, Schaan/
Liechtenstein

Ivoclar Vivadent AG
Bendererstrasse 2
9494 Schaan/Liechtenstein
Phone: +423 235 35 35
Fax: +423 235 33 60
E-mail: info@ivoclarvivadent.com
Web: www.ivoclarvivadent.com

EVO.15 – The world's
safest contra-angle,
developed by Bien-Air

Bien-Air EVO.15 1 :5 L (back)

Bien-Air EVO.15 1:5 L (back)
+ EVO.15 1:1 L (left)

By Bien-Air

Equipped with patented CoolTouch+™ heat-arresting technology,
the EVO.15 is the only contra-angle
proven never to exceed human body
temperature. After years of research
and development, this technology
works to protect both the patient
and the clinician during some of the
profession’s most frequently performed procedures. Additionally,
the EVO.15 features a considerably
smaller and lighter shockproof head
and premieres technological innovations ranging from a new spray/
lighting system to an improved
bur-locking system. Committed to
safety, the EVO.15 gives progressive
dental practitioners peace of mind in
all situations.

In response to public health authorities’ growing concern over patient
burns caused by rotary dental instruments, Swiss medical technologies
company Bien-Air Dental has developed the EVO.15, the safest contraangle on the market today.
In procedures involving contra-angles, the slightest contact between
the instrument’s push-button and
the inside of the patient's cheek may
cause the instrument to overheat,
resulting in possible burn injuries.
"While overheating can be an indication of a damaged or clogged instrument, laboratory evaluations reveal
that this hazard is just as prevalent
in new and properly-maintained
handpieces," says Clémentine Favre,
Chief Technical Officer. She goes on
to specify that the most severe cases
have caused third-degree burns requiring reconstructive surgery, and
potentially exposing the practitioner
to lengthy legal action.

Fanny von Gunten
Communication Project Manager
Länggasse 60, 2500 Bienne 6, Switzerland
E-mail: fanny.vongunten@bienair.com
Web: www.bienair.com

[7] =>

MyCrown

[8] =>

INDUSTRY

Dental Tribune Middle East & Africa Edition | 6/2018

Oral care brand Beverly Hills Formula
finish off a fantastic year in style
By Beverly Hills Formula

added to continually impressive
portfolio.

2018 has been an exceptional year
for trailblazing brand Beverly Hills
Formula. Now synonymous with
the very best in at-home teeth
whitening, the brand has seen a
huge growth and demand for their
products, expanding the business
worldwide at a phenomenal rate.
New product development was
the company’s main objective this
year resulting in two highly innovative, highly effective products

This year saw the expansion of the
Perfect White family, the brand’s
now best-selling and increasingly
popular range. Consisting of the
acclaimed Perfect White Black,
Perfect White Gold, Perfect White
Black Sensitive and Perfect White
Black Mouthwash. After years of
scientific research, the brand was
delighted to announce the introduction of two new products – Perfect White Optic Blue and Perfect

White Gold Mouthwash – products
which look and feel as luxurious as
they sound.
The Perfect White Range shot to
fame with the introduction of Perfect White Black. The brand was the
first to bring activated charcoal to
the market – known for its love of
tannins and the ideal ingredient to
add to teeth whitening products.
The secret weapon, Activated Charcoal, has been clinically proven to
be one of the most effective teeth
whitening ingredients available

today. Perfect White Black works to
whiten teeth, remove surface and
deep stains and helps to eliminate
the bacteria that causes nasty bad
breath.
Perfect White Black Mouthwash
followed on from this, along with
Perfect White Black Sensitive - containing hydroxyapatite, known for
remineralisation and repairing the
enamel, Perfect White Black Sensitive gives an amazing deep clean,
epic stain removal and incomparable protection for sensitive teeth.

NO
COMPROMISE.
Aquasil Ultra+
®

Smart Wetting Impression Material
®

Also, in this innovative range is
Perfect White Gold – a whitening
toothpaste which contains real
gold particles. Gold is known for
it’s anti-bacterial and anti-inflammatory properties. Due to Perfect
White’s non-abrasive stain removal power, it has become one of the
most popular ranges for the brand
to date.
Naturally, the brand was keen to
utilise their extensive knowledge
and bring to the market two excellent products – designed to remove stains, whiten and care for
your teeth & gums at the highest
level.
Perfect White Optic Blue Whitening Toothpaste contains innovative Blue Filter Technology, guaranteeing a whiter brighter smile
after each use. The Blue Filter technology forms a special layer over
teeth during brushing to reflect
the light which creates an optical
whitening effect after each use,
making visible results immediate
with this advanced technology.
The time-tested formulation containing Advanced Hydrated Silicas and Pyrophosphates also provides effective stain removal, and
the 1400 ppmF Sodium Fluoride
protects your enamel at the same
time, for strong and healthy teeth.
Along with Optic Blue is the introduction of Perfect White Gold
Mouthwash, a luxurious, shake to
activate formula containing real
gold particles. Acknowledged for
its anti-bacterial, anti-inflammatory and blood flow regulating
properties, this luxurious mouthwash eliminates bad breath and
provides a long-lasting freshness.
Pyrophosphates help to remove
surface and deep stains for a
brighter and whiter smile, always.
Scientifically formulated to combat bad breath, this innovative
mouthwash is made from crueltyfree ingredients and does not contain parabens.
It’s safe to say that Irish brand Beverly Hills Formula have something
in their range for every preference.
They firmly believe that the creation of safe, effective products and
excellent customer service have
set them apart from their competitors. The brand thanks all its loyal
customers for their support and
looks forward to huge success in
2019.

YOU WORK ON MORE THAN TEXTBOOK CASES.
SO DO WE.
This is no ordinary impression material. Experience better-than-ever performance with Aquasil Ultra+
impression material. The plus means you can now count on revolutionary intraoral hydrophilicity and
intraoral tear strength to optimise performance in all areas, not just one. Because not all cases are
textbook cases, and you deserve a material that works impressively on each and every one.
Learn more at www.AquasilUltraPlus.com.
Beverly Hills Formula
Unit P1/P2 North Ring Business Park
Swords Road
Dublin, 9, Ireland
Web: www.beverlyhillsformula.com
E-mail: info@beverlyhillsformula.com
Tel: + 353 1 842 6611
Fax: + 353 1 842 6647

[9] =>

[10] =>

INDUSTRY

Dental Tribune Middle East & Africa Edition | 6/2018

GUM PAROEX – professional plaque
control for optimal gum health
By Sunstar Europe
The combination of Chlorhexidine
Digluconate (CHX), professional
reference for plaque control and
Cetylpyridinium Chloride (CPC),
included in GUM Paroex products,
has the long-lasting ability to attack
the structure of existing plaque and
prevent the growth of bacteria and
toxins responsible for its formation.
The superior efficacy of GUM Paroex
in the plaque control was proven by
an independent study* with the following results:

• GUM PAROEX 0.12% CHX + 0.05%
CPC is clinically proven to have a
more pronounced effect in reducing
plaque (vs. CHX/ADS) and gum problems than other usual mouthrinses
containing CHX (Fig. 1, Fig. 2).
• The clinical efficacy of GUM PAROEX 0.12% CHX + 0.05% CPC is significantly superior to 0.12% CHX/ALC in
controlling gum problems (Fig. 1).
• 0.20% CHX/ADS efficacy is comparable to a 0.05% Sodium Fluoride
mouthrinse, without any active antibacterial agent (Placebo) (Fig. 1).
• GUM PAROEX 0.12% CHX + 0.05%

CPC clinical efficacy in helping control gum problems is significantly
superior to 0.20% CHX/ADS (Fig. 1).
• The taste of GUM PAROEX 0.12%
CHX + 0.05% CPC is well-accepted
and significantly better than 0.12%
CHX/ALC and 0.20% CHX/ADS formulation. This promotes better patient compliance to treatment (Fig.
3).
• The staining of GUM PAROEX 0.12%
CHX + 0.05% CPC is equivalent to the
staining produced by 0.12% CHX/
ALC or 0.20% CHX/ADS based on
subjective patient evaluation (Fig 4).

* Per Ramberg et al. Effect of Chlorhexidine/Cetylpyridinium Chloride
on plaque and gingivitis: abstract
ID# 182859 IADR WCPD Budapest
2013
Gingival Index (GI) - measure of periodontal disease based on the severity
and location of the lesion.
Plaque Index (QHI) - an index for estimating the status of oral hygiene
by measuring dental plaque that occurs in the areas adjacent to the gingival margin.

Gingival Index (GI) - measure of periodontal disease based on the severity and location of the
lesion.
Fig. 1: Mean Gingival index (GL) change Day 0 Day 21 in 17 patients. Different letters indicate
statistically significant differences in the mean
GL change Day 0 - Day 21 between treatment
groups.

Plaque Index (QHI) - an index for estimating
the status of oral hygiene by measuring dental
plaque that occurs in the areas adjacent to the
gingival margin.

Your Choice
for Professional
Obturation and
Repair Therapies
Game Changer.
Solution for Simple,
Precise and Predictable
MTA Placement.

Fig. 2: Mean QHI (plaque level) change Day 0 Day 21 in 17 patients. Different letters indicate
statistically significant differences in the mean
QHI change Day 0 - Day 21 between treatment
groups.

Taste acceptance
(0- Non acceptance; 8 - High acceptance)
Fig. 3: Subjective taste of the different mouth
rinses evaluated by the VAS method at Day 21
on 17 patients. Different letters indicate statistically significant differences between treatment groups at Day 21.

Staining evaluation
(0- No stains; 8 - Strong stains)
Fig. 4: Subjective tooth staining of the different
mouth rinses evaluated bz 17 patients at Day
21. Different letters indicate statistically significant differences between treatment groups at
Day 21.

DISCOVER OUR ENTIRE MAP RANGE AT WWW.PDSA.CH/MAP
Produits Dentaires SA . Vevey . Switzerland

[11] =>

PROFESSIONAL
PLAQUE CONTROL
FOR OPTIMAL
GUM HEALTH

TWO INTENSITY LEVELS
of CHX for plaque control at
every stage of the treatment

www.sunstargum.com

Dual Action Antiplaque System :
CHX (Chlorhexidine Digluconate)
and CPC (Cetylpyridinium Chloride)
Help reduce dental
plaque accumulation

Prevent growth of
bacteria and toxins

Non-irritating alcoholand SLS-free formula

Help soothe
sensitive gums

[12] =>

12 Why
Why
SALLI
CONCEPT
SALLI
CONCEPT
Why
works
works
SALLI CONCEPT

INDUSTRY

Dental Tribune Middle East & Africa Edition | 6/2018

works Salli concept works
Why

Sitting pressure effects the pelvic area
Sitting pressure effects the pelvicavoid
areait by tilting the pelvis backThe pressure caused by sitting on wards,
andand
it is too
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result
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why
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workstation
Salli workstation

Dentistry – New level of work
ergonomics

By SWAN

to lean forward. Moving and reaching for things is easy and fast on Salli.
Small and practical Salli enables both
the dentist and the assistant to work
close to the patient.

In dental care the sitting position
is the greatest health risk, because
during long operations the position
is unnatural and involves a lot of repetitive movements. Sitting in a bad
position puts twice as much strain
on the spine as standing.

Dentists often retire early because of
various problems in their shoulders,
neck and lower back. Almost everybody working in dentistry is affected
by some kind of sitting disorder,
such as poor circulation in the legs,
shortage of oxygen, problems in hip,
knee and shoulder joints, and genital
health problems.

On a two-part saddle chair the back
is in the same position as when
standing, and the lower back lordosis can be maintained. The gap in
the seat
enables you to keep your
CHAIRS
back straight even when you need

Swing mechanism

Traditional workstation

Traditional workstation
Headache
Shoulder tensions
Bad posture
PoorHeadache
breathing
Slow
bowel
Shoulder
tensions
Mousehand
syndrome
Bad
posture
Lower
pain
Poor back
breathing
Cellulite
build-up
Slow
bowel
Genital
health syndrome
problems
Mousehand
Headache
Jointback
Lower
pain
Shoulder tensions ailments
Varicose
veins
Cellulite
build-up
Bad posture
Genital health problems
Poor breathing
Joint ailments
Slow bowel
Varicose veins

Mousehand syndrome
Lower back pain
Poor blood and lymph circulation
Cellulite build-up
Genital health problems
Joint ailments Poor blood and lymph circulation
Varicose veins




Salli workstation

Fixed width

Active brain
Relaxed shoulders
Posture improves
Breathing
deepens
Active
brain
FasterRelaxed
bowel movement
shoulders
Effortless
use of
mouse
Posture
improves
Healthy
back
Breathing
deepens
Increased
circulation
buttocks
Faster
bowel in
movement
Better genital
health
Effortless
use
of mouse
Active
brain
Joint friendly
Healthy
back
Relaxed shoulders
circulation
in legs
IncreasedGood
circulation
buttocks
Postureinimproves
Better genital health
Breathing
deepens
Joint friendly
Faster
bowel
movement
Good circulation in legs

Salli Swing

Salli SwingFit

The Swing mechanism makes the seat
adapt to your movements, and enables you
to keep the back straight also when you
have to lean forward. The fixed seat width
makes the chair especially suitable for men.

The Swing mechanism enables you to
exercise during the day. Because of the
width adjustment the chair is excellent for
also those who prefer a narrower seat.

Tilt mechanism

Effortless use of mouse
Healthy back
Blood and lymph circulation improves
Increased circulation in buttocks
Better genital health
www.salli.com
Joint
friendly
Blood
and
lymph circulation improves
Good circulation in legs




www.salli.com

Leather quality criteria
A1 quality

AD
7

Salli Twin

Salli MultiAdjuster

An ideal chair for situations where several
people use the same chair and there is no
time for adjustments.

Poor blood and lymph circulation

Width adjustment

CHAIRS

*With tilt mechanism as a standard, without tilt
on request.

Blood and lymph circulation improves

The multiple adjustments make the chair
very versatile. By using the tilt adjustment
you can avoid rounding the back when you
need to lean forward.

Tough, durable and easy
to clean. Smoothened and
evened out – a trace of the
leather’s natural structure
marks are visible.

A2 quality
A combination of naturality,
comfort and durability. The
natural surface marks can
be partly visible but the
leather is still resistant to
wear and tear.

All chairs on this page are available ESD protected.

www.salli.com

Swing

Salli Care

Salli Strong

Upholstery

The upholstery is made
out of surplus leather to
minimize waste material.
This provides an affordable
and environmentally
friendly chair of top quality.

Special strong design,
maximum load 150 kg.
Height and inclination
adjustments by the same
lever.

Salli chairs are available
with several different
upholstery options
according to the chair’s
intended use. For normal
office use we recommend
the breathable and durable
genuine leather, while
laboratories should choose
artificial leather, which can
be easily disinfected. For
industrial environments, we
offer spark-protected seat
covers. The antistatic ESD
materials are best suited for
the electronics industry, but
can also be used in normal
office environments where
static build-up is a known
issue.

SwingFit

Salli Stainless

Salli Classic

Hygienic and easy-to-clean
stainless steel parts. Ideal
for bakeries, laboratories
and food industry.

An alternative only for
women and temporary use.

Upholstery materials

Salli Light

● A1 or A2 quality bovine
leather
● Disinfectable artificial
leather
● Antistatic ESD upholstery
● Upholstery and reupholstery with your own
material*
● Seat re-upholstery
includes new padding
and A1 quality leather,
artificial leather or ESD
● Normal padding
(200 g/m²)
● Extra soft padding
(300 g/m²)

Salli offers ESD
(= electrostatic discharge)
protected alternatives
for electronics industry
and office work. ESD
chairs come with an
antistatic upholstery, a zinc
electroplated seat frame,
and Ø 65 mm ESD castors.

Light and affordable with
the two-part seat qualities.
Single black polyurethane
piece with a groove in the
middle. Comes with a fabric
seat cover (black, grey or
red).

*Fabric size 70 x 80 cm. Check
the suitability of the material, so
that it is not too thick or stiff.

ACCESSORIES
Basic

Tilt

Swing

Technical features of Salli chairs
Upholstery
Seat plate
Gas spring
Height adjustment
Tilt adjustment
Swing mechanism
Base
Castors
Maximum load
Warranty

See options above and leather quality criteria on page 12. Colour options* can be seen on our website.
3 mm steel sheet, painted black. ESD plate is unpainted. The plate of Light models is plywood.
4 lengths, colours metallic and black.
Height
control by hand as a standard; Top & Bottom (foot height control) available. Elbow Rest
Allround
As a standard in Light Tilt, MultiAdjuster, Twin, Stainless and Strong.
* 16 leather colours
Swing, SwingFit, Care Swing, Care SwingFit and Light Swing.
8 is
artificial
leather colours
Allround moves freely on all
Elbow Rest
ideal for
Aluminium base (Ø 540 mm) metallic or black – other models available.
5 fabric colours
thestandard
chair, and
also – other models available.
precision work, or for any task
Ø 65sides
mm,of
soft
castors
around
its
own
axis.
Can
be
in
which
you
need
support
for
120 kg, Salli Strong 150 kg, Salli Light 100 kg.
used
as a support
for 10
either
your arms.
It can be turned
Chairs
(except
Salli Light)
years. Salli Light, tables and accessories 2 years. Salli Driver
1 year.
one arm or both arms.
through 180 degrees.

www.salli.com 13

Elbow Table

Ergorest

A compact and versatile work
station for office or home.
Comes with elbow pads.

Movable Ergorest armrest
is available with or without
Stretching Support. It is ideal
for dentists and in ultrasound
rooms, or to be used as a
rehabilitation aid after shoulder
injuries.

Stretching Support

Foot

Stretching Support is meant for
momentary stretching only. A
backrest isn’t needed, because
in a balanced position the
spine supports the upper body
and the muscles can remain
relaxed.

Foot is an accessory for foot
therapists. Suitable for all chair
models.

Design your own Salli

3
1

1
4

Design
14

Choose your colour combination
for Salli SwingFit, Salli Swing,
Salli MultiAdjuster or Salli Twin.
The seat can have up to six
different colours.

5
6

Rainbow

[13] =>

Certificate & Diploma in
Clinical Endodontics
From British Academy of Restorative Dentistry

Prof. James Prichard, UK
BDS (ULond), MSc(ULond),
LDSRCS (Eng), MFGDP (UK)
FIADFE (USA)

Dr. Antonis Chaniotis, Greece
DDS MDSC

Prof. Paul Tipton,UK
Specialist in Prosthodontics
President, British Academy
of Restorative Dentistry

Certificate | 3 Modules | 12 Days

DUBAI

Prof. Göran Urde, Sweden
Director Futurum Clinic
Program Director P.G Education
Dept. of Materials Sci. & Tech.

Group 3
Registration Open

2019-2020

Dr. Adam Toft, UK
BSc (Hons), BDS (Hons),
MFGDP (UK),
MMedSci (Rest Dent),
Dip Aesth (BARD)
FBARD PGCertEd (Sheffield)

Pathway to UK
Masters

168 CME & Daily
Hands-on

Module 1 | 21-24 March 2019 (4 days) | Fundamental of Endodontics

Programme outline: Introduction to contemporary endodontics. Understanding of instrument design and its
effect on prevention of iatrogenic errors.
Hands-on: Hand filing and lateral compaction techniques.
Module 2 | 19-22 June 2019 (4 days) | Aetiology and Diagnosis of Endodontic Disease

Programme outline: Microbiology of endodontic disease and its relationship with the host immune response.
Hands-on: Rotary Niti and advanced thermoplastic obturation techniques.
Module 3 | 26-29 September 2019 (4 days) | Traumatic Injury, Pain and Its Management

Programme outline: Emergency endodontics and diagnosis in depth. Odontogenic and non-odontogenic pain.
Diagnosis and management.
Hands-on: Rotary NiTi and thermoplastic obturation techniques.

Diploma | 3 Modules | 12 Days

Module 4 | December 2019 (4 days) | Dental Resorption and Pattern of Tooth Fracture & Implant Prosthodontics

Programme outline: Understanding advanced endodontic problems. Handling endodontic failure alternatives
related to implants.
Hands-on: Reciprocating Niti and Carrier based thermoplastic obturation techniques & Implant prosthetic and surgery on phantom heads
Module 5 | March 2020 (4 days) | Restoration of Endodontically Treated Teeth

Programme outline: Occlusion and whole patient care. The restorative endodontic interface. Plastic restoration,
posts, intra and extra-coronal restorations, cuspal coverage amalgam vs composite.
Hands-on: Placement of core restorations and post retained restorations.
Module 6 | June 2020 (4 days) | Management of Endodontic Failure

Programme outline: Endodontic retreatment, surgical endodontics.
Hands-on: Re-treatment of common endodontic obturation materials.
Apical micro-surgery on cadavers (animal).

+971 528423659 | p.mollov@cappmea.com

www.cappmea.com/endo

[14] =>

mCME

Dental Tribune Middle East & Africa Edition | 6/2018

Seven keys to optimising
interdisciplinary orthodontics

CAPP designates this activity for 1 CE Credits

mCME articles in Dental Tribune have been approved by:
DHA awarded this program for 1 CPD Credit Points

By Dr Ashok Karad

Introduction
Orthodontics has always been a discipline that sets the stage for dentofacial aesthetics. With the increasing
desire for appeal and appearance,
orthodontic treatment of adults
has been the fastest growing area
in the field of orthodontics. In addition to aesthetics, increased awareness of malocclusion, the functional
benefits of orthodontic treatment,
advances in materials, aesthetically
pleasing and biomechanically sound
appliances, and an interdisciplinary treatment philosophy have all
played an important role in making
orthodontic treatment popular in
the adult population. However, in
recent years, increased focus on simplified and rapid intervention has
created compromises in treatment
outcomes. Fundamental diagnosis
and systematically sequenced treatment plans are being circumvented
by technology and reliance on laboratory assistance. The diagnostic process, the essence of treatment planning and biologic basis seem to be
diminishing in importance. Often,
orthodontic treatment can be of significant assistance in periodontally
and restoratively compromised patients. The primary goal of orthodontic therapy in such clinical situations
is to reduce or prevent excessive
periodontal surgery by establishing a physiological alveolar crestal
topography and to establish better
occlusal relationships for predictable long-term prosthetic treatment
through customised orthodontic
tooth movements. This article describes a philosophy and treatment
approach that brings together a diverse group of professionals into a
cohesive interdisciplinary team to
provide treatment strategies for the
adult patient. It explains existing
and new orthodontic, periodontic,
surgical and restorative techniques
that provide the best possible solu-

Fig. 1: Diagnostic process

Fig. 2: Organized approach to a final treatment plan.

Fig. 3: Treatment execution.

Fig. 4: Eleven-point interdisciplinary treatment protocol.

tion to complex dentofacial problems.
In clinical practice, orthodontic treatment of adults may be somewhat
different from that of most adolescents.1 Compared with adolescents,
adults are more likely to have dentition that has undergone some
degree of damage over a period,
and they may have other problems,
such as missing teeth, restored teeth,
periodontally compromised teeth
and endodontically involved teeth,
which demand some alterations in
treatment strategy.
In patients with periodontally com-

C
Figs. 5A–E: Tooth position and periodontal health.
(A) Gingival impingement due to deep bite caused a direct periodontal lesion.
(B) Dental crowding led to accumulation plaque that caused an indirect periodontal
lesion.
(C –E ) Orthodontic movement of the teeth into areas of better bone support, parallelism of roots and differential vertical tooth movement.

promised dentition with significant
bone and attachment loss, a conventional approach to orthodontic
tooth movement does not produce
the desired results, as this may lead
to increased tipping of teeth.2 Therefore, in such clinical situations, entirely different biomechanical strategies are required for efficient and
desired tooth movement.3 Absence
of growth potential in adults as opposed to growing patients is another
factor that influences the orthodontic treatment strategy to resolve
adult malocclusions.

1) Establish an organised approach to the diagnostic and

Figs. 6A & B: Dental arch crowding as a
major periodontal concern.
(A) Labially positioned mandibular right
central incisor associated with gingival
recession.
(B) Teeth orthodontically moved into areas of better bone support show partial
attachment gain.

treatment planning process
To formulate a proper treatment
plan and clarity of the final treatment and to prevent any complications and confusion, establishing
an accurate diagnosis is the most
important step. The goal of the diagnostic process in an interdisciplinary
treatment is to produce a comprehensive but concise list of the patient’s problems and to incorporate
various treatment options into a
plan that gives maximum benefit to the patient.4 The orthodontist
should recognise the various elements of malocclusion contributing
to the development of a problem.

This can be achieved by developing
a comprehensive but concise database of useful information derived
from patient’s history, clinical examination and analysis of diagnostic
records (study models, full-mouth
radiographs, and facial and intraoral photographs; Fig. 1). The orthodontist should have comprehensive
knowledge of different disciplines of
dentistry other than orthodontics to
generate the pertinent data. Finally,
the orthodontist should define the
nature of the problem to design a
treatment strategy based on the spe-

ÿPage 13

Figs. 7A–D: Biologic width and its clinical significance.
(A) Pre-treatment photograph showing anterior restorations violating biologic width,
which is seen clinically as gingival inflammation and recession.
(B) Illustration showing biologic width and its components. Total attachment of 2.04
mm is essential for the preservation of periodontal health. Its components include a
mean gingival sulcular depth of 0.69 mm, junctional epithelium measuring 0.97 mm
and mean supra-alveolar connective tissue attachment of 1.07 mm.
(C) Orthodontic treatment to bring about differential forced eruption of teeth #11 and
12.
(D) Restorations are contoured palatally to create interocclusal space to facilitate vertical
movement of incisors.

[15] =>

mCME

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page 14
cific needs and desires of the patient.
This database is then organised in
such a way that it gives a systematic description of the patient’s problems. The team involved can easily refer to this during the treatment
planning process. While arranging
the database of a complex dentofacial problem in a systematic manner,
if the problem list becomes very extensive, it is advisable to classify the
problem list into various areas, such
as orthodontic problem list, restorative problem list and periodontal
problem list (Fig. 2).

2) Define the treatment goals
In the management of a patient
with multiple dental problems, it is
extremely important for the clinician to define the finishing goals
at the beginning of treatment and
continue to focus on them until the
finishing stage, in order to achieve
them with a combination of appropriate orthodontic treatment mechanics, restorations and periodontal procedures. The treatment goals
are mainly focused on establishing
optimal oral health, aesthetics, good
stomatognathic function and longterm stability.
The clinician should be able to visualise the end result before implementing the definitive treatment plan.
This requires clearly defined treatment goals that set the direction of
the proposed treatment plan. Ideally,
an interdisciplinary treatment plan
should address the maximum num-

ber of highest priority problems,
including the chief complaint, and
optimise the treatment results with
maximum benefit to the patient and
less risk involved.
Since complex dentofacial abnormalities frequently present a multifaceted problem list involving
multiple disciplines of dentistry, it
is important to address the patient’s
main concern, whether the patient
is seeking treatment for functional
or aesthetic improvement or both.
Finding a solution to each individual
problem leads to the formulation
of a definitive treatment plan.5 A
well-structured and organised list of
problems ensures that all areas have
been evaluated in the diagnostic
phase and serves as a valuable reference tool during the course of treatment. All specialists involved in formulating the treatment plan for the
patient should provide possible solutions to individual problems based
on their own areas of expertise, and
no problem should be treated as less
important. Provisional treatment
plans are then compared with respect to their overall effects, and the
plan that enhances the treatment
and provides maximum benefit to
the patient, considering the patient’s
chief complaint, is then regarded as
the final and definitive treatment
plan.
The treatment planning process almost always follows the same steps;
however, the treatment sequence
varies significantly from patient to

patient owing to large variations in
morphological configurations and
treatment priorities. Here, it is critical to organise the sequence of various treatment procedures in such a
way that each treatment procedure
performed by one of the specialists from the interdisciplinary team
facilitates the next in order (Fig. 3).
Figure 4 illustrates an 11-point treatment protocol for interdisciplinary
cases.

3) Recognise minor dental
arch crowding as a major periodontal concern
Dental arch crowding presents narrow interproximal spaces, which
may result in a constriction of the
interproximal bone due to reduced
interradicular distance (Fig. 5). This
compromised bone as a result of septal constriction can be a challenge for
both periodontists and prosthodontists. De-crowding of the dentition by
orthodontic tooth alignment widens
the interproximal bone, which can
significantly enhance local host resistance and improve the prognosis
of compromised or infected teeth
(Fig. 6). Other than the aesthetic reasons, the resolution of interproximal
tissue constriction and faulty contact points and embrasures is the
predominant periodontal reason to
eliminate dental arch crowding.6
This integrated orthodontic and
periodontic approach as an alveolar development exercise should be
considered as the most compelling

periodontal rationale for orthodontic therapy. Hence, it is important
to recognise orthodontics as much
more than simply an aesthetic domain.

