DT Asia Pacific No. 1+2, 2015

Asia News / World News / Opinion / Business / Trends & Applications

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DTAP0115_01-03_News 09.02.15 14:49 Seite 1

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

18 News & Opinions

DENTAL TRIBUNE
The World’s Dental Newspaper · Asia Pacific Edition

PUBLISHED IN HONG KONG

www.dental-tribune.asia

NO. 1+2 VOL. 13

Google
How to get on to Page 1
in 2015

Cone Beam CT
Ready for a new standard
of care?

Neoss
Guy Leaver on expansion
plans in Asia
4Page

(DTI/PhotoTwinDesign)

4Page

(DTI/Photo RobertKneschke)

Regional declaration on amalgam Dental
icon
phase-out signed in Bangladesh

dies
at
85
Asia poised to become first continent free from dental mercury waste
The father of the modern dental implant, Per-Ingvar Brånemark,
has died at age 85 in his hometown of Gothenburg in Sweden
from a heart attack. He leaves behind his wife, three children and
four grandchildren.

DT Asia Pacific

Dhaka, Bangladesh: Representatives of dental and civil
society organisations in Asia
recently signed a declaration in
Dhaka, Bangladesh, that calls
for a phase-out of dental fillings
containing mercury throughout
the region. The agreement also
aims for the cease of trade in
amalgam and to educate dental
professionals about mercury-free
alternatives, such as Atraumatic
Restorative Treatment.
Use of amalgam in the treatment of children and pregnant
women is to be prohibited already this year, the paper states.
It also strives for developing
measures to raise public awareness about the environmental
hazards of amalgam and to help
hospitals and dental institutions
continent wide to provide mercury-free dental health care
services. An overall phase-out of
amalgam in dentistry in Asia is
targeted for 2020.

A physician and dedicated researcher, Brånemark accidently
discovered how to anchor titanium in bone, a process known
as osseointegration, when studying the effects of blood flow on
bone healing. He successfully
placed the first titanium implant
in the mid-1960s in a Swedish
patient with several jaw deformities and missing teeth.
His invention was approved by
Swedish health authorities in the
early 1970s. It is still sold today as
the Brånemark system by Nobel
Biocare.
The declaration was formulated last November in Dhaka. (Photo OSVSWA, India)

Signed by dental representa tives from India, Nepal, Bangladesh, Thailand, Pakistan and
Sri Lanka, the declaration is con-

sidered a practical step towards
implementing the Minamata
Convention on Mercury, an international agreement signed by

87 countries two years ago in Japan
that has banned the use of the
‡ DT page 2

During his lifetime, Brånemark
received several honours, including the Swedish Society of
Medicine’s Söderberg Prize and
the European Inventor Award for
Lifetime Achievement. DT
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Recommendations Dentist best job in
the United States
changed
The Food and Drug Administration has updated its recommen dations for the use of bone graft
substitutes containing recombinant proteins or synthetic peptides
in patients under the age of 18.
Owing to reported adverse effects, the regulatory body advises
against routine use of such products in this population. DT

US News & World Report
has announced that dentist and
dental hygienist are again among
the best jobs in the United States,
with dentist at No. 1. Dentist
is also among the 2015 top bestpaying jobs in the country, only
preceded by physicians, who
top the list with an average of
US$188,440 earned in 2013. DT

Japanese researchers have
found that people who wear dentures at night are at an increased
risk of pneumonia. According to
their study, patients who wore
their dentures during sleep were
at a 2.3-fold risk of developing the
condition compared with those
of a control group who removed
their dentures before they went
to bed. Denture wearers were
also more likely to suffer develop
tongue and denture plaque,
Candida albicans, as well as
periodontal inflammation.
The study conducted at the
Nihon University’s School of Dentistry and Keio University’s School
of Medicine in Tokyo examined
228 men and 296 women aged 85
and over in terms of their oral
health status and behaviour. DT

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[2] => Standard_300dpi

DTAP0115_01-03_News 09.02.15 14:49 Seite 2

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

Asia News

ﬂ DT page 1

(DTI/Photo IDA)

substance in industrial products
like batteries and fluorescents
lamps, on the continent. Although
amalgam is generally exempt
from the ban, the convention
recommended phasing down its
use in dentistry worldwide.

Dr Mahesh Vermam, President of the
Indian Dental Association.

If implemented effectively, the
new declaration, formulated in
Dakha, Bangladesh, last November,
would make Asia the largest and
most densely populated continent
to phase out the controversial
material, said Dillip Pattanaik,
Executive Director of the Orissa
State Volunteers and Social Workers
Association, a local non-profit organisation, and one of the initiators of the initiative.
“Amalgam is a primitive, polluting product whose high metal
content leads to cracked teeth.
It is so old that it pre-dates the
birth of Mahatma Gandhi. It has
no role in 21st century dentistry and
it is generally rejected among
younger and more modern dentists,” he commented.

While mercury-free dentistry
is growing even in rural parts of
India, Pattanaik said, more than
70 per cent of dentists in the country are still using it as their primary filling material. The widespread use results in 65 tons of
amalgam waste per year, which,
despite new initiatives to educate
dentists about the benefits of
amalgam separators, is released
into the environment. It is then
transformed into methylmercury,
a highly toxic form of the metal
that poses health risks to wildlife
and human beings.

Journalist, doctor and colleague:

A tribute to Elsa Cayat

“The large number of dental
practitioners and dental professionals both in the private and
government sectors are unaware
of these things and required to be
sensitised to avoid amalgam disposal through the normal sewer
system,” Prof. Mahesh Verma, Indian Dental Association President
and Director and Principal of the
Maulana Azad Institute of Dental
Sciences in New Delhi, told Dental
Tribune Asia Pacific.
Religious practices like Hindu
cremations further add to the
environmental problem, as they
release mercury from dental fillings into the air.
While the environmental effects of amalgam waste in Asia
remain largely unknown, it is
believed that the continent contributes significantly to the overall global burden. According
to a 2013 report released by the
United Nations Environment
Programme, amalgam waste entering the solid waste stream
amounts to 340 tons worldwide.
Total emissions of mercury
resulting from cremation of human remains were estimated at
3.6 tons. DT

From right to left: Marc Revise with Elsa Cayat and fellow journalist Antonio Fischetti.(Photo Archive)
Dr Marc Revise
Scientific Editor,
Dental Tribune France

Elsa Cayat was killed along
with 11 of her colleagues,
in the attack against French
newspaper Charlie Hebdo
in Paris on 7 January 2015.
She leaves behind a 22-yearold daughter.
Elsa worked as a psychiatrist and psychoanalyst. She
had her internship at the
age of 22. “Charlie Divan”

was the name of the column
she wrote for Charlie Hebdo.
She also published two books,
Un homme + une femme = quoi ?
[A Man + A Woman = What?] and
Le Désir et la putain [Desire and
the Whore]. In a twist of irony,
we had been working together
on an essay about death, transmission and love over the past
year. Parental authority and the
lasting damage it can cause was
also one of her favourite themes.

laugh was distinctive. Her enthusiasm and lust for life could
be felt when she would say,
“Sooooo, what’s new with you?”.
Open to many things, she
loved to flick through the
Dental Tribune that I would
sometimes leave on her desk.
On 3 June 2014, we celebrated
the release of Patrick Pelloux’s
book On ne vit qu’une fois!
[You only live once!] with
Charlie Hebdo editor Stéphane
Charbonnier and the rest of
the Charlie Hebdo team. DT

Although a free spirit, Elsa was
always attentive. Her very special

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DTAP0115_01-03_News 09.02.15 14:49 Seite 3

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

World News

3

DTI

LONDON, UK: Electronic
learning could enable millions
more students to train as doctors and nurses worldwide,
according to the latest research.
A review commissioned by the
World Health Organization
(WHO) and carried out by Imperial College London researchers
concluded that e-learning is
likely to be as effective as traditional methods for training
health professionals. These new
findings support the approach
to continuing education Dental
Tribune International (DTI) has
adopted with its free online
education platform for dental
professionals.

several languages. The wide range
of topics includes general dentistry, digital dentistry, practice
management, as well as specialties, such as implantology and

(DTI/Photo Odua Images)

Study finds e-learning as
good as traditional training
for health professionals
endodontology. The webinars
are presented by experienced
speakers and participants are
awarded continuing education
credits. DT
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The Imperial team, led by
Dr Josip Car, carried out a systematic review of the scientific
literature to evaluate the effectiveness of e-learning for undergraduate health professional
education. They conducted separate analyses on online learning, which requires an Internet
connection, and offline learning, delivered via CD-ROMs or
USB flash drives, for example.

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The findings, drawn from
a total of 108 studies, showed
that students acquire knowledge and skills through online
and offline e-learning as well as
or better than they do through
traditional teaching.

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E-learning, the use of electronic media and devices in education, is already used by some
universities to support traditional campus-based teaching or
to enable distance learning.
Wider use of e-learning might
help to address the need to train
more health workers across
the globe. According to a recent
WHO report, the world is short
of 7.2 million health care professionals, and the figure is growing.
The authors suggest that
combining e-learning with traditional teaching might be suitable for health care training,
as practical skills must also be
acquired.
According to Car, from the
School of Public Health at Imperial, “E-learning programmes
could potentially help address
the shortage of healthcare workers by enabling greater access
to education; especially in the
developing world the need for
more health professionals is
greatest.”
While the study focused on
the education of students, DTI
follows a similar approach to
continuing education, offering
webinars via its Dental Tribune
Study Club, which it launched
in 2009. The platform regularly
offers free online courses and in

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[4] => Standard_300dpi

DTAP0115_04_News 09.02.15 10:54 Seite 1

Opinion

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

Je suis
Charlie

A man of
humour and
humanity

Daniel Zimmermann
DTI

Dr Yatoro Komiyama
Japan

A few weeks ago, this simple
French expression brought people around the globe together in
solidarity. Unfortunately, a dear
friend of our French editor was
killed in the terrorist attacks
against the Charlie Hebdo newspaper on 7 January and a Jewish
supermarket in Paris on 9 January.
Our thoughts are with her family
and the bereaved of the other
15 victims.
What remains now after these
horrific events? Obviously, there
is the revealing fact that security,
wherever you are, is an illusion.
Barbaric acts of violence are not
things that happen to someone else
somewhere else; they can affect
you directly and without warning.
Do we persist and go on or do
we give in and play the game of
the devil? My sincere hope is that,
whatever happens, people will
always choose humanity and reason over ignorance and hate. DT
Yours sincerely,
Daniel Zimmermann
Group Editor
Dental Tribune International

Dental Tribune welcomes comments,
suggestions and complaints at
newsroom@dental-tribune.com.
For quick access to
our contact form,
you may also scan the
following QR code.

When I met Prof. Per-Ingvar
Brånemark in his workroom at the
University of Gothenburg at the
beginning of the 1980s, my introduction to him was not good. I was
overly formal because I thought
he would be difficult to approach.
Luckily, he was not.

