DT Asia Pacific No. 6, 2015

Asia News / Dental implantology: Evolution or the road to ruin? / World News / Business / Interview: “We need to congratulate Singapore” / Peri-implantitis: Is it a crisis? / All-ceramic restorations with IPS e.max / Treatment of an unusual presentation of radicular cysts

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DENTAL TRIBUNE
The World’s Dental Newspaper · Asia Pacific Edition
www.dental-tribune.asia

Published in Hong Kong

Vol. 13, No. 6

INTERVIEW

IS IT A CRISIS?

ALL-CERAMIC RESTORATIONS

Dr Iain Pretty about the caries
experience in Asia, the pitfalls of
water fluoridation and what he
considers to be the right measures
to deal with the epidemic.
” Page 10

Risk factors and warning signs of
peri-implantitis and the reasons
why there is no clear consensus on
the prevalence of the troubling
disease yet.
” Page 12

Japanese clinicians demonstrate
a treatment flow with minimally
invasive methods to achieve harmony between pink and white
aesthetics.
” Page 16

Study reveals unrealistic public Halitosis
association
expectations regarding implants launched
In order to address the lack of scientific data on halitosis, the International Association for Halitosis Research (IAHR) was officially formed
on 5 June at a meeting of leading halitosis researchers during EuroPerio8
in London. As new insights into the
problem of bad breath are rapidly expanding, the IAHR aims to promote
research on all aspects of halitosis
and its related issues and to distribute and publicise the research. “Not
only do we need to create awareness
among the public, but we should also
enhance the information and treatment advice for professionals,” president Dr Edwin Winkel from the
Netherlands said.

By DT Asia Paciﬁc
HONG KONG: Dental implants are
gaining increasing popularity in
the treatment of partially dentate
or edentulous patients, and both
the industry and dental professionals offer detailed information
about implant materials, functions and procedures.
Yet, many people are not well informed and tend to overestimate
the functionality of implants,
while underestimating the expertise needed for implant dentistry.
These are the findings of a qualitative study conducted at the University of Hong Kong.
The researchers aimed to evaluate the public’s acquisition of in formation and their perceptions
regarding dental implants, as well
as the effects of these perceptions
on their care-seeking and decisionmaking behaviour.

Patients tend to overestimate the functionality of implants, new research has shown. (© Warren Goldswain)

The study examined a sample of
28 adults between 35 and 64 years
old who had never been engaged

in a dentistry-related job. Moreover, for inclusion in the study,
participants had to have at least

one missing tooth and to have
heard about dental implants, but

” Page 3

Despite affecting a vast number of
people worldwide, sound epidemiologic data on halitosis is rare. While 9 in
10 cases of halitosis are attributable to
tongue coating, gingivitis, periodontitis and other conditions in the oral
cavity, a minority of cases are caused
by systemic diseases or conditions.
AD

AB Dental
expands to
China & HK

Priyanka Chopra at a ﬁlm premiere in 2012. The Bollywood actress and former
Miss World was recently named brand ambassador by Colgate-Palmolive in India.

Malocclusion study WOHD 2015
Research conducted at the University of Adelaide in Australia
has found that children who were
exclusively breastfed from three
to six months, as well as up to six
months had a 33 per cent and a
44 per cent lower prevalence of
open bite, respectively, compared
with children who were never
breastfed by their mothers.

According to the FDI World Dental Organisation, this year’s World
Oral Health Day has continued to
grow, with estimates of the total
world audience rising to just under 27 million. Established in 2012,
the event is celebrated annually on
20 March with numerous awareness-raising events and activities
all over the world.

Simultaneous to the launch of its
customizable implant at the last
Europerio conference in London,
AB Dental has said to have entered
into partnerships agreement with
several dental institutions in Mainland China and Hong Kong.
The new partnerships with Bybo
Dental Group, Dolphins International Dental Academy and Sino
Integrity are intended to help the
Israeli company to distribute their
range of dental implants and related
products such as prosthetics and
imaging services and offer training
courses to dental professionals in
these regions and the Macao Special
Administrative Region. The first of
these seminars featuring international renowned clinical experts is
scheduled to take place in August.

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[2] =>

ASIA NEWS

Dental Tribune Asia Pacific Edition | 6/2015

A$139 million new oral health
centre opens in Brisbane

Fig. 1: (From left to right) Queensland Minister for Health and Ambulance Services Cameron Dick, UQ dean Prof. Lakshman
Samaranayake and Federal Minister for Health & Sport Sussan Ley observing equipment at the new facility. (© Kaylene Biggs,
Australia)—Fig. 2: Photo showing the new complex at Herston campus. (© University of Queensland, Australia)

DT Asia Paciﬁc
BRISBANE, Australia: After five
years of construction, one of Aus-

tralia’s largest and most advanced oral health centres has
opened this month at the University of Queensland’s Herston

campus in Brisbane. The new facility is intended to improve access to dental care for people in
Australia’s second largest state

IMPRINT
PUBLISHER:
Torsten OEMUS
GROUP EDITOR/MANAGING EDITOR DT AP & UK:
Daniel ZIMMERMANN
newsroom@dental-tribune.com
CLINICAL EDITOR:
Magda WOJTKIEWICZ

and northern New South Wales, as
well as to facilitate dental training and research.

ONLINE EDITOR:
Claudia DUSCHEK

Originally set for completion in
2012, construction was expanded
due to flooding, as well as commissions and certifications for
the fit out taking longer than
usual.

COPY EDITORS:
Sabrina RAAFF, Hans MOTSCHMANN

The university is reported to
have spent a total of A$134 million
(US$103 million) on the new complex, of which two-thirds were
provided by the federal and local
governments. It will replace the
university’s former dental school
at Turbot Street, which was returned to the Queensland government last December, and offer
general dentistry services, as well
as a number of specialised treatments, including orthodontics
and periodontics.
Equipment has been increased
with twice as many chairs available for treatment and the acquisition of advanced diagnostic
equipment, like microscopes and
intra-oral cameras.

ASSISTANT EDITORS:
Anne FAULMANN, Kristin HÜBNER

PRESIDENT/CEO:
Torsten OEMUS
CFO/COO:
Dan WUNDERLICH
MEDIA SALES MANAGERS:
Matthias DIESSNER
Peter WITTECZEK
Maria KAISER
Melissa BROWN
Weridiana MAGESWKI
Hélène CARPENTIER
Antje KAHNT
MARKETING & SALES SERVICES:
Nicole ANDRAE
ACCOUNTING:
Karen HAMATSCHEK
BUSINESS DEVELOPMENT:
Claudia SALWICZEK
EXECUTIVE PRODUCER:
Gernot MEYER
AD PRODUCTION:
Marius MEZGER
DESIGNER:
Franziska DACHSEL
INTERNATIONAL EDITORIAL BOARD:
Dr Nasser Barghi, Ceramics, USA
Dr Karl Behr, Endodontics, Germany

Furthermore, surgeons will be
able to record and stream procedures with the help of two
demonstration chairs boasting
state-of-the-art recording equipment.

www.DTStudyClub.com

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and anytime
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ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providersof continuing dental education.
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“It’s a long way from the days
when the smell of eugenol was
ever present,” President of the
Australian Dental Association
and former University of Queensland dental student Dr Rick Olive,
who attended the opening on
Thursday, said. “We were the last
cohort to use the old pumpchairs and slow speed belt-driven
handpieces.”
Plans to update the university’s
dental facilities, which were established in the 1930s, were in
the making for almost 20 years.
Once the design had been
awarded to Brisbane architects
Cox Rayner, constructions for
the new oral health centre began
in 2011. The site finally became
operational late last year. Among
other things, it will connect the
Royal Brisbane and Women’s
Hospital to the Mayne Medical
School.
“The UQ Oral Health Centre
has been a significant project
over several years and is a fine
facility of which we can be proud,”
Vice-Chancellor Prof. Peter Høj
commented.
“UQ has been at the forefront of
Australian dentistry for the best
part of a century, and this ensures
we continue to set the standard
for coming generations.”

Dr George Freedman, Esthetics, Canada
Dr Howard Glazer, Cariology, USA
Prof. Dr I. Krejci, Conservative Dentistry, Switzerland
Dr Edward Lynch, Restorative, Ireland
Dr Ziv Mazor, Implantology, Israel
Prof. Dr Georg Meyer, Restorative, Germany
Prof. Dr Rudolph Slavicek, Function, Austria
Dr Marius Steigmann, Implantology, Germany

Published by DT Asia Pacific Ltd.
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All rights reserved. Dental Tribune makes every
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responsibility for the validity of product claims,
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[3] =>

ASIA NEWS

Dental Tribune Asia Pacific Edition | 6/2015

WCLI Asia Paciﬁc Symposium
By DTI
TAIPEI, Taiwan/IRVINE, Calif., USA:
The World Clinical Laser Institute
(WCLI), the largest dental laser
organisation in the world, will be
hosting a symposium in Taipei on
September 19 and 20. The event will
feature educational content suited
for every dental professional—with
new presenters just announced
in periodontology and paediatric
dentistry.