4) Use orthodontic treatment
in correction of biologic width
violations
Restorative therapies essentially
require a healthy and stable periodontium for long-term success. A
dentogingival unit exhibits a constant interplay between gingival tissue and crown contours, restorative
material, its texture and its margins.
Biologic width is defined as the dimension of space that the healthy
gingival tissue occupies coronal to
the alveolar bone.7 It is further elaborated as a total of supra-crestal fibres,
junctional epithelium and sulcus.8
This concept of existence of a specific width was first published by Gargiulo et al. in 1961 through cadaveric
experiments that revealed a mean
measurement of a total of epithelial
attachment plus connective tissue
attachment of 2.04 mm (Fig. 7).9
D. Walter Cohen is credited with
coining the term “biologic width”.
The significance of this width lies in
the fact that it prevents penetration
of microbes into the periodontium.
In 1977, Ingber et al. recommended
keeping a minimum distance of 3
mm between the restorative margin and alveolar crest for adequate
gingival health maintenance.10 This
3 mm consists of 1 mm of supraalveolar connective tissue, 1 mm of
junctional epithelium and 1 mm of
sulcular depth. Violation of this natural seal disrupts the dentogingival
apparatus, making it susceptible to
the ingress of oral microorganisms
and consequently causing gingival
disturbances such as inflammation,
recession and alveolar bone loss.11,
12
Thus, it is imperative to minimise
irritation to this zone. This measure
of 3.00 mm allows for optimum con-

servation of the mean value of 2.04
mm and provides clinical comfort
even when the margins are placed
0.50 mm within the sulcus.

5) Improve implant site with
orthodontics
This describes a very creative method of forced eruption for implant
site development in a compromised
alveolus. This method increases the
dimensions of the local alveolus. By
controlled extrusion of a tooth, the
optimal amount of hard and soft tissue may be created for placement of
an implant.
Determine the timing of implant
placement
Facial growth is the determinant of
the age for implant placement in
adolescent patients. The osseointegrated implant’s lack of eruptive
potential makes it behave like an
ankylosed tooth, often causing a discrepancy in the occlusal plane due to
continuous eruption of the adjacent
teeth. Therefore, early implant placement poses a greater risk of compromised aesthetics in the long term.
Several studies on young adults
treated with implant-supported restorations to replace missing teeth
have observed discrepancy between
implants and adjacent teeth. In a
study that followed the vertical
changes of maxillary incisors adjacent to implants in a group of adolescents between 15 and 20 years of age
and adults between 40 and 55 years
of age demonstrated infraocclusion
of the implant-supported restorations, with a vertical step of 0.10–1.65
mm and 0.12–1.86 mm in adolescents and adults, respectively.13
Therefore, lack of proper occlusion
and unaesthetic situations in the
anterior region may be common
observations owing to jaw growth

ÿPage 16

A
Figs. 9A–C: Adequate space between the
roots for implant placement. (A) Pre-treatment. (B & C) Mid-treatment.
Fig. 8: Lateral cephalometric superimposition to determine the status of facial
growth.

Figs. 10A–C: (A & B) Optimal space gained with appropriate orthodontic mechanics for
the restoration. (C) Provisional tooth bracketed and attached to the archwire.

Figs. 11A–C: (A) Orthodontic mechanics to open the space. (B)
Adequate intracoronal space. (C) Inadequate space between the
roots of the central incisor and canine as seen radiographically.

Fig. 12 : Assessment of space across three levels.

Figs. 14A–C:
(A) Orthodontic treatment to gain adequate space for implant placement (position #22) and implant site development and to improve deep overbite with an orthodontic bracket attached to a temporary crown on the lateral incisor.
(B) Controlled vertical eruption of a maxillary left lateral incisor root at completion.
(C) Lateral incisor root piece extracted. Note the presence of adequate bony socket walls.

Figs. 13A–C:
(A) Pre-treatment model showing deep overbite and cervical part of the lateral incisor.
(B) Intra-oral periapical radiograph showing the presence of a maxillary left
lateral incisor root piece with good interproximal bone levels.
(C) Pocket depth of 6 mm in the lateral incisor region, indicating facial bone loss.

Figs. 15A & B:
(A) Maxillary left lateral incisor implant restoration.
(B) Intra-oral periapical radiograph after implant placement and after abutment loading.

[16] =>

mCME

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page 15

Fig. 17: Orthodontic treatment to redistribute interproximal space, correct deep bite and
retract maxillary incisors.

Figs. 19A & B:
(A) Pre-treatment smile.
(B) Improved post-treatment smile.

B
Figs. 16A–F :
(A–C ) Pre-treatment intra-oral photographs showing malformed maxillary lateral incisors and interproximal spacing.
(D–F ) Pre-treatment photographs demonstrating impaired smile aesthetics and deep
overbite.

in patients with implant-supported
restorations even if the implants
are successfully integrated. The best
method to determine the status
of facial growth is to superimpose
sequential lateral cephalometric radiographs taken at an interval of six
months (Fig. 8). Generally, the implant should be placed after completion of facial growth (around 17 years
in females and 21 years in males.)
Establish optimal implant space
Adequate space gained for restoration of the normal width of a missing lateral incisor based on aesthetics and occlusion will determine the
appropriate size of the implant to
be placed. When selecting the size of
the implant, it is important to have
1.5–2.0 mm of space between the coronal diameter of the implant and the
adjacent teeth for the development
and maintenance of the papillae.14
After the evaluation of coronal space,
it is important to radiographically
evaluate the interradicular space.

The roots of the adjacent teeth
should be parallel to slightly divergent, with adequate space between
the roots for implant placement
(Figs. 9A & B).
Once the optimal space has been
gained with appropriate treatment
mechanics, an acrylic tooth of proper size and shade can be bracketed
and attached to the archwire for aesthetic purposes (Fig. 10). If the space
gained for the lateral incisor is in
excess, the bracketed acrylic tooth
can be used as a template, which will
help determine the residual space
closure. Clinical evaluation of the
edentulous space and radiographic
evaluation of the root position of the
adjacent teeth should precede appliance removal.
The final implant restoration is
significantly influenced by the position and angulation of implant
placement. For proper placement
of an implant, the minimum space
between the adjacent teeth roots is

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Figs. 18A–F :
(A–C ) Pre-treatment.
(D–F ) Post-treatment: integrated orthodontic and restorative treatment to establish
normal tooth proportions and smile aesthetics.

usually 5.00 mm, providing enough
room for placement of a small-diameter implant, leaving about 0.75 mm
of space for the bone between the
implant and the adjacent roots.15
Position adjacent teeth to facilitate
restorative treatment
It is a common observation that,
when an orthodontist is opening up
space for a missing lateral incisor, as
the force is applied on the crowns of
the central incisors and canines , the
roots are tipped into the lateral incisor region. This leads to adequate
crown space, but the space between
the adjacent roots is reduced, making it impossible for the surgeon to
place an implant (Fig. 11). It is equally
important to take sufficient care
to ensure that there is adequate interocclusal space for the implant
restoration. It is therefore critical to
establish optimal intracoronal and
interradicular space, evaluated both
clinically and radiographically (Fig.
12), for proper implant placement
and long-term predictable restoration.
It is best to place an implant during
the finishing stage of orthodontic
treatment to allow finer manipulation of space, maintenance of space
and sufficient time for osseointegration by the time appliances are
removed. However, if the implant
placement procedure is planned
after the removal of orthodontic
appliances, the gained space should
be maintained during the retention
phase.
Consider biologic augmentation
One of the prerequisites for placing
an implant and subsequent good
soft-tissue integration for more
aesthetic implant restoration is to
have an excellent alveolar ridge. It
is a common clinical observation
that unrestored edentulous areas
typically exhibit compromised bone
levels due to alveolar bone atrophy.
Studies have shown that, if maxillary
anterior teeth are extracted, the alveolar ridge will narrow by 34% over a
period of five years.16
However, these findings related to
the alveolar resorptive change do
not hold true in cases where the

edentulous span has been created
by orthodontic tooth movement.
Another study that evaluated the
long-term width of the alveolar ridge
after the required space was created
for missing maxillary lateral incisors
in adolescent orthodontic patients
revealed that the amount of bone
loss as result of resorptive changes
was less than 1% over a period of four
years.17
Orthodontic implant site development is a process involving root
movement that creates adequate
alveolar ridge width through stretching of the periodontal ligament fibres prior to the implant placement.
This can be accomplished in any part
of the alveolar ridge. In addition to
the compromised alveolar ridge
width, a vertical bony defect at the
site of implant placement can be influenced by controlled vertical root
movement to generate osteoblastic
activity before implant placement
(Figs. 13–15). The goal is to create an
ideal implant site by establishing
adequate alveolar ridge width and
height for a predictable and more
aesthetic implant restoration.

6) Optimise pre-restorative
orthodontics
Often, management of adult patients necessitates modification of
the usual treatment approach owing to anatomical disfigurements
displayed commonly in their dentition caused by previous pathological episodes. Interdisciplinary
treatment required for the holistic
rehabilitation of these individuals
may involve management through
periodontic, endodontic, restorative,
orthodontic and surgical specialties,
among others. Orthodontic therapy
may play a vital role in repositioning
of teeth for subsequently planned
restorative procedures. Such movements may include elaborate alteration of tooth positions to reorient occlusal forces, coordination of upper
and lower arch forms, appropriate
distribution of interdental spaces or
simplified movements as guided by
localised restorative requirements,
such as to improve the crown–root
ratio and achieve parallelism of
abutment teeth.

Figs. 20A & B:
(A) Pre-treatment vertical gingival discrepancy between tooth #11 and tooth
#21 caused mainly by supra-eruption of
tooth #21.
(B) Mid-treatment photograph demonstrating resolution of this discrepancy
by differential vertical orthodontic tooth
movement.

Tooth size plays an important role in
anterior dental aesthetics, and clinicians are often faced with disproportionate widths of anterior teeth in
the day-to-day clinical practice. This
tooth size discrepancy is commonly
found in patients with peg-shaped
lateral incisors. In such situations,
in spite of having the teeth perfectly
aligned and the occlusal discrepancies completely resolved with orthodontic treatment, the abnormal
shape and smaller size of the lateral
incisors pose aesthetic problems.
This requires planned tooth movements for proper space distribution
with orthodontics to restore the normal width of the lateral incisors. If a
lateral incisor is of normal shape, but
only slightly narrower than normal,
and the discrepancy is bilateral, it
may not require any intervention.
However, in the case of tooth size discrepancy that is unilateral or quite
significant, it is imperative to restore
the size of the malformed lateral incisors after completion of orthodontic treatment for overall good treatment results (Figs. 16–19).
Pre-restorative orthodontic movements are primarily determined by
the type of restoration planned for
execution. The main objective of
tooth repositioning is to assist in accomplishment of predictable restorations. A classical case constitutes a
mutilated dentition (often with parafunctional dental lesions, such as
attrition or abfraction) usually along
with presence of old restorations,
which may frequently be functionally and/or aesthetically compromised, possibly resulting in partial
or complete collapse of maxillary
and mandibular arches in the vertical, sagittal and/or transverse planes.
The presence of either upright or
retroclined anterior teeth causes improper anterior guidance without a
definitive vertical stop, which gradually leads to supra-eruption and
subsequent creation of a deep bite.
Pathological migration disrupts interproximal contacts, leading to the
possibility of multiple interdental
caries. Consequently, in the absence
of timely dental intervention, dete-

ÿPage 18

[17] =>

From British Academy of Restorative Dentistry

DUBAI

2019-2021

Prof. Paul Tipton,UK
Specialist in Prosthodontics
President, British Academy
of Restorative Dentistry

Prof. Edward Lynch, UK
The University of Warick, Coventry
PhD, Lond, MA, BDentSc, TCD, FDSRCSEd,
FIADFE, FDSRCSLond, FASDA, FACD

Prof. Göran Urde, Sweden
Director Futurum Clinic
Program Director P.G Education
Dept. of Materials Sci. & Tech.

Prof. James Prichard, UK
BDS (ULond), MSc(ULond),
LDSRCS (Eng), MFGDP (UK)
FIADFE (USA)

Dr. Malcolm Riley, UK
BDS (Lon), LDS RCS(Lon),
FDS RCS(Lon), MRD(Ed),
FDS RCS(Ed)

Dr. Matthew Holyoak, UK,
BDS, Dip Rest Dent
(RCS Eng), MSc (Rest Dent)

Dr. Timothy Eldridge, UK
BDS Birm
Clinical Director myFACE

Dr. Adam Toft, UK
BSc (Hons), BDS (Hons), MFGDP (UK),
MMedSci (Rest Dent), Dip Aesth (BARD)
FBARD PGCertEd (Sheffield)

Dr. Ash Rayeral, UK
BDS MFGDP(UK) MSc
(Aesthetic and Restorative
Dentistry)

Dr. Adam Nulty, UK
BChD MJDF RCS Eng
PGCert MSc (Dist.)
MAcadMEd

Group 5
Registration Open

Pathway to UK
Masters

210 CME & Daily
Hands-on

Certificate | 4 Modules | 15 Days

Module 1 | 19-21 September 2019 | Prof. Paul Tipton & Dr. Adam Toft & Dr. Ashish Rayarel

Treatment Planning in Advanced Restorative Dentistry | The Principles of Occlusion in Advanced Restorative Dentistry | Tooth
Preparation in Advanced Restorative Dentistry
Module 2 | 20-23 November 2019 | Prof. Paul Tipton & Dr. Matthew Holyoak & Dr. Adam Toft & Dr. Ashish Rayarel

Minimally Invasive Veneer Preparations | Master the Art of Composites Part 1 - Adhesion Composites & Anterior Composite
Restorations | Master the Art of Composites Part 2 - Composite Veneers | Master the Art Composites Part 3 - Posterior Composites
Module 3 | 19-22 February 2020 | Prof. Paul Tipton & Prof. James Prichard & Dr. Adam Toft & Dr. Ashish Rayarel

Enhance Your Expertise in Endo Part 1 | Enhance Your Expertise in Endo Part 2 | Occlusal Examination | Emax & Zirconia Anterior
& Posterior Restorations
Module 4 | 08-11 April 2020 | Prof. Paul Tipton & Dr. Malcolm Riley & Dr. Adam Toft & Dr. Ashish Rayarel

Bridge Design | Aesthetic Perio Connective Tissue Grafting | Aesthetic Perio Crown Lengthening | Modern Post and
Core Techniques

Diploma | 4 Modules | 15 Days

Module 5 | September 2020 | Prof. Paul Tipton & Dr. Adam Toft & Dr. Ashish Rayeral

Bridge Preparation Techniques | Articulator selection in Restorative Dentistry | Porcelain Inlays & Onlays | Veneer Cementation
Techniques Practical
Module 6 | November 2020 | Prof. Paul Tipton & Mr. Gary Jenkinson & Dr. Adam Toft

The Art & Science of Aesthetic Dentistry Part 1 & Anterior Diagnostic Waxing | The Art & Science of Aesthetic Dentistry Part 2
& Posterior Diagnostic Waxing | TMD, It's Diagnosis and Treatment | Adhesive Bridge Preparation Techniques
Module 7 | February 2021 | Prof. Paul Tipton & Prof. Edward Lynch & Dr. Adam Nulty & Dr. Adam Toft & Dr. Ashish Rayeral

Minimally Invasive Dentistry | Digital Dentistry Workflow & Photography Principles, Hardware and Storage Part 1 & 2
Module 8 | May 2021 | Prof. Göran Urde & Dr. Timothy Eldridge & Dr. Adam Toft & Dr. Ashish Rayeral

Implant Prosthodontics Part 1 & 2 | Botox & Dermal Fillers – A Dental Facial Aesthetics Part 1 & 2

[18] =>

mCME

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page 16
rioration of the dentition advances
significantly. Adjacent teeth drift
into carious spaces to seal off the broken continuity and decrease the arch
width, producing sagittal discrepancy and loss of vertical dimension.
Such teeth typically present with
tipped roots, which are not parallel
to each other and have non-uniform
interradicular spaces. Rehabilitation of such a dental architecture
involves intense interdisciplinary
planning with the restorative dentist. Treatment thus planned should
involve strategic sequencing of
procedures adhering to the holistic
final result objectives, ensuring predictability at every stage. Establishment of an appropriate interincisal
relationship with suitable anterior
guidance, parallelism of roots and
evenly spaced interradicular architecture, along with well-coordinated
upper and lower arches, forms the
foremost objective of pre-restorative
orthodontic treatment. This creates
a reliable foundation for predictable
distribution of occlusal forces.
Restorations can thereafter be fabricated for long-term functional and
aesthetic stability. Fine tuning of
tooth positions during the finishing stage of orthodontic treatment
can be completed with valuable
inputs from the restorative dentist
in accordance with the proposed
restoration. Likewise, removal of orthodontic appliances can be timed

along with restorative interventions
to ensure avoidance of any untoward tooth movements. Proficient
synchronisation between orthodontic and restorative strategies is the
fundamental aspect for interdisciplinary treatment success.

7) Use customised orthodontic tooth movements to maximise aesthetics
Contrary to traditional orthodontics,
which is focused solely on improvement of static and dynamic occlusal
relationships, contemporary orthodontics encompasses treatment modalities that aim at achieving good
occlusal results in conjunction with
enhancement of the entire dentogingival apparatus, including prime
emphasis on aesthetic outcome. In
a cosmetically concerned society,
aesthetics forms an integral part of
patient expectations. This directly
mandates orthodontic professionals to systemically explore various
factors that promote optimal aesthetics. Adhering to principles of
structural balance and functional efficiency, treatment planning should
diligently incorporate distinctly
defined and customised aesthetic
objectives. Various procedures from
other disciplines of dentistry can
be amalgamated with orthodontic
treatment to refine aesthetic potential.

White and pink harmony
Well-finished orthodontic realignment of teeth constitutes perfection
of white aesthetics within a smile.
However, an ideal aesthetic smile
demands a harmonious balance of
both white and pink components.
Colour, contour and health of gingival architecture constitute the pink
components, which provide the
background framework of a smile.
Completed orthodontic treatment
with appropriately repositioned
teeth, but neglected gingival discrepancies, such as loss of papillae
or an asymmetrical gingival pattern, causes white–pink disharmony,
leading to an unaesthetic smile.18
Two significant factors related to
gingival architecture that need to
be considered are the gingival levels
and the gingival marginal contour or
gingival zenith
The amount of gingiva seen depends
upon the upper lip line in an active
smile. In some individuals, the upper lip does not display any gingiva
on smiling, while in others, gingival
display is evident. For optimum biologic health, functional perfection of
treatment is inevitable, while gingival refinements subjectively elected
are purely cosmetic procedures,
which may not augment towards
health. Thus, cases with no gingival
display in an active smile do not require corrective treatment. Alternatively, cases with noticeable gingival

display require corrective measures
for achieving white and pink balance
within the smile.
According to ideal aesthetic parameters, the free gingival margins of
the maxillary central incisors and canines are at the same level and those
of the lateral incisors are placed
slightly coronal. These margins
should have contours that resemble
the cemento-enamel junction. The
gingival zenith is the most apical
point of the labio-gingival contour.
For the maxillary central incisor and
canine, it is located just distal to the
long axis of the tooth, and for the
lateral incisor, its location coincides
with the long axis of the tooth.19 The
papillary tip of the gingiva should
extend halfway between the incisal
edge and the labio-gingival height
of the contour over the centre of
each anterior tooth. Thus, the height
of the contour of the gingival levels
should be centred on the lateral incisors and placed in the distal onethird for the central incisors and
canines. Such arrangement of the
gingiva provides a semicircular appearance for the lateral incisors and
an elliptical appearance for the canines and central incisors.
Periodontal assembly follows the
erupting tooth. The presence of
asymmetrical tooth eruption will
alter the underlying crestal bone
levels, which provide support to the
overlying gingival pattern. Therefore, asymmetries in gingival levels
will result. Orthodontically, these
clinical situations can be modified
by intrusion or extrusion of teeth
(Fig. 20).

Conclusion

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An interdisciplinary orthodontic
treatment presents a philosophy
and treatment strategy that involves
a group of professionals from other
disciplines of dentistry as a cohesive
team. This approach to managing
complex clinical situations is a highly sophisticated treatment modality
and requires excellent communication and coordination among the
team members. The goal is to simplify and idealise the treatment plan
by providing solutions to a variety of
clinical situations, which improves
the overall treatment prognosis and
enhances the treatment results.
Initially, this approach may seem to
be out of reach of most practitioners;
however, when implemented regularly, this collaborative approach results in very efficient protocols and
execution that patients appreciate
and benefit from. The author has,
since his initial days of orthodontic
practice, enjoyed professional collaboration with specialists from other
disciplines of dentistry in a fruitful
career and continues to maintain
professional enthusiasm with them.
It is hoped that this particular approach to managing complex clinical problems will inspire readers to
engage in their own interdisciplinary
collaboration, and advance the practice of dentistry for the benefit of the
patient and community at large.

surgical orthodontic patient. Am J
Orthod. 1986 Feb;89(2):95–112.
(3) Lindauer SJ, Rebellato J. Biomechanical considerations for orthodontic treatment of adults. Dent Clin
North Am. 1996 Oct;40(4):811–36.
(4) Karad AK, Patil RC. Interdisciplinary orthodontics. In: Karad A,
editor. Clinical orthodontics: current
concepts, goals and mechanics. 2nd
ed. New Delhi: Elsevier India; 2014. p.
325–45.
(5) Roblee RD. Treatment planning:
Phase II of IDT. In: Roblee RD, editor.
Interdisciplinary dentofacial therapy: a comprehensive approach to
optimal patient care. Chicago: Quintessence; 1994. p. 77–99.
(6) Mihran WL, Murphy NC. The
orthodontist’s role in 21st century
periodontic-prosthodontic therapy.
Semin Orthod. 2008 Dec;14(4):272–
89.
(7) Tylman SD. Theory and practice
of crown and bridge prosthodontics.
5th ed. St. Louis, Mo.: Mosby; 1965.
1249 p .
(8) Nevins M, Skurow HM. The intracrevicular restorative margin, the biologic width, and the maintenance of
the gingival margin. Int J Periodontics Restorative Dent. 1984;4(3):30–
49.
(9) Gargiulo AW, Wentz FM, Orban
B. Dimensions and relations of the
dentogingival junction in humans. J
Periodontol. 1961 Jul;32(3):261–7.
(10) Ingber JS, Rose LF, Coslet JG. The
“biologic width”—a concept in periodontics and restorative dentistry.
Alpha Omegan. 1977 Dec;70(3):62–5.
(11) Kois J. Altering gingival levels:
the restorative connection Part 1:
biologic variables. J Esthet Dent. 1994
Jan;6(1):3–7.
(12) Kois JC. The restorative-periodontal interface: biological parameters.
Periodontol 2000. 1996 Jun;11:29–38.
(13) Bernard JP, Schatz JP, Christou P,
Belser U, Kiliaridis S. Long-term vertical changes of the anterior maxillary
teeth adjacent to single implants in
young and mature adults. A retrospective study. J Clin Periodontol.
2004 Nov;31(11):1024–8.
(14) Saadoun AP, Le Gall M, Touati B.
Current trends in implantology: Part
II—treatment planning, aesthetic
considerations, and tissue regeneration. Pract Proced Aesthet Dent.
2004 Nov–Dec;16(10):707–14.
(15) Kinzer GA, Kokich VO Jr. Managing congenitally missing lateral incisors. Part III: single-tooth implants. J
Esthet Restor Dent. 2005;17(4):202–
10.
(16) Carlsson GE, Bergman B, Hedegård B. Changes in contour of the
maxillary alveolar process under
immediate dentures: a longitudinal
clinical and X-ray cephalometric
study covering 5 years. Acta Odontol
Scand. 1967 Jun;25(1):45–75.
(17) Spear F, Mathews DM, Kokich
VG. Interdisciplinary management
of single-tooth implants. Semin Orthod. 1997 Mar;3(1):45–72.
(18) Karad A. Excellence in finishing: current concepts, goals and
mechanics. J Indian Orthod Soc.
2006;40(3):126–38.
(19) Rufenacht CR. Fundamentals of
esthetics. Chicago: Quintessence;
1990. 372 p.

Acknowledgements

Postgraduate students
practice at the largest dental
clinic in Dubai

Opportunities to participate
in overseas
scientific presentations

Eligibility for the Royal College of Surgeons of Edinburgh
and for the Royal College of Surgeons in Ireland Specialty
Membership examinations

The author would like to acknowledge Dr Ratnadeep Patil for providing restorative treatment to the
patients and Dr Aditi Jagdale for
her assistance in preparation of this
manuscript.

References
Accredited by
Ministry of Education

(1) Levitt HL. Modification of appliance design for the adult mutilated
dentition. Int J Adult Orthod Orthognath Surg. 1988;3(1):9–21.
(2) Alexander RG, Sinclair PM, Goates
LJ. Differential diagnosis and treatment planning for the adult non-

Dr Ashok Karad, India
BDS, MDS, M OrthRCS (Edin)
Dr Ashok Karad is a director of Smile Care
in India. He is a diplomate and past Chairman of the Indian Board of Orthodontics,
and former Editor-in-Chief of the Journal
of Indian Orthodontic Society.
Karad has been actively involved in clinical research, continuing education, publications and clinical photography, and
has authored a book titled Clinical Orthodontics: Current Concepts, Goals and
Mechanics.

[19] =>

[20] =>

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 6/2018

Predictable steps to Biomimetic
Class IV restorations
By Dr Anand R. Narvekar, India

Introduction
Composite Artistry has become an
important element of direct restorative treatment in dental practice
today enabling clinicians to create
life-like restorations with individualized characterizations to match the
patient’s natural teeth.
Anterior restorations in the aesthetic
zone tend to constantly challenge
the clinician’s skill, therefore it is
important to plan carefully by combining art and science. Adopting the
Minimally invasive Cosmetic Dentistry (MiCD) concept, introduced by
Dr Sushil Koirala in my treatment
protocol with emphasis on preservation of natural tooth structure “Do
No Harm Dentistry” has helped create predictable aesthetic restorations
that exceed patient expectations.
Fractured upper central incisors are
one of the most common cases of
dentoalveolar trauma in the permanent dentition. The following clinical
case highlights a simple technique
to achieve predictable aesthetics
with natural optical characteristics in a class IV restoration using a
sculptable bio-mimetic direct restorative “Beautifil II LS”

Patient Case
A 35 years old male patient visited
our dental office with a complaint
of chipped upper front teeth ( tooth
# 11,21) resulting from a childhood
injury with no pain or sensitivity .
The patient requested to enhance his
smile with minimally invasive treatment.