No place in clinical dentistry
Dr Sushil Koirala
Nepal

The use of mercury in dental
restorative materials has a long
history. While amalgam fillings are
still popular among dentists in both
developed and developing countries, the toxic effects of the metal
remain a subject of controversy.
In my practice, I stopped performing tooth restorations with
amalgam 15 years ago, not because of its toxicity, but because it
is not a naturo-mimetic and such
restorations require more invasive tooth preparation. Now, we
have various tooth-coloured adhesive restorative materials at our
disposal as an alternative to amalgam. Therefore, its use in clinical
practice largely depends on the

mindset and choice of the dentist
and patient. I personally believe
that, if a dentist considers do no
harm dentistry his or her practice
philosophy and adopts minimally
invasive restorative techniques
to achieve naturo-mimetic clinical results, then silver amalgam
restorations no longer have a
place in clinical dentistry.
When discussing banning
mercury-containing restorative
materials in dentistry, we must
consider what we have been
teaching our students at undergraduate level. If we carefully
look at the restorative dentistry
syllabus in Asia, we see that almost every dental department
still teaches conventional restorative procedures with amalgam.
They also focus on G.V. Black’s
principles of cavity preparation,
which are now considered very invasive and becoming increasingly
obsolete in quality dental practice.

Unless we reconsider restorative
techniques and materials science
in dental curriculums, it will
be difficult to induce practical
changes in clinical practice.
As a practitioner and advo cator of minimally invasive cosmetic dentistry, I have been effectively promoting tooth-coloured
adhesive restorative materials.
I strongly urge young dentists to
perform minimally invasive and
naturo-mimetic dentistry for the
long-term health and beauty of
teeth and smiles. DT

Dr Sushil Koirala is President
of the Asian Academy of Aesthetic Dentistry and a regular
contributor to Dental Tribune.
Dr Koirala can be contacted at
drsushilkoirala@gmail.com.

Yataro Komiyama is founder of
the Brånemark Osseointegration
Center in Tokyo, Japan, and Clinical Professor at Tokyo Dental
College. He can be contacted at
yataro@teabreak.jp.

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Brånemark was a genuine
mentor to all dentists. May his
soul rest in peace and watch over
us forever. DT

Contact Info

ANGZHOU
GU

05.–08.04.2015

During a lecture he gave in
Dallas in 1989 as the first honorary
member of the Academy of Osseointegration, he dropped the pin
microphone. “Maybe I should install a tooth fixture in my rip to
hold this mic,” he joked.

Contact Info

Dental
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His heart was filled with benevolence for his patients. He always
wore a smile and encouraged communication. “The optimal hardware
and software are very important
factors in order to establish osseointegration and to maintain it for
many years. Minimal tissue violation is the most valuable factor of
software.” This is the advice he gave
me in 1982. I always bear it in mind.

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DTAP0115_05_Hafeez 09.02.15 10:56 Seite 1

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

Opinion

Clinical governance—
A system for better health care

(DTI/Photo Minerva Studio)

by it. It can also rate the clinical effectiveness of a particular specialty
or clinician. With patient feedback,
it can furthermore identify any
shortcomings in the system. It will
compel the organisation to strive
for the professional development
of its employees, safeguarding the
clinician’s right to develop professionally. The impartiality of the
system opens the organisation to
scrutiny and maintains the absolute
system of checks and balances.

Dr Kashif Hafeez
UK

While accountability and improvement have been eminent in
health care systems for quite
some time, there is probably no
other time in history when the
relevance and importance of
these have been more advocated.
Learning from our shortcomings
and improving our health care
system towards better patient
care is the goal of clinical governance. I refer to it as the democracy of the health care system, in
which all members of the health
care team have the right to bring
about positive changes.
Accountability and learning
from self-criticism forms the basis
of clinical governance, which provides the framework for taking all

we can provide the best care possible for our patients. It is a structural
framework that incorporates all
pillars of the health care system.
There are channels for the health
care team, management and patients alike. Particularly for the last,
clinical governance provides an
environment free from potential
hazards. In addition, patients are
given a voice in the system through
patient feedback, ensuring that if
they draw attention to any wrongdoing, lessons are learnt and such
mistakes are not repeated.
For our staff and team members, clinical governance ensures
that they will be inducted into the
system effectively in the beginning
and be a part of that system through
organisational meetings and their
annual appraisals throughout
their whole career. This way, they

“...it is time that this essential
system of health care delivery
become established
in developing economies.”
the steps necessary to make the
system more patient friendly. It is
a cyclical process that once established can help to identify the decisive factors for the quality of patient
care. When asked by one of my
trainees when the mechanisms
of clinical governance ensue in
everyday practice, my answer was,
“In a patient-centred practice it
never stops”. It starts as early as
the patient first contacts a practice
or a hospital and encompasses the
entire health care scenario, starting with welcoming and managing
a new patient, ensuring his or her
safety on our premises and advising
him or her about all aspects of treatment. This combination is all about
our transparency to the outside
world, ensuring that arbiters and
our patients can be certain of our
quality of care.
More simply put, clinical governance is the umbrella under which

will have the best opportunity to
improve their skills and advance
their professional development.
Moreover, this allows them to better judge their clinical effectiveness and communication skills.
Since training and career development are integral parts of clinical
governance, it helps the clinicians
to identify their learning needs and
plan their continued professional
development accordingly. Continuing in this loop, they are able to develop improved awareness about
the safety of their work environment, as risk management is one of
the basic pillars of clinical governance. Through research and development opportunities, they can
also learn new skills and treatment
protocols.
Clinical governance is the girdle
of an organisation in a health care
system: it encompasses all aspects

of improved patient care and keeps
all involved units in the loop. The
management of an organisation can
monitor the quality of care provided

Audit is an indispensable part of
clinical governance, as it allows the
system to self-analyse and induce
changes, if needed, that is, we make
improvements and then re-audit.
Once this cycle has been initiated, it
will become a continuous process
of reanalysis and improvement.
The prime feature of this system is
that the whole process is self-sustainable once the system has been
implemented. The checks and

balances in the system will keep it
going and evolving.
The process of clinical governance is quite well established
in the Western world, but it is
time that this essential system
of health care delivery become
established in developing eco nomies. After all, it is all about
the patients: it is to ensure their
continued good care that we study
intensely and pursue professional
development. DT

Contact Info
Dr Kashif Hafeez
is currently in
private practice
in Carterton in
the UK. He can
be contacted at
hafeezkashif@
hotmail.com.
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DTAP0115_06_Hein 09.02.15 10:57 Seite 1

World News

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

“Bowie’s teeth were like everything
else about him: different”
An interview with German tooth artist Jessine Hein
signalled a new chapter in his
career—maybe a comment on
the beauty obsession of our
society: “You want regulated
perfection? Here you have it!”.
The transformation was part of
his development from alien
hero of the heart to world star.
My sculpture intends to underline this, as well as pay homage
to the eras of the crookedtoothed miracle who fell to
earth once upon a time.
Could you believe that
Bowie was not satisfied with
his teeth and underwent cosmetic dental treatment for
that reason? Perhaps, his
crooked teeth were a source of
suffering, as is the case with
many other people.
I do understand how orthodontics can improve one’s self-

The artist herself wearing a tooth mask.

confidence, as I went through
years of tooth alignment myself
in my teens. There are four
teeth missing in my maxillae.

Hein’s hand-sculpted recreation of David Bowie's natural teeth.

David Bowie was undoubtedly a major figure in popular
music in the 1970s and 1980s.
He is also one of the many
celebrities who have undergone cosmetic dental treatment and had his characteristically crooked teeth replaced
with a set of crowns in the
early 1990s. Inspired by
Bowie’s unique original look,
Jessine Hein, a German painter
and sculptor, made a reproduction of the singer’s natural
teeth. Dental Tribune had the
opportunity to speak with Hein
about her denture sculpture
and her perception of beautiful teeth.
Dental Tribune: Ms Hein,
how did you come up with
the idea of recreating David
Bowie’s teeth?
Jessine Hein: Bowie’s teeth
were like everything else about
him: different! Not the aesthetic
norm, not perfect, but they
were strikingly beautiful in the
context of his whimsical and
miraculous being. His smile
revealed an imperfection that
made him seem more real,
more human, someone to identify with even.
An imperfection worn confidentially inspires sympathy.
Bowie was a role model for
many people and I think his
teeth contributed to that. The
vast variety of talents, iconic
style and incomparable phy sique that make up Bowie,
and the different universes he
created around himself, have
always impressed and inspired me. I have been incred ibly fascinated with teeth for
a long time and have paid
close attention to the ivories
of those I admire. Therefore,
I was very conscious about
the loss of the Ziggy Stardust
choppers.

Teeth are an integral part
of interhuman communication.
They are inevitably involved in
laughing, talking, screaming
and of course singing. Bowie
sang to us through his crooked
gaps and it was enchanting!
So the idea for the sculpture
evolved while I was nostalgically longing back to Bowie’s
old teeth.

“...the idea for the sculpture
evolved while I was
nostalgically longing back
to Bowie’s old teeth.”

Have you done any other
artistic projects related to
dentistry that inspired you to
create a denture sculpture?
In the past, I have done small
projects at a dental laboratory,
such as a tooth pendant for my
necklace, which I have worn
ever since and never taken off,
as well as another sculpture:
Tooth Nuckles. With the knowledge acquired during those
projects, I gained an idea of
how I could actually construct
this replica.

Today, however, I celebrate
teeth that are not the norm.
I love the diversity and character
they bring to the human head.
I find it quite sad that these days
almost every child undergoes
some kind of dental treatment
to align his or her differences
solely for aesthetic reasons.
Some of them might grow up
wishing they still had their
characteristic natural look.
I have heard Bowie talk
about his old teeth in a confident way. He stated they looked
fine to him. So, no, I do not think
he felt uncomfortable about
them at the time, quite the
opposite; he was famous for
celebrating his striking body in
all its otherworldliness.

In your opinion, what
drove David Bowie, who was
celebrated as a nerd, to have
his crooked teeth made into a
“perfect” Hollywood smile?
I find it noteworthy that
a pioneer of individualism, the
archetype of “acting out oneself”, decided to “normalise”
his mouth. It seemed paradoxical. However, the dental change
was parallel to a change in his
image and music. It accom panied his development and
I assume that was not pure ac cident, owing to the Hollywood
set of teeth that was chosen
rather than recreating a natural
look when medical intervention was needed.
I cannot imagine that a person like David Bowie willingly
left the interior design of his
mouth to someone else, so
I interpret the pearly whites he
got as a bold statement that

Besides having had trouble
chewing properly, I looked like
a freakish vampire. It was not
very helpful to have an oddlooking set of teeth in this
awkward phase of adolescence.
Back then, I did not appreciate
the beauty in the difference because I was too concerned with
trying desperately to survive as
a shy teenager at school.

What do you intend to do
with the sculpture? Have you
been approached by collectors
and fans of the singer who
would like to purchase it?
The sculpture is currently
with me and will be until an opportunity for exhibiting comes
up. I have various kinds of
sculpture and painting projects
in the making that will need
some more time to develop.
Once they are completed, I envision the David Bowie dentures
being presented in the context
of the new pieces.
I have been contacted by
several potential buyers, but
the sculpture is not currently
for sale, as I would like to
have the option of putting it on
display.

A photo from 2007 showing Bowie with his new smile. (Photo Everett Collection)

Thank you very much for
this interview. DT

[7] => Standard_300dpi

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[8] => Standard_300dpi

DTAP0115_08_Albrektsson 09.02.15 10:57 Seite 1

World News

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

Per-Ingvar Brånemark—
An innovative genius
Prof. Tomas Albrektsson, Sweden, remembers the man who changed
dentistry with the discovery of osseointegration of dental implants
Per-Ingvar Brånemark passed
away on 20 December 2014 at the
age of 85. Throughout his career as
a researcher, he overcame fierce
opposition to dental implants and
revolutionised methods for treating edentulous patients.

rocranium served as fasteners for
silicon prostheses, a much more
attractive option than attaching
them to the patient’s glasses. Since
the first operation in 1977, the use
of the technology has become
widespread internationally.