The WCLI Taipei Symposium will
address topics on today’s challenges
in dentistry, including periodontitis
and peri-implantitis. Dr Sam Low,
past President of the American
Academy of Periodontology, will
present “The Role of Lasers in Perio
and Introduction of a Dual Wavelength Approach for the Treatment

of Perio Disease”. Renowned speakers joining him include Dr Ki-Tae
Koo, who will discuss the “Latest
Developments in Peri-Implantitis
Treatment Solutions, Including
Laser”; Dr Linda Murzyn-Dantzer,
presenting on laser-assisted paediatric dentistry; and Dr Rana AlFalaki, who will cover laser-assisted

periodontic and osseous surgical
techniques.
The WCLI is more than an educational gathering of dentists seeking
clinical knowledge and tips on the
latest technologies in dentistry. The
largest group of its kind, the WCLI is
a close-knit network of thousands of

dental professionals who share a passion for improving the patient experience, elevating their clinical results
to the highest level, and building the
best possible practice they can.
The institute has been holding
world-class educational events for over
ten years. At this year’s Taipei Symposium, dental professionals will be able
to improve their knowledge and techniques in the areas of periodontology,
endodontics, implantology, cosmetic
dentistry and restorative dentistry.
AD

Page 1

LIFELIKE ESTHETICS –
EFFICIENTLY PRESSED

never received one or had any dental consultation regarding dental
implants.
The participants were divided
into six focus groups and had to
discuss dental implants and their
individual knowledge about them.
All of the group discussions were
transcribed verbatim and subjected to thematic content analysis
following a grounded theory approach.
The Chinese research team found
that the participants acquired information on dental implants
through various means, such as patient information boards, printed
advertisements, social media, and
personal connections.
According to the researchers, the
participants expected dental implants to restore patients’ appearance, function and quality of life to
absolute normality. “They regarded dental implants as a panacea
for all cases of missing teeth and
overestimated their functions and
longevity,” the scientists stated.
The participants further underestimated the expertise needed to
carry out the clinical procedures to
place an implant. However, they
were deterred from seeking dental
implant treatment by the high costs,
invasiveness of the procedure, risks
and possible complications.

IPS e.max PRESS MULTI
®

Overall, the study found that the
public is exposed to information
of varying quality and has some
unrealistic expectations regarding
dental implants. Such perceptions
may shape their care-seeking behaviours and decision-making
processes in one way or another,
the researchers said.
“The views and experiences
gathered in this qualitative study
could assist clinicians to better understand the public’s perspectives,
facilitate constructive patient–
dentist communication, and contribute to the creation of positive
clinical experiences in implant
dentistry,” they concluded.
The study, titled “Public perceptions of dental implants: A qualitative study”, was published online
on 8 May in the Journal of Dentistry.

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[4] =>

OPINION

Dental Tribune Asia Pacific Edition | 6/2015

Dental implantology:
Evolution or the road to ruin?
Why and where?

By Aws Alani,
UK
Teeth are highly evolved structures
that have developed progressively
over millions of years in attempts to
protect themselves from caries and
periodontal diseases. Over the years,
many advances have been made
that can treat these various diseases
predictably. Various strategies have
been developed to prevent or slow
down these problems given adequate patient compliance and appropriate personal and professional
maintenance. Despite these very
significant improvements, there are
still instances when patients are
advised that one or other tooth has
to be extracted. It is the obvious
sadness, heartache or despair that
patients are caused by this bad news
that has driven, caring clinicians to
find ways to replace teeth with various devices, including dentures,
bridges and implant-retained prostheses.

Where this technological change
has taken implantology and what
the real reasons are that this was
and is happening need to be examined. Increasingly, the shadow of
peri-implantitis looms likes a spectre over the provision of implants.
Unlike caries or periodontal disease, there is very little consensus
or research that can provide a predictable cure for what now is now a
new breed of disease. Peri-implantitis is relentless once established
within fine threads of the implant,
and the bone resorption and softtissue problems that follow can
result in spectacular problems.
Part of the key issue probably lies

plant surface a veritable inflammation super highway for the
pathogenic organisms. Predictably
enough, the micro-organisms
found on the rough surface are
usually the common pathogenic
ones, but also some species are
found that have previously never
been discovered in the oral cavity.

Patient selection issues
We need to consider the types of
patients whom we are now accepting for implant provision. At King’s
College Hospital, the criteria for
state-sponsored implant provision
largely involve patients with hypodontia and those who have suffered trauma. Usually both cohorts

history of periodontitis and those
with poor oral hygiene are well
known to be at a very significantly
higher risk of peri-implantitis.

Biological versus
mechanical problems
If we are being frank, the pathogenic bacteria-induced diseases
are not the only long-term problem that we are now seeing. The
reported frequency of mechanical
complications has risen over the
years, but the reported problems
are probably only the tip of the iceberg, as many complications have
not and will not be reported for a
variety of understandable reasons.

These problems become much
more worrying when viewed from
ethical, valid consent and medicolegal perspectives. This is particularly
so when patients are convinced to
undergo elective extractions of teeth
that often seem reasonably intact or
treatable with conventional proven
treatment strategies.
It appears that there is a worrying
drift towards aggressive treatment
with extractions in order to provide
a supposed full-mouth rehabilitation with multiple implants. The
increasingly dubious practice of
sacrificing teeth for the sake of implants appears to many concerned
clinicians to be quite irrational.
As ethical oral health practitioners,
deliberately removing saveable
teeth for prosthetic replacement
using implants as support appears
to be consciously flying in the face
of increasingly apparent evidence
of various complications with implants and many would consider
that approach to be foolish. How
many “implantologists” doing that
to others would genuinely have it
done to themselves or done to some
close family member?

Planned
obsolescence
A state-of-the-art implant today
is likely to be obsolete tomorrow.
Electively removing teeth is irreversible and replacing teeth with
implant-retained devices means
that patients are trapped in the era
of the implantology in which these
were placed and restored, that
means issues of machining, surface blasting, roughness, platform
switching, design and attempts at
bone augmentation by cow, coral
or Californian substances. The list
goes on and on and will probably
continue to expand with what
many might consider human experimentation without licence.

P.-I. Brånemark, now sadly deceased, famously quipped: “No one
should have to die with their teeth
in a glass of water beside their bed”.
His original inspiration coupled
with determination, intuition, passion and an ability to surround
himself with a great team of individuals with differing skills made
osseointegration much more predictable. Brånemark’s landmark
studies changed prosthetic dentistry dramatically, but a careful
look at the design of these protocols and the implants themselves
reveal that they were hugely different to the patient selection protocols and the types of implants
being placed today.
Furthermore, the restorations
supported on them were made of
the established materials then and
obeyed traditional mechanical
laws. In terms of biological cleanability, the metal, polished “high
water” abutment design allowed
for optimal interproximal cleaning, while the implant surface itself
was also relatively smooth in comparison with the rougher surfaces
we often see today. Market saturation, cost, profit and market share
in many technology-driven markets often pursue innovation of
some sort of change to help gain
greater market share or profit. The
over-commercialisation of dentistry generally creates a constant
turnover of supposedly new and
better products, where the common notion of “if it ain’t broke don’t
try to fix it” is lost on many directors of marketing or increasingly
profit-driven CEOs.