Treatment Plan
After Intraoral examination, photographs were taken (Fig. 1) and a
treatment strategy was formulated
keeping in mind the patient high expectations for aesthetic restorations
with less invasive treatment.
A direct composite restorative material with low shrinkage, predictable aesthetics, sculptable handling
and easy polishability- Beautifil IILS
was selected. High value translucent
enamel shade was identified to create optical effects of youthful teeth
Materials
Tooth preparation – Diamond Bur
FG, Super-Snap Coarse Disk (Black)
Restoration – Beautifil II LS – shade
A2O, A2, Beautifil Injectable - shade
INC, Beautifil II
Enamel – shade HVT (High-Value
Translucent enamel shade)
Bonding system – Etchant and 2 step

Adhesive system (FL-Bond II)
Finishing & Polishing – Fine Diamond Bur (Red Band on shank) , OneGloss , Super-Snap X-Treme, Direct
Dia Polishing Paste, Super Snap Buff
Disk

Step by Step Restorative
Technique

Shade Selection
Vita Shade guide was used for shade
selection while tooth was hydrated.
Black and white photo is recommended for assessing value. Shade
A2 was selected. (Fig. 2)
Mock Up
• An impression is taken and model
poured using die -stone material.
Freehand build-up of composite for
both teeth to evaluate the final outcome. Both teeth were carefully analysed and identified that each tooth
required a different recipe for layering the composite material. (Fig. 3)
• Silicon putty index made from the
plaster model to create an enamel
shell to guide the build-up of the
palatal enamel layer.
Tooth Preparation
• Rubber dam isolation from premolar to premolar, Rubber dam inverted and floss tied around teeth

Before and after

for further retraction of gingiva to
eliminate contamination with sulcular fluid. (Fig. 4)
• Infinite bevelling of margins to
blend the composite material on

both sides, labial and palatal with a
round ended tapered Diamond bur

ÿPage 22

Fig. 1: Fractured maxillary anterior incisal edge of tooth #11 and 21

Fig. 2: Black and white photo taken with classic Vita shade guide for value
assessment, Shade A2 matches with natural dentition compared to A1

Fig. 3: Buccal view of the composite build-up on the tooth model, showing differences of a fractured incisal edges

Fig. 4: Rubber dam isolation with floss ties

Fig. 5: Labial bevelling of fractured area

Fig. 6: Smoothing incisal edge with the Super Snap Black disk

Fig. 7: Putty index checked intra orally after placing rubber dam

Fig. 8: Palatal shell made using Shofu Injectable INC enamel shade

Fig. 9: Build-up of deep dentin with Shofu Beautifil II LS A20, note the
different amount placed in each tooth

Fig. 10: Thin layer of Beautifil II LS shade A2 placed after placement of
Garrison anterior matrix band with silicon wedge between both central
incisors for better contact and contour of the tooth

Fig. 11: Final enamel layer build-up with Beautifil II Enamel shade HVT of
achieve high-value translucency and finished with an art brush in horizontal motion strokes

Fig. 12: After contouring, finishing done with dura white stone

[21] =>

[22] =>

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page 20
(Fig. 5). Finish with a Super snap
Black disk to avoid leaving any unsupported enamel. (Fig. 6)
• Putty index checked intra orally
and modified to ensure a perfect fit.
(Fig. 7)
• Teflon tape is placed on adjacent
teeth to protect from accidental
etching and bonding.
Restoration
• Selective enamel etching was done
using 32% Phosphoric acid with microbrush agitation and slight overetching of vestibular enamel. Rinse
the etchant, generously with water
for 20 seconds. After gentle air drying, frosted enamel was visible
• 2 Step Adhesive System FL- BOND
II was used. First applied Primer and
left for 10 sec., air dried and followed
by application of the bonding agent,
excess bonding agent is carefully removed by high vacuum motorized
suction, and light cured for 10sec.
• Palatal shell was created us-

ing Beautifil Injectable composite
enamel Shade Inc. Due to excellent
handling properties, a very smooth
palatal shell can be made.
Clinical Tip : this method helps reduce
chair time during the finishing & polishing protocol. (Fig. 8)
• Build-up deep dentin with a layer of
Beautifil II LS shade A2O on the palatal shell to block the light transmission . More quantity was applied in
tooth 21 compared to tooth 11 due to
the extent of fracture. (Fig. 9)
• To attain good contact and emergence profile for better contouring,
a Garrison Anterior band with No. 1
yellow wedge was placed in between
both centrals. A thin layer of Beautifil II LS shade A2 was placed leaving
sufficient space for build-up of final
enamel layer (Fig. 10)
• Final layer of enamel was restored
using Beautifil II High-Value translucent enamel shade HVT to create
some natural surface characteriza-

tions and achieve a high value. The
enamel layer was smoothened with
the help of an art brush. (Fig. 11)
Clinical Tip: final curing is done after
applying glycerine to avoid oxygeninhibited layer.
Finishing and Polishing
• Rubber dam was removed carefully
before starting the finishing & polishing procedure
- The first step of finishing was to
mark the line angles.
- Contouring was done using a tapered fine (red band) diamond point
and Super Snap disk (purple).
- High points were checked and adjusted with 40 micron articulating
paper in static occlusion & 200 micron articulating paper in Dynamic
occlusion.
- Finishing was done with Dura
White stone (Fig. 12) and One gloss,
Clinical Tip: avoid touching the line
angles in order to highlight the line

angles for a more natural contour
- Polishing was done using Super
Snap X-Treme green and red disks
(Fig. 13) until a glossy and reflective
composite surface is achieved
- The final Super polishing was done
with Direct Dia diamond paste with
Super Snap Buff Disk for a high gloss
effect that matches the natural teeth
• Patient recalled after one week for
assessment of restoration and photos taken after rehydration from different angles to check teeth contour
and anatomy.(Fig. 17)

Results
It is often challenging to restore cases
with small fractured incisal edges as
there is limited space available to
manipulate and blend the composite shades.
Proper understanding of the composite material and optical properties of different shades of opaque
dentin, dentin and
enamel help to explore
the natural blending
ability of colours for
this patient and create
restorations that harmonize with natural
teeth.
Attention to detail was
key to achieving surface characterization to

Fig. 13: Polishing with Super Snap X-Treme green disk followed by pink
disc clearly showing the reflection on the tooth

Fig. 14: Intra oral image showing final restoration

Fig. 15: Before and after image digitally overlapped to showcase extent
of actual build-up of the composite restoration

Fig. 16: Frontal view of maxillary anterior teeth showcasing bio mimetic
aesthetics of composite resin with a close match to natural tooth translucency and effects in the incisal area

maximise the aesthetic outcome of
the restoration.
The use of a proper protocol for finishing and polishing helped achieve
a glazed-like composite surface
similar to ceramic or natural teeth as
seen in the extreme close up clinical
photographs

Conclusion
The before and after clinical photos
of this patient case highlights that
predictable life-like restorations can
be created to mimic natural teeth
using a conservative approach with
minimal tooth preparation, selection of the right type and shades of
composites followed by a comprehensive finishing and polishing protocol.

Acknowledgment
Author wish to thank Shofu Dental
Asia-Pacific Pte. Ltd. and Garrisons
USA for their Support.

Shofu Dental Asia-Pacific PTE LTD
10 Science Park Road, #03-12 The Alpha
Singapore Science Park II
Singapore 117684
Tel: (65) 6377 2722
Fax: (65) 6377 1121
E-mail: jwu@shofu.com.sg
Web: www.shofu.com.sg

Fig. 17: Artistic side view of both dental arches in anterior guidance 1
week post-treatment showcasing complete rehydration of tooth and
natural life-like aesthetics

Rehabilitation of a dentition damaged by bruxism
Prosthetic treatment using monolithic all-ceramic crowns and composite bridges
By Dr Meni Chatzinikolaou, Dr
George Papavasiliou, Dr Theodoros
Gonidis & Maria Spanopoulou,
Greece
The present report describes the
reconstruction of a severely worn
dentition with the use of fixed restorations and with maximum preservation of the existing tooth structure.
Implants were employed for the restoration of the partially edentulous
lower jaw. Rehabilitation of the generally worn teeth was attained with
all-ceramic materials. Temporization
was preceded by splint therapy and
comprehensive pre-prosthetic treatment. The press technique and the
CAD-on technique were utilized in
the transfer from the temporary to
the final all-ceramic reconstruction.
This report describes the individual
treatment stages and discusses the
approaches taken in these stages.
For some years now, monolithic allceramic restorations have been a
frequently used treatment option
for the reconstruction of destroyed
tooth structure. Their benefits include the ability to eliminate the
use of metal, to implement a costefficient manufacturing procedure

and to exclude the risk of chipping
associated with veneering ceramics.
With the increase in the use of allceramic materials, the failure rate of
some of these materials at high loads
(bruxism and other parafunctions)
has been discussed. However, advances in materials engineering and
adhesive technology have led to the
introduction of ceramic systems (e.g.
lithium disilicate) that can be used
for high load bearing restorations.

Introduction
This report focuses on the prosthetic treatment of a severely worn
dentition in a bruxer. A consistent
treatment plan is as critical to a successful rehabilitation as is a correct
diagnosis and the implementation
of pre-prosthetic treatment measures. Material selection also becomes
a crucial criterion of success or failure. We are of the opinion that it is
possible to use all-ceramic materials
in patients with bruxism - even if
the ceramics manufacturers mostly
state otherwise -, as long as the materials are selected appropriately to
accommodate the requirements of
the given indication and then applied correctly. Yet, there is no such
thing as a universal ceramic. Rather,

the treatment team must take a decision that does justice to the specific
circumstances of the indication at
hand. Monolithic restorations made
of lithium disilicate (IPS e.max Press,
Ivoclar Vivadent) using the press
technique are possible for the treatment of single teeth. When fabricating long-span restorations (e.g.
implant-supported bridges), a combination of lithium disilicate and
zirconium oxide may present a viable alternative to purely monolithic
zirconium oxide or metal-ceramic
restorations.

Rehabilitation of a dentition
damaged by bruxism
The term "bruxism" refers to various parafunctional activities of the
stomatognathic system. Bruxism is
assumed to have multiple possible
causes. Causal treatment of bruxism should depend on whether the
disorder is caused by medical or psychosocial factors. The oral and physical consequences of bruxism vary in
severity depending on the severity
of the parafunctions. In many cases,
bruxism correlates with at least
some degree of dental attrition or
wear. Particularly in patients with an
inadequately restored, interrupted

dentition, for instance in older people, the residual teeth which still
have contact to the antagonists may
be affected by a severe loss of tooth
structure. Generally, rehabilitation
of a patient with a worn dentition
presents a considerable challenge to
the treatment team. In this context,
extensive pre-prosthetic planning
and consistent implementation
of the treatment plan are essential
prerequisites for the success of the
treatment. Primary objective of the
rehabilitation is to establish a stable
occlusion and an adequate vertical
dimension. Implementing a diagnostic and therapeutic stage are just
as essential on the pathway to a fullmouth rehabilitation as are wearing
a protective splint and performing
regular check-ups. Before restoring
the worn dentition, a decision as
to which materials to use has to be
taken. On the one hand, the risks
of a preparation trauma should be
minimized. On the other hand, adequate strength should be provided
to rule out chipping of the material
or damage being caused to the temporomandibular joint. In addition,
the aesthetic expectations of the patient should be considered. If veneering ceramics are used, chipping in
the areas of high masticatory stress

is another risk that should be taken
into account.
Strength of all-ceramic materials
in dentition of patients with bruxism
First, we have to decide which of the
two aspects should be given predominance: aesthetics or adequate
strength under high masticatory
stress. Strength is decisive for the
long-term stability of a restoration, particularly in patients with
bruxism. The higher the crystalline
content, the stronger the ceramic
material is. This is particularly true
for oxide ceramics (ziconium oxide, strength > 1000 MPa), which is
a material that has a dense microstructure and is consequently highly
opaque. It may therefore not always
meet the aesthetic requirements of a
restoration. While more recent zirconium oxide versions offer increased
translucency, their strength is considerably lower than the strength of
their predecessors. Conventional silicate ceramics are based on a leucitereinforced glassy phase, which has a
beneficial effect on aesthetics. With a

ÿPage 26

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RESTORATIVE

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page 22

Figs 1A- B: Dentition damaged by bruxism with partially edentulous arches and severe loss of vertical dimension

Fig. 2: Bite registration at rest and assessment of the
loss of height in vertical dimension

Fig. 4: Vacuum-formed tray prepared from the waxup as guide for surgical crown lengthening procedure

Figs 6 and 7: Build-up of teeth 12, 11, and 21 with endodontic posts made of glass fibre-reinforced composite

Fig. 5: Sutures after surgical crown lengthening in the
maxillary jaw

Fig. 3: Wax-up of the planned prosthetic situation

Fig. 8: Composite build-ups on teeth 12, 11 and 21 and cast build-ups on teeth 22, 23 and 24

Fig. 9: X-ray template (derived from the wax-up)

Fig. 11: Insertion of the implants with the help of the
guiding template

Figs 13A-B: CAD/CAM based fabrication of long-term temporaries from high performance PMMA

strength of 80 to 200 MPa, however,
their strength is woefully low. Having an initial flexural strength ranging from 360 to 400 MPa, lithium disilicate glass-ceramic materials (IPS
e.max Press and CAD) are located between the strength values of zirconium oxide and conventional silicate
ceramics. Lithium disilicate is naturally translucent and is indicated for
monolithic single-tooth restorations,
three-unit bridges (premolar region),
hybrid abutments and hybrid abutment crowns. Monolithic restorations significantly reduce the risk of
chipping compared with veneered
restorations and are therefore particularly advantageous for patients
with bruxism. A possible route to
employ this material also for posterior bridges is to use the CAD-on
technique (IPS e.max CAD Veneering Solutions) to produce composite
bridges. If this technique is used, the
framework is created from highstrength zirconium oxide and then
a monolithic veneering structure
made from comparatively "elastic"
and above all aesthetic lithium disilicate is sintered to it. This special
combination of materials and the
homogeneous ceramic bond created between them results in strong
restorations that can withstand severe masticatory forces and prevent
fractures from occurring. Even if, according to the manufacturer, these
indications are contraindicated for
patients with bruxism, from a pragmatic point of view, two material
concepts emerge as possible routes
to an all-ceramic full-mouth rehabilitation: monolithic restoration
using high-strength lithium disilicate glass-ceramics and the CAD-on
/ Veneering Solution technique for
posterior bridges.

Clinical case

Preoperative situation, diagnosis
and treatment planning
A 67-year-old male patient presented with a functionally and aesthetically severely compromised denti-

Fig. 12: Implant abutments in situ

tion. His pressing need at the initial
assessment was to have his dental
situation improved. He wanted his
teeth to be restored to their "old"
functional and aesthetic shape. His
general medical history did not reveal anything unusual. He did not
complain about TMJ problems or
jaw tension.

tion, long-term temporization, insertion of three implants in the lower
jaw, final prosthetic reconstruction
with all-ceramic restorations.

The gaps in his upper posterior region had been prosthetically filled
with restorations that were now
defective. In the mandible, the patient was edentate in the posterior
region on both sides. The teeth that
were still in situ showed signs of
generalized dental wear. A detailed
clinical and radiological assessment
revealed an extensive loss in vertical dimension, severe abrasion and
attrition, pronounced bruxism and
a high lip line (Fig. 1). The occlusal
and incisal surfaces showed flat,
sharply confined wear facets that
corresponded to the opposing teeth.
The cervical areas of the teeth were
characterized by wedge-shaped noncarious defects (abfractions) typically observed in bruxers. Anterior
esthetics was negatively affected by
several factors. For instance, the incisal edge line jarred with the lower
lip curvature. This mismatch was
caused by the loss of tooth structure,
change in the length-to-width ratio
of the anterior teeth and interruptions in the anterior row caused by
the loss of proximal contacts.
Diagnosis: Generalized abrasion
with a severely reduced vertical jaw
base relationship, prosthetically inadequately restored dentition with
missing teeth and free-end gaps.
Each tooth was individually assessed
for its risk of failure and all of them
- except for teeth 27 and 28 - were
given a good prognosis.

Functional reconstruction and
crown lengthening
An impression of the oral situation
was taken and the situation was
recorded using a facebow. By determining the interocclusal space at
rest (freeway space), we were able
to evaluate the loss of height in the
vertical relation (Fig. 2). In the lab, the
models were mounted on a semiadjustable articulator. The pre-prosthetic phase was begun by having
the patient wear a splint to stabilize
the bite. For this purpose, an occlusally adjusted splint was prepared to
attain the envisaged vertical height
in a centric condylar position. The
patient wore this appliance for three
months. He had no problems in adjusting to the new VDO.
When the diagnostic wax-up was
created, the functional requirements
and aesthetic expectations of the
patient were taken into consideration (Fig. 3). Removal of the existing
restorations was followed by surgical crown lengthening of the upper
and lower teeth in the anterior and
premolar region. A vacuum-formed
tray was created from the diagnostic wax-up and used as a template,
or guide to attain the planned tooth
length (Fig. 4). Excess tissue was carefully removed, the gingival tissue
around the teeth incised and temporarily folded back and the bone
reduced by the necessary height. The
surgical site was closed with loose sutures (Fig. 5).

Treatment plan: Functional restoration of the vertical dimension
of occlusion (VDO), surgical crown
lengthening, restorative reconstruc-

Upon completion of the healing
phase, preparation of the teeth for
the restorative treatment began.
The amalgam fillings and secondary

The treatment was implemented in
two phases:
1. Initial (pre-prosthetic) phase
2. Restorative (prosthetic) phase

caries were meticulously removed.
Some of the teeth required preparation for the placement of the crowns.
Teeth 12, 11, and 21 received endodontic treatment with glass fibre
reinforced endodontic posts (FRC
Postec Plus, Ivoclar Vivadent, see Figs
6 and 7) and a core build-up made
of self-curing composite (Multicore
Flow, Ivoclar Vivadent). The endodontic posts consisting of a specially
developed composite matrix offer
a natural translucency and dentinlike elasticity (flexural strength). The
composite used for the core buildup is available in several shades and
provides favourable mechanical
and aesthetic properties. Teeth 22, 23
and 24 received cast gold posts (Fig.
8) and the other teeth were built up
with composite to enable them to be
used as abutments.
Implant insertion
An X-ray template was created on
the basis of the wax-up and then
used for planning the position of the
implants in the lower jaw. Perforations were applied to the occlusal
surface of the template at the implant exit points that were deemed
most suitable for achieving an ideal
prosthetic restoration and filled with
radiopaque material (Fig. 9). Preparation of a CT scan with the template
in place was followed by virtual implant position planning in region 36,
45 and 46 (Fig. 10). We reworked the
X-ray template into a guiding/drilling template for the insertion of the
implants. The surgical intervention
was uneventful. Subsequently, the
three implants (Astra Tech, Dentsply
Implants) were inserted into the local bone (Fig. 11), healing abutments
were screwed onto the implants and
the implant sites were closed with
sutures.
Long-term temporization
The patient received a long-term
temporary restoration to stabilize
the planned vertical occlusal dimension and to validate the aesthetic ob-

Fig. 10: Implant position
planning on the CT image

jectives. A high-performance PMMA
(TelioCAD, Ivoclar Vivadent) was
used for the fabrication of the temporaries. Wax-up and CAD/CAM enabled a swift implementation of this
stage (Fig. 13). Although a monolithic
design was used, the translucent
properties of the polymer lent a lifelike appearance to the temporaries
(Fig. 14). The patient was very comfortable with the restorations and
did not report any functional complaints. The aesthetic appearance
was considerably improved, which
was reflected in both the patient's
speech and facial expression.
Permanent prosthetic restoration
The patient was wearing the longterm temporaries for an adequate
length of time to get used to the
new VDO, which was then to be
transferred to the permanent restoration. Once the temporaries were
removed, an impression of the prepared teeth was taken using a vinly
polysiloxane precision impression
material (Virtual, Ivoclar Vivadent).
The propitious hydrophilic properties of the impression material allow
for a detailed and accurate recording of the oral hard and soft tissues
[B. K. Nøvling , University of Texas
, 2001], providing the ideal conditions for obtaining high-precision
working models. The validated occlusal position was transferred to the
articulator using a sequential split
mouth method (Fig. 16). A facebow
registration was performed for the
skull-related repositioning of the upper jaw model.
All-ceramic single-tooth crowns
In line with the treatment plan, the
dental technician created monolithic single-tooth crowns using lithium
disilicate. Polychromatic press ingots were used for the press technique (IPS e.max Press Multi, Ivoclar
Vivadent) to achieve the planned

ÿPage 26

[25] =>

[26] =>

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page 24
aesthetic result with maximum efficiency (Figs. 17a and b, Fig. 18). These
ingots feature a shade and translucency progression from the dentin
to the incisal area, allowing natural
looking restorations to be obtained
in a single press procedure. The need
for using the time-consuming layering technique is eliminated. Efficiency is therefore increased and the risk
of chipping minimized. To impart
the restorations with an age-appropriate appearance, characterizations
were applied only to the surface by
designing fine micro- and macrotextures and by creating characterizations with the help of stains.
All-ceramic implant abutments
The implants were fitted with customized hybrid abutment crowns
made of lithium disilicate (IPS e.max
CAD). The hybrid crowns were designed using CAD software, ground
from specially developed lithium disilicate blocks and extraorally bonded to a titanium base using a specialist luting composite (Multilink
Hybrid Abutment, Ivoclar Vivadent,
see Figs 19 and 20). Subsequently, the
monolithic hybrid abutment crowns
were screwed into place in the oral
cavity. The IPS e.max CAD blocks
for the manufacture of hybrid abutments or hybrid abutment crowns
feature a pre-fabricated interface (e.g.
for the Sirona Ti base) and ensure a
high accuracy of fit. In our opinion,
the reduced flexural strength of the

lithium disilicate, compared with
zirconium oxide, has a favourable
effect on the patient's chewing comfort and the implants. In view of the
fact that implants have no inherent
mobility and therefore have only
reduced tactility, we assume that
lithium disilicate provides a suitable
abutment material for restorations
in patients with bruxism.
All-ceramic bridges
To somewhat cushion the high
masticatory forces that are to be expected in a bruxer to be occurring
in the posterior region, we opted for
lithium disilicate, here too. However,
here the focus was on reliability and
strength. For this reason , we decided to design what is termed as a
composite bridge (IPS e.max CAD
Veneering Solutions). This unique
combination of lithium disilicate
(LS2) and zirconium oxide (ZrO2) allows the fabrication of tooth- and
implant-supported bridge constructions that offer an exceptional overall strength and aesthetically pleasing properties. Two structures are
required to create the restoration:
a high-strength zirconium oxide
framework (IPS e.max ZirCAD) and
a glass-ceramic veneering structure
(IPS e.max CAD, see Fig. 21). After
both structures were manufactured
using a CAD/CAM procedure (inLab
MC-XL, Sirona), the framework was
tried in and fine tuned down to the
last fine details before finalization

(Fig. 22). The short processing times
required to complete the structures
increase the rate of efficiency and
productivity. After the try-in, the two
structures, which had been milled or
ground separately, were fused together to achieve a homogeneous
ceramic bond using a fusion glassceramic (IPS e.max CAD Crystall./
Connect, Ivoclar Vivadent, see Fig.
23). The fusion process takes place at
the same time as the crystallization
process of the lithium disilicate.
Seating the restorations
The IPS e.max Press restorations
were seated using a dual-curing luting composite (Variolink Esthetic
DC, Ivoclar Vivadent) that features
optimum aesthetic properties. The
glass-ceramic components were pretreated using a single-component
primer (Monobond Etch & Prime,
Ivoclar Vivadent) acccording to the
manufacturer's instructions. The
tooth preparations were conditioned
with an adhesive (Adhese Universal,
Ivoclar Vivadent, see Figs. 24 and
25). Once an appropriate shade of
luting composite was selected, the
glass-ceramic restorations were permanently seated using an adhesive
luting technique (Fig. 26).
The IPS e.max CAD hybrid crowns
were screwed into place (Fig. 27) and
the screw channels sealed using an
aesthetic composite filling material.

The zirconium oxide supported IPS
e.max CAD-on bridges were seated
using a self-curing resin cement
(SpeedCEM Plus, Ivoclar Vivadent).
We checked all functional and aesthetic parameters and then showed
the patient how to wear a protective splint (Figs 28 to 31). The splint
should be worn during the night.
Furthermore, regular check-ups at
four-month intervals were planned.

Discussion
All-ceramic materials are sometimes
described as too risky for the prosthetic rehabilitation of patients with
bruxism. Even today, bruxism is often mentioned as a contraindication.
This is certainly true as far as conventional ceramic materials with a high
brittleness are concerned. When it
comes to these materials, the failure
rates at high loads (parafunctions)
should be critically assessed. However, advances in material engineering and adhesive technology have
led to considerable progress. In the
view of the writer, modern ceramic
materials and concepts can be suitable for restorations in patients with
bruxism - provided that they are
processed in accordance with the
clinical indication.
Overview of the data for the materials used in this report
IPS e.max CAD-on: Clinical data of
up to three years of clinical wear are

available for the CAD-on technique.
The mean observation period is 21
months for bridges and 36 months
for crowns. Two studies examined
29 three-unit bridges [Watzke et al.,
2012; Blatz et al., 2012]. No failures
have been reported to date. Another
study including 30 bridges was initiated in 2012 [Sailer et al., 2012]. Still
another study [Beuer et al., 2012]
was also initiated in 2012. In addition, a prospective study carried out
at the University of Pennsylvania by
von Blatz et al. evaluated the performance of what are termed as composite bridges manufactured using
the CAD-on technique. Twenty-five
patients received a three-unit CADon bridge. After six months of service, all restorations were rated as
"very good" or "good".
IPS e.max Press: Data of up to ten
years are available for lithium disilicate restorations made using the
press technique. A survival rate of
97% after a mean observation period
of 5.6 years has been established on
the basis of 642 restorations (crowns)
– five external clincial studies [Böning et al., 2006; Etman and Woolford 2010; Guess et al., 2012; Gehrt
et al., 2012; Dental Advisor 2012] and
an internal Ivoclar Vivadent study.
Failures (2.5 %) were attributable to
fractures (1.6 %), endodontic compli-

ÿPage 28

Figs 14A-B: Upper and lower jaw with the long-term temporaries in place

Fig. 15: Upper jaw impression for the fabrication of
the permanent restorations

Fig. 16: Transfer of the validated vertical relation using a sequential split mouth procedure

Figs 17A-B: Waxed-up crowns on the model and waxed to the investment ring base.

Fig. 18: Ceramic crowns after completion of the press
procedure

Fig. 19: Milled IPS e.max CAD abutment crown before
bonding

Fig. 20: IPS e.max CAD abutment crowns before being
screwed into place

Fig. 22:Try-in of the framework prior to finalization

Fig. 23: Completed CAD-on bridge

Fig. 25: Conditioning the tooth preparations

Fig. 26: Light-curing after adhesive bonding of the
crowns

Figs 24A-B: Conditioning the glass-ceramic components

Fig. 21: Milled zirconium oxide framework and
ground lithium disilicate veneering structure

Fig. 27: Screw-retained IPS e.max CAD restorations

Fig. 28: Situation after placement of the all-ceramic restorations

Fig. 29: Evaluation of the functional parameters, here in laterotrusion

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[28] =>

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page 26

Figs 30A-B: Occlusal view of the restorations in the upper and lower jaw

cations (0.2 %) and secondary caries
(0.2 %). Four of the crowns (0.6 %)
were excluded from the study due
to crack formation. Chipping occurred in 3.4% of the restorations
but could be repaired in all cases
in situ. Systematic studies on the
survival rate of conventional glass-

ceramic materials show a fracture
rate of 3.8 % [Heintze and Rousson,
2010a]. The survival rate of metalceramic crowns is 95.6 % after 5 years
[Pjetursson et al. 2007]. Biological or
technical complications were reported in 5 to 10%. Having a fracture rate
of 1.6% and a survival rate of 97.5%,

IPS e.max Press shows better clinical success rates than conventional
materials, such as glass-ceramics or
metal ceramics. Particularly if used
for monolithic structures, the material appears to be suitable for patients with bruxism.

Fig. 31 A relaxed and happy patient after completion of the treatment

Conclusion
In the clinical case described in
this report, the treatment goal was
achieved and the functional and aesthetic expectations of the patients

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were fully met. All-ceramic restorations were employed for the rehabilitation of the dentition that had
been severely damaged by bruxism.
If we take a retrospective view, the
importance of thorough diagnostics, careful treatment planning and
a step-by-step pre-prosthetic treatment phase becomes evident. Consistent adherence to the treatment
plan is equally important. Only after
the planned vertical dimension is
achieved with the help of long-term
temporaries should the permanent
prosthetic restoration phase be begun. When selecting the materials
for the prosthetic restoration, the
high functional loads to which the
dentition of a bruxer is exposed
should be considered and, ideally,
monolithic structures should be preferred. If these points are taken into
consideration, long-term stability of
the bite and, if appropriate materials are used, high aesthetics can be
achieved.