An extremely gifted scientist,
Brånemark was also as witty and
quick on his feet as they come. Various language editions of Reader’s
Digest, hardly considered a medical journal of note, published
an article in the late 1960s about
his research on microcirculation.
At the end of his first lecture about
dental implants in Landskrona in
Sweden in 1969, a member of the
audience, who turned out to be
a senior academic of Swedish
dentistry, rose and commented,
“This may prove to be a popular
article, but I simply do not trust
people who publish themselves in
Reader’s Digest.” As it happened,
that senior academic was well
known to the Swedish public for
having recommended a particular
brand of toothpick. Brånemark
immediately rose and struck back,
saying, “And I don’t trust people
who advertise themselves on the
back of boxes of toothpicks.”

Titanium implants installed in
the femur were the next spin-off
of Brånemark’s research. Patients
with above-knee amputations
cannot have socket prostheses
around soft tissue and may have to
rely on a wheelchair to get around.
Inserting titanium screws in the
femoral stumps permitted the
installation of a prosthesis and
the ability to walk again. I can still
remember the first patient as if it
were yesterday. Another teenage
girl had been run over by a streetcar in Gothenburg and had aboveknee amputations in both legs.
She was consigned to spending
the rest of her life in a wheelchair.
The operation was highly successful and she learnt to walk again.

Young and naive as I was,
I thought they were just poking fun
at each other, but it turned out to be
the opening shot of an eight-year
battle with the dental profession.
When someone cast aspersions on
dental implants several years later
because Brånemark
was not a practitioner, he lost no time
in replying, “Teaching
them anatomy is good
enough for me.”

Per-Ingvar Brånemark.

surround himself with a team of
researchers.
Brånemark continued to pursue his studies in microcirculation
in animal models and ultimately
in humans. A plastic surgery technique was used to prepare softtissue cylinders on the inside of
the upper arm. He then inserted
optical devices encased in titanium that enabled intravital microscopy of microcirculation in
male volunteers.

partment of Anatomy. Brånemark
used a hollow optical device
surrounded by titanium to study
microcirculation in rabbit bone,
permitting both bone and blood
vessels to grow through a cleft
where they could be examined
by means of light microscopy.
During such an experiment in
1962, he discovered that the optical
device had fused into the bone, a
process that he eventually dubbed
osseointegration. He revealed his
incomparable strength as a researcher at that very
moment, realising immediately that the discovery had clinical potential and determining
to focus on the development of dental implants,
an enterprise that had
hitherto been regarded
as beyond the scope of
medical science.

Brånemark completed his medical
training at Lund University in 1959 with
a doctoral thesis on
Brånemark grasped
microcirculation in
the fundamental truth
the fibula of rabbits.
that edentulousness re Grinding the bone to
presents a significant
a state of transpadisability, particularly
rency permitted the
for people who cannot
use of intravital mitolerate dentures for
croscopy to analyse
some reason. He operthe blood flow in both
ated on his first patient
bone and marrow tisin 1965, a mere three
sue. The thesis, which
years later. The acafound wide recognidemic community was
tion both in Sweden
Dental Group Editor Daniel Zimmermann talking to Per-Ingvar
and abroad, landed Brånemark at a conference in Gothenburg in 2009. (Photo Archive) largely distrustful and
hostile to the new apBrånemark an approach. The debate was not put
pointment at the Department of
By the late 1960s, he was able
to rest until 1977, when three proAnatomy of the University of
to produce the highest resolution
fessors at Umeå University in SweGothenburg just a year later. He
images of human circulation in the
den announced that Brånemark’s
was appointed as Associate Pro - history of medicine. Many people
technique was the recommended
fessor of Anatomy (later received
are familiar with Lennart Nilsson’s
first-line treatment. Opposition in
a full professorship) in 1963, which
photographs of circulation that
qualified him for laboratories of
were taken at Brånemark’s labo - other countries eventually waned
as well and dental implants, origihis own and the opportunity to
ratories and developed at the De-

nally manufactured by a mechanic
in the basement of the Department
of Anatomy, scored one international triumph after another.
Nowadays, an estimated 15–20
million osseointegrated dental implants are installed every year, and
a number of different academies in
the field hold annual conferences
attended by as many as 5,000 participants each. The University of
Gothenburg features a permanent
exhibit on osseointegration technology and there is a museum in
Brånemark’s honour at the Faculty
of Stomatology of Xi’an Jiaotong
University in Xi’an in China. The
P-I Brånemark Institute has been
also established in Bauru in Brazil.

Not only dentistry
Back in the 1970s, Brånemark
began collaborating with ear
specialists and technicians at
Chalmers University of Technology to explore the additional potential of osseointegrated implants
for developing hearing aids inserted behind the ear. Hundreds of
thousands of patients around the
world have had operations based
on the technology initially developed in Gothenburg under his
direction. Those of us who were
on the team at the time will never
forget a teenage girl who suffered
from the effects of thalidomide.
The medicine had caused not only
limb deformities, but also hearing
loss in many patients. Equipped
with the new hearing device, she
learnt to speak flawlessly.
The team also targeted facial
deformities occasioned by congenital or acquired injuries. A number
of implants installed in the visce-

Acclaimed around the world
Brånemark was fuelled by a
passion to help difficult-to-treat
patients, and many of his clinical
discoveries from the first dental
implant on were made in response
to cases that had been regarded
as hopeless. His innovative genius, fortified by a large research
laboratory at the Department
of Anatomy, also skyrocketed
Gothenburg-based pharmaceutical companies like Nobel Biocare
and Astra Tech into leading positions in the global market. He was
devoted to the academic community’s social responsibility long before many of his colleagues were
aware of, much less accepted,
the concept. Ultimately, the world
came around and he was awarded
honorary doctoral degrees by
29 universities and honorary memberships by more than 50 scientific
associations—not to mention the
Royal Swedish Academy of En gineering Sciences’s medal for
technical innovation, the Swedish
Society of Medicine’s Söderberg
Prize, the European Inventor
Award for Lifetime Achievement
and many other distinctions
around the world. DT

Contact Info
P r o f . To m a s
Albrektsson is
working as a
professor at the
universities in
Gothenburg and
Malmö in Sweden. He can be
contacted at tomas.albrektsson@
biomaterials.gu.se.

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DTAP0115_09_Leaver 09.02.15 10:57 Seite 1

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

Business

“Operating in Asia is
completely new to us”
An interview with Neoss Chief Financial Officer Guy Leaver, UK

(DTI/Photo Jcomp)

tage of this development by
choosing the right contacts for
this marketplace.

As one of the few manufacturers of dental implants, UK
company Neoss has not operated in Asia before. With a recent financial support package
of £1.5 million from Yorkshire
Bank, the company intends to
develop new business in countries like Japan, China and
Taiwan. Dental Tribune Asia
Pacific had the opportunity
to speak with Chief Financial
Officer Guy Leaver about the upcoming market entry and what
makes Neoss stand out from its
numerous competitors there.
DT Asia Pacific: Mr Leaver,
how is this investment package
helping you with your market
entry into Asia?
The investment package will
support our product launch in
Asia initially. Currently, we are
going through regulatory approval processes in Japan, China
and Taiwan. It is difficult to say
exactly when, but our expectation is that this year, probably in
the second half, we will actually
start to make initial sales. While
we expect the growth to be significant, we need the facility for
our cash flow in the beginning,
as there will a certain amount of
money going out before money
actually comes in.
What are your initial expectations for the region?
Since we do not have any sales
in these countries at the moment,
operating in Asia is completely
new to us. We obviously have
projections and want to see this
business grow consistently over
time into something substantial.
Initially, we will focus on our
dental implant system, as this
is the product segment we are
expecting approval for this year.
In the future, we will expand to
our full product range, including
new products we are introducing
that could also potentially target
these markets. It is not an implant

but works in conjunction with
implants and is going to address
the same customer base. We will
be launching it at the International Dental Show in Cologne
and and other shows and congresses around the world in the
upcoming months.
Will you sell directly in Asia
or through distributors?
We have already signed up
with business partners in these
markets. In Japan, for example,
we have an experienced distributor who has personal contact
with a number of leading clinicians in the country who we understand are interested in using
our implant system. It always
helps to have this kind of endorsement. We are also working
with a major distributor in China
and will see how that evolves.
Potentially, we will put a person
in charge of China, but this will
depend on how successful we
are. If we feel there are more opportunities, we can always tweak
the model. There is also an experienced distributor we will be
partnering with in Taiwan who
has previously distributed a competitor’s product.
Generally, we try to choose
people who understand what our
product is all about, are familiar
with the market and know what
works in that marketplace.
For Western manufacturers,
the market environment in
Asia can be tough. Where do
you see the challenges for your
company there?
As with many of these markets, business in Asia is primarily
relationship based, so you need
to become involved with the right
people and institutions. This is
particularly important in China,
where there are a growing number of small private dental practices offering dental care in addition to the large government-run
hospitals. We aim to take advan-

Where do you want to position yourself in the market?
We want to position ourselves
in the same way as we do in most
markets by delivering a product
that is the best there is. We
strongly believe that we have a
good package. Our company was
founded by a clinician and an engineer, so our focus is on delivering exceptional clinical performance and product quality. There
is no point in introducing a product that is not as good as someone
else’s. Our product has to be that
good or even better.

a value product. We do not sell
cheap or offer massive discounts.
It is a good quality product at
good pricing. In terms of customer service, we aim for exceptional logistics and support.
Take Europe, for example, it is
pretty much next-day delivery,
so if you buy something from us
in Germany, it will probably be
there at noon the following day.
Few of our international competitors can achieve the same.

We always want customers to
understand that they are getting

Thank you very much for
the interview. DT

Guy Leaver

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DTAP0115_10_Naz 09.02.15 10:58 Seite 1

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

10 Business

Google: How to get on to Page 1 in 2015
(DTI/Photo Twin Design)

Naz Haque
UK

The holy grail for any organisation’s online marketing is
to appear on Page 1 of Google
search results. Imagine how
many patients you would gain.
How would you like to achieve
this without spending thousands of pounds? This is possible if you have time on your
hands and reduce online competition through local listing.
According to Google, there
are over 40,000 search queries
every second. This roughly
amounts to 3.5 billion searches
per day globally, with a significant portion of this (increasing
all the time) being searches on
mobile devices.
Google is always tweaking
and improving the search factors
to deliver search results based
on the user’s intent. Therefore,
it is understandable that your
website should be focused on
AD

patients and easy for Google to
find and read. Even without a
state-of-the-art website, it is pos-

sible to appear on Page 1. Organic
(natural non-paid) rankings are
achieved by being relevant and

breakfasts, or newspapers are
recommending dentists in your
town. Even if there is no link to
your website, having your address will benefit your rankings.
Google reviews can only be
submitted by individuals with
their own Google Account. I do
not recommend allowing patients to provide reviews using
your practice Internet connection, as Google may identify the
location and think the reviews
may not be authentic or independent. Once you have received
seven reviews, Google will place
a number of stars next to your
practice name on the map listings. The more five-star reviews
you have, the higher your score
will be. It has been documented
that having five stars encourages
a 23 per cent increase in click
through to your website.

having authority in the online
world, and depend on online
competition.