Ethical, moral
and legal issues

in the surface exposed to the susceptible patient’s oral environment,
as most microbiologists will allege.
The bacterial content and makeup of the biofilm is a reflection
of the surface on which it resides.
Implant surfaces have become
progressively rougher in order to
hasten the early osseointegration
processes and to try to provide
patients with their restoration
quicker in an ever more competitive financial environment.
However, speed is not always
helpful. Experience shows that
some things are better achieved
gradually.
Once exposed to the environment of a susceptible patient, the
macro-topography of the threads
provides an ideal ecological niche
for bacterial proliferation. Further
nano-level features make the im-

are likely to present with wellmaintained, minimally restored
dentition or with scope for oral
health improvement prior to consideration for any restoration, let
alone an implant. Unfortunately,
we are unable to provide this treatment for smokers.
This is in stark contrast to the
patients who may be provided with
implants in general and specialist
practice, such as patients who are
likely to have lost teeth as a result
of plaque-associated diseases. Indeed, it could be considered a paradox by many interested observers
that some clinicians are providing
patients with implant-retained
restorations when they have
shown that they are highly prone to
plaque-associated disease via tooth
loss and have not demonstrated
any real capacity for changing that.
Patients who smoke, those with a

Over time, the components of
implants have shown notable
weaknesses. Screw loosening, fractured screws, loose abutments and
the cracking of ceramic can be laborious and expensive to manage.
One aspect, which may be lost on
some, is that since they lack a periodontal ligament dental implants
cannot and will never be able to
acclimatise to changing occlusal
and non-axial forces. These are
very likely to create stresses within
the masticatory system, thereby
resulting in breakages. These forces
are compounded greatly if patients
exhibit parafunction on a daily basis and that is sometimes an unknown risk factor until it is too late.
The more implants that are placed,
usually the fewer teeth are present, resulting in a net reduction in
physiological feedback and thereby creating an increased chance of
failure of some type.

Now comes the time for implant
manufacturers to take stock of their
many “market-driven” mistakes, including fast initial integration with
the roughest possible surfaces. Instead they need now to produce
proven (i.e. not speculative) designs
to better prevent these well-known
problems of infection and breakage.
A wiser, pragmatic approach appears to be to concentrate everyone’s efforts on saving teeth and
thereby eke out their usefulness
for the patient’s lifetime. Recently,
the legendary Prof. Jan Lindhe, interviewed in the British Dental Journal,
summarised the state of play as
follows: “There is an overuse of implants in the world and an underuse
of teeth as targets for treatment”.

Aws Alani is a Consultant in Restorative
Dentistry at Kings College Hospital
in London, UK, and a lead clinician for
the management of congenital abnormalities. He can be contacted at
awsalani@hotmail.com.

[5] =>

WORLD NEWS

Dental Tribune Asia Pacific Edition | 6/2015

Researchers reveal new insights
into the internal structure of dentine
By DTI
BERLIN, Germany: Being subjected
to massive forces, human teeth
consist of one of the most durable
organic materials. To date, the high
crack resistance of dentine has
not been fully understood. An interdisciplinary team of scientists
has now analysed the complex
structure of dentine, revealing
that its mineral particles are precompressed and internal stress
works against crack propagation
to increase the resistance of the
bio-structure.
Engineers already use internal
stresses to strengthen materials
for specific technical purposes.
Now it seems that evolution has
long known about this trick and has
put it to use in our teeth. Unlike
bones, which are composed partly
of living cells, human teeth are not
able to repair damage. Their bulk is
made of dentine, a bonelike material consisting of mineral nanoparticles. These mineral nanoparticles
are embedded in collagen protein
fibres, with which they are tightly
connected. These fibres are found
in every tooth and lie in layers,
making teeth tough and damage
resistant.
Researchers from the Julius Wolff
Institute at Charité – Universitätsmedizin Berlin, together with several national and international
partners, have examined these
bio-structures more closely. They
performed microbeam in situ
stress experiments at the BESSY II
synchrotron radiation source at
Helmholtz-Zentrum Berlin and
analysed the local orientation of
the mineral nanoparticles using
the nano-imaging facility of the
European Synchrotron Radiation
Facility in Grenoble.

lieve that the balance of stresses
between the particles and the protein is important for the extended
survival of teeth in the mouth,”
Charité scientist Jean-Baptiste
Forien stated.

The study, titled “Compressive
residual strains in mineral nanoparticles as a possible origin of enhanced crack resistance in human
tooth dentin”, was published in the
Nano Letters journal on 26 May.

HKIDEAS
Hong Kong International Dental
Expo And Symposium

7 – 9 AUGUST

Hong Kong Convention and Exhibition Centre
1 Expo Drive, Wanchai, Hong Kong
Preluminary Faculty
Professor Bilal Al-Nawas (Germany)
Professor Mark Bartold (Australia)
Dr. John Lin (Taiwan)
Dr. Derek Mahony (Australia)
Professor Chooi-gait Toh (Malaysia)
Dr. Patrick Tseng (Singapore)

Call for Abstracts:
Deadline: 15 April 2015
Early-bird Registration:
Deadline: 15 May 2015

Prevention

Quality of Life

“Our group was able to use
changes in humidity to demonstrate how stress appears in the
mineral in the collagen fibres,”
Dr Paul Zaslansky from the Julius
Wolff Institute explained. “The
compressed state helps to prevent
cracks from developing and we
found that compression takes
place in such a way that cracks cannot easily reach the tooth inner
parts, which could damage the
sensitive pulp.”

The scientists also examined
what happens if the tight mineral–
protein link is destroyed by heating. In that case, dentine becomes
much weaker. “We therefore be-

sequently, fillings cannot sustain
the stresses in the mouth as well as
teeth do. “Our results might inspire
the development of tougher ceramic structures for tooth repair or
replacement,” Zaslansky hopes.

When the tiny collagen fibres
shrink, the attached mineral particles become increasingly compressed, the research team learnt.

In this manner, compression
stress helps to prevent cracks from
running through the tooth.

Their results may explain why artificial tooth replacements usually
do not work as well as healthy teeth
do: they are simply too passive,
lacking the mechanisms found in
the natural tooth structures. Con-

Evidence-based

Aesthetics

Longevity

Healthy Aging

Organizer

www.hkideas.org

[6] =>

WORLD NEWS

Dental Tribune Asia Pacific Edition | 6/2015

“Xylitol is here to stay”
An interview with Professor Emeritus Kauko K. Mäkinen, Finland

Professor Emeritus Kauko K. Mäkinen posing with a model of the xylitol molecule.

During the early 1970’s, xylitol and
other natural sweeteners were extensively tested in Finland as potential replacements for sugar.The series of over
20 research reports,published together
in Acta Odontologica Scandinavica in
1975, became collectively known as the
“Turku Sugar Studies”. Approaching

the 40th anniversary of the publication,
Dental Tribune had the opportunity to
speak with Professor Emeritus Kauko
K. Mäkinen, who led the original Turku
research together with Arje Scheinin,
about xylitol’s impact on caries levels,
its popularity in Finland and the sweetener's future prospects.

Dental Tribune: Prof. Mäkinen, you
were involved in the first extensive
studies of xylitol in the seventies—
how far has the sweetener come since
then?
Prof. Emeritus Kauko K. Mäkinen:
The awareness of xylitol among consumers and healthcare professionals
has increased significantly since the
early 1970’s. However, knowledge
about xylitol is not equally distributed across the world. Although
awareness may approach 100 per cent
in Finland, the situation is different
in other countries and the level of
awareness depends on the level
of dental and medical education in
each country.
As you mentioned, in Finland, xylitol
seems to be a part of daily life?
Xylitol is indeed known by virtually all Finns and is also used by
most people in Finland on a daily

basis. Parents and grandparents have
adopted a habit of buying xylitol
gum, pastilles or lozenges for their
children and grandchildren. At many
day-care centres, children learn to
use xylitol after lunch.
In Germany, for example, you can buy
xylitol as a sweetener and it is also
added in gum, but it is not widely
known to the public as a mainstream
product. Why do you think there is
such a difference in “popularity”?
You are right about the situation in
Germany. I cannot help but wonder
why this could be, since xylitol was
discovered by German chemists and
its medical use in infusion therapy
is best known by German physicians.
It is possible that German dentists
do not value early caries prevention
as much as the dentists and the
authorities do in Scandinavia. One
would need a strong and committed
distributor and an official endorsement from the German Dental
Association.
When you did your research for the
Turku studies, did you expect to find
xylitol to be so beneficial, especially
for oral health?

daily amounts that are taken at least
three to five times a day.
Do you have any data on how much
xylitol is consumed in Finland or
worldwide?
These figures are possessed by
xylitol manufacturers and they do
not provide any production-related
information to us. However, the
annual production worldwide must
be tens of thousands of tons since
xylitol is produced in China, Russia
and in other countries. The first true
xylitol plant in the world was in
Finland and was sold to DuPont a few
years ago. When production started
in Finland in the 1970’s, 3,000 to
50,000 tons were made during the
first few years, but overall, production is by far much larger now.
How should the sweetener be used in
daily life?
My current recommendation is
about 7–10 g per day, evenly distributed throughout the day. The first
dose in the morning, the last after
oral hygiene at bedtime. Always after
meals and sugary snacks. Use it about
5 times a day, not less. Use two pellets
or one stick of gum but the gum must

“Overall caries prevention takes
place as a result of multi-faceted
efforts and programs, xylitol
being a part of the whole.”
We did not anticipate the magnitude of this preventative effect.
We considered it a welcome surprise.
Later, of course, after learning how
xylitol works and after we learned
to understand the chemical mechanisms involved, we started to regard the findings as natural and
expected.