About the Authors
Theodoros Gonidis
He was born in Athens, Greece and graduated Dental Technology from the Technological Educational Institute (TEI) of
Athens. He continued his studies at the
School of Dentistry of National and Kapodistrian University of Athens, Greece and
graduated in 2012. Next year he entered
the Prosthodontics postgraduate department of the faculty.
Contact info:
E-mail: toddgonidis@icloud.com
Address: Agiou Konstantinou 40
Maroussi, Athens, Greece
Meni Chatzinikolaou
She has been an active member in various
scientific meetings either as an author
or a presenter of research projects, while
having a number of essays published in
foreign journals.
Dr Chatzinikolaou
He is a member of the Hellenic Prosthodontic Association and the European Association of Osteointegration (EAO).
Contact info:
E-mail: xnmeni@icloud.com
Address: Eleftherias square 6
Koridallos, Athens, Greece
George Papavasiliou
He is a Prosthodontist, currently holding
the position of Tenured Assistant Professor, Department of Prosthodontics, School
of Dentistry at the National and Kapodistrian University of Athens, Greece.
Contact info:
E-mail: geopap@dent.uoa.gr
Address: Iroon Politechniou16
Chalandri, Athens, Greece
Maria Spanopoulou
She was born in Athens, Greece and graduated Dental Technology in 2004 from
the Technological Educational Institute
(TEI) of Athens. Already in 2000 she started her professional activity in her father's
lab, Advanced Dental Laboratory.
Contact info:
Web: www.adl-mariaspanopoulou.com
E-mail: info@mariaspanopoulou.com
Address: Leoforos Pentelis 7a
Vrilissia, Athens, Greece

[29] =>

LASER

Dental Tribune Middle East & Africa Edition | 6/2018

Nd:YAG laser-assisted removal of
instrument fragments
By Dr Georgi Tomov, Bulgaria
The Nd:YAG lasers tested in laboratory studies have been claimed to
be able to successfully manage the
removal of instrument fragments
within root canals1–4. This is done in
four ways, all correlated to temperature effects:
1. Laser melts the dentine around the
fragment and then Hedstrom files
are used to bypass and retrieve the
fragment.
2. Laser melts the entire fragment.
3. Laser energy melts the solder, connecting the fractured instrument
with a brass tube charged with solder
and placed at the exposed coronal
end of the fragment.
4. Laser welds the file fragment positioned within a metal hollow tube
(e.g. Endo-Eze Tip, Ultradent Products; Figs. 1a & b).
The removal of a claimed minimum
amount of root dentine1,2,4 can be attributed to the potential given to the
user of Nd:YAG laser to distinguish
dentine1 from obstructions by the
difference in acoustics produced by
the two materials. Ebihara et al. observed that some orifices of the dentinal tubules were blocked with melted dentine after laser irradiation.1 Yu
et al. found that the temperature
rose by 17°C to 27°C, but argued that,
since the initial temperature was
lower than human body temperature, these results were irrelevant.2
The findings demonstrated that a
pulsed Nd:YAG laser irradiation has
the capability of removing broken
files. The success rate reported by Yu
et al. was 55 per cent.2 However, the
thermal effects found after Nd:YAG
irradiation in dry root canals were
considerable (Figs. 2a–c). Thus, the
focus now is on the outcomes of using a laser fibre inserted into a hollow tube (alone or in the presence
of solder) both to avoid dentinal carbonisation and to achieve welding
between the separated file and metal
tube.

Intraoral laser welding
The intraoral laser welding phenomenon is well researched.1–4 Even for

Figs. 1a: Welding of separated
K-type file in Endo-Eze® Tip (18
gauge) using Nd:YAG laser irradiation at 400mJ and 10Hz

Figs. 1b: Longitudinally crosssectioned metal tubes with
melted K-type files inside

metals that absorb well, such as steel,
the laser light is initially reflected. A
small percentage of the laser light is
absorbed, heating the metal surface.
The increased surface temperature
increases the absorption of the laser
power. This creates a snowball effect, in which the material is rapidly
heated by the laser, leading to melting and the consequent formation of
a weld.
Hagiwara et al. performed laser
welding on stainless steel or nickeltitanium files using an Nd:YAG
laser in order to evaluate the retention force between the files and the
metal extractor.3 Additionally, they
evaluated the increase in temperature on the root surface during laser irradiation. They reported that
the retention force on stainless steel
was significantly greater than that
on nickel-titanium. The maximum
temperature increase was 4.1°C. The
temperature increase on the root
surface was greater in the vicinity
of the welded area than at the apical
area. Scanning electron microscopy
(SEM) revealed that the files and extractors were welded together. Simi-

Figs. 2a: Undesirable thermal
effects of Nd:YAG irradiation
(3W, 300mJ, 10Hz) in a dry
root canal

lar results were found by Tomov (unpublished data; Fig. 3).

In vitro study
Cvikl et al. used a brass tube charged
with solder and placed at the coronal
end of the fractured instrument in
their in vitro experiment.4 Nd:YAG
laser energy was used to melt the
solder, connecting the fractured instrument with the brass tube. They
reported that the fractured end odontic instruments were removed

Figs. 2b-c: When the optic fibre comes into contact with the dentinal wall it
can cause carbonisation and melting. SEM image of a control dentinal surface
(b) and dentine irradiated with an Nd:YAG laser, revealing areas of melting
and dentinal tubule closure (c).

successfully in 17 out of 22 cases (77.3
per cent) in which more than 1.5mm
was tangible. When less than 1.5mm
was tangible, the removal success
rate decreased to three out of 11 cases
(27.3 per cent).

All figures: © Georgi Tomov, 2016

These results obtained from in vitro
experiments indicate that the laser
welding method is effective in removing broken instruments from
root canals, but its efficacy has to be
further verified in clinical trials.

Dr Georgi T. Tomov, DDS, MS, PhD
Associate Professor and Head of the Department of Oral Pathology
Faculty of Dental Medicine
Medical University of Plovdiv, Bulgaria
E-mail: dr.g.tomov@gmail.com

Editorial note: This article was published in laser international magazine, Issue 1/2018.

Fig. 3: SEM image of a K-type file after Nd:YAG laser irradiation at 400mJ and 10Hz revealing a melted metal surface with an irregular
granular structure after solidification.

Mastering the implant digital workflow
By Dr Ross Cutts, UK
Whether we like it or not, we are embracing the digital era in our brave
new world. Many dental practices
are now becoming paper-free – a
digital innovation – and even using
tablet computers to record patient
details and medical histories. We are
continually surprised by the rising
age of the technologically savvy patient, particularly those of a certain
generation who perhaps we assume
would be less so than the perceived
iPhone generation.
This change in the patient demographic and attitude towards technology is filtering through to us in
the dental profession. The nuts and
bolts of implant dentistry tends to
lend itself more readily to the digital
revolution of dentistry in the UK and
now globally. Many practitioners

Fig. 1: Intraoral scanner

Fig. 2: Printed models

Fig. 3: 2-D radiograph

Fig. 4: 3-D radiograph

opposed to or reluctant to embrace
it are actually being influenced by it
through shifting workflows in dental
laboratories, even where more traditional clinical practices are followed
chairside. Quite often, wet impres-

sions are poured and stone models
are scanned to produce STL files for
laboratories to process during crown
and bridge unit manufacturing.
As an implant clinician, one does
not have to invest in a CT scanner or

chairside intraoral scanner—there
are ways that other centers and laboratories can provide these services.
However, having these tools at one’s
disposal greatly increases one’s efficiency and means one is not reli-

ant on external services for one’s
patients.

ÿPage 30

[30] =>

DIGITAL

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page 29

Fig. 6: coDiagnostiX screenshot of guide production

Fig. 5: coDiagnostiX™ screenshot

So how do we begin the implant
digital workflow? Successful implant
treatment begins with thorough
case assessment and planning of the
proposed restoration. This is important for all cases, not just what we
deem the complex ones. Even the
most experienced implant clinician
can miss a potential treatment planning hazard, especially during a busy
day. Accurate study model casts
are an essential part of this; however, we can now use intraoral scans
preoperatively to begin the digital
workflow. We take a scan rather than
impressions to form digital models.
Our laboratory can then use these to
create digital wax-ups of proposed
treatment outcomes.
We are routinely used to 2-D radiographic imaging techniques in dentistry, but with the availability and
access to CBCT scanning devices
now, we are able to assess bone quantity and quality of proposed implant

Fig. 7: Printed surgical guide

surgical sites. With ever-reducing
doses of 3-D imaging and improving accuracy, we are able to use CBCT
scans, combined with clever software packages such as coDiagnostiX
(Dental Wings), to plan safe and accurate implant placement and restoration. We are able to preoperatively
plan precise implant placement with
safe surgical margins away from important anatomical structures, such
as the inferior alveolar nerve or maxillary sinus. From this, we are then
able to design and either mill or print
a surgical guide to use for precise implant placement.
Even with assisted surgery or guided
surgery, there are sometimes certain
restrictions that prevent us from
achieving the most ideal implant
placement, such as this case shown
where posterior access in the second
molar region was reduced, so achieving the perfect parallel was extremely difficult.

There are fully guided systems available that allow for absolutely precise implant placement, but these
are fraught with complexities and
should be reserved for experienced
clinicians. The accuracy of surgical
guides should not be used to make
up for a lack of surgical competency
however.
There are many factors to be considered when using urgical guides, including whether the guide is tooth-,
soft tissue- or bone-supported.
Tooth-supported allows the greatest
degree of accuracy.
If tooth-supported, · are there windows in the guide that direct full
seating of the guide?
· are the teeth that support exact positioning of the guide mobile? Any
mobility adds a degree of inaccuracy.
· is the guide made from a direct
intraoral scan or a scan of a study
model? If scanning a study model, is
this an accurate stone model representation?
Otherwise, there
is the risk of poor
seating and inaccuracy of the
guide. If soft tissue-supported,
mobility completely negates
any accuracy of
the guide, so it
should only be
used for a pilot
drill and then a
more conven-

tional surgical protocol adopted.
If bone-supported,
· raising of a very large surgical flap
is likely.
· it is very difficult to ensure accurate full seating of a bone-supported
guide in the precise planned position and this relies upon external
fixation.
Once the implants are placed in situ
and fully integrated, we then have a
choice of conventional wet impression techniques versus digital intraoral scanning. For the majority of
cases, intraoral scanning is extremely predictable and reliable—more
so than conventional techniques—
with milled (and lately printed)
models having excellent properties
and less accumulation of processing
errors. However, deeply placed implants relative to adjacent teeth with
deep contact points are very difficult to scan and pick up. Straumann
tissue level implants offer a very
straightforward restorative platform
to scan from. With greater numbers
of implants and fewer teeth to act
as reference points, intraoral scanning becomes less reliable—particularly across the arch—so we need
to exercise caution and be aware of
its limitations. We have used composite flow stuck to the soft tissue
to increase reference points for our
scanners, increasing their ability to
stitch images more accurately together. With this in mind, we cannot assume the scan is accurate and
any framework fabricated would be

non-passive; therefore, we must use
other methods to verify the scan’s
accuracy. We have found locking
temporary abutments within a composite framework intraorally the
easiest and most reproducible way
to do this. It then allows us to design
and mill a truly passive framework
by Createch and a temporary acrylic
bridge.

Conclusion
There are many opportunities to
opt in and out of using technology
regarding the digital implant workflow. For anyone considering capital
investment, the most important
question to ask is, how will or can
this improve the outcomes I provide
to my patients, and then determine
whether that warrants the expenditure. Too often are we subjected
to sales pitches of the next biggest
thing by company sales representatives and gadgets and gizmos end up
by the wayside.
Acknowledgements to Andy Morton
and Ian Murch, the fantastic laboratory technicians at Borough Crown
and Bridge that I work closely with.
Editorial note: This article was published in cadcam international magazine, Issue 2/2018.
Dr Ross Cutts is the principal dentist at
Cirencester Dental Practice in Cirencester
in the UK. He can be contacted at:
cuttsrg@aol.com

Fig. 8: Postoperative radiograph of implant placement.

Fig. 9: Surgical placement of LL67 implants

Fig. 10: Tissue-level implant

Fig. 11: Scanbodies

Fig. 12: Crowns on printed model

Fig. 13: Crownsin sit

Fig. 14: Composite flow material used to increase
scanning reference points

Fig. 15: Verification jig locked in situ to verify passive
implant positioning

Fig. 16: Createch framework showing the fit surface

Fig. 17: Final metal-ceramic bridge in situ

[31] =>

NEWS

Dental Tribune Middle East & Africa Edition | 6/2018

Majority of children perceive loss of first
tooth positively
By Dental Tribune International
ZURICH, Switzerland: Although
losing primary teeth can be unsettling and painful for children, an
interdisciplinary research group at
the University of Zurich (UZH) has
now found that children’s feelings
towards this experience are predominantly positive. The study also
established that previous visits to
the dentist, as well as parental background and level of education, affect
how children experience the loss of
their first tooth.
Children generally lose their first
primary tooth when they are about
6 years old. This gradual process is
probably one of the first biological
changes to their own bodies that
children experience consciously. The
emotions that accompany this milestone are extremely varied, ranging
from joy at having finally joined the
world of grown-ups to fear about the
loss of a body part.

development,” said study co-author
Prof. Moritz Daum, from the institute of developmental psychology
at the university. This finding is important for dentists and parents
alike: “Especially where cavities are
concerned, it’s worth communicating with children prudently,” added
Daum. “This way, emotions in connection with teeth and dentists can
be put on the most positive trajectory possible.”

The study, titled “Emotions experienced during the shedding of the
first primary tooth”, was published
online on 15 September 2018 in the
International Journal of Paediatric
Dentistry ahead of inclusion in an
issue.

Researchers from the University of Zurich have found that children mostly experience the
loss of their first primary tooth as something positive.
(Photograph: Nenad Nedomack/Shutterstock)

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An interdisciplinary team of researchers at UZH, in cooperation
with the City of Zurich’s school dental services, has examined the feelings that children experience when
they lose their first primary tooth
and what factors play a role. The scientists surveyed parents of children
who had already lost at least one of
their primary teeth. Of the nearly
1,300 responses received, around 80
per cent of parents reported positive
feelings, while only 20 per cent told
of negative emotions.

Moreover, the study found that socio-demographic factors are related
to children’s feelings. For example,
children were more likely to have
positive feelings such as pride or joy
if their parents had a higher level of
education and came from non-Western countries. The researchers indicate that cultural differences could
be at play here. These include education style and norms that parents
pass on to their children, as well as
transitioning rituals that accompany
the loss of the first baby tooth.
“Our findings suggest that children
deliberately process previous experiences concerning their teeth and
integrate them in their emotional

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The researchers found that previous visits to the dentist played a role
regarding children’s feelings. Those
whose previous visits were cavityrelated and thus perhaps associated
with shame or guilt experienced
fewer positive emotions when they
lost their first primary tooth. If, however, previous dental appointments
were the result of an accident, and
thus an abrupt, unexpected and
painful event, the loss of the first
primary tooth was more likely to be
associated with positive emotions.
According to lead author Dr Raphael
Patcas, from the Clinic of Orthodontics and Paediatrics Dentistry, one
possible explanation for this is that
primary teeth loosen gradually before falling out—a process that, unlike an accident, unfolds slowly and
predictably. This is also supported by
the finding that children who experience the loosening of a tooth over an
extended period tend to have more
positive feelings. The longer the
preparation and waiting time, the
greater the relief and pride when the
tooth finally falls out.

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[32] =>

INTERVIEW

Dental Tribune Middle East & Africa Edition | 6/2018

CEREC and single visit dentistry
By Dr Mohamed Hassanien, Egypt
We caught up with the Owner of
Computerized Dental Clinic (CDC),
Egypt, Dr Mohamed Hassanien.
CDC is comprised of predominantly
Dentsply Sirona equipment and
consumable products as part of their
commitment to offer the best possible service to their patients, with
digital dentistry at the heart of their
practice.
Please briefly explain how long
you have been working at CDC and
your background in dentistry.
CDC has been in operation for 16
years. I worked for 13 years as a Prosthodontist at the old CDC Heliopolis
branch which only had two operating rooms. I then opened our second
fully digital branch, CDC Sheraton,
with another three operating rooms
and a 3D cone beam facility, which
has been fully functioning for 3 years
now.
I started working in my own private
lab to do my lab work myself with
the conventional techniques until
I bought my first inLab MCXL in
2008. I used to be a clinician at the
same time.

Please tell us about your specialism within your practice?
CDC offers multiple specialties for
maximum patient care and satisfaction:
• Fixed Prosthodontics - all-ceramic
crown and bridge solutions to complete smile makeovers and full
mouth restorations.
• Restorative - root canal treatments
and teeth restorations.
• Implantology - implant solutions
and bone augmentation.
• Periodontology - gum care and surgeries
• 3D CBCT and diagnostics
• Paediatric treatments and oral
prophylaxis
• Orthodontics treatments and aligners
• Oral hygiene and bleaching
What triggered your initial interest
in digital dentistry?
I’ve always been interested in technology and that naturally led me
into the field of modern digital dentistry. Patient satisfaction has also
always been my ultimate goal and so
digital dentistry offered lots of clinical merits such as precision, speed,
ease and overall control of the treatments protocols.

How long have you been working
with Dentsply Sirona products?
I have been working with Dentsply
Sirona for 16 years in my own private
practice, however my university was
fully equipped with Dentsply Sirona
equipment’s as well, so their products and tools were part of my foundation in my educational journey.
When did you invest in your first
piece of Dentsply Sirona equipment, and what was it?
My first piece of Dentsply Sirona
equipment was a C2 treatment centre in 2003.
Your practice uses Dentsply Sirona
products and equipment predominantly. What would you say is the
advantage to your workflow and
your practice by making this decision?
The equipment is the highest quality
from Germany and that is definitely
reflected in the clinical outcome. The
ease and simplicity of all the clinical workflow steps and superior after sales technical support and care
means that my practice is as efficient
as possible.

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Dr Mohamed Hassanien, Egypt

How do you find the CEREC workflow? From scanning, designing, to
grinding/milling and sintering/fi
nalsation.
The CEREC workflow is simply amazing, and exactly what I wanted from
a chairside solution. I have full control over the treatment plan phases.
I closely evaluate the clinical situation depending on the clinical case,
prepare and scan easily, drawing my
margins the way I want them to be,
respecting my preps and changing
my parameters accordingly, depending on the material selection. I
choose whether I want to grind my
restorations or even use the extra
fine grinding mode for superior precision and fine margins. I have the
option to wet mill or dry mill my
zirconia based crowns for the best
fit. With the CEREC SpeedFire I can
sinter, stain and glaze chairside and
deliver my restorations on the same
day. Put simply, with CEREC, I feel I
am the master who has full control
of each clinical workflow step.
Why did you choose CEREC over
other CAD/CAM systems?
CEREC is a high end CAD/CAM solution that has been in the market for
more than 30 years with the highest
clinical performance and precision.
Lots of CEREC milled restorations
and specimens are being tested and
evaluated in research centres all over
the world. In addition there are thousands of clinical follow up cases, with
over 20 years of successful clinical
performance, published in international journals. The global popularity of CEREC is an added value, where
lots of cases are being discussed accross hundreds of training centres
and online training websites, and
therefore the learning curve is faster
for new users.
Just Google CEREC and you will find
more than 2 million search results!
Can you explain your experience
with the Dentsply Sirona sales process, from initial interest through
to purchase and after-sales support?
Dentsply Sirona sales reps I’ve dealt
with have been very helpful and are
highly qualified. All my purchases
have been very smooth and accommodating. Medi-Tech in Egypt (authorised Dentsply Sirona dealer), also
offered high-end after sales technical
support.
What are the types of cases you do
with CEREC? E.g. restoration, implantology, orthodontics.
The question should actually be
‘what can’t I do with CEREC? Simply,
I do everything with CEREC. Inlays,
onlays, endo crowns, full crowns,
micro prep veneers, veneers, bridges,
screw retained implant abutments,
cement retained implant abutments
and surgical guides. Now CEREC is

not only a quadrant solution, it’s a
full mouth solution.
How has CEREC, and single-visit
dentistry, affected the satisfaction
of your patients?
Patient satisfaction is very important for me. Patients will often take
videos of the milling process and
share it over their social media platforms. They are very happy having
an aesthetic restoration to the highest degree of precision, all in a single
visit. I also get a lot of referrals from
their families and friends after they
have shared their treatment experience.
How has CEREC and digital dentistry impacted your business?
Year on year my business has increased thanks to the implementation of digital dentistry in my practice and my list of patients is growing
every year.
In your opinion, can you achieve
a high return on investment with
CEREC and digital dentistry?
Definitely, CEREC and digital dentistry are a good investment if they
are used the right way. I haven’t met
a CEREC owner who regretted the decision of investing in CEREC. It’s now
a lifestyle for me.
What would you say was your goal
with CEREC, and would you say
you have achieved this yet?
My goal with CEREC was to use it for
full mouth solutions, and this has
been achieved with the recent materials available, including software
and hardware updates. I can do that
with great confidence and full patient satisfaction.
What do think your biggest
achievement has been in your
career to this point and how did
Dentsply Sirona help to make that
a reality?
Stepping into the field of digital dentistry has been a great achievement
in my career. Dentsply Sirona’s technology development and continuous support definitely has had a positive impact and made my dream
come true.

Dr. Mohamed Hassanien, Egypt
Owner of Computerized Dental Center
(CDC)
Graduated with a Bachelor of Science degree in Dentistry from Misr University for
Science & Technology in Egypt in 2002.
He graduated with a Master of Science
degree in Fixed Prosthodontics, Faculty of
Dentistry - Cairo
University in 2008. Later in 2011, he had
completed his PHD degree in Fixed Prosthodontics from Cairo University.
• CEREC and inLab user for 10 years
• ISCD Certiﬁed CEREC Trainer (2011 to
present)
• Dentsply Sirona certiﬁed inLab trainer

[33] =>

Mastership Programme
Lasers in Dentistry

Certiﬁcation Course

From Aachen Dental Laser Center &
RWTH International Academy - RWTH Aachen University & CAPP

DUBAI
AACHEN

Group 7
Registration Open

Prof. Dr. med. dent.
Norbert Gutknecht
DDS, MS, PhD
Germany

Dr. Dimitris Strakas
DDS, MSc, PhD
Greece

Dr. Miguel Rodrigues Martins
DDS, MSc, PhD
Portugal

Priv.-Doz. Dr. rer. medic.
Rene Franzen
Germany

Pathway to
German Masters
84 CME
& Daily Hands-on

One-year clinical specialisation course for selected wavelengths
Module 1 | 23-26 October 2019 (4 days) | Laser Safety, Laser Devices and Diode Lasers

Laser Safety Officer course | e-learning | Laser technique (Diode lasers) | High power Diode lasers (clinics) |
Scientific background and clinical indications | Skill training every day of every clinical indication | Patient treatments
(demonstrations)
Hands on: Pigmentation on soft tissue, gingivectomy and gingivoplasty, frenectomy, fibroma removal, crown
lengthening, depigmentation, endodontic procedure- canal irradiation performed on sheep heads | Patient treatments (demonstrations)

Module 2 | 11-14 March 2020 (4 days) | Module Erbium Lasers

Laser Safety Officer course | e-learning | Laser technique (Diode lasers) | High power Diode lasers (clinics) |
Erbium Lasers (clinics) | Laser technique (Erbium lasers) | Er:YAG and Er,Cr:YSGG | Scientific background and clinical
indications | Skill training every day of every clinical indication | Patient treatments (demonstrations)
Hands on: Preparation in enamel and dentine, generation of a retentive surface, canal decontamination, apicectomy,
soft-tissue cut with short pulses, soft-tissue cut with long pulses, open curettage, crown lengthening and bone
preparation performed on sheep heads. | Patient treatments (demonstrations)
Module 3 | 13-16 December 2020 (4 days) | Combined Wavelengths Therapy Concepts & Mastership Exams

Laser therapy concepts with the use of 2 different wavelengths | Written multiple-choice exam |
Oral Exam (presentation of 5 patient treatments cases with diode or Erbium lasers) |
Graduation Ceremony, after successful completion of an examination at RWTH Aachen University |
600 hours total workload | Over the complete course duration: case documentation & discussions
The programme targets dentists who would like to specialise in certain wavelengths. Over the course of one year, participants are taught fundamental physical
and technical knowledge, and how to recognise primary, secondary, and tertiary indications on 12 attendance days split into 3 modules held over 3 educational
blocks. This programme concludes with an official certificate of RWTH Aachen University, and is offered in collaboration with the RWTH Aachen International
Academy, the post graduate education wing of the University..

+971 528423659 | p.mollov@cappmea.com

www.cappmea.com/laser

[34] =>

PAEDIATRIC

Dental Tribune Middle East & Africa Edition | 6/2018

Lowest possible radiation exposure
in paediatric dentistry: The 3D Low Dose Mode
By Dentsply Sirona
In paediatric dentistry, clinicians
need to pay special attention to the
doses of radiation that are exposed
to young patients. The following case
study shows both the importance of
3D imaging to complete diagnosis
while demonstrating that this can be
achieved using the Low Dose Mode
of the Orthophos SL 3D X-ray unit.

Methods
In this case, the author took an initial
two-dimensional panorama image
using the Orthophos SL 2D/3D hybrid X-ray unit. Due to an incidental
finding and the suspicion of an additional problem requiring treatment,
a 3D image was taken using the hybrid unit’s Low Dose Mode.

Case Study
A young patient presented with
lower jaw symptoms. Tooth 38 had a
difficult arrangement (Dentitio difficilis). A traditional panorama image
was taken using the practice’s Orthophos SL 2D/3D hybrid X-ray unit.
The initial imaging showed several
problems including that the mandibular canal was covering the root
of tooth 38. It also showed that the
roots of teeth 38 and 48 were in the
process of breaking down and that
tooth 28 was displaced.
I suspected that tooth 26 suffered
from inflammation of the root tip.
In order to confirm the diagnosis, the
practice took a DVT but in Low Dose
Mode with the Orthophos unit. By
using a 3D image, it was clear that the

mesial root of tooth 26 was indeed
inflamed and infected. The 3D image
also helped to show the positional
relationship of tooth 38 to the mandibular canal and the inter-radicular
position of tooth 28. It also showed
osteolysis from tooth 27. In this
case, the 3D image enabled a more
complete diagnosis of the young
patient’s symptoms and revealed
several problems that were not immediately obvious.

Summary
In this case, 3D imaging in Low Dose
Mode delivered a high enough quality image to make a full diagnosis of
the patient’s symptoms in order to
develop of complete treatment plan.
Low Dose Mode offers a reduction of

radiation of up to 85 percent in comparison with traditional 3D imaging
which is a benefit particularly in paediatric dentistry as children are more
vulnerable to radiation-induced cancers.

Results
Even in Low Dose Mode, the 3D images enabled proper visualisation of
the positional relationship of tooth
38 to the mandibular canal and enabled the author to determine which
of the three roots of tooth 26 was
infected.

According to the transversal
slice image (TSI) of the Low
Dose scan the displaced tooth
28 shows no signs of its roots
being resorbed.

The first signs of osteolysis are recognisable.

The image confirms the suspicion of apical osteitis of the mesial root.

The generated panorama image shows the displacement of tooth 28.

Positional relationship of tooth 38 to the mandibular canal.

Mandibular movement monitoring may
help improve oral sleep apnoea devices
By Dental Tribune International
NAMUR, Belgium: To date, continuous positive airway pressure is still
the industry standard when it comes
to treating sleep apnoea. However,
the cumbersome machines are not
well tolerated by patients. In a new
study, researchers have demonstrated that mandibular movement (MM)
monitoring can be used to assess the
efficacy of other oral devices.
In the study, 56 patients with obstructive sleep apnoea (OSA) were
fitted with a custom mandibular
advancement splint (oral appliance
therapy) and had their midsagittal
MM tracked. Patients were evaluated
at the end of the titration procedure.
During the titration procedure, different degrees of advancement are
trialled up and down to find the single best amount to control apnoea
events for the particular patient.
Lead investigator Dr Jean-Benoît
Martinot, from the Sleep Labora-

tory at the Sainte-Elisabeth site of the
UCLouvain Namur teaching hospital, explained that the novelty of the
study was tracking sleep MM in order
to assess the effectiveness of oral appliance therapy (OAT). “Our study
suggested for the first time that MM
monitoring represents a powerful tool for assessing the efficacy of
OAT,” he continued.
According to the study’s results, by
the end of titration, all indications of
OSA had decreased compared with
the initial baseline. Overall, patients
also showed a reduction of vertical
respiratory MM and sleep respiratory
effort, as well as a dramatic decrease
in obstructive hypopnoea. Scores
from the apnoea–hypopnoea index
and oxygen desaturation index also
dropped, and the researchers found
that MM monitoring also helped reveal the presence of central apneas.
With new technology on the horizon, the researchers believe that MM

A new study has shown that mandibular movement monitoring can be used to assess the efficacy of oral devices to treat obstructive
sleep apnoea. (Photograph: tommaso79/Shutterstock)

monitoring could potentially represent a cost-effective and easy-to-implement tool for sleep clinics to use
when titrating oral appliances. “MM
monitoring during sleep is practical

and informative for measuring indices of residual respiratory events
when OSA is treated by oral appliances,” commented Martinot.
The study, titled “Mandibular move-

ment analysis to assess efficacy of
oral appliance therapy in OSA”, was
published online on 6 November
2018 in Chest ahead of inclusion in
an issue.

[35] =>

IADR / Kulzer Travel Award 2019
Call for applications
Join us at the 97th IADR General Session & Exhibition in Vancouver, BC, Canada
The International Association for Dental Research (IADR), in cooperation with Kulzer, has founded the
IADR / Kulzer Travel Award.
The objective of this award program is to encourage young investigators to undertake research in new /
innovative testing methods of dental materials, and new ideas and approaches to improve and develop
dental materials.
An award will be granted to one person from each of the following regions: North America,
Latin America, Europe, Africa / Middle East and Asia / Pacific.
®

Each of the five winners will receive US $2,500 for expenses to attend and present their results at
the 97th IADR General Session & Exhibition in Vancouver, Canada, June 19 – 22, 2019.