That the time period of your
business page has been verified
and is visible is also a factor to
its visibility.

On Page 1 of Google, aside
from the organic listings, there
are typically three to seven map
listings. The most feasible way
of achieving Page 1 rankings in
your location is to register for a
Google My Business listing first.
If it has already created a listing,
you will have to claim and verify
this. Choose the tags relevant to
the services your provide (dental
practice) and ensure that your
phone number (geographical
number) is displayed, as well

These simple steps will set
you in the right direction to
achieving Page 1 rankings. Remember the results will be specific to your location and based
on the user’s search terms.
Google is focused on the user, so
if there are seven other practices
nearer to the user’s post code
they inevitably will be higher
up on the results list. Consider
organic or pay-per-click campaigns if you want to have a
higher chance of success.

“Citations are a key factor
for ensuring Google
recognises your presence
in your location.”
as your address and post code.
Do also brand the page with your
logos and personalise it with
photographs of your team and
practice (not necessary for rankings but highly advised). Finally,
encourage your patients to leave
you a five-star review on this
page. This is a very important
factor.
Once you have your page set
up and optimised, the next step is
to establish your online authority
by inserting a link to your Google
Business Place on your website.
Ensure that your website has
your contact details displayed.
Then list your address details
in local and large directories
(try not to get carried away) and
ask local businesses to cite your
details online. Ensure that the
details are always consistent and
accurate, as inconsistent address
or telephone number details will
confuse Google.
Citations are a key factor for
ensuring Google recognises your
presence in your location. It may
be that local hotels, bed and

There are no guarantees with
Google, but you should always
focus on building visibility where
Google is looking, because your
patients will be directed there.
The recipe for success in any business is focus on serving the client,
and it seems the same rule applies with your online marketing.
Focus on the patient in using the
platform is key to everything. DT

Contact Info
Naz Haque, aka
the Scientist, is
Operations Ma nager at Dental
Focus. He has
a background in
mobile and network computing,
and has experience supporting a
wide range of blue-chip brands,
from Apple to Xerox. As an expert
in search engine optimisation,
Naz is passionate about helping
clients develop strategies to enhance their brand and increase
the return on investment from
their dental practice websites.

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MiCD ad (lady)revised-A3.indd 1

3/2/15 14:29

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DTAP0115_12-13_Pisa 09.02.15 11:00 Seite 1

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

12 Trends & Applications

Easy and effective—Long-span bridges
fabricated with the CAD-on technique

Fig. 1

Fig. 2

Fig. 3a

Fig. 3b

Fig. 4

Fig. 5

Fig. 6a

Fig. 6b

Fig. 7

Fig. 8

Fig. 9

Fig. 1: The patient required a new prosthetic restoration. Teeth #11 and #21 could not be saved and had to be removed.—Fig. 2: Situation after teeth #11 and #21 had been extracted and the site allowed
to heal.—Figs. 3a & b: The aesthetic and functional parameters were evaluated in the patient’s mouth with the help of a temporary.—Fig. 4: The gingival contour was shaped in the oral cavity.—Fig. 5:
The temporary in its planned, ideal situation.—Figs. 6a & b: The temporary and master model were digitalised (CAD software).—Fig. 7: The ZrO2 framework was prepared for milling (CAM software).—
Fig. 8: The ZrO2 framework being milled.—Fig. 9: As the primary structure, the sintered ZrO2 framework provided the base for the digital production of the veneering structure.
Massimiliano Pisa
Italy

For some time, we have been
benefitting from IPS e.max®
CAD-on/Veneering Solutions
(Ivoclar Vivadent), a working
technique that combines lithium disilicate (LS2) and
zirconium dioxide (ZrO2). In
addition to IPS e.max ZirCAD
and IPS e.max CAD blocks
(Ivoclar Vivadent), the technique includes the use of a
high-frequency vibrating device

(Ivomix, Ivoclar Vivadent) and
a special thixotropic fusion
glass-ceramic to join both of
the ceramic structures. In this
case report, we will demonstrate how to implement the
technique step by step in order
to achieve natural-looking and
functional restorative results.
In our case, the patient visited the dentist because was she
unhappy about her maxillary anterior restoration. The ceramic
material had flaked off at several

sites and the function of the
metal–ceramic bridge was impaired. Consequently, she wanted to have it replaced (Fig. 1).
A detailed examination of the
clinical situation established
that, owing to severe bone atrophy, teeth #11 and #21 were not
suitable for anchoring a new
dental prosthesis to them and
that they would have to be extracted. Since the patient was unwilling to undergo augmentative
procedures, placing an implantretained prosthesis was not an

option. Instead, we decided to install a fixed bridge that would be
anchored to abutment teeth #14
and #12 on one side and to teeth
#24 and #22 on the other side.
The area surrounding teeth #11
and #21 would have to be reconstructed with artificial gingiva.

Treatment procedure
After removal of teeth #11
and #21, the extraction site was
allowed to heal for a sufficient
period (Fig. 2). Meanwhile, the
technician fabricated a diag-

Fig. 10

Fig. 11

Fig. 12a

Fig. 12b

Fig. 13

Fig. 14

Fig. 15a

Fig. 15b

Fig. 15c

Fig. 15d

Fig. 16

nostic temporary for evaluation
of the aesthetic and functional
parameters. In order to achieve
a harmonious smile, the incisal
edges of the anterior teeth had
to be lengthened considerably
(Figs. 3a & b).
During the try-in, the contour
of the artificial gingiva was determined and shaped (Fig. 4). Based
on the wax-up, the technician
created a temporary that was
again evaluated in the oral cavity
and adapted to the aesthetic and

Fig. 17

Fig. 10:The ZrO2 framework on the model.—Fig. 11: Situation after milling of the veneering structure (LS2 ).—Figs. 12a & b: Joining the framework and veneering structure (IPS e.max CAD Crystall./Connect).

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DTAP0115_12-13_Pisa 09.02.15 11:00 Seite 2

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015
functional requirements of the
patient. The situation achieved
with this rather gradual approach was used as a reference
in the subsequent fabrication of
the final restoration (Fig. 5).
It was then time to select the
materials and manufacturing
method that would allow the
data gathered in the previous
processes to be converted into a
high-strength aesthetic restoration. We opted for the IPS e.max
CAD-on technique/IPS e.max
CAD Veneering Solutions, as this
method allowed for accurate reproduction of the diagnostic waxup. Dedicated software divides
the data into two sets for the production of the ZrO2 framework
and the LS2 veneering structure.
The model and the wax-up were
both digitalised and imported
into the program (Figs. 6a & b).

the surrounding natural dentition
(Figs. 16 & 17).
Chipping of the veneering
ceramic on ZrO2 frameworks can
often be traced back to a failure
to observe the material-specific
technical requirements. By using
the CAD-on technique described
in this report, the risk of failure
can be minimised for these
kinds of restorations, because the
strength of the veneering ceramic
used with this technique is four to
five times higher than that of conventional veneering ceramics.

The high strength of the
ceramic has been confirmed in
a study that compared bridges
manufactured using the CAD-on
technique with ZrO2 bridges
veneered using an individual
layering technique.1 The results
of the study showed that the
strength of the CAD-on bridges
was twice as high (2,188 ± 305 N)
as the strength of conventionally
veneered bridges.
In this case, accurate diagnostic measurements taken at
the preoperative stage, in-depth

Trends & Applications 13
knowledge of the materials involved in the treatment process,
and excellent collaboration led to
a highly aesthetic result without
the need for surgical intervention. The procedure ideally combines two outstanding materials
and has proven to be both reliable and cost-effective.

Reference
1 Tauch, D. & Albrecht, T., “In vitroFestigkeitsprüfung von viergliedrigen
Brücken: Die CAD-on-Technik, Teil 3”,
Das Dental Labor, 58/12 (2010), 16–23.

Contact Info
Massimiliano Pisa
is a dental technician at the Dental Giglio laboratory in Florence
in Italy. He can
be contacted at
maspis@me.com.

Acknowledgement: This case
was conducted in collaboration
with dental technician Paolo Vigiani
and Dr Leonardo Bacherini from
Florence. I would like to thank
them both for their support. DT

The primary structure (framework) was created using ZrO2
according to the CAD/CAM technique. Its accuracy of fit was
checked on the model and then
the framework was sent to the
practice for try-in (Figs. 7–9).
The framework showed an excellent fit and did not require any
reworking (Fig. 10).
Based on the data, the veneers were milled from IPS
e.max CAD. This secondary
structure was easy to adapt to the
framework (Fig. 11). Still in their
intermediate (pre-crystalline)
state, the LS2 veneers were adjusted to match the pre-existing
morphological characteristics.
A base for veneering the gingival
parts was also created. Contouring the artificial gingiva with
composite material by a dentist
would happen at a later stage.
We were now ready for the
final stage. After checking the
functional and morphological
parameters, we joined the ZrO2
framework and LS2 veneer with
the IPS e.max CAD Crystall./
Connect fusion glass-ceramic
and an Ivomix mixing device
(Figs. 12a & b). Crystallisation or
fusion firing was conducted in a
Programat furnace using a dedicated firing program. Afterwards,
the restoration was customised to
match the specific characteristics
of the patient’s dentition and subjected to a characterisation/glaze
firing process (Figs. 13 & 14).

Completing the restoration
After the try-in, the restoration was returned to the labo ratory to add some final touches.
A few characterisations were
applied according to the given
requirements. Those areas of
the framework to be veneered
with composite were etched to
prepare them for the application
of the composite material. In
the practice, the gingival parts
were reproduced using gingivacoloured composite with the
temporary as a guide (Fig. 15).
A natural-looking gingiva shield
was achieved by applying the
material in small quantities in
several steps. Finally, the allceramic bridge was seated using
conventional procedures. The
result was a restoration that
blended in so well that it could
hardly be distinguished from

The 36th Australian Dental Congress
Brisbane Convention and Exhibition Centre - an AEG 1EARTH venue
Wednesday 25th to Sunday 29th March 2015

Invitation from the Congress Chairman
On behalf of the Local Organising Committee of the 36th Australian Dental Congress,
it is with great pleasure that I invite you to attend Congress and enjoy the river city of Brisbane.
Over three and a half days, highly acclaimed International and Australian speakers supported by contemporary
research, will present a wide range of subjects relevant to practice. These presentations will be complimented
by hands on workshops, Lunch and Learn sessions, specific programmes for members of the dental team.
Social activities will be available for relaxation purposes.
The Brisbane Convention and Exhibition Centre is adjacent to the Southbank Precinct on the banks of
the Brisbane River. Nearby is the Queensland Performing Arts Complex, the Queensland Museum and
the Queensland Art Gallery and Gallery of Modern Art. A comprehensive industry exhibition will be
held alongside the Congress enabling delegates access between scientific sessions to view
the latest in equipment and materials.
Come and join us for the scientific programme, the opportunity to meet
colleagues and the experience Brisbane has to offer.