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Is there a measureable impact on
caries levels and dental health that
can be attributed to the sweetener?
We cannot give any figures of the
effect of xylitol in caries incidence
in the above instances. Overall caries
prevention takes place as a result of
multi-faceted efforts and programs,
xylitol being a part of the whole. It is
impossible to differentiate between
the effect of each individual preventative measure since all of them are
in action simultaneously, such as
tooth brushing, the use of fluorides,
the application of sealants, etc.
The caries preventative effects of
xylitol that were reported in the literature are based on clinical trials.
Xylitol does, however, significantly
increase the efficacy of overall caries
prevention, provided that the use of
xylitol is habitual and is based on the
consumption of sufficiently-large

be 100 % xylitol. One may “tolerate”
some maltitol in it, but no sorbitol,
unless the sorbitol amount is very
small (<5 %). Some companies use
only 5–10 % xylitol and call their
product "a xylitol gum", which is false.
Are there any known side effects?
Regular consumers who use xylitol for dental purposes have no side
effects. If somebody accidentally
consumes larger single doses, for
example, 20–30 g, some individuals
may have transient diarrhoea. However, sorbitol, mannitol and common milk causes much more severe
symptoms. Of course, small children
must use xylitol gum under parental
guidance.
Do you think xylitol could be playing
a greater role in the future, maybe in
developing countries?
Xylitol is here to stay. We are
already using xylitol in developing
countries. Vietnam is one example
and, in thinking, it is still a developing
country. Xylitol is currently being
used in hundreds of dental, medical,
cosmetic and other products all over
the world. Its popularity is increasing
steadily, but not abruptly.
Thank you very much for the interview.

[7] =>

2015

ASIA-PACIFIC SYMPOSIUM

LEARN THE LATEST ADVANCES IN LASER DENTISTRY
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Dr. Sam Low
Periodontist
Former President of American Academy of
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Dr. Ki-Tae Koo
Periodontist
Associate Professor in Periodontics,
School of Dentistry, Seoul National University
Seoul, Korea

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Pediatric Dentist
Assistant Professor University of Colorado,
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Colorado, USA

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does not approve or endorse individual courses or instructors, nor does it
imply acceptance of credit hours by boards of dentistry.

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Tribune Group GmbH i is designated as an Approved PACE Program Provider by the
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maintenance credit. Approval does not imply acceptance by a state or provincial board of
dentistry or AGD endorsement.

[9] =>

Dental Tribune Asia Pacific Edition | 6/2015

BUSINESS

MIS launches new implant
at special event in London
Manufacturer says new V-Concept delivers true innovation to implant dentistry
By DTI
LONDON, UK: MIS Implants Technologies launched a new implant
at a special event in London that
promises immediate biological
benefits for better treatment outcomes. The new V3 is a multi-use
implant suitable for a wide range of
surgical scenarios, according to the
Israeli implant solutions provider,
and is ideal in anterior regions, as
well as in regions where space and
bone may be limited and good aesthetic outcomes are essential.
Designed in collaboration with
leading clinicians, including Prof.
Nitzan Bichacho and Dr Yuval
Jacoby, both from Israel, as well as
Dr Eric Van Dooren from Belgium,
the development of V3 took two
years to complete, MIS Product
Manager Elad Ginat stated. He said
that it will be available to visitors
to EuroPerio8 from Thursday and
to clinicians worldwide in the upcoming months.
“MIS is immensely proud of our
innovative position in the global
implants industry, which has led
to the development of the unique
V3 implant system. It’s a widely

The launch event took place at the Science Museum in London.

anticipated evolutionary next step
in dental implant performance, designed for the benefit of clinicians
and their patients all over the
world,” Ginat stated.

support of stable surrounding soft
tissue for restorations with improved aesthetics. According to Ginat,
the neck provides solid anchorage at

three points in the crestal zone
while forming three compression-free gaps at the sides
(between the implant and the
osteotomy), thus favouring
conditions for better osseointegration, such as high pri- MIS Product Manager Elad Ginat.
mary stability, bone compression and crestal bone resorption.
switching, V3 also features a variable
The gaps encourage blot clot formathread and self-tapping capability,
tion at the bone–implant interface
micro-rings, a concave inter-thread
to promote the initial scaffoldfor maximum bone–implant conbuilding process for bone growth
tact, as well as a flat apex supporand allow more space for blood poolting immediate placement engageing and the establishment of a stable
ment. Ginat added that clinicians
blood clot. This way, V3 provides
can enjoy all of these design beneclinicians with advantages from the
fits without having to learn new
start, achieving a greater volume of
protocols. Furthermore, a dedicatbone and soft tissue at the onset of
ed surgical kit makes procedures
implant placement.
especially simple, safe and accurate,
resulting in ease of placement for
the dentist and shorter recovery
A high-performance conical contime for patients, he explained.
nection implant with platform
AD

The design of V3 aims to provide
both specialists and general practitioners with optimum flexibility in
implant planning and placement
for a restorative-driven approach.
In particular, the triangular shape
of the coronal portion is intended to
encourage bone regeneration and
to gain greater volume of bone in

everX Posterior

The overall failure
rate of Class II restorations after
seven years, according to a 2011
study by Van Dijken and Pallesen,
was 14.9 per cent. Nearly half of
those cases were caused by composite fractures.
Developed in response to the increasing demand by dental specialists for a low-cost treatment alternative for large restorations, everX

composite
material and slowly
propagates through the filling and
the tooth structure, thus extending
the limits of direct restorations.
GC recommends that everX
Posterior always be covered with
a light-curing universal composite,
such as one from the GC G-ænial
product family, in order to achieve
a highly aesthetic appearance and
strong wear resistance.

.
Dr

SINGAPORE: According to research,
the most common reason for failing composite fillings is fracture
of the composite, followed by secondary caries.

Posterior from GC Asia features
a strong composite substructure
made of short glass fibres that are
said to provide a fracture toughness
equal to collagen-containing dentine
and almost double that of a conventional composite. According to
the manufacturer, the fibres
effectively prevent and arrest crack propagation
that often starts from
the surface of
the

By DTI

GC enhances fracture toughness
with new composite

K ris h n a

[10] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 6/2015

“We need to congratulate Singapore”
An interview with Dr Iain Pretty, Professor of Public Health Dentistry at the University of Manchester in the UK
and co-director of Colgate-Palmolive’s Dental Health Unit
sort of thing. Ensuring that
those water supplies are perfectly fluoridated is complex
and depends on the logistics.

Caries prevalence remains high in
most parts of Asia despite international and national efforts to
address the disease. At the recent
Asia Pacific Dental Conference in
Singapore, Dental Tribune South
Asia had the opportunity to talk to
Dr Iain Pretty from the University
of Manchester about caries on
the continent, the pitfalls of water
fluoridation and what he considers the right measures for dealing
with the condition.
Dental Tribune South Asia: According to the recently published
Global Burden of Disease report
by your colleagues in London,
35 per cent of the world’s population
currently suffer from untreated
carious lesions in their permanent Dr Pretty (right) in talks with Dental Tribune South Asia. (© DTI)
dentition. Is this a matter of conyet we still find access to be difficult.
These things combined probably accern?
Similar issues can be seen in the US.
count for it.
Dr Iain Pretty: While we still have
a significant problem with caries, we
have seen a massive reduction in the
It is about encouraging people to
Could the Singaporean model be
overall caries burden since the late
visit the dentist when available, to
transferred to the rest of Asia?
1960s and early 1970s. For the most
use evidence-based products, such as
I would agree that the assessment of
part, this has been due to the introfluoridated toothpaste, to brush reguwater fluoridation has an important
duction of fluoride toothpaste.
larly and to seek care whenever they
role to play, although I think that it is
can. As with all public health problems,
not water fluoridation only. As I have
What we see now is that the burden
it is going to require joint thinking
mentioned, the evidence supports
of the disease is concentrated in
between many stakeholder groups.
that it was also the introduction of
groups that are difficult to reach. We
fluoride toothpaste that helped with
have eradicated the disease in many
caries reduction. It has been probably
A high-income country such as Singaindividuals and they are now cariesboth things working in tandem.
pore appears to have a different caries
free. But those who do have caries are
experience from most countries in Asia.
a much smaller population and carryIt also depends on water consumpWhat do you consider the main differing a greater burden of the disease.
tion. Asia covers a large area and one
ences when it comes to the managewould not want to fluoridate water in
ment of caries here?
It is now up to organised dentistry,
Thailand, where the water is naturally
Versus the rest of Asia, Singapore is
as well as government and policyhighly fluoridated. Generally, it rea relatively high-income country and
makers, to see how we can reach those
mains difficult to fluoridate the water
has the benefits of water fluoridation.
individuals. It is often not only a quessupplies of small individual villages,
Access to dental care is also good and
tion of finance or income levels. For
where people will often have water
programmes that help support dental
example, in the UK we have free densupplies, but use a different supply for
education and oral health are introtistry for the vast majority of people,
drinking, cooking, laundry and that
duced as early as primary school.