VANCOUVER, BC, CANADA· JUNE 19-22, 2019

More information about this award and the application process can be found on the IADR Website:
www.iadr.org
Deadline for submission: January 14, 2019

Giving a hand to oral health.

© 2018 Kulzer GmbH. All Rights Reserved.

Kulzer GmbH · Leipziger Straße 2 · 63450 Hanau · Germany · kulzer.com

[36] =>

NEWS

Dental Tribune Middle East & Africa Edition | 6/2018

Faculty of Dentistry, Oral & Craniofacial
Sciences at King's College London
World leading in dental, oral and craniofacial education, research and clinical care
By King’s College London
As the Dental Institute at King’s College London enters the 20th year
anniversary of its formation, they
emerge with a fresh leadership team
and a new name to recognise the
breadth and depth of their education
and research portfolios.
• Professor Michael Escudier as
Deputy Executive Dean. Professor
Escudier is the current Dean for the
Dental Faculty at the Royal College of
Surgeons London.
• Professor Kim Piper as Dean for
Education. Professor Piper is currently Head of Admissions and Widening Participation for Medicine and
Dentistry at Queen Mary University
of London, and Professor of Oral Pathology.
• Professor Abigail Tucker as Dean
for Research. Principal Investigator
and Professor of Development &
Evolution, Professor Tucker holds a
Wellcome Senior Investigator award
to study the middle ear.
• Professor Nigel Pitts as the academ-

ic lead for Impact. Professor Pitts is
the leader of the Global Collaboratory for Caries Management initiative
and chair of the Alliance for Cavity
Free Future.
King’s distinguishes itself with a
unique research portfolio in dental,
oral and craniofacial sciences, embracing blue skies discovery research
in addition to translational and clinical sciences. The research focuses on
three key pillars which will link with
each other, the wider health sciences
at King’s, and with external partnerships.
• Development, Regeneration, Repair
& Tissue Engineering, led by Professor Paul Sharpe
• Immunity, Infection & Host Microbiome Interactions, led by Professor
Gordon Proctor
• Clinical, Translational & Population Health, led by Professor David
Bartlett
The International agenda is led by:
• Professor Jenny Gallagher - New-

land-Pedley Professor of Oral Health
Strategy and Honorary Consultant in
Dental Public Health.
• Professor Jeremy Green - Principal
Investigator and Professor of Developmental Biology.
The newly appointed team will sup-

port Professor Mike Curtis, Executive
Dean, a distinguished microbiologist
with a robust track record of academic leadership. Professor Curtis’
current research is focused on the
role of the oral microbiome in maintaining oral health and developing
disease, and key microbial virulence

determinants of oral bacteria.
See more at https://www.kcl.ac.uk/
dentistry/newsevents/news/newsrecords/2018/october/the-facultyof-dentistry-oral-craniofacial-sciences-at-king's-college-london.aspx

Discover our range
of master’s level and
short courses.

Adult stem cells
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Postgraduate education and training opportunities: MSc, MClinDent
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A team of researchers at King’s College London and their collaborators
have discovered why laboratorygrown tissues may fail when used to
treat a range of conditions. For the
last 20 years stem cells have been
routinely placed within 3D biodegradable materials or “scaffolds”
to grow new tissues to treat conditions such as osteoarthritis or heart
failure. The discovery of why these
engineered tissues have often failed
to live up to their promise may now
resolve some long-standing conflicts
in the field and enable more successful transplants in the future.
The study is a collaboration by a
team of researchers at King’s College
London, Imperial College London,
University College London and the
Francis Crick Institute. The impact
for the field will be that scaffold
design will no longer be simple. Researchers will now have to design
scaffolds that take into account that
cells will modify their surroundings
once they are inside.
“The positive side of this discovery is
that now we know cells make these
modifications and it impacts their
fate,” explains Dr Gentleman. “When
we provide stem cells with a 3D
structure to help them form a tissue,
we have to remember that they will
modify the environment we present
to them. To really coax them to form
the tissue we want, we have to find
ways to harness this effect so that the

local environment they create is one
that will drive their differentiation
down the correct path.”
“Bi-directional cell-pericellular matrix interactions direct stem cell fate”
published in Nature Communications on 3 October, 10.00 BST. It can
be viewed at Nature Communications under the Digital Object Identifier number 10.1038/s41467-01806183-4. View the paper online here:
https://rdcu.be/8oKF.
Dr Eileen Gentleman is a Principal
Investigator in the Centre of Craniofacial and Regenerative Biology at
King’s College London. The Gentleman lab works at the interface of
stem cell biology, chemistry and
materials science to develop innovative biomaterials for regenerative
medicine.

[37] =>

Certificate & Diploma in
Clinical Implantology
DUBAI

From British Academy of Dental Implantology
& British Academy of Restorative Dentistry

2019-2020

Faculty Leads:

Prof. Göran Urde, Sweden
Programme Director of Implantology
Postgraduate Education Faculty of
Odontology, Malmo University

IMPANT SYSTEM SPONSOR

Prof. Paul Tipton, UK
Specialist in Prosthodontics
President, British Academy
of Restorative Dentistry

Dr Christer Dahlin, Sweden
Specialist Oral & Maxillofacial
SurgeryProfessor in Oral
Surgery and Guided Tissue
Regeneration

15 Implants
& Lab Work Included

Prof. Arwa Ali ALSayed,
Saudi Arabia
B.D.S., M.S., M.Sc., M.C.D.

Dr. Ninette Banday, UAE/USA
Specialist Restorative Dentist
& Implantologist

Live Treatment
Group 3
Hands-On (40%) 168 CME
Registration
Available Open

DENTAL LAB SPONSOR

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Module 1 | 25-28 June 2019 (4 days) | Basics of Implantology

Programme outline: implant market, osseointegration, treatment alternatives, treatment planning and patient
selection, basic surgical techniques and protocols. Hands-on training: surgical techniques and medico-legal aspects
to implant dentistry.
Module 2 | 31 October - 03 November 2019 (4 days) | Treatment Planning and Surgical Treatment

Programme outline: implant design, radiographic techniques, implant surgery, implant specific treatment planning.
Basic practice management.
Module 3 | 23-26 January 2020 (4 days) | Restorative Aspects of Implantology

Programme outline: restorative techniques, prosthetic hands-on training, patient treatment, follow-up and
oral hygiene, complications to avoid and treat. In depth practice management.

Diploma | 3 Modules | 12 Days

Module 4 | 16-19 April 2020 (4 days) | Immediate and Early Loading Concepts and Treatment of the Resorbed Jaw

Programme outline: tooth now concept, immediate and early loading concepts from single tooth to fully
edentulous patients, severely resorbed jaws, sinus lift and ridge splitting techniques, hands-on training and
live patient surgical treatment.
Module 5 | 11-14 June 2020 (4 days) | Medical Compromised Patient and Soft and Hard Tissue Management |
Aesthetic and Restorative Challenging Patient

Programme outline: medications related osteonecrosis, GBR techniques, soft tissue management, implant
aesthetics, ceramics and implants.
Module 6 | 03-06 September 2020 (4 days) | Rare Complications and Techniques

Programme outline: rare complications, combination implants and teeth, live patient treatment, written and oral
examination and case presentations.

+971 528423659 | p.mollov@cappmea.com

www.cappmea.com/implant

[38] =>

NEWS

Dental Tribune Middle East & Africa Edition | 6/2018

CAPP upgrades and relocates its state-of-art
phantom head training centre
In September 2018, CAPP opened its brand new dental training centre in Dubai. CAPP Training Institute
is a world-class facility hosting continuing professional development events and hands-on training
courses since 2016. CAPP has been organising continuing dental educational programs since 2005.
By Dental Tribune MEA / CAPPmea
The CAPP Training Institute is
equipped with the latest dental
equipment such as phantom heads,
clinical units with high, low and
speed-increasing handpieces supported by dental compressors, microscopes, the latest TV/AV equipment and a lot more. The training
centre consists of two sections – a lecture room hosting up to 35 delegates

and a phantom head facility hosting
up to 30 delegates in a modern and
trendy atmosphere. It is easily accessible by road and public transport
and offers free of charge parking facilities.
Only from its opening on the 27th of
September until end of November
2018, 42 training days have taken
place educating over 400 dental professionals in various topics such as

Prof. Paul Tipton teaching “Occlusion” in the lecture room of the training
centre

implants, restorative, aesthetic, laser,
endodontics, dental technology and
others. In 2019, the CAPP Training Institute is already booked for 168 days
and it is open for external companies and educational institutions to
rent the facility.
The institute is a venue for a broad
range of short and long intensive
dental specialised hands-on training
courses organised in a friendly teach-

ing environment by presenters and
facilitators who are well experienced
and highly regarded within their
fields of expertise. The main courses
running are namely the Restorative
Aesthetic Dentistry Certificate and
Diploma, the Clinical Endodontics
Certificate & Diploma, the Clinical
Implantology Certificate & Diploma
and the Lasers in Dentistry Mastership programme.

A delegate using speed-increasing handpiece to prepare a tooth on the
phantom head

View of the training facilities of the CAPP Training Institute

Minimal Invasive Dentistry
HANDS-ON COURSE
13 February 2019
Wednesday

CAPP Training Institute
Dubai | UAE

Area of interest:
General Dentistry

AED 2,200
$ 600

Prof. Edward Lynch, UK/USA
He is a specialist in 3 disciplines, Endodontics, Prosthodontics and Restorative
Dentistry as well as being a BUPA Consultant in Oral Surgery, and presents at
many prestigious postgraduate courses worldwide each year.

Prof. James Prichard teaching Clinical Endodontics under magnification

Course Objectives
The morning session will consist of lectures covering minimally invasive dentistry and the afternoon
practical will include minimally invasive dentistry, ozone, the latest methods for caries removal, use of
GIC's, adhesives and composites, and the placement of the conservative new minimally invasive One
Visit Crowns.

Course Outcome
On completion of this day, the delegate will be able to have understanding of the principles of minimal
invasive dentistry:
• Comprehensively detect and diagnose carious lesions (occlusal caries attached dental plaque, proximal
or smooth surface lesions. Electrical conductance, quantitative laser ﬂuorescence, laser ﬂuorescence,
tuned aperture computer tomography, optical coherence tomography.)
• Apply eﬀective treatment to identiﬁed carious lesions (remineralisation and pH, adjustment of oral
environment. Air abrasion. Cavitation. Minimal cavity designs. Adhesive materials such as glass ionomer
cements (GICs). Resin based composites/dentine bonding agents. Lamination. Tunnel/internal/mininbox/slot preparations. Laser cavity preparations.)
• Monitor those patients given minimal invasive surgery and evaluate (portfolio of patients, their needs vs
treatments, outcomes, corrective/further treatments.)
• Learn the latest methods and research with tooth whitening
• Learn all about and place, bond, ﬁnish and polish the new minimally invasive One Visit Crowns

Minimal invasive veneer preparation on phantom heads

www.cappmea.com/courses
CONTACT

ACCREDITATION

CAPP EVENTS
Onyx Tower 2 | Oﬃce P204 & P205
The Greens | Dubai | UAE
Mob/WhatsApp: +971502793711
Tel: +971 4 347 6747
E-mail: events@cappmea.com
Web: www.cappmea.com

CAPP designates this activity for 14 CE Credits

Est. DOH-Abu Dhabi 14 CME | Est. DHA 12 CME

Sinus-lift hands-on training on sheep jaws using piezosurgery with
Dr. Christian Makary

[39] =>

39

EVENT

Dental Tribune Middle East & Africa Edition | 6/2018

10th Dental Facial Cosmetic Int'l
Conference & Exhibition Impressions

Over 3000 delegates attended the two day event 10th Dental Facial Cosmetic Conference & Exhibition

Dr Munir Silwadi – Conference chairman

Dr Christian Makary, Lebanon presented during the 10th Dental Facial
Cosmetic Conference & Exhibition

Dr Aisha Sultan – President of the Emirates Dental Society

Dr Carlos Sabrosa, Brazil lecturing on veneers

The event once again established itself as the region’s largest scientific
dental conference

The event once again established itself as the region’s largest scientific
dental conference

Assoc Prof Cristian Dinu, Romania lecturing on Guided one Regeneration

Free CME Training at the booth of 3M with Dr Carlos Sabrosa

Dr Sylvia Rahm, Germany lecturing on composite restorations

Free CME Training with Dr MohanadZuhair Kamalah on Bio-film Management

Prof Andrea Mombelli, Switzerland presented during the 10th Dental
Facial Cosmetic Conference & Exhibition

Free CME Training at the booth of Dentsply Sirona with Dr AbdelAziz
Yehia

Hands-on training with Dr Matthew Holyoak

Hands-on training on phantom heads

Dr Marc Lazare, USA presented during the 10th Dental Facial Cosmetic
Conference & Exhibition

Over 3000 delegates attended the two day event 10th Dental Facial Cosmetic Conference & Exhibition

[40] =>

Dental Tribune Middle East & Africa Edition | 6/2018

POSTER PRESENTATION

1st Place Poster Presentation Winner
th
10 Dental Facial Cosmetic Conference, Dubai, UAE
A Novel Approach to Improve Repair Bond Strength of Repaired Acrylic Resin: An in-Vitro Study on
the Shear Bond Strength
Masoumah S. Qaw, Tahani H. Abu Showmi, Danah F. Almaskin, Zahra A. AlZaher,
Mohammed M. Gad BDS, MSc, Reem Abualsaud, BDS, DScD, Fahad A. Al-Harbi BDS, MSD, DScD

Introduction

Results

Denture bases are subjected to fracture if dropped or stressed beyond
their fracture strength. Therefore, denture repair is needed sometimes.
Many mechanical and chemical factors affect the repair strength.
The aim of the study was to introduce a new approach that increases
the bond strength at denture base resin/repair resin interface. This
study evaluated the effect of mechanical surface treatments with
intermediate material applications (alumina blasting + silane coupling
agent [SCA] or methyl methacrylate [MMA]) on the shear bond
strength (SBS) of repaired denture base material. It also evaluated the
combined effect of nano-ZrO2 and surface treatments on the SBS of
repaired acrylic denture base and compared the values with those of
unreinforced PMMA resin. In addition, the treated surfaces were
characterized by means of scanning electron microscope (SEM).

The mean bond strength value of repair resin to alumina blasted
denture base specimens with application of intermediate agents was
significantly higher in comparison to control group (P<0.05). For
surface treatment, alumina blasting followed by SCA application,
showed the highest SBS values (15.42±1.98MPa). Nano-ZrO2
addition resulted in statistically significant increase (p<0.05) except
for AB, and AB+MA repaired with 5% and 7.5% nano-ZrO2 (P>0.05)
(Figure 3). SEM showed that alumina blasting produced rougher and
porous surface, while SCA and MA application reduced the
irregularities and deep pits (Figure 4).
Shear Bond Strength- Mean and SD
25
20

Materials & Methods
SBS (Mpa)

Heat-polymerized acrylic resin was used to fabricate 130 cylindrical
blocks 15 mm in diameter. Specimens were divided into different
groups according to surface treatment and NZ concentration (Figure 1).
Repair resin was mixed and applied to the bonding area and
polymerized at 37°C for 10 minutes. SBS (MPa) testing was
performed using universal testing machine (Figure 2). Scanning electron
microscopy (SEM) was used. Statistical analysis was done using
ANOVA and Tukey post-hoc test at α = 0.05.

15
10
5
0

Figure 3. Mean, SD, and significance of all tested groups for shear bond strength values of repaired
specimens (MPa)

Figure 4. SEM images showing the effect of surface treatment before repair. (A) Control specimen;
(B) Alumina-blasted; (C) Alumina-blasted + SCA; (D) Alumina-blasted + MA.
Figure 1: Study workflow. C=control, AB= Alumina blasting, SCA=Silane coupling agent, MA= Methyl
methacrylate based composite bonding agent, NZ= Zirconium oxide nanoparticles, SEM= Scanning
electron microscope

Conclusions
Within the limitations of the study, following conclusions were drawn:
• Mechanical surface treatment using alumina abrasive air-particles
improved the shear bond strength.
• SCA and Methyl methacrylate based composite bonding agent
application to mechanically treated repair surfaces improved the
repair bond strength and could be used as a new adhesive
technique for denture repair.
• Application of SCA in combination with Nano-ZrO2 reinforced
repair material enhanced the repair bond strength.

References
•
•

Figure 2: Schematic diagram showing a specimen fixed in the jig, which is mounted on universal
testing machine for shear bond testing.
TEMPLATE DESIGN © 2007

www.PosterPresentations.com

•

Gad MM, Fouda SM, Al-Harbi FA, Näpänkangas R, Raustia A. PMMA denture base material enhancement: a
review of fiber, filler, and nanofiller addition. International Journal of Nanomedicine. 2017; 12:3801-3812.
Vasthare A, Shetty S, Kamalakanth Shenoy KK, Shetty MS, Parveen KA, Shetty R. Effect of different edge profile,
surface treatment, and glass fiber reinforcement on the transverse strength of denture base resin repaired with
auto-polymerizing acrylic resin: An In vitro study. J Interdiscip Dentistry 2017; 7:31-7.
Gad MM. Evolution of Denture Repair and a Review of New Era. J Dental Sci 2017, 2(2): 000125.

[41] =>

POSTER PRESENTATION

Dental Tribune Middle East & Africa Edition | 6/2018

2nd Place Poster Presentation Winner
th
10 Dental Facial Cosmetic Conference, Dubai, UAE
Prevalence of distal caries in mandibular second molar
related to impacted third molars in RAKCODS
Dr. Aya Khanji
Research Supervisor: Dr. Sabrin Ali, Research Coordinator: Dr. Carolina Duarte
Introduction
Failure of normal tooth eruption, due to various
factors, is referred to as impaction. The most
common impacted teeth are mandibular third molars.
It is diﬃcult to treat and it is indicated to be removed
without delay to avoid caries development in the
neighboring second molar and loss of both teeth.
Extraction of the third molar results in less
complications and better dental health, improved
gum health in the area adjacent to the second molar.

Aim:
The aim of this study was to
evaluate the prevalence of
distal caries in second molar
teeth due to impacted third
molar teeth in RAKCODS and
their relation to gender and age.
Keywords: Impacted third molar,
Distal caries, Radiographic study,
Orthopantomograms.

Materials and methods:
A total of 100 Orthopantomograms (OPGs) of patients reporting to RAKCODS
over a period of three years were screened and randomly selected according
to inclusion and exclusion criteria. The data was collected and cross checked
for any discrepancies and entered into excel spread sheet. Descriptive analysis
of the data was done and results were displayed as graphs.
Results:
According to this study, 20% cases show distal caries on mandibular second molars and 80% cases
show healthy second molars. There was no relation between gender and impaction, but when studied
independently, it showed that mesial impaction was more common in males, and horizontal impaction
was more common in females. Age wise, there was no relation between age and cavity existence.

Conclusion:
A total of 80% of the patients with impacted third molars had no distal caries on mandibular second
molar. It was found that there is no relation between gender and impaction, and that there are equal
chances of caries existence regardless of age or gender.
REFERENCES
1. ASIF, S. A., SYED, N., SHAH, A. A., & Akhtar, M. U. (2014). DENTAL CARIES AND
PERICORONITIS ASSOCIATED WITH IMPACTED MANDIBULAR THIRD MOLARS" A CLINICAL AND
RADIOGRAPHIC STUDY. Pakistan Oral & Dental Journal, 34(2).
2. Brkić, A. Impacted Teeth and Their Inßuence on the Caries Lesion Development.
3. Marciani, R. D. (2012). Is there pathology associated with asymptomatic third
molars?. Journal of Oral and Maxillofacial Surgery, 70(9), S15-S19.

[42] =>

Dental Tribune Middle East & Africa Edition | 6/2018

42

POSTER PRESENTATION

3rd Place Poster Presentation Winner
th
10 Dental Facial Cosmetic Conference, Dubai, UAE
Determining Stages Of Non-Cavitated Fissure Caries Using
Optical Coherence Tomography (OCT)
E. Zaina,d C.M. Zakianb H.P. Chew a,c

a) University of Malaya, Kuala Lumpur b) Kevork Instruments, R&D department, Mexico
c) Minnesota Dental Research Center for Biomaterials and Biomechanics, Minneapolis, Minnesota, United States
d) Department of Restorative Dentistry, Lincoln University College, Kuala Lumpur, Malaysia

INTRODUCTION
Staging of non-cavitated fissure caries (NCFC) lesions is essential as these lesions are preventable and can potentially be reversed or arrested by risk adjusted
and non- invasive strategies [1]. Visual inspection is the most ubiquitous method used in the staging of fissure caries lesions clinically. Visual detection system
such as the International Caries Detection and Assessment System (ICDAS) has been proven to have good accuracy and reproducibility [2]. However, such
systems require training and calibration with a reference examiner [2] and can be time consuming [3]. It also falls short of true quantification as it uses
qualitative assessment. Optical Coherence Tomography (OCT) is a non- invasive, non- radiative , high resolution cross sectional imaging modality that utilizes
near–infrared light operating at 1310-nm.

OBJECTIVE

The objective of study was to assess the performance of OCT in determining stages of NCFC using OCT backscatter intensity profile (A-scan).

MATERIALS AND METHODS
3. Sectioning and imaging
2. 3D OCT imaging

4. Final cohort selection

1. Sample selection

Fig a
90 investigation sites (ISs) from 46
extracted permanent human
premolars were initially scored using
ICDAS 1 and 2

7. Mean A-scan

An overall mean A-scan for each Ek
code was computed. Total Areaunder-the-curve (AUCT) between
physical depths of 0-150µm
subsurface (blue dotted lines) was
computed for each Ek code

3-dimensional (3D) scans of
3mm in x-y-z axis were
performed using a Sweptsource (OCT OCS1300S,
Thorlabs Inc.).

The ISs were sectioned perpendicular to
fissure for Polarized Light Microscopy (PLM)
to thickness of <200µm and imaged under
4x magnification after imbibition in water
using Nikon E 90i microscope.

Mean A-scan was generated from 50 A-scans (red arrow) at each ISs using Matlab

CONCLUSION
References:

R
E
S
U
L
T
S

5. Selection of OCT B-scan

Single OCT B-Scan was selected (Fig b) out of 104
B- scans based on fissure anatomy (red arrow)
corresponding to PLM image (Fig a-white arrow)

6. Data extraction and analysis

Post hoc Dunnet T3 test comparing for Ek code 1 and 2

Final cohort was selected on PLM image using
Ekstrand (Ek) histology criteria with final sample
size of Ek1=30 and Ek2=60 ISs.

Fig b

SN,SP,AUROC values for differentiating Ek code 1 and 2

OCT has potential to differentiate NCFC using OCT backscatter intensity profile (A-scans). Such
quantitative measurements can be useful for monitoring the state of early lesions and enable timely
remineralization.

1. Gomez, J. (2015). Detection and diagnosis of the early caries lesion. BMC Oral Health, 15 Suppl 1, S3.
2. A.Jablonski-Momeni, V. Stachniss, D.N. Ricketts, M. Heinzel-Gutenbrunner, K. Pieper, Reproducibility and accuracy of the ICDAS-II for detection of occlusal caries in vitro, Caries Res. 42 (2) (2008) 79–87.
3. M.M. Braga, L.B. Oliveira, G.A. Bonini, M. Bonecker, F.M. Mendes, Feasibility of the International Caries Detection and Assessment System (ICDAS-II) in epidemiological surveys and comparability with standard World Health Organization criteria, Caries Res. 43 (4) (2009) 245–249
. study was supported by High Impact Research MoE Grant UM.C/625/1/HIR/MoE/DENT/11 from the Ministry of Education Malaysia.
This

[43] =>

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www.dental-tribune.me

Published in Dubai

November-December 2018 | No. 6, Vol. 8

Direct pulp capping as
a conservative procedure to
maintain pulp vitality
By Dr. Jenner Argueta, Guatemala
From a completely optimistic
point of view, the ultimate goal for
every dentist performing a restorative and/or endodontic procedure
should be to maintain the pulp vitality and functionality of the tooth
without any discomfort for the patient. The pulp tissue is needed to
provide nutrition, innervation and
immunocompetence, with these
acting as a defence mechanism and
alerting to the presence of any external aggression.1
The pulp tissue may be exposed
to the oral environment as a result
of dental caries or by mechanical

means when performing restorative
or prosthetic procedures. Two possible treatment options in these types
of cases are root canal therapy and
tooth extraction; the former procedure is a good choice, whereas the
latter should be avoided at all costs
in order to maintain the patient’s
oral health and natural function.2–4
A third alternative in the case of pulp
exposure is to use conservative vital
pulp therapy procedures, which include direct pulp capping, indirect
pulp capping where the pulp is not
fully exposed, and partial or total
pulpotomies; this way, it is possible
to maintain the vitality of the tooth,
the nociceptive function and the

body’s self-defence system. Thanks
to the points mentioned previously,
among others, it has been shown
that teeth with no root canal therapy
survive longer than those that have
been treated endodontically.2, 5, 6
Next, we present two clinical cases in
which the pulp tissue was exposed
mechanically when carious tissue
was removed. In both cases, it was
managed to maintain the pulp vitality of the affected teeth by means of
direct pulp capping. The vital pulp
capping protocol suggested in this
article is presented in the first case.
The second case describes a treatment performed with long-term
follow-up, where full formation of

calcified tissue below the capping
material could be observed by means
of radiography. The treatment protocol was similar in both cases.

SUBSCRIBE NOW
https://me.dental-tribune.com/e-paper/
4/18

issn 2193-4673 • Vol. 14 • Issue 4/2018

roots
international magazine of

endodontics

opinion

3-D endodontic instrumentation:
Revision of a historical protocol

industry report

Strategies for the treatment of
extremely curved root canals

case report

Clinical Case 1
The 24-year-old patient attended
the dental clinic with transient provoked pain in tooth #19 (Fig. 1). The
diagnosis was reversible pulpitis. The
carious tissue was removed under
complete isolation, producing two
incidences of pulp exposure, with
minimal bleeding (Fig. 2). Bleeding
was stopped by applying pressure
for 10 seconds using a cotton swab
dampened with a sterile saline solution. The cavity was disinfected
with 2.5% sodium hypochlorite (Fig.

Management of referred pain

3), and then white mineral trioxide
aggregate (MTA, Produits Dentaires)
was placed as a direct pulp capping
material (Fig. 4). To ensure that the
MTA was placed accurately, the MAP
System micro-applicator for dental materials (Produits Dentaires)

ÿPage A2

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[47] =>

ENDO TRIBUNE

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page A1

Fig. 1

Fig. 2

Fig. 4

Fig. 5

Fig. 7

Fig. 10

Fig. 13

Fig. 16

Fig. 3

Fig. 6

Fig. 8

Fig. 9

Fig. 11

Fig. 12

Fig. 14

was used. This
system allows
the clinician to
place the material exactly on
the exposure
site, and this
avoids staining
the
dentinal
walls,
which
could over time
show pigmentation due to the
material used
(Figs. 5 & 6).
Once the MTA
was placed on

Fig. 15

the sites of pulp exposure and the
deep parts of the pulp chamber roof,
a light-curing calcium hydroxide
paste was applied.
This was used to protect the material (Fig. 7) and to be able to proceed
to the bonding procedure, to put the
final restoration of the tooth in place
during the same session (Figs. 8 & 9).
Seven days after the procedure, the
patient was completely asymptomatic and the tooth responded normally to sensitivity tests. In clinical
situations like this, it is expected that
there will be radiographic evidence
of mineralised tissue formation be-

low the cap between six and nine
months after the procedure.7

Clinical Case 2
The 35-year-old patient attended the
dental clinic with transient provoked
pain in tooth #4. The diagnosis was
reversible pulpitis. The same vital
pulp therapy protocol described
in the first case (Figs. 10–12) was followed, except that in this case, the
permanent restoration was not
put in place during the same session. In its place, a temporary nonradiopaque restorative material was
placed.
This made it possible to ascertain

the suitable thickness of the pulp
capping material and its precise positioning at perforation level, while
keeping the dental margin clear for
a good bonding protocol (Figs. 13–15).
It has been reported that the success
rate of vital pulp therapy procedures
may drop when the final restoration is put in place two days after the
initial procedure.8 The MAP System
is very useful for precise and stable
placement of the capping material
in direct procedures, indirect procedures, and partial and total pul-

ÿPage A3

[48] =>

endo tribune

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page A2
potomies. Here, the final restoration
was placed 15 days after the initial
procedure and the patient was completely asymptomatic. Nine months
later, full formation of calcified tissue could be seen at the level of the
pulp capping, the tooth remained
vital and the patient was completely
asymptomatic (Fig. 16).