Titanium sponsor:

Dr David H Thomson

Congress Chairman
36th Australian Dental Congress

Educating for Dental Excellence
facebook.com/adacongress twitter.com/adacongress youtube.com/adacongress adc2015.com

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14 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

Cone Beam Computed Tomography:
Is dentistry ready for a new standard of care?
Dr Lee M. Whitesides
USA

Since its commercial introduction into dentistry in 2001,
cone beam computed tomography (CBCT) has been rapidly
evolving into a new standard of
care in maxillofacial imaging.
In just over a decade, CBCT has
exploded onto the dental landscape and permitted dental
professionals a degree of threedimensional (3-D) anatomic
truth in maxillofacial imaging
previously unavailable and
unattainable.

standard of care may include
such language as: the dentist is
under duty to use that degree
of skill and care which is expected of a reasonably competent
and prudent dentist under the
same or similar circumstances.
Standards of care may be local,
regional or national.

Standard of care influences
The influence of an emerging
technology, like CBCT, into a new
standard of care involves many
criteria. These criteria include

maintains that scientific evidence presented to the court must
be interpreted by the court as
“generally accepted” and expert
testimony must be based on scientific methods that are sufficiently established and accepted.
In Frey, the court opined:
“Just when a scientific principle
or discovery crosses the line
between the experimental and
demonstrable stages is difficult
to define. Somewhere in this
twilight zone the evidential force

tomography and CBCT has been
tested and proven sound over
many years of application in
the medical and dental arena.
The Hounsfield unit is the widely
recognised standard quantitative scale for describing radiodensity and provides doctors
with a known standard and error
rate in computed tomography.
The widespread acceptance of
CBCT by the medical and dental
community is demonstrated by
the ever increasing presence
in dental and medical practices

Like many other new technologies, which have progressed
from the extraordinary to the
ordinary and thus gained acceptance by professionals and
patients, CBCT has advanced
from exceptional use to almost
commonplace use in dentistry
as cost decreases, access to the
technology increases, and potential adverse patient interaction
(i.e. radiation exposure) is attenuated. Today, CBCT is seen by
many in dentistry as the standard
operating procedure for many
dental implant, orthognathic, orthodontic, or endodontic cases.

CBCT has also been recognised by general dentists and specialists as a means by which they
can separate, identify, and distinguish their practices as being on
the vanguard of technology in patient care. Today’s patients expect
their dentist and physicians to
be contemporary with technology
and services. CBCT provides the
doctor with a technology, which
not only has significant advantages in treating patients but also
has a noteworthy “wow” factor as
the 3-D images are seen on a large
screen in “real time” for the doctor and patient to view.
CBCT, like plain film radiographic studies, may be con sidered a revenue generator for
a practice. The more a CBCT
machine is utilised, the more revenue it will generate. Additionally, the owner may allow others
in the profession to utilise the
machine for a fee, thereby reducing his overall cost of operation.
Standard of care is a legal not
a medical or dental concept.
Standards of care are constantly
evolving as methods and techniques in patient care improve.
An appropriate definition for

but are not limited to: court verdicts, expert testimony, literature
support, professional guidelines,
cost and availability of the technology, reimbursement by third
party payers, and multi-specialty
use and recognition.
Taken individually, these criteria do not constitute a mandate
for any technology as a standard
of care. Nor are these the only criteria one may use in determining
standard of care. Taken together,
these criteria provide strong evidence that CBCT technology has
sufficiently evolved to be considered the standard of care in maxillofacial imaging in selected
cases to assist the dentist in
treatment for patients in need of
dental implants, orthognathic
surgery, manipulation of difficult
impacted teeth, orthodontics,
endodontics, and many other
facets of dentistry.

The legal perspective
The legal system in the
United States is complex and
fragmented. No database exists
to search verdicts in dental malpractice cases in which CBCT
has played an important or pivotal role. For a new technology to
become admissible as a standard
of care in court, it must pass the
Frey test. This standard comes
from Frey v. United States which
is a 1923 in a case discussing the
admissibility of a polygraph test
as evidence. The Frey standard

Expert testimony is by definition the opinion of one practitioner. It is an opinion based
on fact, evidence, experience,
and knowledge which the expert
believes to be relevant, valid,
and upheld in the scientific community.
When reviewing a case for
suspected malpractice the expert examines many things,
including, but not limited to:
chart notes, radiographic studies, depositions, and professional
correspondences. In the last five
years, the author has noticed a
remarkable increase in the number of cases in which plaintiffs
and defence attorneys, as well as
experts, rely on pre and/or postprocedure CBCT imaging studies
to assist in proving malpractice
or defending good practice. Posttreatment radiographic imaging
to prove malpractice or support
good practice is not new to medicine. In fact in the years preceding WWI, some of the highest
malpractice claims were awarded in cases where post-treatment
radiographs played a pivotal
role.

(DTI/Photo Robert Kneschke)

The advancement of CBCT in
dentistry has caught the attention of manufacturers of radiological equipment. In 2001, only
one company sold a CBCT system. In 2014 there are at least
20 companies selling CBCT machines and technology. Henry
Schein, a leading distributor of
dental equipment has seen CBCT
sales expand from 5 per cent of
their digital imaging sales to almost 50 per cent of digital imaging sales in the last five years.

states (Iowa, South Dakota, and
New Hampshire) an expert need
only be qualified in a related field
to offer an opinion. Experts are
used by the courts to educate
the judge and jury as to what constitutes normal minimal acceptable care of a patient in a given
environment.

of the principle must be recognised, and while the courts will
go a long way in admitting experimental testimony deduced from
a well-recognised scientific principle or discovery, the thing from
which the deduction is made
must be sufficiently established
to have gained general acceptance in the particular field in
which it belongs.”

of the technology. Additionally,
The Intersocietal Accreditation
Commission, an accreditation
organisation for medical and
dental imaging, has developed
guidelines and accreditation criteria for 3-D CBCT imaging.
Thus CBCT appears to have satisfied both the Frey and Daubet
criteria for acceptance as a standard of care technology.

In many jurisdictions and in
Federal court, the Frey standard
is superseded by the Daubet
standard. The Daubet standard is
used by a trial judge to make a preliminary assessment of whether
an expert’s scientific testimony is
based on reasoning or methodology that is scientifically valid and
can properly be applied to the
facts at issue. Under this standard,
the factors that may be considered
in determining whether the
methodology is valid are:

Not to discount the value of
CBCT imaging or its ability to
successfully satisfy the Frey or
Daubet criteria, the absence of
CBCT is not de facto evidence of
lack of a standard of care imaging. Many patients present to
their dentist with uncomplicated
cases where traditional two-dimensional radiographic studies
are appropriate and provide the
dentist with standard of care imaging of the patient. For the more
complicated cases, 3-D imaging
may be employed to provide the
dentist with superior anatomic
evidence in treatment planning
and diagnosis. Three-dimensional imaging with CBCT can
also be used in uncomplicated
cases, but it may not necessarily
be considered as the standard of
care for every case in 2014.

• theory or technique in question
can be and has been tested,
• it has been subjected to peer
review and publication,
• there is a known or potential
error rate,
• the existence of maintenance
standards controlling its operation,
• widespread acceptance within
a relevant scientific community.
The theory or technique behind medical grade computed

Expert Testimony
An expert is a person with
sufficient minimal qualifications
to render an opinion on the subject at hand. Not all experts are
created equal, and in fact in three

Logic would dictate that if
plaintiffs and defence counsels
and experts are making CBCT
part of their strategy, then CBCT
must be not only prevalent and
pertinent but of significant value
in the formation of an opinion
by an expert (and the jury) when
reviewing a case. CBCT can be
seen as an additional and important piece of information to help
explain why the doctor did what
he did or why an unfortunate
outcome occurred. Additionally,
CBCT provides powerful and
easily understandable images
for layperson jury.
Recognising the value that
CBCT adds to a case does not
necessarily indicate that CBCT
is the standard of care in each
and every case. The decision to
obtain a CBCT study before the
procedure is determined by the
dentist based on his experience
and knowledge of the case.

Literature Support
For any technology to be
considered as a standard of care,
a plethora of literature in support
for the technology should exist.
The literature must discuss the
risk and benefits of the technology, its application to patient
care, and guidelines and protocols for acceptable use.

‡ DT page 16

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16 Trends & Applications
ﬂ DT page 14

To assess the influence of CBCT
in the dental literature, the author
performed a PubMed literature
search in October for the words
cone beam CT, cone beam CT +
dental, cone beam CT + dental
implants, cone beam CT + orthodontics, cone beam CT + oral
surgery, cone beam CT + endo dontics in the search line. The
results are in Table 1.
Evaluation of Table 1 data
clearly shows a significant presAD

Key words in search

Number of articles

Year article first appeared

CBCT
CBCT + dental
CBCT + dental implant
CBCT + orthodontics
CBCT + oral surgery
CBCT + endodontics

5,537
1,951
617
725
1,041
313

1988
1998
2002
2003
1998
2007

Table I

ence in the literature of articles
pertaining to the use of CBCT in
the various disciplines in dentistry. The vast majority of literature
discovered pertains to addressing
the use of CBCT in treatment
planning and diagnosis of pa-

tients in dental implant therapy,
oral and maxillofacial surgery,
orthodontics, and endodontics.
Articles on new applications of
CBCT technology to patient care
were also prevalent in the sample.
Some articles addressed the risk

and benefits of CBCT but none
denounced CBCT as harmful to
the patient or insignificant in
treatment planning and diagnosis. Two similar PubMed reviews
of the literature on CBCT were
performed by authors Alamri et al
(Applications of CBCT in dental
practice: A review of the literature. Gen Dent 2012: 60(5):
390–400) and De Vos et al (Conebeam computerized tomography
(CBCT) imaging of the oral and
maxillofacial region: A systematic
review of the literature. Int J Oral
Maxillofax Surg2009;38: 609–625).

Both of these exhaustive articles
demonstrate the plethora of literature addressing CBCT and its
application in the many disciplines
in dentistry.