On an individual basis, government and policymakers need
to assess whether it is possible to
fluoridate the water, whether it is
already naturally fluoridated or
to what level it needs to be fluoridated. Much, of course, depends
on temperature or the amount
of water that is consumed. In
some cases, water fluoridation
might not even be possible and
that has nothing to do with the
Asian regions. For example, in
North West England, it is not easy
to bring fluoridated water into
certain areas, such as where the
water-flow is just not great because there are mountains in the way.
There are also political arguments, a
state and the logistics, the natural condition of the water and the cultural use
of water. All of these things need to be
considered. I think we need to congratulate Singapore for its initial fluoridation efforts and the fact that it has continued with that. Areas that can should
look towards Singapore as an example.
Community-based interventions implemented in many Asia countries have
achieved mixed results. What are the
main obstacles there?
Generally, what one would hope for
is that community-based interventions are locally driven, locally informed and evidence based. I think we
need to be very careful with taking a
programme that appears successful
in one region and simply applying it to
another region. One really has to look
at the particular countries. It may not

be appropriate for them. For example,
water fluoridation may be the best
choice for some countries, whereas
community programmes, such as
supervised toothbrushing, may work
best for others.
More broadly, income and resource
levels, as well as the availability of the
dental workforce, are inadequate.
However, there is a great deal of evidence that well-planned community
interventions can make a difference,
particularly in children and older
adults. We need a good level of resourcing for dental public health activities.
What other measures do you consider
useful to halt or reverse decay levels in
Asia?
I think that education is a really
important factor, so that parents,
children and older adults are aware
that there are evidence-based interventions that they can do at home.
Other measures are ensuring that
self-care is done effectively and that
access to dental professional care is
made as widely available as possible.
Clearly, in some countries where the
dentist per capita ratio is still very low
further work needs to be done.
We should also be using communities to deliver messages and simple
treatments, in terms of distributing
toothbrushes and toothpaste and
having community-based champions. Something like that can be very
helpful and not necessarily restricted
to developing countries. Scotland, for
example, used the Child Smart programme to embed local community
leaders in developing and enhancing
oral health.
Thank you very much for the interview.

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[12] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 6/2015

Peri-implantitis: Is it a crisis?
By Dr Michael R. Norton, UK
this condition is often asymptomatic to the patient and as such
is typically only diagnosed at
routine recall. Hence there is a
need to recognise that when implant treatment is completed the
patient should remain on annual
reviews for at least the first five
years, and thereafter once every
two years.
On presentation with mucositis
a combination of mechanical
debridement and sub-mucosal decontamination and antimicrobial
therapy are indicated. The treatment should be repeated three
times within a two week period, socalled Triple Therapy (Norton M).

In the US over 500,000 implants are
placed each year, whilst in the UK
that figure was around 140,000 for
2010. The prevalence of peri-implantitis has been reported to be up to
29 per cent 1 most notably in patients
whose implants are placed within
a partial dentition. This yields a
potentially vast number of implants,
possibly as many as 185,000 in the
US and UK alone that might succumb to some form of peri-implant
disease on an annual basis.
The bacteria found within periimplant lesions are similar to
those found in deeper periodontal
pockets,2, 3 and cross infection by
periodontopathogens as a primary
aetiology has been implicated as
a possible pathway. However the
wide variety of implant designs,
surfaces etc. make the treatment
of peri-implantitis much less predictable and subject to much
greater variability than periodontal disease, where natural teeth
present a known anatomy and well
defined surface structure.
In 2008 a systematic review4
of the literature regarding periimplantitis using PubMed and the
Cochrane library revealed little
consensus on the treatment of this
troublesome condition. One study
reported on the efficacy of submucosal debridement using ultrasonics or carbon fibre curettes5,
while two others compared the
effect of an Er:YAG laser against
that of mechanical debridement
and 2 % chlorhexidine as a combined therapy.6, 7
The first found similar results
between laser and combined therapies, while the second concluded
that the laser effect was limited to
a six month period. A further study
compared combinations of oral
hygiene instruction, mechanical
debridement and topical minocycline with a similar regime which
substituted 0.1% chlorhexidine as the
antimicrobial.8 The former seemed
to confer some benefit while the
latter showed limited or no clinical
improvements. Finally, a study comparing two bone regeneration proce-

dures reported clinically significant
improvements mediated by both.9
Nonetheless a multitude of
other studies have also been published reporting on the efficacy
of tetracycline10, CO2 laser11, and
photocatalytic decontamination
amongst others in the treatment of
peri-implantitis.12 Such a plethora
of therapies makes it difficult for

yet this has been a consistently
cited risk factor in many other
studies. Indeed in a study published
in the Swedish Dental Journal in
2010, the percentage of implants
with peri-implantitis was significantly increased for smokers compared to non-smokers (p = 0.04).14
Other factors that have been
implicated include excess cement,

the clinician to choose a regimen
that is both within the reach of the
average clinician and has some
documented reliability.

Risk factors
There have been a number of risk
factors cited for peri-implantitis.
Recently, in a study published in the
Journal of Clinical Periodontology,
a clear association was demonstrated through multi-level statistical analysis between risk of periimplantitis and location, specifically the maxilla, while overt periimplantitis was shown to be highly
correlated to patients with a predisposing history of periodontitis,
and being male.13 Surprisingly in
this particular study no correlation
was demonstrated with smoking,

poor oral hygiene, and prosthesis
design which are of course interrelated with some prostheses
making effective oral hygiene untenable, while others present deep
margins that make removal of excess cement almost impossible.

Warning signals
Peri-implantitis rarely presents
unannounced unless of course
the patient fails to be placed on a
regular recall programme or fails
to attend for regular review. Early
signs are often apparent in the
form of peri-implant mucositis.
This condition is characterised
by mucosal oedema, rubor and
bleeding on probing (BOP). By
definition it is not associated with
purulence or bone loss. However

The protocol is as follows:
1. Mechanical scaling of implant
surface with titanium or carbon
fibre curettes.
2. Sub-mucosal irrigation with 5–10 mL
chlorhexidine (0.2 %) per site, at
the deepest level of the pocket on
all sides of the implant.
3. Application of Minocycline Gel
2 % (Dentomycin, Henry Schein
Ltd) at the deepest level of the
pocket on all sides of the implant.

However once peri-implant mucositis has taken hold it is unfortunate that it is often exacerbated
by the design of implants today.
The presence of a rough surface,
taken to the top of an implant, and
the application of microthreads
or grooves have been proposed as
potential confounding factors for
the advance of the lesion due to
biofilm formation and bacterial
contamination of the surface which
leads to bone loss and further surface exposure. With advancing
bone loss it often results in colonisation of the deeper pockets with
well known periodontopathogens
and infection ensues. This then is
peri-implantitis.
Peri-implantitis is characterised
by the presence of vertical or crater-