Obtaining the right diagnosis is key
to the success of conservative pulp
therapy. An ideal case is a diagnosis
of reversible pulpitis with no previous history of spontaneous or prolonged dental pain.9 It is generally accepted that a history of spontaneous
pain or pain at night is associated
with the existence of an irreversible
pulp inflammation process.10, 11 In

these cases, the success of direct pulp
capping may be questionable,12 although there are studies indicating
that vital pulp therapy can be successful even in these situations.2, 13 –15
When it comes to the long-term
success of conservative pulp procedures, it is extremely important to
provide a final permanent restora-

tion for the tooth that ensures a suitable marginal seal. The reason is that
this last factor, in conjunction with
the absence of bacterial contamination during the procedure, is among
the most important factors to consider in order to avoid subsequent
pulp inflammation.4, 16 The success
rate reported for vital pulp therapy
procedures using MTA with a follow-

up period of up to ten years is greater
than 80%17 — a fairly high percentage for a dental procedure within
that functional period.
Editorial note: A list of references is
available from the publisher. This article was published in the 3/2018 issue
of roots_international magazine of
endodontics.

A contemporary endodontic
approach using bioceramic cement
By Prof. Dr Leandro A. P. Pereira
Endodontics is the specialty of dentistry which prevents or treats pathologies of pulpal and periaplical
origins. The ultimate goal is to cure
the endodontic disease and allow the
affected tooth to reestablish its aesthetic/functional functions through
a complementary restorative treatment.
Obturation of the root canal system
is an important step in endodontic
treatment and its function is to fill
and seal the canals to prevent their
recontamination. With the evolution
in intracanal microbiological knowledge and the impact of new canal
modeling instruments with continuous or alternating rotation, we know
that it is not possible to completely
eliminate the microorganisms in-

side the endodontic microanatomy.
However, we also know that this is
not necessary for success, and that
the significant reduction in the levels of intracanal infection, in most
cases, is sufficient to achieve success
(SIQUEIRA). Thus, at the time of obturation, it is necessary to create an
intercanal environment which is unfavourable to the population growth
of the remaining bacteria. Therefore,
another function of obturation is to
prevent or hinder the growth of residual bacteria not eliminated during the cleaning and disinfection
process.
To achieve the desired objectives,
obturation cements must have essential properties in order to be used
clinically. These are: capacity to fill,
seal, and present dimensional stability; not being soluble in the organic

tissue fluids; having a film thickness
or no more than 50 micrometers;
being radiopaque; having good
drainage; not producing chromatic
alterations; having suitable working
time; to set and be easy to manipulate and easy to remove if necessary;
to promote cementogenesis; to be
biocompatible and non-irritating to
the tissues of the periapex (Kenneth
M. Hargreaves 2001).
However, with the development
of new materials and rehabilitative concepts in the era of adhesive
dentistry, the search for two other
characteristics has become increasingly important in the development
of new endodontic cements. One
of them is the absence of eugenol,
which interferes in the strength of
the bond of the resin systems (VANO
et al 2006). The other characteristic

is bioactivity. Bioactivity is the capacity of a material to be integrated
with the tissues and structures of the
organism with which it is in contact.

responsible for the superior adaptation of this material to the dentin
(Torabinejad 1995 Reyes-Carmona
2009).

Bioactivity of the MTA is known
as biomineralization and was first
described by Reyes and Carmona
in 2009. In one in vitro study, the
authors used scanning electron microscopy images to observe the integration of the MTA with the dentin
through deposition of numerous apatite groups on the dental collagen fibrils throughout the dentinal tubule
surface in contact with the MTA. Another very interesting factor is that
the authors observed that the more
contact time the material had with
the dentin, the more extensive the
mineralizations were. These mineralizations took place, integrating the
material with the dentin, and may be

However, the low drainage capacity of MTA does not allow for its
use as an obturating cement. Thus,
to get the benefit of this material’s
biocompatibility, a new class of obturating endodontic cement was
created, known as silicate-based cements. This designation is derived
from the components which make
up the MTA and which are present in
these cements. They are: Tricalcium
silicate, Dicalcium silicate, Calcium
Oxide and Tricalcium aluminate.
The clinical case below shows the

ÿPage A4

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[49] =>

endo tribune

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page A3
After the modeling of the canals, the
system of canals was dried and filled
with EDTA-T 17% and an Irrisonic
ultrasound tip (Helse) was used to
passively activate the substance for
3 cycles of 15 seconds with renewal
of the substance for each cycle. After
the ultrasound passive activation,
the canals were again irrigated with
5ml of Sodium Hypochlorite at 2.5%.
The main gutta percha cones were
tested and adjusted. After this, the
system of canals was dried with aspiration micro-cannulas connected to
a vacuum suctor.
The Fillapex MTA cement (Angelus)
was prepared and introduced into
the canals using the main gutta percha cones. The excess from the cones
was cut using a heat transfer system
(Touch’n Heat Sybron Endo) and
cold-compressed vertically. The pulp
chamber was sealed with photopolymerizable composite resin and
the patient was sent to her dentist
for definitive restoration of the dental element to be performed. After
17 months, the patient came in for a
control consultation, and on the Xray, it was possible to observe endodontic success characterized by the
absence of signs and symptoms, the
tooth functioning physiologically,
normality of the periapex, and reabsorption of the surplus Fillapex MTA.

Fig 1: Initial X-ray

Fig. 2: Initial clinical condition

Fig. 3: Clinical aspect after removal of the provisional restoration

Fig. 4: Access to the pulp chamber and location of the canals

Fig. 5: Modeles and disinfected canals

Fig. 6: Canals obturated with Gutta Percha and Fillapex MTA

Fig. 7: Final X-ray

Fig. 8: Control X-ray after 17 months

use of the Fillapex MTA cement (Angelus) associated with gutta-percha
cones for endodontic obturation of
a case of endodontic treatment performed in a single session.
A 56-year-old female Caucasian patient came to the office complaining
of spontaneous, pulsing pain which
did not cease with the use of analgesics and anti-inflammatories in
the left mandible region. She had a
negative response to the test of apical palpation and vertical and lateral
percussion on all the teeth of this
quadrant. Thermal tests showed an
exacerbated, long-duration positive
response both the long-term to both
cold and heat on tooth 37. On the
other teeth of the quadrant, a slight,

short-duration positive response
shown to cold, with a negative response to heat.
According to the classification of the
American Endodontics Association,
tooth 36 had a pulpal and periapical
diagnosis of irreversible inflammatory pulpitis with normal periapex.
The treatment indicated was endodontic treatment.
The treatment was conducted in its
entirety with the use of an Operative
Microscope, varying the magnification between 2.5 and 12.5X. Access
the pulp chamber was done with a
1013 spherical diamond bit followed
by a 3082 conical-truck diamond
bit and the finishing was done with

a conical-truck diamond ultrasonic
tip (E7D Helse). After location of the
canals, a type-K #10 file was slowly
introduced until reaching 2/3 of the
initial X-ray length of the tooth. This
was followed by a reciprocating instrument #25.06 (Reciproc -VDW)
with apical progression in sequences
of 3 movements around 1 mm in amplitude in the apical direction. With
each sequence of 3 movements with
the reciprocating instrument, irrigation was done with 5 ml of sodium
hypochlorite at 2.5% and a type-K
#10 file was take to 2/3 of the X-ray
length of the tooth. This procedure
was repeated until the Reciproc 25
instruments would reach this preestablished length.

The next step was to conduct electronic odontometry with a foramen
locator and to establish the real work
length. On the work length, the diameter of the region was verified
through introduction of different
calibers of manual type-K files until
one of them is observed to adapt to
the lateral walls of the canals. In the
mesial canals, the instrument which
adapted to this region was the #30,
and in the distal canal, #40. In this
way, and in the same initial operative sequence or preparation, modeling, and irrigation, the mesial canals were prepared for the Reciproc
40 (VDW) instrument, and the distal
was prepared for the Reciproc 50
(VDW) instrument.

References
1. José F. Siqueira Jr and Isabela N.
Rôças. Clinical Implications and Microbiology of Bacterial Persistence
after Treatment Procedures. J Endod.
2008 Nov; 34(11):1291-1301.
2. Torabinejad M1, Hong CU, McDonald F, Pitt Ford TR. Physical and
chemical properties of a new rootend filling material. J Endod. 1995
Jul;21(7):349-53.
3. Kenneth M. Hargreaves, Stephen
Cohen, Louis H. Berman. Cohen’s
Pathways of the Pulp. Ed 10; Mosby
Elsevier, 2011
4. Vano M, Cury AH, Goracci C, Chieffi N, Gabriele M, Tay FR, Ferrari
M. The effect of immediate versus
delayed cementation on the retention of different types of fiber post
in canals obturated using a eugenol
sealer. J Endod 2006; 32(9):882-5.
5. Reyes-Carmona JF1, Felippe MS, Felippe WT. Biomineralization ability
and interaction of mineral trioxide
aggregate and white portland cement with dentin in a phosphatecontaining fluid. J Endod. 2009
May;35(5):731-6
6.AAE Consensus Conference on Diagnostic Terminology: background
and perspectives.
7. Glickman GN. J Endod. 2009
Dec;35(12):1619-20

Dr Jenner Argueta, Guatemala
Master in Endodontics
Senior Lecturer in Endodontie at Universidad Mariano Gálvez de Guatemala
Board member of Academia de Endodoncia de Guatemala

Prof. Dr Leandro A. P. Pereira
Endodontics Professor of São Leopoldo
Mandic Faculty
Dental Master and PhD in Pharmacology, Anesthesiology and Drug Therapy
UNICAMP
Endodontics Specialist - Surgical Microscopy - Sedation Inhalation

[50] =>

Dental Tribune Middle East & Africa Edition | 6/2018

endo tribune

Top performance Flexible NiTi file
HyFlex EDM performs well internationally
Full control in
the dental practice
As an established Endo provider,
COLTENE has been working closely
with leading dentists, universities
and endo experts for many years.
The multitude of sophisticated
treatment aids, ranging from specially hardened instruments to bioactive obturation materials, reflects
the self-image of the Swiss innova-

HyFlex EDM File Sequence

By Coltene
In the course of two major international events in the dental industry,
Swiss dental specialist COLTENE
interviewed over 130 dentists and
Endo experts about their experiences with its latest NiTi file system.
The results of the product tests are
more than impressive: 98% of the
participants would continue to use
the HyFlex EDM for the treatment
of their endodontic cases, even after
the tough test.

The necessary cutting edge
Every two years, both the International Dental Show in Cologne (IDS
for short) and the Congress of the European Society for Endodontics (ESE
Congress) serve as an international
platform for professionals with an
interest in endodontics to exchange
experiences between colleagues.
Thus, both events in 2017 provided
the ideal occasion for a large-scale
test campaign for the latest NiTi file
generation from COLTENE. Selected
dentists and joint practices throughout Europe were given the opportunity to put the flexible HyFlex
EDM’s file system through its paces.
76% of the participants particularly
praised the high flexibility that leads
to good adaptation in the canal. The
pre-bendable files work reliably in
all the lengths and sizes currently
available on the market without displacing the centre of the canal. Like
the proven HyFlex™ CM files, the
HyFlex™ EDM files also possess the
so-called “Controlled Memory“ effect and are distinguished by their
high level of flexibility. In contrast
to classic NiTi files, they have almost
no recovery effect and can be prebent. As a result, the files move perfectly through the centre of the canal, which significantly reduces the
risk of ledging, transportation and
perforation. During autoclaving,
they recover their original shape so
that they can be reused safely until
a visible break in their spiral structure clearly indicates the end of their
service life. At the same time, the innovative manufacturing process by
means of spark erosion contributes
to the high breakage resistance of
the HyFlex EDM files, particularly

under heavy-duty use. In fact, HyFlex EDM files are up to 700% more
resistant to cyclic fatigue compared
to traditional NiTi files. A special
combination of material surface
and tapering allows a significant
reduction in the number of files
used without compromising the
preservation of the natural root canal anatomy. These smart features
were also evaluated positively in the
test and the dentists use the robust
high-performance instruments primarily for cases where they want to
produce reliable results quickly with
a reduced number of files.

Additional files sizes allowing more flexible application
Due to limited access endo experts
often want more flexibility from
their instruments. Pre-bendable
tools can extend the horizon into
new dimensions. Particularly in a
limited working space, modular
nickel-titanium systems display
their full strength. With a total of
seven highly flexible file variants,
COLTENE offers a wide-ranging HyFlex NiTi program. In addition to the
usual lengths of 25 mm, all preparation files of the popular EDM series
are also available in 21 mm working
length. The application of the more
agile, shorter models is particularly
recommended in of the posterior
molars and in patients with craniomandibular problems.
The new HyFlex EDM 20/.05 preparation file augments the existing
HyFley EDM line. The additional
file enables fans of the flexible NiTi
range to treat curved channels only
with the efficient EDM files. After
creating a glide path with the Glidepathfile 10/.05, the new file with the
same taper allows minimally invasive, fast preparation of the canal.
Subsequently the actual shaping can
be done in the usual manner with
the universal file HyFlex EDM OneFile, size 25. Depending on the channel anatomy, apical preparation can
be finished with EDM files up to ISO
size 60. Even in these large sizes the
files work safely and without transportation of the canal centre.

tion leader. True to the company’s
motto “Upgrade Dentistry”, the
COLTENE service team regularly
asks practice owners and endodontic specialists about their wishes for
even more confident work in virtually all situations. This also formed
the basis for the development of the
production process called “Electrical Discharge Machining” (EDM for
short) by the dental manufacturer’s

renowned R&D department, which
ultimately gave the exceptionally
break-resistant files their name. The
practice-oriented Endo offer is complemented by a large number of application-related workshops, training materials and personal services.

Further product information:
https://hyflex.coltene.com/

[51] =>

endo tribune

Dental Tribune Middle East & Africa Edition | 6/2018

The pathway to perfect endodontics
Julian Webber introduces the latest glide path file from Dentsply Sirona that completes
the WaveOne Gold reciprocating system.
By Julian Webber, UK
“The endodontic glide path is a
smooth, radicular tunnel from canal
orifice to physiologic terminus. Its
minimal size should be a ‘super loose
No. 10’ endodontic file.” John West
DDS, endodontist, Tacoma, Washington, USA and key opinion leader for
Dentsply Sirona.
The glide path is the starting point
for all endodontic shaping procedures. It fulfils a biological requirement indicating that we can get from
the orifice of the canal to the terminus, giving us a road map for all
other shaping instruments to follow.
Whilst some endodontists do not believe a glide path is necessary prior to
starting the shaping procedure with
mechanical endodontic shaping instruments the literature is unequivocal that without a glide path ledges,
blockages, perforations and instrument fracture can easily occur. In my
opinion, if there is no glide path, we
should not be attempting to use any
nickel titanium rotary or nickel titanium reciprocating shaping files.
Hand files or dedicated mechanical

ÿPage A8

Julian Webber, UK

Endo Micro Surgical Retreatment

Endo non-surgical and surgical retreatment

(Management of Endodontic Failure)

HANDS-ON COURSE

HANDS-ON COURSE
17-18 April 2019
Wednesday-Thursday

CAPP Training Institute
Dubai | UAE

Area of interest:
Endodontics

19-20 April 2019
Friday-Saturday

AED 4,400
$ 1,200

Area of interest:
Endodontics

Visiting Professor and Programme Leader, MClinDent in Endodontology at BPP University.

He currently serves as an active member of the Hellenic Society of
Endodontology and the Academy of Microscope Enhanced Dentistry
and is a certiﬁed member of the European Society of Endodontology.

Course Objectives

DAY 1 - Delegates will be able to:

DAY 1 - By the end of the course delegates will understand:

Remove guttapercha obturations from root canals.
Remove Carrier based obturations from the root canals.
Remove paste obturations and remove ﬁber posts.
Have the oportunity to use most of the current technology used during retreatment
procedures.
DAY 2 - Delegates will be able to:

• Bypass and remove broken endodontic ﬁles.
• Understand all the preventive measures to avoid complications during endodontic
instrumentation.
• Repair a pulp ﬂoor perforation.
• Obtutrate an internal resorption defect.
• Perform apical plugs with biocompatible materials.

•
•
•
•
•
•
•
•

Outcomes of endodontic microsurgery vs traditional apicectomy.
The science behind eﬀective local anaesthesia in endodontic microsurgery.
The use of a dental operating microscope in endodontic microsurgery.
Flap design and tissue handling to improve post-surgical healing.
How to eﬀectively prepare an osteotomy.
Correct methods of ultrasonic root-end preparation and how to identify anatomical markers.
Which equipment is appropriate for use in micro-surgical techniques.
Eﬀective suturing and postoperative care including analgesia.
DAY 2 - By the endo of the course delegates will have:

•
•
•
•
•
•
•

Been calibrated to a dental operating microscope.
Have identiﬁed cases where surgical intervention is appropriate.
Have raised a ﬂap with microsurgical instruments.
Created an osteotomy and identiﬁed anatomical markers.
Performed root end resection and retrograde preparation of the root canal space.
Performed microsurgical suturing.
Developed a post-operative care strategy to minimize complications and improve healing.

www.cappmea.com/courses
CONTACT
CAPP EVENTS
Onyx Tower 2 | Oﬃce P204 & P205
The Greens | Dubai | UAE
Mob/WhatsApp: +971502793711
Tel: +971 4 347 6747
E-mail: events@cappmea.com
Web: www.cappmea.com

AED 4,400
$ 1,200

Prof. James Prichard, UK

Dr. Antonis Chaniotis, Greece

•
•
•
•

CAPP Training Institute
Dubai | UAE

www.cappmea.com/courses

ACCREDITATION

CONTACT

ACCREDITATION

CAPP designates this activity for 14 CE Credits

CAPP EVENTS
Onyx Tower 2 | Oﬃce P204 & P205
The Greens | Dubai | UAE
Mob/WhatsApp: +971502793711
Tel: +971 4 347 6747
E-mail: events@cappmea.com
Web: www.cappmea.com

CAPP designates this activity for 14 CE Credits

Est. DOH-Abu Dhabi 14 CME | Est. DHA 12 CME

[52] =>

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[53] =>

ENDO TRIBUNE

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page A6
glide path files can be used beyond a
K-file size 10 to expand the working
width and pre-shape the canal, creating adequate access which is essential if rotary or reciprocating instruments are being used. As the shaping
file moves down the canal there is
considerable torsional effect on the
instrument, so if the canal is rather
tight or narrow then the file can have
difficulty progressing. An expanded
glide path will mitigate this issue.
Mechanical glide path files follow
and expand the original anatomy of
the root canal. They greatly improve
shaping results, reduce chair time
and help to “augur” debris coronally
and out of the canal, helping reduce
the likelihood of post-operative pain.
The original mechanical PathFile
instruments from Dentsply Sirona

consisted of three rotary expansion
files. This evolved into ProGlider,
a single glide path expansion file
used in a rotary motion made from
a pre-manufacture heat treatment
technique known as M-Wire, which
increased flexibility and provided
greater resistance to cyclic fatigue.
With the launch of the new generation WaveOne Gold reciprocating
files in 2015, it became obvious there
was now a need for a reciprocating
glide path expansion file to complete the WaveOne Gold system.
Four of the original key opinion
leaders involved in the development
of WaveOne Gold; my colleagues,
Dr. Clifford Ruddle (USA), Dr. Sergio
Kuttler (USA), Dr. Wilhelm Pertot
(France) and myself have now gone
on to develop and launch WaveOne
Gold Glider from Dentsply Sirona.
We were assisted in this project by
Dr John West (USA) and Drs. Berutti,
Cantatore and Castellucci (Italy).
The WaveOne Gold Glider reciprocating glide path file uses the same
post manufacturing heat treatment
process as WaveOne Gold. This technique gives the instrument the same
distinctive gold appearance, but
more importantly, it significantly
improves its strength and flexibility
when compared to NiTi that has not
had this heat treatment. Specifically
designed as a single use instrument
the ring on the shaft, just as with WaveOne Gold files, will expand if the
file is put through a steriliser, rendering it unusable.
Using the same parallelogramshaped cross section as WaveOne
Gold, the reciprocating motion
means the backward movement
of the file is greater than the forward movement, reducing the torsional effect on the instrument and
greatly increasing its resistance to
cyclic fatigue. It comes with a size
15 tip in a choice of three lengths
(21, 25 and 31mm) with an active
length of 16mm. The 11mm shaft
length helps to improve access to
the more difficult-to-reach areas of
the mouth. Due to its flexibility and
lack of shape memory the file can be
slightly pre-bent, helping to improve
the placement of the tip in the back
of the mouth or for patients with
limited opening.

WaveOne® Gold

Now with WaveOne® Gold Glider

Surf the canal
with confidence
WaveOne® Gold offers you the simplicity of a one-file
shaping system combined with higher flexibility* to respect
the canal anatomy. Now available with a corresponding glide
path file to optimize your shaping preparation. Experience
the feeling of confidence throughout your treatment.

Rx Only

ST8/ B EN W1G0 ADV 000 / 03/2017 – updated 04/2018

The process of obtaining a glide path
with a No. 10 hand file, expanding
the glide path with WaveOne Gold
Glider, then shaping the canal, in the
majority of cases, with a single WaveOne Gold Primary file, provides
dentists and endodontists with a
simple technique that can be accomplished with confidence. WaveOne
Gold Glider completes the WaveOne
Gold reciprocating system, making
the preparation and shaping of canals even easier whilst taking safety
to a new level.

About the Author
Julian Webber was the ﬁrst UK dentist to
receive a Masters Degree in Endodontics
from a university in the USA. He received
his BDS from Birmingham University in
1974 and his MSc and Certiﬁcate in Endodontics from Northwestern University
Dental School, Chicago, USA in 1978. He
has been a practicing endodontist in Central London since 1978 and opened the
Harley Street Centre for Endodontics in
October 2002.
Julian has travelled abroad on many occasions to lecture to major world dental
congresses and endodontic societies.
Through his various workshops and
hands-on courses, he has helped to train
many general dentists in the skills of modern endodontic technique.

[54] =>

Published in Dubai

November-December 2018 | No. 6, Vol. 8

www.dental-tribune.me

VITAPAN EXCELL:
For predictable, aesthetic and functional results
By VITA Zahnfabrik
For predictable and functional aesthetic results in restorations, in
addition to dental technology ex-

perience, we need a denture tooth
designed on the basis of the aesthetic
and functional standards set by nature. VITAPAN EXCELL (VITA Zahnfabrik, Bad Säckingen, Germany) is

an example of this kind of anterior
tooth, which is characterized by vibrant shapes with “golden proportions.” Tooth axes, the length/width
ratio and angle characteristics are

consistently patterned after nature.
In addition, its special layered structure enables a natural play of shade.
In the following case report, Darius
Northey, Dental Technician (Buder-

im, Australia) shows how he was able
to successfully use the new denture
tooth for an implant-supported restoration.

ÿPage B2

Fig. 1: Initial situation: The insufficient restorations showed a midline displacement and functional disharmonies

Fig. 2: Two implants were inserted in the incisal region to functionally
stabilize the restoration in the mandibular

Fig. 3: A custom-made tray was used in the mandibular for a mucodynamic fixation impression

Fig. 4: A simple bar construction was poured and fixed with synthetic
material to the abutments

Fig. 5: The centric and temporomandibular movements were recorded
with the gothic arch

Fig. 6: First, the aesthetic zone of the maxillary duplicate was reduced,
then replaced with VITAPAN EXCELL, and finally tried in

Fig. 7: The final wax setup in the articulator with molded gingival anatomy before the try-in

Fig. 8: After the try-in, a mucodynamic impression with setup was taken
in the maxilla

Fig. 9: The final occlusion-adjusted, mucodynamic impression in the duplicated denture base

Fig. 10: Based on the bite registration of the setups, the maxilla could be
accurately rearticulated

Fig. 11: VITAPAN EXCELL and LINGOFORM were conditioned with
VITACOLL to ensure good adhesion to the base

Fig. 12: The vestibular plate was customized with several synthetic material layers in different gingival shades

Fig. 13: The bridge and attachments were integrated by polymerization
of the synthetic material base

Fig. 14: The finished restorations after elaboration and polishing in static
occlusion

Fig. 15: Result: The patient was very happy with the naturalness of the
new restoration

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◊Page B1
Initial clinical situation
A 78-year-old female patient was
dissatisfied with the positional stability of her mandibular prosthesis.
The acrylic teeth appeared abraded,
stained and very dull. After the consultation, the patient decided on
two implants in the mandibular in
order to achieve greater functional
stability, and was referred to an oral
surgeon. After a healing period of
three months, the implants were osseointegrated in the incisal region
of the mandibular. First, the patient
did not want a new total prosthesis
in the maxilla, although the midline
was shifted extremely to the right
and functional disadvantages due
to the well-worn and irregular occlu-

sion were to be expected. She feared
that her usual appearance would be
altered by a new restoration. However, following a comprehensive
consultation, she finally opted for a
new restoration.

First steps towards restoration
The restoration in the mandible
began with an anatomical alginate
impression. So that it could be oriented to the old maxillary prosthesis
using the copy denture technique,
this was duplicated with putty and
reproduced with a cold polymer for
denture bases. For the mandible, a
custom-made impression tray was
made, a mucodynamic impression
was taken in several steps and the

impression cap was affixed. Using
the model, a simple bar construction
was fabricated and affixed with synthetic material to the attachments. A
wax rim was created over the bar in
the mandible, and plates for the imaging of the Gothic arch positioned
on this and the maxillary duplicate.
Laterotrusion, protrusion and centric were recorded and affixed. The
duplicate was successively reduced
in the setup area in order to first
position and try in the VITAPAN EXCELL anterior tooth and then the VITAPAN LINGOFORM posterior tooth.

Prostheses fabrication and
finalisation
After a complete functional and

aesthetic try-in, a mucodynamic
impression with wax setup on a duplicate base was taken in the maxilla.
The bite was registered with silicon.
In the maxilla, a final master model
was produced and articulated according to the vertical dimension.
The maxilla and mandibular setups
were embedded in cuvettes, boiled
out and pressed with heat-curing
polymer into different gingival
shades. After polymerization, both
works were rearticulated and an occlusion check was done. The prostheses were processed with fine-cut
carbide milling tools and rubber polishers. The final polishing was done
with pumice and polishing paste, as
well as a buffing wheel. The patient

was very satisfied with the functional and aesthetic result. Thanks to the
lifelike shapes with “golden proportions,” the three-dimensional anatomically layered construction and
the multifaceted surface texture, the
prosthetic restoration with VITAPAN
EXCELL appears very natural.

tion of the most suitable ingot is a
good start. The framework material is available in all VITA¹ classical
shades.

bit of Crème (Figs. 4 and 5).
After the stain firing, a single glaze
(Universal Stain & High Flu Glaze)
is applied, covering the monolithic
restoration (Fig. 6). The final shade
check using shade tabs confirms the
quick and easy shade reproduction
and great aesthetics (Fig. 7).

Darius Northey, CDT, Australia
Graduated as a Dental Technician after
working in the family business for many
years. 1997 Established his own dental
laboratory in Sydney, Australia. 20042006 Completed the ‘Advanced Diploma
of Dental Prosthetics’.

All-ceramics for every need
By Dentsply Sirona
Zirconia and Zirconia-Reinforced
Lithium Silicate (ZLS) complement
each other when it comes to all-ceramic oral rehabilitation with excellent performance. The aesthetic appearance is further perfected either
by using the staining technique or
by providing a uniform type of veneer with a single ceramic material.
The following report illustrates the
laboratory workflows when using

this material, along with the potential benefits to the dental laboratory
in terms of added business opportunities.
Zirconia and Zirconia-Reinforced
Lithium Silicate (ZLS) are high-performance ceramics with complementary — and sometimes overlapping — indications. This mainly
applies to crowns and, in the case of
pressable ZLS (Celtra® Press), threeunit anterior bridges whose distal-

most abutment can be any tooth
between the lateral incisor and the
second premolar. The three clinical
cases shown here present three examples of aesthetic restorative designs (Fig. 1).

Example 1: Extra-translucent
zirconia, monolithic
The task is to reproduce an A2 shade
on a monolithic crown made of the
extra-translucent zirconia material
Cercon® xt (Fig. 2). The correct selec-

To achieve pleasing basic aesthetics, a
final individualisation is performed
with three universal stains and glaze.
The crown body is first customised
with a bit of Pink (Fig. 3). The enamel
ridges are highlighted with Incisal
Stain i1, while the incisal area with its
mamelon structures is refined with a

ÿPage B3

Fig. 1: The smart Celtra® Press stain recipe simplifies the selection of
shades and reduces inventory costs.

Fig. 2: The goal was to reproduce the A2 shade on a monolithic crown
made of extra-translucent zirconia.

Fig. 3: Individualisation with three universal stains and glaze. Some Pink
is applied to the crown body first.