Professional Guidelines
For a technology such as
CBCT to become a standard of
care in dentistry, guidelines for
its use and application in patient care must be established
by the organisational bodies of
those disciplines in dentistry who
employ the technology to treat
patients. In dentistry, the dental
practitioners most involved in
the use and application of CBCT
in patient care include general
dentists, oral and maxillofacial
surgeons, endodontists, oral and
maxillofacial radiologists, orthodontists, and periodontists.
The American Dental Association has over 180,000 licensed
dentists representing approximately 75 per cent of dentists in
the USA. The American Dental
Association published an advisory statement article in its
principal journal, The Journal of
the American Dental Association,
in August 2012. The article discusses the many positive aspects
of CBCT, but stops short of calling
CBCT a new standard of care.
Rather, the ADA encourages the
dentist to use CBCT “selectively,
as an adjunct to conventional
radiography”. The ADA further
recognises the value and presence of CBCT by including CBCTrelated courses at its annual
meetings and continuing education courses during the year.
The American Association of
Oral and Maxillofacial Surgery
(AAOMS) has over 9,000 members representing approximately
95 per cent of oral and maxillo facial surgeons practising in
the US. Literature addressing the
application of CBCT in oral and
maxillofacial surgery has been
around since 2007. The AAOMS
has offered continuing education
in the use and application of
CBCT for patient care as far back
as 2011.The AAOMS has worked
with the IAC to develop guidelines and accreditation criteria
for 3-D CBCT imaging. In a recent survey of OMFS residency
programmes, 87 per cent of
programme directors acknowledged the use of CBCT in patient
care by their residents.
The American Association
of Endodontists (AAE) and the
American Association of Oral
and Maxillofacial Radiologists
(AAOMR) have released a formal
position paper on CBCT. This
paper makes many important
points, such as limiting the field
of vision to minimise radiation
exposure and increase resolution, careful patient selection
in CBCT, and the responsibility
of the clinician to interpret the
entire image. The position paper
goes on to declare “the use of
CBCT in endodontics should be
limited to the assessment and
treatment of complex conditions”. The article then lists nine
of these “complex conditions”.
In summation, the position paper
recognises the value of CBCT as
‡ DT page 18

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18 Trends & Applications
ﬂ DT page 16

an adjunct to 2-D images and
“CBCT may provide dose savings
over multiple traditional images
in complex cases”.
Literature pertaining to the
use of CBCT in endodontics
first appeared in the Journal of
Endodontics in 2003. The American Association of Endodontists
sponsor continuing education in
endodontic related CBCT on
their website and the organisation devotes valuable time at its
annual meeting to CBCT as it
relates to modern endodontics.
Most residencies (44 of 47) in
endodontics provide CBCT for
patient care.
Literature pertaining to
CBCT in dentistry dates back to
1998. The AAMOR devotes considerable effort to continuing
education relating to CBCT both
on its website, through CE
events, and at its annual meeting.
All seven ADA approved residencies in Radiology incorporate
CBCT education and training
into the resident curriculum.
The tremendous value of
anatomic truth in complex orthodontic cases involving patients
with cleft lip and palate, impacted teeth, and maxillofacial
deformities is widely recognised
and discussed in the literature.
Review of the AAO annual meeting lecture syllabus shows CBCT
is a prominent topic for today’s
orthodontist. In a recent article in
the Journal of Dental Education
by Smith et al use of CBCT in
orthodontic programmes in the
US and Canada was evaluated.
This article showed the following:
• 83 per cent of orthodontic programmes have access to CBCT,
• 73 per cent of programmes
report “regular” use of CBCT
in patient diagnosis,
• Areas of CBCT use focuses
on diagnosis and treatment
planning for: impacted teeth,
craniofacial anomalies, TAD
placement, TMJ assessment,
upper airway analysis, and
maxillofacial development.
Literature discussing CBCT
in periodontics first appeared in
the AAP journal over a decade
ago. The American Association
of Periodontist annual meeting
agenda and the Journal of Periodontology demonstrate a heavy
influence of CBCT in the field of
periodontics. All 51 post-doctoral
US periodontal programmes use
CBCT in patient care.
The International Congress of
Oral Implantologists (ICOI), the
world’s largest dental implant
organisation and provider of dental implant continuing education
with an excess of 25,000 active
members, published a consensus
report on CBCT in its journal
Implant Dentistry in April of 2012.
In the article, authored by many
leaders in the dental implant field,
the ICOI states: “The literature
supports the use of CBCT in dental
implant treatment planning particularly in regards to linear
measurements, 3-D evaluation of
alveolar ridge topography, proximity to vital anatomic structures,

and fabrication of surgical
guides.” The ICOI reminds the
dentist that use of CBCT must be
justified in each case and should
be considered as an imaging
alternative where conventional
radiographs may not provide
sufficient anatomic truth. Literature discussing the application
of CBCT in implant dentistry is
ubiquitous and comprises the
lion’s share of research in applying CBCT technology to dentistry.
The vast majority of post-doctoral
residencies involved in dental
implant patient care and all private dental implant training
courses in the US incorporate
CBCT in their dental implant
education curriculum.
Many professional organisations in dentistry for general
dentists and specialists have
weighed in on CBCT by providing recommendations, guidelines, and a position paper. While
these guidelines are beneficial
in establishing a society or specialty’s position on CBCT, they
are not mandates. Recommendations, guidelines, CE programmes, and position papers
are used by professionals to influence the practice of their discipline. As the practice of the
discipline changes in response to
many factors including, but not
limited to court verdicts, expert
testimony, literature support,
professional guidelines, cost of
the technology, and reimbursement by third party payers; the
recommendations, guidelines,
and position papers may facilitate the evolution of CBCT into
a standard of care. Thus, in 2014
the professional organisations
that comprise dentistry may not
formally declare CBCT is the
standard of care for every patient,
but these organisations do recognise the influence CBCT is
having on the profession.

Educational Institutional
Participation
For a technology to be considered a standard of care, those in
the profession must be educated
in its application in patient care.
In US, 56 of the 57 dental schools
(98 per cent) have CBCT available for patient care for predoctoral students. Forty-seven
(84 per cent) incorporate CBCT
education in their pre-doctoral
curriculum. In a survey performed by the author and others
202 general practice residency
(GPR) and advanced education
in general dentistry (AEGD)
programmes were surveyed regarding use of CBCT by their
residents. Eighty-two programme
directors responded to the survey.
Of the 82 respondents, 56 (68 per
cent) of program directors (PDs)
responded affirmatively when
asked if CBCT was used in patient
care by their residents. The author also surveyed 102 PDs in oral
and maxillofacial programs in
the US. Fifty-four PDs responded.
Of the 54 PDs responding 47
(87 per cent) affirmatively when
asked if CBCT is used in patient
care by their residents. In a
phone survey of endodontic res idencies, 44 of 47 PDs indicated
their residents use CBCT in
patient care. All seven ADAapproved oral and maxillofacial
radiology programmes use CBCT

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015
in patient care. Additionally, all
51 periodontal residency PDs
indicated that their residents
employ CBCT technology in
patient care. In orthodontics,
83 per cent of US-based orthodontic programmes use CBCT in
patient care.

Cost and Availability
The cost of CBCT machines
today range from US$150,000 to
US$250,000 with yearly maintenance fees in the US$8,000 to
US$20,000 range. As with any
emerging technology, advances
create a secondary market for
slightly used machines. Each new
step forward in technology renders the CBCT machine of only a
few years ago slightly out-of-date,
despite its obvious value and its
superiority to two dimensional
films. As time progresses and
advancement in the quality and
capabilities of the newest machines demonstrate themselves,
the slightly non-contemporary
machine will represent a significant advancement for the dentist
versus 2-D radiography, while not
burdening the dentist with significant cost. This will undoubtedly
lead to an increase in the number
of dental professionals utilising
CBCT in their practices. The
bottom line for most practices
in regards to CBCT machines is:
can I afford this for my practice?
To determine affordability, the
price of the machine (purchase
and maintenance) must be considered against potential revenue generated by the machine.
Revenue can be directly from
patients, insurance companies, or
from other dentists who utilise the
CBCT machine. A cost-effective
alternative to owning and oper ating a CBCT device can be the
outsourcing of the study to a third
party (dentist or facility) and insourcing the software necessary
to employ the images in treatment
planning and diagnosis.
CBCT machines are becoming ubiquitous as more dentist
purchase the machines and
more third party non-dentist
owned imaging centres enter the
market. Since more dentist and
more patients are becoming exposed to the technology, patient
acceptance will increase, facilitating the incorporation of CBCT
into the mainstream culture of
dentistry. The increasing omnipresence of CBCT technology
will not singularly make it standard of care, but it will serve
to increase patient awareness of
the technology, which in turn
will influence what the public
perceives as a standard of care.

The insurance industry
Reimbursement from major
insurance companies and government-sponsored health care is
traditionally the last to embrace
(i.e. pay for) a new service such as
CBCT. Although codes for medical CBCTs have been around for
decades, specific codes for in office CBCTs began to materialise in
2009. Current reimbursement
rates for in-office CBCTs average
around US$300, provided the
study is covered.
By providing dentists with a
CPT code, the insurance industry

has validated the technology of
CBCT and thus acknowledged
its value in treatment planning
and diagnosis. As time progresses,
insurance companies may, as
they have in the past, require
CBCT owner/operators to obtain
a certification via the IAC or
some other regulating entity for
an owner/operator to qualify for
financial reimbursement from
any third party payer.
Two of the major malpractice
carriers of the insurance industry (OMNSIC and MedPro) have
influenced the evolution of
CBCT as a new standard of care
by offering coverage for CBCT
owner/operators commensurate
with the level of risk to which the
owner/operators are exposed.
Were CBCT studies believed to
be of little value or represent
minimal risk these leaders in
the dental malpractice industry
would not offer such coverage.
Additionally OMNSIC requires
the owner/operator to have
CBCT images interpreted by
a dental or medical radiologist
to minimise risk.

Multispecialty use
and recognition
Dentistry has nine recognised specialties; four (oral and
maxillofacial surgery, endodontics, oral and maxillofacial
radiology, and orthodontics) and
the American Dental Association
have produced literature to
address the impact of CBCT on
patient care. Of the remaining
five specialties, periodontics and
prosthodontics could logically
be appropriate groups to produce
a position paper on CBCT given
their members participation in
dental implant treatment of patients. Paediatric dentistry may
soon provide a position paper
once the long-term studies have
been done to assess the risk versus benefits analysis with respect
to the total overall radiation dose
and its effect on the paediatric
population. The specialty of dental public health is unlikely to
weigh on the matter.
The value CBCT has in diagnosis and treatment of patients
is widespread and recognised
by medical disciplines such as
plastic and reconstructive surgery,
ENT, Craniofacial/CLP surgeons,
and OMFS trauma surgeons.
These medical disciplines recognise the high quality three dimensional detail CBCT provides
and assists doctors in the treatment planning and diagnosis of
their patients. Such widespread
and multidisciplinary application of CBCT imaging contributes to CBCT is becoming
a new standard of care.

CBCT in the dental culture
Many in the dental profession
acknowledge the benefit of 3-D
imaging to patients and doctors.
There is little dispute that CBCT
provides superior representation of the anatomy verses 2-D
plain films. Quality of product
acknowledged, at least four aspects of CBCT must work their
way through the dental culture
before CBCT becomes A standard of care: cost, availability,
legal, and patient expectations.
Two of these aspects (cost and

availability) will more likely than
not be determined by the invisible hand of the market as the
Keynesians laws of supply and
demand move the dental industry to provide the best possible
service at a price patients and
insurance companies are willing
to pay. The third (legal) will be
slowly determined in the court
systems as attorneys and experts
begin to rely more on CBCT in
support of their clients’ cases.
Patient expectations are difficult to accurately ascertain.
We know patients expect our
practices to be contemporary.
Buying the latest and greatest
machine for your practice may
not be wise if cost exceeds benefits both clinically and financially. As CBCT becomes widely
accepted and expected by our
patients due to aggressive marketing or clinical relevance, incorporating the technology into
one’s practice may not be entirely
necessary but prudent as others
in the profession who possess
the technology appear to be more
contemporary and advanced in
their patient care.
There are many questions
yet to be answered definitively
regarding CBCT:
1. Who is responsible (and liable)
for interpreting the images?
2. Is an entire field of view interpretation necessary or simply
the pertinent structures?
3. Must all images be interpreted
by a board certified oral and
maxillofacial radiologist or
can the ordering doctor interpret the images?
4. What level of training is suf ficient to own and operate the
machine, as well as, and interpret CBCT images?
5. What cases deserve a CBCT?
6. If the patient refuses a CBCT
and the dentist believes a
CBCT is necessary for successful case completion, must the
dentist complete the case without the CBCT study or can he
refuse the case without fear of
legal repercussions?
Lastly, as mentioned earlier,
standard of care is an evolving
concept. Darwin stated clearly
any organism (or concept in this
case) which is subject to the laws
of evolution must adapt in response to outside forces in order
to survive. The standard of care
in dentistry is adapting to CBCT
as forces (legal, financial, clinical, and consumer) act upon
the industry to account for the
powerful influence CBCT has on
treatment planning and diagnosis of patients. While recognising
that all that glitters is not gold,
CBCT may soon represent a new
gold standard by which many
cases will be judged. DT

Contact Info
Dr Lee M. Whitesides
is an oral surgeon
from Dunwoody
near Atlanta in
the US. He can
be contacted at
Drmac5678@gmail.com.