like bone defects and spontaneous
purulence and bleeding on palpation (Figs. 1 & 2). It is typically
associated with deep peri-implant
pocketing > 5mm.
This condition is undoubtedly
of increasing concern due to some
principle factors, such as the almost exclusive use of roughened
implant surfaces, the treatment
of partially dentate patients with
a history of periodontal disease,
the placement of implants with
inadequate bone volume resulting
in facial dehiscences, as well as the
use of cement retained prostheses.
Implants with a micro-roughened surface texture have presented excellent long-term data
and until recently there has been
very little published in the literature demonstrating a susceptibility of these surfaces to this condition. However recent work by
Albouy et al 15, 16 has received widespread attention with concern for
the evidence that suggests some
modern micro-textured surfaces
may be completely resistant to
decontamination.16
Ultimately, if left unchecked and
untreated, it may become impossible to arrest the condition, leading
to wholesale failure of the case
(Figs. 3 & 4). Such failures impose a
tremendous strain and burden on
the clinician (let alone the patient),
destroying the confidence of a patient who has endured significant
expense and trauma and occasionally results in a breakdown of communication between both parties
that all too often sadly results in a
legal claim of negligence. Such claims
can be hard to defend for patients
where no warnings and/or supportive periodontal/peri-implant
therapy have been undertaken.
Treatment typically requires
surgical access to excise any fibrous capsule and for direct access
to the implant for surface decontamination. The author’s preference
until now has been to use chlorhexidine and tetracycline solution
for this purpose while others have
reported the use of citric acid and
hydrogen peroxide amongst others.17 The use of lasers has also been
extensively reported.6, 7, 18–20 However in a recent systematic review a
meta-analysis could only be done
for Er:YAG laser as the literature on
all other laser types was weak or
heterogenous.21
The author has recently completed the acquisition and treatment
of 20 patients in an efficacy study
using Er:YAG water laser (Morita,
AdvErl Evo) and it is hoped that
publication of the results will be
forthcoming. Indeed promising
data has already been published to
date using this same machine.22, 23
Nonetheless this methodology
remains outside the reach of most
general practitioners and has yet to
be proven predictably effective. As
such most attention therefore remains focused on physical debridement via surgical intervention and
topical antimicrobial therapies.

[13] =>

[14] =>

TRENDS & APPLICATIONS

14
Open flap debridement, defect decontamination, and repair as well as
pocket elimination have all become
the mainstay of those treating this
condition.
So is there a crisis? The problem is
that there is no clear consensus on
the prevalence of the disease since
this will vary according to the cut off
values for the clinical parameters
measured24 and to date there appears
to have been little consensus of these
cut off values. As such estimates of

Dental Tribune Asia Pacific Edition | 6/2015

“...there is no clear consensus on the
prevalence of the disease...”
incidence of the disease appear to
vary from 28 to 56 per cent of subjects
and 12 to 43 per cent of implant sites.25
Furthermore there is an ongoing
controversy about the initiating

AD

process of peri-implant disease since
it is potentially considered a primary
infection of periodontopathic origin
by some26 while others hold that it is
a secondary opportunistic infection
subsequent to bone loss caused by

other etiological factors27 such as
a provoked foreign body reaction or
iatrogenic dehiscence of the bone,
exogenous irritants such as dental
cement, bone loss through occlusal
overload etc. If the latter is true then

controlling the disease is theoretically made more simple by controlling the conditions for the implant,
such as ensuring adequate buccal
bone thickness, avoiding or controlling more carefully the use of dental
cement, and paying closer attention
to the occlusion.
In an effort to gauge the rate of
mucositis and peri-implantitis requiring surgical intervention, the
author audited his patient pool in the
year 2014. Out of a total of 191 patient
reviews constituting 795 implants
only 15 patients (7.9 per cent) required triple therapy at 20 implants
(2.5 per cent) for mucositis while
10 patients (5.2 per cent) required
surgical decontamination at 10 implants (1.3 per cent).
As can be seen this is well below
the figures proposed in the article
by Zitzmann & Berglundh (2005).25
This may of course reflect a more
liberal approach to cut off values
for parameters such as pocket depth
and bleeding on probing as proposed
Klinge in 2012.

PRINT
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DIGITA N
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E
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Nonetheless after over 20 years
running a practice dedicated to implant dentistry the author’s own
audited failure rates indicate that
less than 1 per cent of implants present as late failures, owing to periimplantitis or fixture fracture as a
result of bone loss. This would corroborate the findings by Jemt et al
in which a cohort of patients already
diagnosed with peri-implant bone
loss showed a slow rate of additional
progressive bone loss over a 9-year
follow-up with an implant failure
rate of 3 per cent.28
In all likelihood it is the author’s
view that peri-implantitis is only a
crisis if we allow bad implant dentistry to persist where there is a lack
of control of the initiating factors as
described above, and that it is more
rather than less likely that it is the
result of a secondary opportunistic
infection rather than a direct susceptibility to primary infection of periodontopathic origin. However, there
will clearly be some patients with
a high genetic susceptibility with
other predisposing factors such as
the presence of untreated periodontal disease, smoking and diabetes
who may well succumb as a result of
primary infection.
Furthermore there remains a clear
need to better define the different
types of peri-implant disease and to
establish a consensus as to the cut off
values for the different parameters
used to evaluate the disease so that
future figures for incidence and
prevalence are comparable.
Editorial note: A complete list of reference
is available from the publisher.

The DTI publishing group is composed of the world’s leading
dental trade publishers that reach more than 650,000 dentists
in more than 90 countries.

Dr Michael R.
Norton runs a
practice dedicated to implant &
reconstructive dentistry in London
in the UK. He
can be contacted at drnorton@
nortonimplants.com

[15] =>

[16] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 6/2015

All-ceramic restorations with IPS e.max
Minimally invasive methods to achieve harmony between pink and white aesthetics
By Dr Masayuki Okawa & Shigeo Kataoka, Japan
Minimally invasive restorations have
long become a reality owing to the
improvements in bonding materials
and the enhanced strength of ceramic
restoratives. However, a solid understanding of the materials’ properties
and clinical steps is essential to be
able to benefit from these advances.
We believe that ineffective all-ceramic
restorations can largely be attributed
to human error caused by a lack of familiarity with the materials, as well as
incorrect tooth preparation or bonding procedures. Five case studies will
be presented in this article to demonstrate the flow of treatment from initial examination and diagnosis to final
cementation.
In the first case, the patient’s teeth
were badly stained (Fig. 1). Even after
repeated whitening, the appearance
was still not satisfactory. The patient
finally presented to the practice with
the wish to have his teeth restored
with veneers.
A few years ago, all-ceramic crowns
on metal or zirconia frameworks
would have been the method of choice
to treat such severely discoloured
teeth. Now, we favour a minimally
invasive approach with lithium disilicate (LS2; IPS e.max Press, Ivoclar
Vivadent). Given its high strength
(400 MPa), this material is even suitable for veneers with a layer thickness
of as little as 0.3 mm (Fig. 2). From a
wide range of shades and different levels of translucency and opacity, users
can select the ideal ingot for every patient situation. Other convincing features include high accuracy of fit and
excellent aesthetics.
Harmony and beauty are inherent
in natural teeth. As dentists, we must
reproduce this effect with artificial
materials. IPS e.max Press has enabled
us to emulate the nuanced colour effects of natural teeth. The patient’s
state of oral health is first assessed
and the information gathered in the
process forms the basis for the subse-

Indexing the tooth horizontally
into three areas (cervical, coronal and
incisal) allows the amount of tooth
structure being removed during
preparation to be checked. Additionally, a guide in the shape of the final
tooth preparation may be used as a
reference in complex micro-veneer
preparations.

Shade selection

Figs. 1 & 2: First case: Severely discoloured teeth restored with ceramic veneers (IPS e.max Press).—Figs. 3 & 4: Second case: After a distal
cusp fracture, the tooth was restored using ceramic materials. Considering the occlusal masticatory forces, we decided to use high-strength
IPS e.max Press LS2 ceramics in conjunction with the staining technique (Restoration fabricated by Takahiro Aoki, dental technician).

quent treatment planning. The key to
success is to involve the dental laboratory at this stage already and to share
the information gathered in the assessment process with the technician.
In addition to taking the usual oral
and facial images, radiographs and
impressions, we perform cephalometric analyses and jaw function
tests, depending on the indication. In
addition, we evaluate the aesthetic
characteristics. By consulting the
treatment partners, we seek to gather
as much information as possible
with the aim of using this data to
prepare a treatment plan in which
we consider not only the tooth to be
restored, but also the overall balance
between the facial configuration and
oral cavity.

Staining technique
vs cut-back technique
Although the staining technique
has a favourable effect on strength,

The preparation is performed under a microscope, resulting in clearly
defined margins, thereby facilitating
the work of the technician and enhancing the accuracy of fit.

it places limits on the aesthetic design of the restoration. When we treat
patients who require restorations in
the anterior region, we prefer to use
the refractory die method (IPS e.max
Ceram, Ivoclar Vivadent) or the cutback technique (IPS e.max Press). In
the posterior region, however, we often opt for the staining technique.
The result of a study conducted at
New York University demonstrates
the high strength of monolithic
LS2 restorations manufactured in
conjunction with the staining technique.1 Against such a background,
we only occasionally use the layering or cut-back technique for fullcoverage crowns and often choose
to design the occlusal surface with
IPS e.max Press owing to its high
strength (Figs. 3 & 4).