Fig. 4: The enamel ridges of the occlusal surfaces are highlighted with
Universal Stain i1.

Fig. 5: In the incisal region, the mamelon structures are refined with the
Universal Stain Créme.

Fig. 6: Finally, the glaze is applied (High Flu).

Fig. 7: Checking the shade - A perfect A2 shade match.

Fig. 8: The goal was to reproduce an A2 shade on a crown framework
made of extra-translucent zirconia.

Fig. 9: The entire VITA1 range is available when selecting the ingot (True
Colour Technology). The result is a framework that already approximates
the desired shade.

Fig. 10: The labial and palatal aspects of the enamel are built up with
Enamel.

Fig. 11: Finishing. This is how the desired shape and surface texture are
incorporated.

Fig. 12: Design of the incisal edges - A fine line of Créme.

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◊Page B2

Fig. 13: Final modifications are made to the incisal area.

Fig. 14: One incisal and a bit of stain are enough to make a restoration
vivid.

Fig. 15: The goal was to achieve premium aesthetics without limitations.

Fig. 16: The bridge framework is made of pressable zirconia-reinforced
lithium silicate milled to a reduced anatomical contour.

Fig. 17: The upper part of the crown is built up with dentin, creating delicate mamelon structures.

Fig. 18: In the incisal area, the areas between the mamelons receive
Enamel Opal Transparent.

Fig. 19: The incisal ridges receive a bit of Enamel Opal Transparent.

Fig. 20: Completing the build-up with additional Enamel material.

Fig. 21: After ceramic firing, the finishing stage begins with the sealing of
the interdental spaces with Dentin.

Fig. 22: A mixture of Effect Enamel and Enamel Opal is applied cervically

Fig. 23: The marginal ridges are supported with another Effect Enamel.

Fig. 24: A thin layer of neutral Enamel Opal is added in the central labial
region.

Fig. 25: The incisal edges are finalised with Enamel Effect.

Fig. 26: Final processing. At the glazing stage, ...

Fig. 27: ... some Universal Stain Créme is applied in the incisal area to obtain delicate individual features.

its final shape in a finishing step that
includes creating desired surface texture after ceramic firing (Fig. 11).
The restoration is finalised with stain
and glaze in a single step. A fine line
of Crème is painted onto the incisal
edges (Fig. 12). The final step is the application of Universal Stain i1 in the
incisal region (Fig. 13).
Fig. 28: Final check. The desired shade was matched exactly, presenting a natural appearance and a highly salient depth effect.

Pressable ZLS can be individualised
in a very similar manner. The lightoptical properties of the framework
material (Celtra® Press) already ensure a high level of aesthetics — close
to that of veneering ceramics.

Example 2: Extra-translucent
zirconia, cut-back technique

To reproduce an A2 shade on a crown
framework made of extra-translucent zirconia, the most closely
matching ingot is again chosen (as in
the first example; Figs. 8 and 9). Mamelon structures are included at the
time of designing the framework.
The labial and palatal aspects of the
enamel layer are built up with Celtra® Ceram Enamel E1 (Fig. 10) while at
the same time giving the restoration

The desired shade has been achieved,
and the restoration looks “live” with
just one enamel material and some
stain (Fig. 14). A ZLS framework (Celtra® Press) can be customised in a
similar way. Achieving the desired
result requires only a single incisal
material and some glaze thanks to
the favourable light-optical properties of the pressable material.

Example 3:
ZLS, fully veneered
For premium aesthetics without
limitations, the framework is milled

from pressable ZLS to a reduced anatomical contour (Figs. 15 and 16). The
upper part of the crown is built up
with Celtra® Ceram Dentin DA2, creating delicate mamelon structures in
the process (Fig. 17). The incisal edge
and the areas between the mamelons and on the incisal ridges strips
are emphasised with Enamel Opal
Transparent EO4 (Figs. 18 and 19).
Enamel E1 completes the build-up
(Fig. 20).
After the ceramic firing, the restoration is finished and prepared for
the second layer. The interdental
spaces are closed both labially and
palatally with Dentin DA2 (Fig. 21). A
mixture of Effect Enamel Sunset EE3
and Enamel Opal Transparent EO4 is
used on the cervical aspect (Fig. 22).
The mesial and distal ridges are supported with Celtra® Ceram Enamel
Effect Sky EE5. A thin layer of the
neutral Enamel Opal Extra Light EO1
is added in the central labial area (Fig.
24). The incisal edges are finalised

with Enamel Effect Ivory EE6.
After the ceramic firing, the shape
is finalised and the desired surface
texture is created. This is followed by
applying the glaze (High Flu), with
some Universal Stain Créme applied
in the incisal area for the most delicate individual features (Figs. 26 and
27).
The target shade has been matched
exactly, with the opalescence of the
incisal edge supporting the natural
appearance of the restoration. In
addition, an excellent depth effect
is achieved between the mamelons
and on the incisal ridges, thanks to
the Enamel Opal Transparent EO4
used (Fig. 28).
High-translucency zirconia frameworks can be veneered in a similar
manner, yielding highly aesthetic
restorations with a perfectly match-

ÿPage B4

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Dental Tribune Middle East & Africa Edition | 6/2018

Dental
Technician Int’l
Meeting 12 April
2019 in Dubai
By Dental Tribune MEA / CAPPmeaa
The Dental Technician International
Meeting (DTIM) is the continuation
and growth of CAPP’s Dental Technician Sessions during the last 11 years.
Round table presentations with hands-on training with dental technicians

These Dental Technician Sessions
were accomplishments not only for

dental laboratory owners and dental
technicians but for the entire dental
technology profession.
The DTIM will be held on the 12
April 2019 at the Madinat Jumierah Conference Centre. Over 200
dental technicians, clinical dental
technicians (CDTs), lab owners, trade
visitors and more are expected to attend.
During the event, delegates will be
able to attend free of charge handson trainings that will be organising
by the companies. During the sessions dental technicians will be able
to work with the product provided
ad learn new techniques.
The DTIM takes place in conjunctions with the 14th CAD/CAM &
Digital Dentistry Conference & Exhibition which will be attended by over
2,000 dental professionals.
Who Should Attend?
– Dental technicians
– Clinical Dental Technicians (CDTs)
– Dental lab owners

CAPP Events
Onyx Tower 2 | Office P204 & P205
The Greens | Dubai | UAE
P.O. Box: 450355 Tel: +971 4 347 6747
Web: www.cappmea.com
E-mail: events@cappmea.com

◊Page B3
ing shade. Due to its higher strength,
this framework material is also suitable for posterior bridges.

Cercon®

Makes you smile
Cercon with True Colour Technology sets new standards for zirconia when it
comes to reproducing the classic 16 VITA* shades.
Cercon xt – extra translucent zirconia:
• Demonstrates extra high translucency and unparalleled shade accuracy with a life- like
aesthetics especially for the anterior region (bending strength: 750 MPa) and complements
the Cercon product portfolio
• Saves processing time and increases productivity (no need to dip, to stain or to veneer)
Cercon ht – high translucent zirconia:
• Offers a wide range of indications in the anterior and posterior region (bending strength:
1200 MPa). With Cercon ht as a high translucent material you can choose different
performance levels out of one disk

dentsplysirona.com

Outcomes for the dental laboratory
ZLS frameworks and also zirconia
frameworks (with different translucencies) can be aesthetically refined in several ways. One method
includes finalisation by staining —
achieving pleasing basic aesthetics
safely and easily with a monolithic
restoration.
At a higher level of aesthetic sophistication, the framework can be
veneered with ceramics. The innovative Celtra® Ceram material presented here provides an aesthetic
link between ZLS and zirconia. This
veneering ceramic allows the dental
technician to individualise frameworks made of both materials using
the same standardised technique.
This is possible using the cut-back
technique or by full veneering for
premium aesthetics without limitations. This variability gives dental
technicians a comprehensive allceramic treatment and performance
concept.
¹Not a registered trademark of Dentsply Sirona.

* VITA is a trademark of VITA Zahnfabrik

Dentsply Sirona
The Bay Gate Tower Dubai, UAE
Tel.: +971 4 523 0600
Web: www.dentsplysirona.com

[58] =>

www.dental-tribune.me

Published in Dubai

November-December| No. 6, Vol. 8

We have an enormous influence
on children’s overall health
By Dental Tribune International
Parents of children with systemic
disease often wonder in the dentist’s office what oral health problems they can expect for their child.
Depending on the type of systemic
disease, there can be complications
in terms of the child’s oral health. In
this context, Dr Karolin Höfer, senior
physician at the University Hospital
of Cologne, studies oral disease in
children with chronic renal insufficiency or congenital heart defects.
In her presentation at the Oral-B
Up-to-Date event, she spoke about
the typical oral health problems of
paediatric kidney and heart patients
based on her own research and compared these with current systematic
reviews. She then, in a very personal
interview gave helpful suggestions
for the support and treatment of
these children in everyday life.
Dr Höfer, why do you like working
with children?
Dr Karolin Höfer: My passion lies
in working with children and young
people; that’s why I specialised in
paediatric dentistry, with a special
focus on children with systemic disease. In dentistry, we say: one either
loves it or leaves it.
With every one of my young patients, whether they have a medical
history or are healthy, I have to gain
their confidence on an emotional
level first, aside from the dentistry
challenge. Working with children
who are traumatised and have medical histories in particular requires
sensitive handling in order to build
trust, which is the foundation of successful treatment. Intuition, taking
sufficient time, patience and empathy are essential here.
Successful treatment of children
with cancer or severe heart problems
or others at high risk is achievable
by using special techniques, such as
ritualised behaviour management.
After a difficult treatment, having a
child smile and ask when he or she
can come back is the best endorsement in daily practice.
What patients do you work with?
Most of my patients have a systemic
disease and are with me from birth
up to age 25. The period between
ages 18 and 25 is considered a transition phase; from child to adult.
After careful paediatric treatment,
a deterioration of the condition is
frequently reported during the transition phase. For example, we treat
patients with cystic fibrosis, congenital heart defects, chronic kidney
disease and immunosuppression,
for example, after a transplant or
during cancer treatment. Every day,
we ask ourselves: Are there correla-

Dr Karolin Höfer, Germany

tions between these systemic diseases and oral disease and/or disease
that affects tooth development? As
dentists, we should know how these
systemic disease can affect oral
health. We are already aware of the
well-known interactions with some
chronic diseases, such as congenital heart disease, diabetes mellitus,
arthritis and chronic diseases of the
bowel and kidney.
What questions do dentists have to
ask when treating these patients?
First of all, it is important to identify
the child’s dental problem. Secondly,
it should be determined whether
the child has certain diseases and
whether there are interactions with
oral disease. And thirdly, which specialists in other disciplines should be
consulted before dental work commences must be established.
How do you see your position as a
dentist within the holistic therapy
of these children?
I am not responsible for the patient’s
entire medical recovery. However, I
see myself as a physician, mediator
and member of a team of paediatric
specialists. When we treat patients
with systemic disease, we need to be
in contact with specialists from all
disciplines. As experts in oral health,
we have an enormous influence on
children’s overall health. Every den-

tist should consult with the treating
paediatricians of children with preexisting conditions. It’s about the
overall well-being of the child. Even
a tooth cleaning can take on another
meaning for these children. Healthy
people associate it with health, wellbeing and aesthetics. For children
with systemic disease, however,
an intensive prophylaxis can have
major implications for their general
health, for example, should pathogenic bacteria enter the bloodstream
of a child, say, with immunosuppression.
You work with children who have
congenital disease. You have conducted interesting studies on the
prevalence of caries and gingivitis.
What have your results been?
If one considers the tooth decay process of healthy children in Germany
20 years ago, about five teeth were
affected by tooth decay, while today,
only one tooth on average is affected. Up to 85 per cent of 3-year-olds
have no caries; however, the remainder may have up to four carious
teeth. As I said, these figures involve
healthy children.
For children with systemic disease,
the situation is different. Children
with heart disease have a demonstrably higher prevalence of caries.
On average, four to seven teeth are

affected. Children with kidney disease have a risk of caries comparable
to that of healthy children; however,
this group presents a much higher
risk of developing gingivitis. Gingivitis could thus be understood as
enabling bacteria to enter the bloodstream. Children with cystic fibrosis
also have a very low caries prevalence, but owing to the frequent intake of antibiotics, the composition
of their saliva is altered, so in this
patient group, frequent enamel hypoplasia has been determined.
Why should paediatric dentistry be
interested in such interactions?
If there are potentially about 700
different species of bacteria in the
mouth, and children with heart disease have an increased risk of caries,
the danger actually exists that these
bacteria will reach the bloodstream
via the mouth. We are speaking here
of bacteraemia. Bacteraemia is not a
disease in itself and is not a risk for a
healthy patient; the immune system
automatically fights the invading
bacteria. For patients with systemic
disease, the starting point is different. It is therefore not surprising
that, with bacteraemia, oral streptococci, in particular the viridans
streptococci, can be detected. Blood
cultures reveal, for example, that viridans streptococci, as part of the oral
cavity, are also responsible for 50 per

cent of infectious endocarditis cases.
Of course, bacteraemia does not automatically lead to endocarditis. As
I said, a healthy body can normally
deal with such bacteria. Patients with
pre-existing conditions like heart
disease, however, have a higher risk
of endocarditis. Ideally, children with
a serious heart disease should have
their teeth cleaned prior to upcoming heart surgery.
How frequently does bacteraemia
develop after dental procedures?
Occult bacteraemia can result from
routine activities such as toothbrushing, but of course also through
different dental procedures. Bacteraemia develops most frequently
after surgeries like tooth extractions. Here, the frequency is usually
100 per cent. These bacteria can be
released during periodontal procedures, such as scaling and root planing, and even during professional
tooth cleaning, bacteria enter the
bloodstream in around 40 per cent
of patients. It is very interesting that,
even after brushing and interdental
care, the frequency of bacteraemia is
about 68 per cent. As I said, a healthy
body normally deals with such bacteria, but the picture is different for patients with systemic disease, particu-

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Dental Tribune Middle East & Africa Edition | 6/2018

◊Page C1
this genetic defect and a patient’s
dental status?
Patients with cystic fibrosis often
have an accumulation of viruses,
fungi and bacteria in their airways,
which can in turn lead to pneumonia. These patients are under constant drug therapy. As dentists, we
should comply with special hygiene
regulations. We should be aware that
the particulate matter that normally
develops during dental treatment
is to be avoided. One danger, for example, is lung infections, which can
be triggered by bacteria like Pseudomonas aeruginosa. This risk can
be prevented by using an external
water supply.

larly children with congenital heart
disease. If we find a carious lesion in
these children, we would treat this
immediately in consultation with
the paediatric cardiologist in order
to avoid further infections. For our
paediatric colleagues, it is more difficult to diagnose carious lesions. We
do, however, have an excellent working relationship with our colleagues
from the paediatric clinic. They are
well trained and refer patients to us
promptly and regularly for checkups before surgical procedures.
You also mentioned cystic fibrosis, a congenital metabolic disease
that leads to the formation of thick
mucus, for example in the lungs,
intestine and liver. What interactions have you observed between
Dr Karolin Höfer, Germany

What measures do you recommend to reduce the risk of bacteraemia for these risk groups?
We are currently conducting an intervention study in collaboration
with the paediatric nephrology division at the University of Cologne.
In addition to treating gingivitis
through intensive prophylaxis, the
goal of the clinical trial is to determine the bacterial risk after toothbrushing. For bacteria identification,
blood cultures and oral microbiomes
are examined. We want to examine
the influence of a patient-centred
intensive prophylaxis programme
and improved oral hygiene on the
change in the oral microbiome. We
hope in the long term to improve
oral hygiene through regular checkups and instructions, and to implement an interdisciplinary prevention programme for children with
chronic kidney disease.
Furthermore, we hope to achieve
a substantial improvement in oral
health with targeted tooth cleaning
and intensive prophylaxis, and to
eliminate the daily bacteraemia risk
in children at risk, as well as carious
lesions and gingivitis. This includes a
regular recall system for these highrisk patients adapted to their individual needs.
What are your recommendations
for parents?
I would like children to look forward
to their dental appointment with
me. Through a very intensive relationship with the children and their
relatives, I replace the cliché of an uncomfortable and angst-ridden dental
visit with trust in dental treatment.
We should give today’s generation
of children a new perception about
dentists. Of course, for many parents
who have a child with a systemic disease, oral hygiene is not their top priority. However, all the results of my
clinical trials to date have shown that
oral health has only a positive effect
on the overall health of children with
systemic disease, but besides that,
the quality of life and self-confidence
of my young patients are enormously strengthened.
What is your appeal to your peers
in practice?
It is enormously important to take
children in dental treatment in hand,
accompany, explain and find a way
to bring dentistry goals in line with
the systemic disease.
We must achieve oral health in children as quickly as possible and maintain it for the long term through individual prevention programmes. The
treatment of children with systemic
disease should always take place in
consultation with the treating paediatrician. Every practice staff member
should contribute to paediatric dentistry being perceived by parents as
a specialist field in interdisciplinary
cooperation with paediatricians and
serving the well-being of their children.

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hygiene tribune

Combination of breast milk and babies’
saliva shapes healthy oral microbiome,
study suggests
By Dental Tribune International
BRISBANE, Australia: There is much
debate of the pros and cons of breastand bottle-feeding. A research team
from the Queensland University of
Technology (QUT), in collaboration
with the University of Queensland,
both in Australia, has found that
breastfeeding, at least in terms of
oral health of the baby, is beneficial.
According to lead author Dr Emma
Sweeney, from the Institute of
Health and Biomedical Innovation

at QUT, the team’s earlier studies
had found significant differences in
the prevalence of key bacteria in the
mouths of breastfed and formulafed babies and that breastmilk and
saliva interactions boost innate immunity by acting in synergy to regulate the oral microbiome of newborn
babies.
For the recent study, a variety of
microorganisms were exposed to
breastmilk and saliva mixtures.
The results showed that inhibited

growth of the microorganisms took
place immediately and for up to one
day regardless of whether the microorganisms were considered pathogenic or commensal in an infant’s
mouth.
“Our findings suggest that breastmilk is more than a simple source
of nutrition for babies because it
plays an important role in shaping
a healthy oral microbiome,” said
Sweeney. “Our previous research
found that the interaction of neo-

natal saliva and breast milk releases
antibacterial compounds, including
hydrogen peroxide. The release of
this chemical compound also activates the lactoperoxidase system,
which produces additional compounds that also have antibacterial
activity, and these compounds are
capable of regulating the growth of
microorganisms,” she added.

health and well-being and also has
an impact on infections and diseases
in babies’ early lives.
The study, titled “The effect of breastmilk and saliva combinations on the
in vitro growth of oral pathogenic
and commensal microorganisms”,
was published online in Scientific Reports on 11 October 2018.

According to the research team, the
composition of a baby’s mouth microbiota has an important role in its

Researchers develop new method for
identifying oral cancer
By Dental Tribune International
SÃO PAULO, Brazil: In a discovery
that may help the early identification of oral squamous cell carcinoma
(OSCC), researchers in Brazil have
found a correlation between the cancer’s progression and the abundance
of specific proteins present in tumor
tissue and saliva. The discovery offers parameters for predicting the
progression of the disease and may
help in overcoming the limitations
of clinical and imaging exams.
“We worked on the study for five
years until we achieved this breakthrough,” said contributing author
Adriana Franco Paes Leme, a researcher at the Brazilian National
Bioscience Laboratory—part of National Energy and Materials Research
Center (CNPEM) in São Paulo.
During the first phase of the study,
researchers used laser microdissection and proteomics to map the
proteins in mouth cancer tissue and
correlate them with the clinical characteristics of the patients. This analysis enabled the identification of several proteins, such as CSTB, NDRG1,
LTA4H, PGK1, COL6A1, ITGAV and
MB—with differing levels of abundance depending on the tumor
area—and link them to key clinical
outcomes.
After identifying and quantifying
proteins in about 120 tumor tissue
samples, the second phase of the
study saw researchers deploy two
protein verification strategies. “One
strategy consisted of gauging the
abundance of the selected proteins
in independent tissue samples using immunohistochemistry with
antibodies. The other consisted of
monitoring the same preselected
targets in patients’ saliva,” explained
Paes Leme.
“Saliva is a promising source of
markers, as well as being a fluid obtained by noninvasive collection,”
she explained. “We verified the
proteins in saliva from 40 patients.
Technical triplicates were analysed
to achieve the highest possible con-

fidence level for the results in this
phase of the study.”

sity, as well as other institutions in
and outside of Brazil. It was funded

by the São Paulo Research Foundation, with the research conducted at

the National Energy and Materials
Research Centre.

AD

After analysing the saliva samples,
researchers used bio-informatics
and machine learning techniques to
obtain prognostic signatures. From
here, they were able to verify which
of the proteins or peptides were
selected during the first phase and
could thereby distinguish between
patients who had or did not have cervical lymph node metastasis.
According to the study’s results, it
was possible to identify three specific
peptides—LTA4H, COL6A1 and CSTB
—that can be used as a signature to
classify patients with and without
cervical lymph node metastasis.
Researchers believe that this could
potentially help doctors overcome
the limitations of clinical exams and
guide personalized treatment strategies.
“The data led to robust results that
are highly promising as guides to defining the severity of the disease. We
suggested potential markers of the
disease in the first phase of the study
and verified these markers in the
second phase, enhancing the reliability of the findings and showing that
these markers are effective in classifying patients with cervical lymph
node metastasis,” said Paes Leme.
Scientists are now working on a new
study designed to use translational
techniques to build affordable biosensors that are capable of detecting
prognostic signatures in patients’
saliva.

save the date

08 NOVEMBER 2019
InterContinental Hotel
Dubai Festival City
DUBAI, UAE

Part of 11th Dental Facial Cosmetic Conference & Exhibition

The study, titled “Combining discovery and targeted proteomics reveals
a prognostic signature in oral cancer”, was published on September 5
in Nature Communications.
Partners of the study included the
São Paulo State Cancer Institute, the
University of Campinas’s Piracicaba
Dental School and Institute of Computing, the University of São Paulo’s
Mathematics and Computer Science
Institute in São Carlos, the Dental
School of the West Paraná Univer-

Contact Us
Mobile: +971502793711
Telephone: +971 4 347 6747
E-mail: events@cappmea.com
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ORGANISED BY

[61] =>

4

hygiene tribune

Dental Tribune Middle East & Africa Edition | 6/2018

Dental Hygienst Seminar Impressions
Part of the 10th Dental Facial Cosmetic Conference & Exhibition, Dubai, UAE

312 dental hygienists attended the Dental Hygienist Seminar

Dr Mohammad Kashif Shafiq Khot – Seminar chairman

Dental hygienists attending the Dental Hygienst Seminar

Dental hygienists listening to the lectures

Robyn Watson, Australia lecturing on Periodontal Therapy

Prof Andrea Mombelli, Switzerland presented during the Dental Hygienist Seminar

Amanda Gallie, UK lecturing on salivary dysfunction

Mary Mowbray, New Zealand lecturing on management and prevention
of Peri Implant disease

Dental hygienists listening to the lectures

Dr Penelope Jones, Australia lecturing on sitting posture

Dr Nadia Mohd Saleh lecturing on Oro Facial Pain

Sawsan Jaffer AlThaqafi, Bahrain presenting during the Dental Hygienist
Seminar

Sitting posture lecture exercise

Hands-on training with Dr Penelope Jones

Dental hygienists listening to the lectures

Hands-on training with Amanda Gallie

Hands-on training with Amanda Gallie

[62] =>

Published in Dubai

November-December 2018 | No. 6, Vol. 8

www.dental-tribune.me

Implants should only be inserted
when periodontal conditions are stable
By Dr Jan H. Koch, Germany
Biofilm is the most significant cause
of inflammatory bone loss around
teeth and implants. Diagnostics, biofilm management and, where necessary, treatment help in patients
with this problem. The W&H No
Implantology without Periodontology workflow should provide stable
tissue prior to implantation through
prevention, and implant success in
the long term through aftercare –
something that is advantageous to
both the patient and the treatment
team.
Implant treatment can significantly
improve quality of life after tooth
loss.1,2 The long-term prognosis is
generally good, but biological complications are common.3 Peri-implantitis and its preliminary stage,
mucositis, occur in a substantial proportion of patients.4 As is the case for
periodontitis and gingivitis, oral biofilm is the main cause.5,6 This microbial biocoenosis can also encourage
the development of severe systemic
disease in the event of pathological
changes, such as endocarditis and
inflammatory bowel disease.7
The only difference in the microbial flora in periodontitis and periimplantitis is in the detail.8 Compared with healthy conditions, the
quantity and aggressiveness of the
pathogenic microorganisms change
in both diseases.5,6 Bone loss around
implants is generally more rapid
and leads to more extensive defects
than when it occurs around teeth.9

Accordingly, preventative care is
advised even before implant treatment.

Determining risks and providing periodontal treatment
Periodontitis is a key risk factor for
peri-implant inflammation. This
means untreated periodontitis patients have an increased risk of periimplant inflammation through to
implant loss.10 The risk is also higher
when patients who are initially treated are not included in a supportive
periodontitis treatment/recall programme.11
Leading periodontists therefore recommend carrying out a screening
procedure before implant treatment
using, for example, the periodontal screening index or periodontal
screening and recording.12 Bleeding
on probing and pocket depths are
determined at selected positions. An
extensive check of the periodontal
status should be carried out if the results are abnormal.13
Taking a careful medical history, including previous systemic exposure,
is also important.13 This provides important information about increased
risk of inflammation, for example
in patients with diabetes that is not
being optimally managed.14 Furthermore, patients should be informed
of the risks relating to implants.
Where necessary, initial periodontal
treatment is carried out. First, professional tooth cleaning establishes

Fig. 1: Calculus removal using an ultrasound (W&H Tigon (+) with a 3U
tip) is a key part of professional tooth cleaning. (Photograph: W&H)

Fig. 3: If marginal periodontitis is diagnosed, the initial debridement can
be carried out very efficiently with an air scaler (sonar technology, W&H
Proxeo with 1AP tip). (Photograph: W&H)

healthy gingival conditions. In this
procedure, calculus (Fig. 1) and biofilm (Fig. 2) are removed as far as the
gingival sulcus. In combination with
careful instruction on oral hygiene,
this gives the patient the basis for
long-term freedom from inflammation.15
Removal of subgingival coatings (debridement) is carried out using sonic
or ultrasonic devices and special
periodontal tips as initial periodontal treatment (Fig. 3). Manual instruments can also be used. Further surgical and/or regenerative measures
may be necessary, depending on the
situation.

Periodontal aftercare
for long-term success
In the periodontal aftercare subsequent to implantation, soft (biofilm) and hard coatings are regularly
professionally and mechanically
removed.16,17 In the subgingival and
supragingival areas, ultrasonic devices are generally used for this (Fig.
4), in combination with manual instruments where necessary. Alternatively, subgingival air polishing can
be used in combination with periodontal attachments and powders.18
Checking for individual risk factors,
such as smoking and diabetes, and
working towards a healthy lifestyle
are also recommended for a good
long-term prognosis after periodontitis treatment.13,19 If the patient had
severe periodontitis before the initial
treatment, the recall frequency will

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be increased accordingly, partially
to prevent peri-implant inflammation.20

Proactive implant treatment
If the patient has received good
preventative treatment and where
necessary has received preliminary
periodontal treatment, implant
treatment can be planned. A suboptimal implant-supported prosthesis
increases the likelihood of biofilm
forming.21 In order to avoid this, the
correct implant position, sufficient
distances from adjacent teeth and an
ideal axial alignment should be considered during the planning phase.
A sufficiently sized bone site and
soft tissue that is well supplied with
blood are needed for successful implant healing and a good long-term
prognosis. Prior or simultaneous
augmentation may be needed to
achieve this. In contrast to this, the
time at which the implant is inserted
and the treatment is provided plays
a less significant role.22,23
In order to support predictable and
stable implant treatment, it is also
necessary to prepare the implant
bed using suitable methods and
equipment. This can be achieved using high-performance implantology
motors in combination with surgical
contra-angle handpieces. Using a low
speed and an ample supply of sterile cooling fluid is essential during
preparation.24 Otherwise, the bone
can overheat and affect the healing
process.

Fig. 2: Rotary cleaning with prophylaxis polishing cups and brushes
(W&H Proxeo prophylaxis contra-angle handpiece) ensures smooth surfaces on teeth. It enables patients to check biofilm effectively at home.
(Photograph: W&H)

Fig. 4: Ultrasound devices are particularly suitable for UPT, for example in
combination with periodontal tips (W&H Tigon (+) with 1P tip).
(Photograph: W&H)

Alternatively, the implant bed can be prepared with piezo-surgical systems, for which
special sets of instruments are available.25
Bone can be worked on
in a gentle yet highly
effective manner using other special instruments. Indications
include alveolar ridge
splitting, surgical tooth
removal, and the preparation of bone blocks
or lateral windows for

augmentation.26 Highly advanced
piezo-surgical devices are also minimally invasive in soft tissue.