[19] => Standard_300dpi

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you will receive a
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Tribune Group GmbH is the ADA CERP provider. ADA CERP is a service
of the American Dental Association to assist dental professionals in
identifying quality providers of continuing dental education. ADA CERP
does not approve or endorse individual courses or instructors, nor does it
imply acceptance of credit hours by boards of dentistry.

33

C.E.

CREDITS

Tribune Group GmbH i is designated as an Approved PACE Program Provider by the
Academy of General Dentistry. The formal continuing dental education programs of this
program provider are accepted by AGD for Fellowship, Mastership, and membership
maintenance credit. Approval does not imply acceptance by a state or provincial board of
dentistry or AGD endorsement.

[20] => Standard_300dpi

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20 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

“Photo-functionalisation is effective
on any implant surface type”
An interview with Dr Takahiro Ogawa, US
tistry in the US, Dr Takahiro
Ogawa is one of the main advocates worldwide for photoenergy-mediated activation of
implant materials, a process
also known as photo-functionalisation. Dental Tribune Asia
Pacific recently had the opportunity to talk with him about
the benefits and prospects of
this innovation.

Dr Takahiro Ogawa

A professor in the Division of
Advanced Prosthodontics at
the University of California,
Los Angeles School of Den-

Dental Tribune Asia Pacific:
Photo-functionalisation is
achieved by exposing titanium
surfaces to ultraviolet light.
Would you describe this in more
detail and the mechanical or
chemical processes that take
place during the process?
Dr Takahiro Ogawa: Photofunctionalisation is a 12-minute
conditioning of dental implants

Dental Tribune International
The World’s Largest News and
Educational Network in Dentistry
www.dental-tribune.com

in the device immediately prior
to implant placement. The reason for this process is that titanium ages with time, and this
particularly affects its ability to
integrate with bone.
The photo-energy activation
device boasts an optimised combination of ultraviolet lights
that effectively remove hydrocarbon from the implant surface,
transforming the surface from
hydrophobic (water-repelling)
to hydrophilic (water-friendly).
This change in properties, together with the clean titanium
surface, attracts more osteogenic cells. Photo-functionalised
titanium surfaces are electrostatically positive and further
enhance cell attraction because
cells are electro-negative.
All this is intended to make
osseointegration of dental implants much better and faster.
The ageing process of implants degrades hydrophilicity.
Can the features of an aged implant surface be fully restored
by photo-functionalisation,
and does the technology have
any limits?
Not at all. A series of studies
have indicated that photo-functionalisation is effective on any implant surface type tested whether
acid-etched, dual acid-etched,
oxidised, sand-blasted, nanofeatured or machined surfaces.
While photo-functionalisation
can restore implant properties
to a degree similar to when it
was manufactured, the revitalised
implant surfaces degrade timedependently in the same way as
those of regular implants. Therefore, dental implants undergoing
treatment with the device need
to be placed immediately.
Has the technique been tested
in in vivo studies and, if so, what
results have you found so far?

According to a number of
preclinical studies, the strength of
osseointegration can be increased
three times by photo-functionalisation at the early healing stage.
Photo-functionalisation makes
implant and abutment surfaces
bacteria phobic.
The bone-implant contact
of photofunctionalised implants
reached 98.2 per cent, compared
with 50–55 per cent achieved
with the control implants.
Moreover, it has been found
that photo-functionalisation increases the quality of marginal
bone formation, as well as improves the outcome of guided
bone regeneration, when applied to titanium mesh. Studies
indicate that there are not only
short-term benefits of photofunctionalisation. Reliability
and predictability in function
and aesthetics are expected to
increase with time, providing
clinicians with a new strategy
for a better long-term prognosis
for dental implants and reducing
the risk of peri-implantitis.
You say that photo-functionalisation could become a
standard procedure for dental
implant therapy. When will
that happen, in your opinion?
Dentists in Japan have been
using photo-functionalisation
for approximately three years.
In Europe, premarketing of the
photo-functionalisation device
has recently started. I believe that
other regions will catch up shortly
and make this technology a global standard in implant dentistry.
A number of projects are
also underway utilising photofunctionalisation in the field of
general bone engineering and
orthopaedic implants and reconstruction.
Thank you very much for
the interview. DT

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DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015

Trends & Applications 21

Forensic odontology—
Broader than just identification
Dr Richard Bassed
Australia

Nowadays, most people will
associate forensic dentistry primarily with identification and
bite mark analysis. These areas
do indeed form the majority
of an odontologist’s workload.
There are, however, other aspects of the discipline that are
just as important but perhaps
less well known. These include
cranio-facial trauma analysis,
age estimation for both living
and deceased individuals, dental manifestations of child
abuse, dental malpractice investigations, as well as dental
insurance fraud.
Forensic odontology is an
integral part of the medico-legal
process. With this comes a responsibility borne by forensic
odontology practitioners for the
requisite education, qualifications and ongoing training.
Courts and legal institutions now
require that we have evidencebased research upon which we
can rest our findings and conclusions. In addition to knowledge of
the law, we have to have knowledge of human anatomy and its
relationship to injury patterns
and interpretation. Knowledge of
bite mark patterns due to assault,
trauma and sexual abuse, as well

Fig. 2a

Of all the scientific methods,
molecular biology is the only
method that can mathematically
quantify the degree of certainty
for a particular match, with the
other methods (including odontology) being somewhat dependent on more subjective methodology and expert opinion. This
reliance on even a small level of
subjectivity can raise issues in
courts when lay people do not
have a deep understanding of the
methods employed in an expert’s
conclusion.
Fig. 1
Figs. 1: Comparison of ante-mortem (AM) and post-mortem (PM) radiographs, leading to a positive identification.

system. As the majority of the
forensic odontology caseload
concerns the identification of
unknown deceased individuals,
most discussion in this article
will concentrate on this.
Honouring the dead is a fundamental precept in all societies.
The extent of this communal
attention to the deceased varies
across the world, but in essence
every person hopes that his or
her remains will be treated with
respect after death. This respect
for the dead includes, for many
societies, robust identification
of the deceased so that relatives
and friends are able to treat the
remains with appropriate ceremony and are able to visit the

Hal Hallenstein, the Victorian
State Coroner from 1986 to 1994,
also had firm views concerning
the importance of human identification, articulated in the following quotation: “It is a hallmark of
our civilisation that we regard
it as an affront, an indignity, an
abrogation of our responsibilities, that a person could live
amongst us, die and be buried
without a name.” In fact, the
importance of identification of
the deceased is enshrined in the
Victorian Coroners Act 2008 (Section 67), which states “A coroner
investigating a death must find,
if possible, the identity of the
deceased, the cause of death, and
the circumstances in which the
death occurred.”

Fig. 2b

common method used to identify
the deceased in all jurisdictions
is undoubtedly visual recognition by a relative or close friend.
There is continual debate concerning the veracity of this
method, given the propensity for
error, which has been well documented, especially in mass casualty events and in situations in
which the deceased has suffered
trauma to the face. From the
forensic medical/scientific perspective, visual recognition is
not proof of identity, but is only
presumptive.

Theory of
human identification
Methods used to achieve positive human identification can be

Confusion can arise from
the fact that there is often no
unanimous indication regarding
which and how many characteristics are necessary in order to
achieve a positive identification.
The recurrence of discordant
features excludes identity; the
occurrence of several concordant features commonly observed within the population
does not allow a final judgment
on identification, whereas even
a few features rarely observed
can lead to a positive match.
An example of this is a case in
which the written dental chart
describes amalgam restorations
in each first molar.
If the same is found in the deceased, is this sufficient evidence
to confirm identity? Definitely

Fig. 2c

Figs. 2a–c: A more difficult case highlighting that sometimes a degree of interpretation is required.

as child abuse injury manifestations, is also required, as is
knowledge of assessment techniques used when the age of an
individual is unknown. Finally,
there is a need to have knowledge of human identification
methods, principles and practices, as well as mass disaster
identification procedures and
protocols, and the ethical issues
involved in the examination and
management of dead bodies,
and to have an understanding of
human rights issues involved in
war crimes investigations.
All of these require thorough
knowledge of cranio-facial ana tomy, dental anatomy, dental and
skeletal development, injury
interpretation and medico-legal
report writing. It is also important to have a good understanding of the law relating to the
practice of dentistry, the coronial
system, and the criminal justice

resting place of the deceased
whenever they wish. So important is the perception of personal
identification in almost all societies that authorities will go to
extraordinary lengths to ensure
that deceased individuals are
not interred in unmarked graves,
or cremated without a name.
To be buried anonymously
goes against all of our religious,
cultural and ethical belief systems, and implies that a life
unremembered and unmourned
was really a life without con sequence. William Gladstone,
Prime Minister of Britain in the
mid-1800s, encapsulated this
sentiment better than most when
he said, “Show me the manner in
which a nation cares for its dead
and I will measure with mathematical exactness the tender
mercies of its people, their loyalty
to high ideals, and their regard
for the laws of the land.”

Positive identification of the
deceased not only satisfies a
commitment to probity, but also
resolves many legal issues surrounding an individual’s death,
such as inheritance and life insurance. If a deceased person
remains unidentified, then technically he or she will not be declared dead for a number of
years, thus creating further distress to families who not only are
unable to put their lost loved one
to rest, but may suffer financially
as well.
Personal identification of the
deceased, and occasionally the
living, is achieved through a variety of scientific and sometimes
unscientific methods. Practitioners from forensic science, forensic medicine, law enforcement
and coroners’ offices apply their
own particular set of skills to an
identification problem in order
to arrive at an answer. The most

separated into two broad categories. The first consists of those
methods that are presumptive
for identification, such as circumstantial evidence, property
associated with the body, and visual recognition. These methods
involve a high degree of subjectivity and rely on identifiers that
are not intrinsic to the body itself,
are dependent on lay interpretation, and therefore can be falsified or mistaken (commonly
known as secondary identifiers).
The second category relies on
scientific analysis of identifiers
that are intrinsic to the body,
such as dental restorations, fingerprints, DNA, and verifiable
medical records (primary identifiers). These involve characteristics that can be objectively
appraised and compared to antemortem exemplars in both a
quantitative and a qualitative
way and that are difficult or
impossible to falsify.

not, as many people share this
restoration pattern. If, however,
we also have ante-mortem radiographs of those restorations
displaying the exact shape, size
and location within each tooth,
and these compare favourably
with the post-mortem radiographs, then few would argue
that a positive match cannot be
confirmed. There is, however,
still no way to quantify this
match, to put a probability ratio
or a percentage certainty to it.
It may be necessary in some
cases to compare all of the teeth
in a mouth in order to arrive at
a match. In other cases, a single
tooth with an unusual or complex restoration may be sufficient. It has long been the wish
of identification experts to be
able to quantify such matches,
but no reliable method has yet
‡ DT page 22

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22 Trends & Applications
ﬂ DT page 21

been devised and so a degree
of expert subjectivity is still
required.
Prior to the availability of scientific methods applicable to the
issue of positive human identification, the only real option for
relatives and friends to recover
the mortal remains of their loved
ones was to visually examine
them, and make a decision regarding whether the person before them was indeed who they
believed him or her to be. On the
face of it, positive human identification by visual recognition
would seem to be a fairly simple
matter, as long as the deceased
has undamaged facial features.
We can all recognise people who
are well known to us by their
facial features and mannerisms,
even in poor light and at odd
angulations. This has been
shown to be true in many studies
concerning the recognition of
living people via CCTV security
footage. Why then are there documented cases of misidentification through visual recognition
of the deceased, even of intact
and undamaged faces?
The process of visual recognition is complex and until quite
recently not well understood.
Clues as to the identity of an individual, either living or deceased,
rest not only with the physical
structure of the face, but also with
the variety of facial expressions,
the display of various mannerisms, and the context in which
the individual is seen.