Preparation
Minimising invasiveness is one of
the goals of aesthetic dentistry.
While the work of the dental techni-

Veneer restorations are incorporated by bonding the restoration
material to the tooth structure
using an adhesive technique. Although the materials for adhesive
bonding have been improved to enhance the bond strength to dentine,
the preparation borders should
nonetheless be limited to the
enamel to attain reliable adhesion.
Generally, the shape of the preparation is designed in such a way
that it takes both aesthetic and biomechanical aspects into account.
For this purpose, a silicone key may
be created on the basis of the diagnostic wax-up.

Transparency—
the key to aesthetic
restorations
When restoring discoloured teeth,
we tend to select an ingot with high
opacity. However, using an opaque
ingot entails the risk of obtaining

cian may be supported by removing
large amounts of tooth structure,
this cannot be an acceptable reason
for an unnecessarily high level of
invasiveness. However, if a tooth has
been prepared insufficiently, the
technician may find it difficult to
achieve an aesthetically satisfactory
restoration in the correct shade.

Aesthetic restorations of discoloured teeth usually require the
removal of larger amounts of tooth
structure than usual. With the introduction of LS2, however, we have been
able to achieve shade adjustments
with minimal reduction of tooth
structure. For this, communicating
the colour of the tooth preparation to the technician is essential.
Photographs, shade tabs and digital
shade-measuring devices are examples of instruments that can be used
for shade communication. While
shade-measuring devices are suitable for objective shade evaluations,
they only provide information on a
limited gamut of colours. They cannot convey subtle nuances. Photographs of the teeth with the shade
tabs placed next to them are better
suited to this purpose. Using toothcoloured IPS Natural Die Material
(Ivoclar Vivadent) is particularly useful for the fabrication of veneers on
discoloured teeth.

Fig. 5: Third case: Tooth #21 during the try-in of the framework with a water droplet.—Figs. 6–7c: Fourth case: If varying amounts of tooth structure have been removed, controlling the shade of the tooth preparation
is tricky. In this case, teeth #11 and 21 were restored with full-coverage crowns and teeth #12 and 22 with veneers.—Figs. 8 & 9: Fifth case: Spot etching prior to attaching the temporary restoration.

[17] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 6/2015

17
aesthetic dentistry was associated
with the reduction of healthy tooth
structure. However, we would like
to reverse this unfavourable image
by pointing out that IPS e.max is a
material that allows for minimally
invasive methods to achieve aesthetic restorations.
Reference
1. Guess et al. 2010

Fig. 10: Removal of temporary luting composite.—Fig. 11: Tooth surface cleaning prior to the ﬁnal cementation of the veneers.—Fig. 12: Completed veneer restoration.

a “white” restoration that appears
too bright.
Veneers should be of a similar
translucency to the natural teeth.
In the case of severe discoloration,
an appropriate translucency can be
achieved by selecting an ingot in a
translucent bleach shade. A masking
effect is then achieved with the
base material, that is, framework, of
a thickness capable of blocking out
the severely discoloured areas, while
the shade of the restoration is reproduced with the veneering ceramic
(IPS e.max Ceram). This approach
allows the technician to achieve a
sufficiently powerful masking effect
while maintaining the translucency
of the restoration.
Accuracy of fit is one of the success
factors for an aesthetic restoration.
Since we started using IPS e.max
Press, we have been able to try in the
frameworks. This is not possible with
veneers fabricated using the refractory die method. At the try-in, the
shape, shade and marginal fit are
checked. White wax is used to contour the planned tooth shape on the
framework and then the restoration
is inserted in the patient’s mouth for
a try-in. Adjustments, such as modification of the crown length and
shape, can now be applied.
Veneers may be tried in with try-in
pastes. However, we use water for this
purpose because it has a better fluidity. After a drop of water has been
applied to the inside surface of the
veneer, the veneer is placed on the
tooth preparation (Fig. 5). This requires a meticulous working method
under the microscope. At first, a white
line appears between the preparation margin and the framework. If
the marginal fit is accurate, the water
penetrates and the line disappears.

Shade adjustment
by layering
If several adjacent teeth had to be
restored for different indications in
the past, the restoration, allowing
for little variation in shade, had to be
fabricated first (e.g. veneers first and
then crowns fabricated to match the
shade of the veneers). Given its excellent light-scattering properties,
IPS e.max Press allows users to fabricate all restorations simultaneously
(Figs. 6–7c).
We try not to change the shade of
the ingot even when working with
several tooth preparations showing inconsistent shades. A minute
change in thickness is all that is required to control the base shade.
In this way, shade interpretation can

be simplified for shade adaptation
by layering. One of the characteristics
of the IPS e.max LS2 ceramic is that it
maintains its translucency.
If all of the teeth were reduced by
the same amount of tooth structure,
it would remain challenging to
match the shade of the restorations
that require varying build-up layer
thicknesses. If the thickness of the
frameworks has been maintained to
match the shade by means of the
framework, the amount of layering
ceramic must be reduced accordingly. In this case, the luminosity of
the dentine may be increased by using bleach shades, and saturation
may be intensified by internal staining. This method is often applied in
adjacent teeth where one is vital and
the other is non-vital.
Often, preparations with varying
amounts of removed tooth structure
also show inconsistent layering
thicknesses. As a result, shade matching becomes more difficult. Since IPS
e.max Press is available in several
levels of brightness, translucency
and intensity, a satisfactory result
can be achieved in such challenging
situations by selecting an appropriate ingot and combining it with IPS
e.max Ceram.

Cementation
Adhesive bonding is essential to
minimally invasive dentistry. In
veneers in particular, adhesion by
bonding plays a more important role
than does mechanical retention.
If a veneer fails, it is often because
a faulty bonding procedure has been
applied.

Placing
the temporary
A temporary restoration is not simply a short-term tooth replacement.
It is a therapeutic step that requires
full attention. We use a transparent
luting composite (Telio CS Link,
Ivoclar Vivadent) for the placement
of temporaries. First, small spots of
the prepared surface are etched using
the spot-etching technique (Fig. 8)
and then a touch of bonding composite is applied to attach the temporary
restoration (Fig. 9).

Pretreating the tooth
surface in preparation
for ﬁnal cementation
Since semi-translucent luting composite is difficult to detect, caution
should be taken to ensure that no
residue is left on the tooth prior to
final cementation (Fig. 10). Working
under a microscope is recommended.

The tooth is cleaned thoroughly
to create a clean environment. Fluoride-free and peroxide-free cleaning procedures using a soft brush
are suitable for this step (Fig. 11).

Cementing
the ﬁnal restorations
For the cementation of the veneers, we use the light-curing Variolink Veneer composite (Ivoclar
Vivadent), which exhibits a high
degree of shade stability. The sequence of steps is as follows: placement of retraction cord, cleaning of
the inner restoration surface with
Ivoclean (Ivoclar Vivadent), silani-

sation and finally cementation. A
rubber dam is applied to create
a dry environment for the application of the bonding material. Adjacent teeth are separated with strips.
The restorations can now be seated
(Fig. 12).
It is important to use Liquid Strip
(Ivoclar Vivadent) to prevent the
formation of an oxygen-inhibited
layer.

Discussion
IPS e.max Press LS2 glass-ceramic
is compatible with minimally invasive procedures. Until recently,

Dr Masayuki Okawa
is a dentist at
Daikanyama Address Dental Clinic
in Tokyo in Japan.
He can be contacted at info@
daikanyamadental.com.

Shigeo Kataoka
is a dental technician from Osaka in Japan. He
can be contacted
at octc@bc4.sonet.ne.jp.

[18] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 6/2015

Treatment of an unusual presentation
of radicular cysts
By Dr Manthan Desai, India

Fig. 1: Preoperative view of the lesion.—Fig. 2: Preoperative radiograph.—Fig. 3: Debridement of the lesions.—Fig. 4: DFDBA graft placement.—Fig. 5: Harvested autologous periosteum.—Fig. 6: Autologous periosteum
placed as a barrier membrane.—Fig. 7: PRF placed as a barrier membrane.—Fig. 8: Sutured ﬂap with 3-0 silk suture.

Radicular cysts are the most common (52–68 per cent) cystic lesions
affecting the jaw.1 They are commonly found at the apices of involved teeth and sometimes lateral
to accessory root canals. They are
a direct sequel of chronic periapical
infection.1 Most of them are asymptomatic and are discovered when
periapical radiographs are taken of
teeth with non-vital pulps. Patients
often complain of slowly enlarging
swellings. Radiographically, most
radicular cysts appear as round or
pear-shaped unilocular radiolucent
lesions in the periapical region. The
cyst may displace adjacent teeth or
cause mild root resorption.2
The following case report presents the successful treatment of
radicular cysts using autologous
periosteum and platelet-rich fibrin
(PRF) with demineralised freezedried bone allograft (DFDBA).