Stability measurement and
bone surgery
Once the implant has been screwed
into its final position, the primary
stability can be safely and precisely
determined using resonance frequency analysis. The technology is
available either separately or as an
optional module in an implantology
motor. If the ISQ (Implant Stability
Quotient) value measured is 66 or
higher, early intervention is possible,
and if it is over 70, treatment must
be provided immediately.27
An exposure protocol based on the
ISQ value improves the prognosis
of treatment. Simply measuring
the torque resistance, however,
does not provide the same level of
clinical safety.28 If reduced ISQ values
are measured after the implant has
been inserted, a two-phase protocol
is generally chosen. After exposure, a
new measurement can then be used
to determine whether osseointegration has been successful (secondary
stability) and loading will be predictable at this point.29

Hygiene-friendly prostheses
The emergence region should be designed to ensure that it is atraumatic
to the tissue for long-lasting implant
restorations. The implant–abutment
connection, material, surface and
emergence profile must be biocompatible and mechanically resilient
over the long term. The transgin-

ÿPage D2

Fig. 5: Implants and suprastructures are routinely cleaned, for example
using ultrasound devices and special plastic instruments (W&H Tigon (+)
with 1I tip). (Photograph: W&H)

[63] =>

implant tribune

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page D1
gival components should also be
accessible for individual and professional cleaning and for probing.20
Definitively integrating abutments
or other components at implant level immediately (“one abutment, one
time”) has also proved to be effective.30 In combination with good hygiene and correspondingly healthy
tissue, this concept can probably be
used to achieve a more stable attachment of the implant to the oral cavity than if the components have to
be replaced several times - a requirement for peri-implant health.
Whether it is with crowns, bridges,
partial or complete prostheses, the
implant-supported superstructure
should be designed so that the patient can maintain it without any
difficulty.20 Additionally, a distance
of at least 2 mm between the bone
and the mucosal edge of the prosthesis appears to be advised to prevent
infection and subsequent bone loss.31

Peri-implant aftercare
Experts recommend treatment immediately after the initial occurrence of symptoms of inflammation
to avoid peri-implant bone loss from
the start.20 Mucositis affects almost
half of all implants, and since pa-

tients often have several implants,
it occurs in a high percentage of patients.32 The prophylactic or periodontal recall programme established
after the implant has been inserted
should therefore be continued.20,33
At-home oral hygiene should be
carefully tailored to the new prosthesis and the patient accordingly
instructed on this.34 In combination
with professional biofilm management, good preventative efficacy can
be achieved in this way.35
The risk of peri-implantitis decreases
from 43.9 per cent (no recall) to 18.0
per cent if a patient receives a recall
appointment carried out carefully
each year, in other words by more
than half.36 Ultrasonic systems with
special instruments that do not affect the materials are suitable for
this, such as those made of PEEK (Fig.
5), or appropriate manual instruments.37

Mechanically
preventing mucositis
As for periodontitis patients, periimplant recall includes regular
screening with a clinical check of
both periodontal and peri-implant
tissue for symptoms of inflammation, probing and, where necessary,
radiographic diagnosis.9 A frequen-

cy of two to four times a year has
proved to be effective.17 Deep probing values and bleeding occur more
commonly in patients with periimplantitis than in those with mucositis; pus secretion only occurs in
patients with peri-implantitis.38
If a patient has mucositis, professional supragingival and subgingival
biofilm removal reduce the risk of
the inflammation advancing to periimplantitis. Local and systemic antibiotics used as supportive measures
or air polishing, however, show no
additional benefit.20,39

Treating peri-implantitis
Peri-implant bone loss can develop
even if good preventative care is provided, for example if the patient’s
oral hygiene is not sufficient. Most
minimal defects should be treated
in a non-surgical manner using periimplant debridement.37 Mechanical
removal of coatings using suitable
ultrasonic systems, supported by
Er:YAG lasers, antibacterial photodynamic treatment, air polishing,
or treatment with local or systemic
antibiotics, where appropriate, has
shown promising results.37
If closed treatment is no longer possible, the defect must be surgically

exposed and carefully decontaminated. This is carried out after flap
preparation by removing inflamed
tissue and cleaning the surface of
the implant using, for example, ultrasonic or piezo-surgical systems.
Measures designed to regenerate the
bone carried out after this procedure
have been successful.40 Special piezosurgical instruments are available
for the surgical treatment of periodontal defects.
After treatment, the patient is once
again intensively instructed on oral
hygiene and made aware of the need
for continual recall. If necessary, the
frequency can be selected to be higher than previously in line with periodontal aftercare. If biofilm management is carried out consistently, the
implantological results can remain
stable for several years even after
the periodontitis, mucositis or periimplantitis has healed.33,39

and professional biofilm management where possible for every patient.
Ideally, this preventative workflow
should start well before each restorative measure, before periodontitis
can develop. It is essential if implant
prosthetic treatment is planned or
has already been integrated. Patients
will be pleased with the long-term
success of the treatment and will
be pleased to return to a practice or
clinic they trust.
Editorial note: A list of references and
information is available from the
publisher by scanning this QR code
using your mobile phone. More information can be found at niwop.
wh.com.

No Implantology
without Periodontology
Successful implant treatment requires consistent, long-term preventative thinking. In each phase, this
includes regular periodontal and
peri-implant screening in combination with individually tailored risk
management, oral hygiene training

Case report: Prosthetic procedure with Atlantis
Anatomical shape, support and colour provided by the use of
an Atlantis patient-specific abutment in gold-shaded titanium
By Dr Fernando Rojas-Vizcaya & Mr
Francisco Ortega, Spain

Case
36 year-old patient with a vertical
fracture of tooth 46. The treatment
plan was to extract the tooth and
replace it with a dental implant using a conventional installation and
loading protocol. The challenge was

to restore the position of the gingival
contour and the inter-proximal papillae, as for a natural tooth. In order
to achieve a long term natural result,
an Atlantis Abutment was selected
to provide the optimal anatomical
shape, support and colour.

Dr Fernando Rojas-Vizcaya, DDS, MS
Department of Prosthodontics
University of North Carolina, Chapel Hill,
NC, USA
Director of the Mediterranean Prosthodontic Institute, Castellon, Spain
www.prosthodontics.es
Mr Francisco Ortega, CDT
Labordent, Malaga, Spain

Fig. 1: A vertical fracture of tooth 46. When probing, a distal narrow isolated pocket measuring more than 15 mm was detected.

Fig. 2: In the radiograph, a radiolucency along the distal wall of the distal root with the typical “J” shape seen in vertical root fractures could be
observed.

Fig. 3: Tooth extraction was performed without damaging the alveolar
walls. The socket was scraped and sutured without using grafting material.

Fig. 4: After 8 weeks of healing, the soft tissue over the extraction area
was completely healed.

Fig. 5: After 8 weeks, the amount of bone formation into the socket allowed for implant placement.

Fig. 6: Using a surgical stent, the osteotomy could be performed in an adequate position in 3 dimensions, using the zenith of the cervical contour
of the planned restoration as a reference point.

ÿPage D3

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implant tribune

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page D2

Fig. 7: The implant was placed 3 mm apical to the cervical contour of
the planned restoration, symmetrically from mesial to distal, and 2 mm
to the lingual in order to preserve the buccal bone that will support the
soft tissue.

Fig. 8: A 7 mm healing abutment was placed to guide the soft tissue to
an optimal healing situation.

Fig. 9: The healing abutment was removed after 6 weeks and a final impression of the implant position and the shape of the soft tissue was sent
together with the opposing model to the dental laboratory.

Fig. 10: The Atlantis Abutment was virtually designed with the emergence width of the replaced molar and manufactured in titanium with
a titanium nitride coating.

Fig. 11: The Atlantis Abutment in gold-shaded titanium, together with
the Atlantis abutment screw, was sent to the dental laboratory.

Fig. 12: The subgingival portion of the abutment will give the anatomical shape, support and color to the surrounding soft tissue. The final
crown restoration in zirconia was fabricated.

Fig. 13: Final implant restoration with the finishing line close to the gingival margin, allowing for easy removal of excess cement in the subgingival area. The restoration was ready to be delivered to the patient.

Fig. 14: The Atlantis Abutment was placed with some pressure of the soft
tissue. After a few minutes, the ischemia disappeared and the abutment
was seated in the correct position.

Fig. 15: Verification of correct seating of the abutment using a radiographic image. Note that the transitional portion of the abutment follows the contour of the bone.

Fig. 16: The Atlantis Abutment in gold-shaded titanium was torqued
according to the implant manufacturer’s recommendation of 25 Ncm.
The screw head was covered and the crown was later cemented to the
abutment.

Fig. 17: After 8 years, radiograph is showing a perfect fit of the restoration, the spaces created for the inter-proximal papillae, and the position
of the bone at the level of the implant.

Fig. 18: After 8 years, a perfect adjustment of soft tissue around the restoration (buccal view) was observed, filling the space for the inter-proximal
papillae and giving a natural position of the soft tissue contour.

The evolution of the Neoss implant system:
A retrospective follow-up of three patient cohorts
treated with three types of Neoss implants
This article reports on three patient cohorts with three types of Neoss implants. The retrospective analysis shows
excellent long-term results with the Neoss implant system. The results also indicate that the introduction of the
ProActive implant surface led to improved clinical outcomes in difficult cases.
By Dr Thomas Zumstein, Switzerland & Dr Herman Sahlin, Sweden

factors change together with the
change of implant design.

effect of implant design changes in a
more controlled manner.

Introduction

Here we have a clinical material
where the same surgical protocol has
been used by the same surgeon at the
same clinic but with three generations of Neoss implants. That gives
us a unique opportunity to study the

For each new generation of Neoss implants - i.e. Bimodal Straight,
ProActive Straight and ProActive Tapered - the clinical outcome of the
first 50 consecutive patients treated
in one private office has been ret-

The effect of dental implant design
changes on the clinical outcome is
usually difficult to study in a structured way. When comparing study
data from different studies, several

rospectively analysed. Data on the
Bimodal and the ProActive Straight
patient groups have been published
earlier.1,2

Materials and methods

Patients
This retrospective study analyses
three patient cohorts consisting of

the first 50 consecutive patients
treated with three types of Neoss
dental implants (Neoss Ltd, Harrogate, UK):
• Bimodal Straight implants
• ProActive Straight implants
• ProActive Tapered implants

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[65] =>

Dental Tribune Middle East & Africa Edition | 6/2018

◊Page D3
The Bimodal implant had a straight
implant body with a blasted surface.
The ProActive Straight implant has
exactly the same implant geometries as the Bimodal implant, but
with the blasted and etched hydrophilic ProActive implant surface. The
ProActive Tapered implant has the
same ProActive surface, the same
prosthetic connection and cutting
features as the ProActive Straight
implants but with a tapered implant
body.

implant tribune
Zumstein, Sahlin

supracrestal with half of the collar
above bone level. In the two ProActive cohorts, all implants were
placed with the implant-abutment
connection at bone level.
Healing protocol
Three different healing protocols
were utilized: Two-stage healing,
one-stage healing with delayed loading and immediate loading.
Prosthetics
Implants were restored with single crowns, partial bridges, fixed
full bridges, or overdentures (Figure
1). All restorations were fabricated
using conventional prosthetic techniques on NeoLink abutments (Neoss Ltd). Frameworks were made of
titanium or gold, and both porcelain and acrylate were used as veneering materials.

Letters on Implant Dentistry 2017; 1: 35-38

Bimodal
2003 2005

Implant
surgeries

2010

183 implants

31 f 19 m

76 full jaw

50 patients

159 implants

Bone grafting

2015

10 year follow-up

ProActive Straight
2005

50 patients

2010

Implant

79 partial

28 single

GBR: 126 No GBR: 57

Bone grafting

2015

5 year

ar in
bone
mber
like-

implant collar.

the other groups, partly due to differences
in placement
grafting. However,
as clearly seen in Figure 1, the number
depth.
of implants decreased for each new group. This most likeA Neoss 4.0 mm straight implant is outlined to show the
bone levels in reference to the implant collar.

Marginal bone level (mm)

Cumulative survival rate (CSR)

The patients were examined clinisurgeries follow-up
GBR: 91 No GBR: 68
28 f 22 m
37 full jaw 96 partial
26 single
cally and radiographically before
treatment. They were thoroughly
informed of the surgical and folBone grafting
51 patients
101 implants
ProActive Tapered
low-up procedures and gave their
written consent before treatment.
2005
2010
2015
All treatment steps were part of the
routine procedures at the clinic,
Implant 3 year
and no extra measures were taken
surgeries follow-up
Zumstein, Sahlin
for the cause of the study. The study
33 f 18 m
15 full jaw 50 partial 36 single
GBR: 66 No GBR: 35
was conducted in full accordance
Letters on Implant Dentistry 2017; 1: 35-38
Zumstein, Sahlin
Fig. 1: Overview of studies
with ethical principles, including
Figure 1: Overview of studies
the World Medical Association Declaration of Helsinki.
ProActive Straight
ProActive Tapered
healing, one-stage healing with delayed loading and immeand a resorbable BioGide membrane (Geistlich, SwitzerProActive Straight
ProActive Tapered
100% Bimodal
Surgical protocol 100%
100%
diate
loading.
land)
was
performed
simultaneously
with
implant
place100%
98.9%
Patients were
given antibiotics (Da100% 100%
98.5%
100%
100% were treated using a staged GBR
100%
ment. Larger defects
100%
98.9%
lacin, 300 mg, Pfizer AG, Zurich,
98.5%
98.2%
procedure. First, either an autologous bone block and a reProsthetics
Switzerland) prior to the proce95%
95%
sorbable membrane (BioGide) or a bone substitute materiImplants were restored with single crowns, partial bridgdure, and the implant surgery was
95%
95%
performed under local anaesthesia
al (BioOss) and a non-resorbable ePTFE membrane (Goes,95%
fixed full bridges, or overdentures (Figure 1). All95%
resto93.5%
(Ultracain D-S Forte, Sanofi-Aventis,
re-Tex Regenerative Membrane, Gore Medical, Flagstaff,
rations were fabricated using conventional prosthetic tech90%
90%
Geneva, Switzerland).
AZ, USA) were used. Implants were placed after a healing
niques on NeoLink abutments (Neoss Ltd). Frameworks
90%
90%
90%
90%
period of 6 months. ePTFE membranes were removed in
were made of titanium or gold, and both porcelain and
In cases of localized horizontal and
the same operation. In some cases, sinus floor augmentaacrylate were used as veneering materials.
vertical defects, a guided bone re85%
85%
tions were made85%
simultaneous with implant placement eigeneration (GBR) procedure using
85%
85%
85%
BioOss and a resorbable BioGide
Follow-up
ther by the use of a series of osteotomes or by using a lateral
membrane (Geistlich, Switzerland)
The patients were scheduled for annual check-ups with
window technique.
80%
was performed 80%
simultaneously
clinical
Flapped surgery
80%
80% was used. Implant sites were prepared
80% and radiographic examination. Follow-up data
80% was
1
2
3with 4implant
5 placement. Larger
0
2
3
de- 1
0
5
10 were placed in0accordance
1
2with the
3 manufac4
5
0
3
collected from
the 1-,1 3-, 5-, and210-year visits.
and implants
fects were treated using a staged
Follow-up (years)
Follow-up (years)
Survival analysis
was performed,
turer’s guidelines.
Follow-up (years)
Follow-up (years)
Follow-up
(years) and marginal bone
GBR procedure. First, either an aulevels were measured from periapical radiographs. Mesial
Implant placement depth varied between the different
tologous bone block and a resorbNo GBR
No GBR was
able membrane (BioGide) or a bone
and distal bone levels were measured and an average
treatment groups: In the Bimodal treatment cohort 59%
GBR
GBR
substitute material (BioOss) and a
calculated. Baseline measurements were taken at time of
of the implants were placed with the implant platform at
non-resorbable ePTFE membrane
implant
placement
forlower
the ProActive
and atthe
time of
bone
and
were
placed
supracrestal
with
halfsurvival
of GBR
tudy groups. The
Bimodal GBR group showed lower
survival
raterates
than
Fig. 2:
Implant
overthe
time rates
for the
threelevel
study
groups.
The
Bimodal
GBR
group
showed
lower
rate
than
the
other
groups.
Figure
2:survival
Implant
survival
over
time
for41%
the
three
study
groups.
The
Bimodal
group
showed
survivalgroups
rate than
(Gore-Tex Regenerative Membrane,
prosthesis delivery for the Bimodal group.
the collar above bone level. In the two ProActive cohorts,
other groups.
Gore Medical, Flagstaff, AZ, USA)
all implants were placed with the implant-abutment conwere used. Implants were placed afnection
at bone level.
ter a healing period of 6 months. Follow-up
groups were whether this is due to the studied
and follow-up
status for each treat- protocol. Hence, theRESULTS
ePTFE membranes were removed The patients were scheduled for ment group is presented in Figure 1.
similar in gender distribution
and
patient
population,
the surgical
Baseline data,
treatment
schedule
and follow-up
statusand
for
In the
Bimodal
all followed patients have attendly reflects
a shift
in the
general
implant
population
over
tendlyinreflects
shift inIn some
the general
implant
population
check-ups
withgroup,
clinicalover
and
the sameaoperation.
cas- annual
percentage
of
sites
requiring
bone
prosthetic
protocol,
the
meticulous
each treatment group is presented in Figure 1.
Healing protocol
examination.
Followes, sinus floor augmentations were radiographic
grafting.
However,
as
clearly seen of follow-up
In
the
Bimodal
group,
all
followed
or the has
implant
ed
the
10
year
check-up.
In
the
ProActive
Straight
group,
time
where
the
percentage
full archschedule
restorations
deroup,
time
where the percentage of full arch restorations has de- Three different healing protocols were utilized: Two-stage
made simultaneous with implant up data was collected from the 1-, 3-, patients have attended the 10 year in Figure 1, the number of implants properties.
theandpatients
have
completed
5 yearInfollow-up,
and
in
creasedforand
percentage
5-,
10-year
visits.
placement
either
the use of a se-of single
decreased
eachthe
new
group. This of single crown restoration has
check-up.
the ProActive
Straight
nd in
creased
and
thebypercentage
crown
restoration
has the
36
ries of osteotomes or by using a lat- the ProActive Tapered group, the
most
likely reflects
shift
the years.
group,
the follow-up
patients haveis completIn conclusion, the studies show ex3 year
comincreased
over athe
lastin10-15
comincreased
the last 10-15 years.
Survival analysis was performed, ed the 5 year follow-up, and in the general implant population over cellent long-term results with the
eral windowover
technique.
pletedmarginal
(Figure bone
1). levels were ProActive Tapered group, the 3 year time where
The results
indicate
long-term
clinical
and
the percentage
of excellent
full Neoss
implant system.
Theresults
results
The
results
indicate
excellent
long-term
clinical
results
Flapped surgery was used. Implant measured from periapical radio- follow-up is completed (Figure 1).
arch restorations has decreased and also indicate that the introduction
Implant and
survival
is shown
in Figure 2. In the Bimodwith the Neoss implant system. The bone levels are maindistal
bone
levsites the
wereNeoss
prepared
and implants
the percentage of single crown res- of the ProActive implant surface led
modwith
implant
system.graphs.
The Mesial
bone levels
are
mainwere measured
and an average
al group,
the cumulative
survival
ratesurvival
after 10
years in
was
tainedhasonincreased
a stableover
level
year inclinical
all groups
with
an
were placed in accordance with the els
theafter
last one
Implant
is shown
Fig- toration
to improved
outcomes
in difs was
tained
on a stable
level after one
in all Baseline
groups measurewith an ure 2. In the Bimodal group, the 10-15 years.
wasyear
calculated.
manufacturer’s
guidelines.
ficult cases.
93.2% for augmented sites (8 implant failures) and 98.2%
average long-term bone level change in the Bimodal group
ments were taken at time of im- cumulative survival rate after 10
8.2%
average
long-term
bone
level
change
in
the
Bimodal
group
placement for the ProActive
Implant placement depth varied plant
results indicate
years was In
93.2%
augmented The
for non-augmented
sites (1 failure).
theforProActive
between
5 and excellent
10 yearslongis lessReferences
than 0.1 mm.
groups0.1
andmm.
at time of prosthesis de- sites (8 implant failures) and 98.2% term clinical results with the Neoss 1. Zumstein T, Billstrom C, Sennerby
between 5
the
different
treatment
Active
between
and
10 years
is less than
Straight
group,
cumulativefor
survival
rate after
The
Bimodal
implant
lower
ratecliniin
for the
Bimodalthe
group.
groups: In the Bimodal treatment livery
system.
The bone
levels are showed
non-augmented
sites5(1 years
failure). implant
L. A 4- to
5-yearsurvival
retrospective
years
The 59%
Bimodal
implantwere
showed
lower for
survival
rate in
cohort
of the implants
maintained
on asites
stable(93.2%
level after
ProActive
cal and radiographic
studyin
of imNewas 98.5%
augmented
sitesIn(1thefailure)
andStraight
98.9%group,
for
augmented
vs. 98.2%).
No difference
ResultsNo difference in im- the cumulative survival rate after one year in all groups with an aver- oss implants placed with or withplaced with the
implant
platform
% for
augmented
sites
(93.2%
vs. 98.2%).
non-augmented
sites schedule
(1 failure).5 In
thewas
ProActive
data, treatment
at bone level and 41% were placed Baseline
years
98.5% for Tapered
augmented age long-term bone level change in out GBR procedures. Clin Implant
sites (1 in
failure)
and 98.9%
for non- the Bimodal group between 5 and 10 Dent Relat Res. 2012;14:480-90.
pered
group, no failures occurred, resulting
cumulative
survivaugmented sites (1 failure). In the years is less than 0.1 mm.
2. Zumstein T, Sennerby L. A 1-Year
rvival rates after 3 years of 100% forProActive
augmented
sites
as no
well
as
Tapered
group,
failures
Clinical and Radiographic Study on
occurred, resulting in cumulative The Bimodal implant showed Hydrophilic Dental Implants Placed
ell as
non-augmented sites.
0.5 rate in augmented
survival rates after 3 years of 100% lower survival
with and without Bone Augmentasites (93.2% vs. 98.2%). No differ- tion Procedures. Clin Implant Dent
for augmented
sitesinasFigure
well as nonMarginal bone levels over time
are shown
3.
0.5
ence in implant survival between Relat Res. 2016;18:498-506.
augmented sites.
1.0
In the Bimodal group, the bone resorption from prosthesis
ure 3.
augmented and non-augmented 3. Andersson P, Degasperi W, Verrocbone
over time are sites were seen for the ProActive chi D, Sennerby L. A Retrospective
delivery to 10 years was 0.4 ± Marginal
1.2 mm.
In levels
the ProActive
1.0
hesis
shown in Figure 3. In the Bimodal implants. This
Study on Immediate Placement of
1.5 indicates that imStraight
group,
the
bone
resorption
from
implant
placegroup, the bone resorption from plants with the ProActive surface Neoss Implants with Early Loading
Active
prosthesis
to 10Tapered
years was experience less complications than of Full-Arch Bridges. Clin Implant
1.5
ment to 5 years was 0.7 ± 0.6 mm.
In the delivery
ProActive
place0.4 ± 1.2 mm. In the ProActive implants with the Bimodal surface. Dent Relat Res. 2015;17:646-57.
0 line with
2 earlier4
6
8
10
group, the bone resorption from
implant
to 3
This finding is in
Straight
group,placement
the bone resorption
pered
Follow-up (years)
from implant placement to 5 years studies showing that ProActive imyears
was
0.5
±
0.6
mm.
0
2
4
6
8
10
to 3
was 0.7 ± 0.6 mm. In the ProActive plants performed better than
All groups showed stable bone
levels
after
first
year.
Bimodal implants when placed
Tapered
group,
thethe
bone
resorption
Follow-up (years)
from implant placement to 3 years directly after total extraction of
None of the patients in any of the
study groups showed any
remaining teeth and loaded with a
was 0.5 ± 0.6 mm.
year.
3
ProActive
Tapered
ProActive Straight
Bimodal
fixed bridge within
3 days.
signs of peri-implantitis.
d any
All groups showed stable bone levels after the first year. None of the No case of peri-implantitis was
Figure 3: Marginal bone levels. All groups showed bone
ProActive Tapered
ProActive Straight
Bimodal
patients in any of the study groups recorded in the studied patient
DISCUSSION
Aboutlongest
the Authors
resorption
0.7 mm
follow-up timeshowed any signs of peri-implantitis. population
duringless
thethan
3-10 years
of toDrthe
Thomas Zumstein
The
three
patient
Fig.
3: Marginal
bone levels. All
groupslevels.
showedAll
bone
resorption
less
thanbone
0.7 cohorts
mm to the were treated according to the
follow-up.
This
is bone
an interesting
Figure
3: Marginal
bone
groups
showed
point.
The
levels inand
the Bimodal
groupLuzern,
is lower
than
Private Practice,
Switzerland
longest follow-up timepoint. The bone levels in the Bimodal group is lower than the Discussion
encouraging
finding.
However,
adsame
clinical protocol. Hence, the groups were similar in
the other groups, partly due to differences in placement
resorption
less
than
0.7 mm
to the
longest
other
groups, partly
due
to differences
in placement
depth. follow-up timeThe three patient cohorts were treat- ditional studies and larger patient Dr Herman Sahlin
o the
depth.are needed to establish Neoss Ltd, Gothenburg, Sweden
A Neoss
4.0The
mm bone
straightlevels
implantin
is outlined
to
show the
bone is
levels
in reference
to the ed according
point.
the Bimodal
group
lower
than
gender
distribution
and percentage
of sitestorequiring
the same bone
clinical populations

A Neoss 4.0 mm straight implant is outlined to show the
bone levels in reference to the implant collar.

[66] =>

ortho
issn 1868-3207 • Vol. 3 • Issue 2/2018

international magazine of orthodontics

case report

Anti-ageing medicine and orthodontic appliance
therapy treatment: An interdisciplinary approach

technique

Tooth whitening and orthodontics:
The icing on the cake

interview

The Carriere Motion 3D Appliance:
Revolutionising Class II and Class III corrections

AVAILABLE SOON

Just scan the QR code and to get further details.

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[68] =>

[69] =>

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[cover] => DT Middle East & Africa No. 6, 2018

[toc] => Array ( [0] => Array ( [title] => Dubai Health Authority bags two golden International Stevie Awards [page] => 01 ) [1] => Array ( [title] => Whole mouth extractions in children on the rise in the UK [page] => 02 ) [2] => Array ( [title] => Do it your way – with CEREC [page] => 03 ) [3] => Array ( [title] => Predictable implant impressions [page] => 04 ) [4] => Array ( [title] => PlanMill dentists to get even more choice [page] => 06 ) [5] => Array ( [title] => EVO.15 – The world's safest contra-angle, developed by Bien-Air [page] => 06 ) [6] => Array ( [title] => Oral care brand Beverly Hills Formula finish off a fantastic year in style [page] => 08 ) [7] => Array ( [title] => Seven keys to optimising interdisciplinary orthodontics [page] => 14 ) [8] => Array ( [title] => Predictable steps to Biomimetic Class IV restorations [page] => 20 ) [9] => Array ( [title] => Nd:YAG laser-assisted removal of instrument fragments [page] => 29 ) [10] => Array ( [title] => Mastering the implant digital workflow [page] => 29 ) [11] => Array ( [title] => News [page] => 31 ) [12] => Array ( [title] => Interview [page] => 32 ) [13] => Array ( [title] => Paediatric [page] => 34 ) [14] => Array ( [title] => News [page] => 36 ) [15] => Array ( [title] => Event [page] => 39 ) [16] => Array ( [title] => Poster Presentation [page] => 40 ) [17] => Array ( [title] => Endo Tribune Middle East & Africa Edition No. 6, 2018 [page] => 46 ) [18] => Array ( [title] => Lab Tribune Middle East & Africa Edition No. 6, 2018 [page] => 54 ) [19] => Array ( [title] => Hygiene Tribune Middle East & Africa Edition No. 6, 2018 [page] => 58 ) [20] => Array ( [title] => Implant Tribune Middle East & Africa Edition No. 6, 2018 [page] => 62 ) [21] => Array ( [title] => Ortho Tribune Middle East & Africa Edition No. 6, 2018 [page] => 66 ) ) [toc_html] =>

Table of contents

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