Fig. 5a

sual recognition is not an option, usually because of trauma,
incineration, decomposition,
or multiple deaths resulting
from a single incident, then
forensic practitioners are able
to rely on more scientific means
to determine identity. The
common methods employed
include molecular biology,
medical record comparison,
fingerprints, and dental record
comparison.

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015
tio and are thus scientifically
quantifiable as to the strength of
the match. With any DNA technique, the cautious juror should
not convict on genetic fingerprint evidence alone if other factors raise doubt. Contamination
with other evidence (secondary
transfer) is a key source of incorrect DNA profiles, and raising
doubts as to whether a sample
has been adulterated is a
favourite defence technique.

then be reconciled with antemortem surgical notes.

Dental identification
When good quality antemortem dental records are available for comparison with postmortem examination findings,
positive identification is a relatively simple matter (Figs. 1). For
many cases, however, such a
simple resolution is not so easily
achieved. Often ante-mortem

Identification methods
Visual recognition, despite
the lack of scientific validity
and the propensity for error,
will for all practical purposes
remain as a major method for
positive human identification.
When it is determined that vi-

Personal identification via
dental record comparison is
similar to fingerprint analysis in
that there is, as discussed above,
an element of subjectivity involved in the matching process.
Where dental identification differs, and is perhaps easier to
comprehend for lay people, is in
the nature of the evidence being
compared. With dental evidence,
matches are commonly assessed
by comparing both ante-mortem
and post-mortem radiographs
of easily identifiable man-made
(and most often handmade)
restorations. Unlike the minute
nature of the whorls and swirls
of fingerprint evidence, dental
radiograph comparisons are often so obviously similar that any
reasonable person is able to say
that the images belong to the
same person.

Other aspects
Fig. 3

Fig. 4

Fig. 3: An example of cranio-facial trauma in a homicide case. Accurate injury description can be vital in these cases.—
Fig. 4: Age estimation using a standard atlas of development results in an age range that can either lead to identification
or help police in limiting their search criteria for a missing person in the case of discovered unknown remains.

DNA profiles are encrypted
sets of numbers that reflect a
person’s DNA make-up, which
can also be used as the person’s
identifier. Although 99.9 per cent
of human DNA sequences are
the same in every person,
enough of the DNA is different
to distinguish one individual
from another, unless they are
monozygotic twins. DNA profil-

Fig. 5b

Identification using fingerprints (friction ridges) relies on
an examination of ante-mortem
prints already on file with authorities (exemplars), or more commonly comparison with latent
prints retrieved from an object
the subject of the examination
was known to have touched. Fingerprint identification involves
an expert, or an expert computer

dental records are incomplete
or many years old or there are
no radiographs. Couple this with
incomplete remains or remains
damaged by fire and/or trauma
and the difficulties are magnified
(Figs. 2a–c). Reproducing the
exact angulation and aspect of
an ante-mortem radiograph in a
post-mortem radiograph, taken
in less than ideal circumstances,

Fig. 5c

Figs. 5a–c: Multiple development sites used for age estimation of late teenage individuals: in this case, the third molar, the medial clavicular epiphysis, and the
spheno-occipital synchondrosis, all of which are useful age indicators in the late teenage years.

A deceased person has lost
all facial expression, animation,
and context and simply looks
different from when he or she
was alive. Incipient decomposition changes may also be
present and go unrecognised.
Couple this with the stress and
trauma being experienced by
the identifier, who may well
have never seen a dead body
before, and it is easy to see how
someone may make a mistake.
This is compounded by the way
visual identifications are often
performed, in that the deceased
is presented to the identifier
to confirm what the authorities
already believe they know.

employed with varying degrees
of certainty, depending on the
circumstances of the case.

ing uses repetitive sequences
that are highly variable, called
variable number tandem repeats
(VNTRs), particularly short tandem repeats. VNTR loci are very
similar in closely related humans, but so variable that unrelated individuals are extremely
unlikely to have the same VNTRs.
In situations in which a full
nuclear DNA profile is not attainable, for example in ancient
or degraded remains, mitochondrial DNA analysis may be used,
although with less certainty.
Identification using DNA evidence
relies on the comparison of an
ante-mortem sample (reference
sample) with a post-mortem
sample, and may include direct
comparison of the decedent’s
DNA (e.g. Guthrie cards or an
ante-mortem blood sample), or a
comparison with relatives’ DNA
(parents, children or siblings), to
arrive at a conclusion. The conclusions of molecular biologists
are expressed as a probability ra-

system operating under threshold scoring rules, determining
whether two friction ridge impressions are likely to have originated from the same finger or
palm (or toe or sole). The validity
of forensic fingerprint evidence
has been challenged by academics, judges and the media. While
fingerprint identification was an
improvement on earlier anthropometric systems, the subjective
nature of matching (especially
when incomplete latent prints
are used), despite a very low error rate, has introduced an element of controversy.
Medical record comparison
can be used for identification
purposes when there is sufficient
ante-mortem evidence of unique
medical intervention or disease.
Examples include the discovery
of medical prostheses, such as
pacemakers and prosthetic hips,
which will have engraved on
them serial numbers, which can

can also be challenging. In order
to reach conclusions to these
difficult identification puzzles,
the forensic dentist not only
needs a solid grounding in all of
the techniques available, but also
requires a level of experience
and, in the early years, a degree of
mentoring.
Dental identification is not
only achieved using comparison
of restorations; other features of
the teeth and maxillofacial ske leton may also be employed. Root
morphology, sinus configuration, unusual crown shape, and
pulp chamber morphology are
all factors that can be considered
in the absence of restorations,
as long as there are high-quality
ante-mortem images with which
to make a comparison. Study
models, sport mouth guards, partial dentures, orthodontic appliances and photographs of the
dentition are all useful aids for
a forensic odontologist and are

Aside from identification case
work, odontologists are asked
to provide medico-legal opinions
on a variety of topics as outlined
in the introduction. Bite mark
interpretation is probably the
most recognisable of these to the
lay audience and involves the
assessment of injuries to the skin
that are suspected of being
caused by human teeth. This
area of forensic practice is
fraught with difficulty, as the
highly subjective nature of the
conclusions reached is almost
completely based upon opinion
rather than scientific research.
There are so many problems associated with the interpretation
of bite marks that to describe
them all here is beyond the scope
of this introductory article.
Cranio-facial trauma analysis is a growing area of forensic
odontology practice, and involves examination of both living
and deceased individuals and the
provision of opinions concerning
accurate anatomical description
of the injuries (Fig. 3), degree of
force (mild, moderate severe),
and direction of force application. Occasionally, opinions are
also sought regarding the exact
nature of the weapon used, although caution needs to be exercised in this regard, as unless the
implement bears unique characteristics that are imparted to the
body interpretation will be very
difficult. This area of odontology
practice predicates a thorough
knowledge of cranio-facial anatomy, the biomechanics of bone,
and the effect on anatomical
structures of various degrees of
force.
Age estimation has always
been a function of the forensic
odontologist, and traditionally
has been based upon interpretation of dental development and
comparison with published standards for tooth development
(Fig. 4). The majority of age estimation work has concentrated
on the ageing of children up to
15 years. Beyond this age, dental
development becomes relatively
unreliable, as only the third molar is available for assessment,
and this tooth is notoriously vari-

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DTAP0115_21-23_Bassed 09.02.15 11:01 Seite 3

DENTAL TRIBUNE Asia Pacific Edition No. 1+2/2015
able in its development. It has
been recognised recently, however, that published standards
for tooth development may not be
as accurate as assumed, owing
to the fact that they were constructed many decades ago and
in other parts of the world, and
therefore may bear little resemblance to modern populations.
Considerable work is currently
underway to address this issue,
with new population datasets
being established around the
world.
Odontologists are also researching the ability to estimate
more accurately the age of older
individuals, around the adult/
child demarcation age of 18 years.
This is being achieved through
the use of multifactorial approaches, where the third molar
and various other skeletal development sites are assessed
together in order to arrive at an
estimate (Figs. 5a–c). This is seen
as important research in light of
the increasing need to determine
the legal status of individuals
such as asylum seekers, accused
human traffickers who may be
children and risk being incarcerated in an adult prison, child
soldiers, and victims of sexual
assault in developing countries,
all of whom are unlikely to possess proof of age documentation.
It has been shown that more
than half of all cases of child
abuse involve cranio-facial injuries, perhaps owing in part to
the significance of the face and
mouth in communication and
nutrition. Forensic odontologists
are rarely involved in these dif ficult cases, but despite this play
an important role in injury description and providing help with
determination of causation. All
of the principles involved in
cranio-facial trauma analysis for
adults are applicable here, but
with emphasis on the developing
anatomy and different biomechanical characteristics of the
child facial skeleton.

of the deceased in some parts of
the world represents a serious
and ongoing issue for governments and humanitarian organisations. Good record-keeping is
not only of benefit to forensic
practitioners, but also relevant
to improved health services and
outcomes for patients in general,
so part of the work of odontologists includes educating health
authorities in less developed
parts of the world to encourage
good record-keeping. The benefit of good record-keeping can
be seen in recent mass fatality

incidents, such as the Victorian
Black Saturday bushfires, where,
despite the availability of a wellresourced DNA capability, more
than half of all victims were
identified by dental record comparison.
The scope of forensic odontology is broader than identification alone and encompasses
a range of activities, anything in
fact where the practice and theory of dentistry intersect the law.
To be a competent practitioner
in this discipline requires not

Trends & Applications 23
only a comprehensive understanding of odontology theory
and technique, but also a degree
of knowledge and experience in
a variety of forensic fields, including law, pathology, clinical
forensic medicine, molecular
biology and anthropology. The
forensic odontologist encounters
all of these disciplines in different case scenarios, and in order
to understand how the odontologist can contribute best to an
investigation he or she needs to
comprehend the capabilities and
limitations of these fields. DT

Dr Richard Bassed
is a senior forensic
odontologist and
Head of Human
Identification
Services at the
Victorian Institute of Forensic
Medicine in Melbourne in Australia. He can be contacted at
richard.bassed@vifm.org.

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Find more info and your local dealer
www.planmeca.com

Planmeca Oy Asentajankatu 6, 00880 Helsinki, Finland.
Tel. +358 20 7795 500, fax +358 20 7795 555, sales@planmeca.com

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[cover] => DT Asia Pacific No. 1+2, 2015

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Table of contents

[toc_titles] =>

Asia News / World News / Opinion / Business / Trends & Applications

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