Case Report
A 17-year-old female patient reported to the Department of Periodontics, HKES’s S. Nijalingappa
Institute of Dental Sciences and
Research, Gulbarga, India, with a
chief complaint of pain, swelling
ongoing and pus discharge in the

lower anterior region since two
months. Past history revealed
trauma in the lower anterior region
five years ago with recurrent
swelling and pus discharge.
On intraoral examination, inflamed and swollen gingiva was
seen in relation to 41, 42, and 43 (FDI
notation). A draining fistula was
seen on the labial aspect in relation
to 41 (Fig. 1). 42 had grade I mobility,
whereas no mobility was noticed
with 31, 41, and 43. A pulp vitality
test was negative with 41, 42, and 43,
while adjacent teeth showed normal response. Periodontal probing
depth was ⭐ 3 mm for concerned
teeth, and no clinical attachment
loss was seen. They were also
painless on vertical percussion.
On radiographic examination, two
radiolucent areas of size approximately 2 x 2 mm were seen in relation to 41, 42, and 43 (Fig. 2). No
root resorption was seen.
The treatment plan comprised of
endodontic treatment of non-vital
teeth followed by surgical enucleation of cystic lesions if necessary.
The treatment plan was explained
to the patient, and a written informed consent was obtained. In
the same visit, root canal treatment

was started under rubber dam
application followed by working
length determination. After complete biomechanical preparation,
two per cent chlorhexidine gluconate was used as an irrigant and
intracanal medicament. In the subsequent visits, root canal treatment
was completed. Persistent pus
discharge was observed at three
months after endodontic treatment, and surgical enucleation was
planned.
The procedure was as follows:
local anaesthesia was administered, crevicular incisions were
given, and a full thickness mucoperiosteal flap from 41 to 43 and
a split thickness flap in regio 31
and 32 were reflected. The area was
degranulated revealing two small
perforations of the buccal cortical
plate in the regions of 41 to 43 of size
1 x 1 x 1 mm. The remaining buccal
cortical covering was carefully removed with rotary and hand instruments to expose the rest of
the lesions of size 3 x 3 x 2 mm.
Fragmented pieces of the lesion
were freed from the bone, and
a complete curettage of the cystic
lesions was done (Fig. 3). The cystic
cavities were thoroughly irrigated,
and a root biomodification of in-

volved teeth was done using tetracycline. DFDBA was mixed with
sterile saline solution and grafted
in an attempt to close the defect
via osteoconduction (Fig. 4). Autologous healthy periosteum was
harvested from regio 31–32 (Fig. 5),
and PRF was prepared from the
patient’s blood, as described by
Choukroun et al.3 The lesion was
covered with periosteum, over
which PRF was placed as a second
layer of barrier membrane covering the graft (Figs. 6 & 7).
The flap was coronally advanced
and closed with interrupted sutures using 3-0 black braided silk
(Fig. 8). A periodontal dressing was
applied at the surgical site. The patient was prescribed amoxicillin
500 mg TID and diclofenac sodium
50 mg TID both for 5 days with
0.12 per cent chlorhexidine gluconate rinse BD for seven days. The
patient was asked to report after
a week for suture removal, and the
curetted tissue was submitted for
histopathological examination.
The patient returned for the postoperative visit, and the healing was
uneventful.
Histopathology revealed the
presence of a varying thickness of

epithelium with fibrocellular connective stroma. The epithelium
was disrupted with infiltration of
chronic inflammatory cells along
with vacuolations within the epithelium. The connective tissue
showed dense infiltration of lymphocytes and plasma cells with
few macrophages (Fig. 9). A diagnosis of radicular cyst was given.
The patient was followed up for
nine months. A radiograph at six
months shows a healing lesion
(Fig. 10). A subsequent radiograph
nine months after operation (Fig. 11)
reveals increased radiopacity where
the bone graft was placed, and no
evidence of recurrence of the lesion
was seen (Fig. 12).

Discussion
A radicular cyst is an odontogenic cyst of inflammatory origin
preceded by a chronic periapical
granuloma and stimulation of
cell rests of Malassez found in
the periodontal membrane. The
pathogenesis of radicular cysts
comprises of three distinct phases:
the phase of initiation, the phase
of cyst formation, and the phase of
enlargement.4 The initial swellings
of these radicular cysts are usually
bony hard, but as they increase in

Fig. 9: Histopathology of excised cyst.—Fig. 10: Six months postoperative radiograph.—Fig. 11: Nine months postoperative radiograph.—Fig. 12: Healing at nine months after operation.

[19] =>

TRENDS & APPLICATIONS

Dental Tribune Asia Pacific Edition | 6/2015

“...in large or non-healing lesions, the
endodontic treatment alone is not efﬁcient...”
size, the covering bone may become very thin despite initial subperiosteal bone deposition. With
progressive bone resorption, the
swellings exhibit “egg shell crackling”. The associated teeth are
always non-vital and may show
discolouration. Although the associated teeth usually show no root
resorption, there may be smooth
resorption of root apices. When
cysts are intact, cyst cavities may
be filled with brown- or strawcoloured fluid, giving them a shimmering gold appearance.4 Radicular cysts are inflammatory lesions
leading to bone resorption and can
reach great dimensions and become symptomatic when infected
or with great size due to nerve compression. The main cause of failure
of endodontic treatment is generally accepted to be the continuing
presence of microorganisms in
the root canal system that have
either resisted treatment or have
reinfected the root canal system.
Enterococcus faecalis was the most
frequently found microbe in such
cases.5 Chlorhexidine gluconate has
been proposed for use both as an
irrigant and as a medicament especially in endodontic retreatment.
As a medicament, it is more effective
than calcium hydroxide in eliminating E. faecalis infection inside
dentinal tubules.6 As an irrigant, it
appears as effective or superior to
sodium hypochlorite in the elimination of E. faecalis.7 The adult human periosteum is highly vascular
and is known to contain fibroblasts,
osteoblasts, and stem cells. Skoog8
subsequently introduced the use of
periosteal flaps for closure of maxillary cleft defects in humans; he
reported the presence of new bone
in cleft defects within 3–6 months
following surgery. Furthermore, animal studies have reported heterotopic ossification in different organs after implantation of free periosteal grafts.9, 10 In all age groups,
the cells of the periosteum retain
the ability to differentiate into various cells.11 On the basis of these
observations, it can be hypothesised
that the periosteal membrane can
contribute to the stimulation of
new bone formation and has an immense potential for regeneration.

efficient and surgical treatments
like marsupialisation or enucleation should be considered.15 In
this case, surgical enucleation was
preferred and was performed uneventfully.

Conclusion
To conclude, a radicular cyst is
a common condition found in
the oral cavity. However, it usually
goes unnoticed and rarely exceeds

the palpable dimension. This case
report illustrates the successful
management of a radicular cyst
with enucleation and endodontic
treatment.

Case Reports in Dentistry, vol. 2013,
Article ID 893791, 5 pages, 2013. doi:
10.1155/ 2013/893791

The use of autologous periosteum and PRF has a promising
future in periodontal regeneration.

Dr Manthan Desai
is a periodontologist and oral
implantologist
from Mumbai
in India. He can
be contacted at
manthandesai.md@
gmail.com.

Editorial notes: A list of references is
available at the publishers. The authors
declare that they have no conflict of
interest. This article was first published in:

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PRF belongs to the new generation of platelet concentrates with
simplified processing. PRF contains
a variety of growth factors, which enhance healing by increasing angiogenesis and matrix biosynthesis.12
The immense osteoinductive capability of DFDBA is well-described in
the periodontal literature.13
The treatments of these cysts
are still under discussion, and
many professionals opt for a conservative treatment by means of
endodontic technique.14 However,
in large or non-healing lesions, the
endodontic treatment alone is not

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Fax +61 3 8727 7222

PNG - Meddent - Tel: + 675 320 3718
Cambodia - Pro Dent Trading Co., Ltd.
- Tel: +855 23 883 179
Singapore - Eastland Dental - Tel: 6296 5660
Philippines - GDS Dental Supply - Tel: +632 463 1884
Myanmar - Silver Lotus - Tel: + 95 1 290 847
New Caledonia - EURL IDEM - Tel: + 687 286511

Hong Kong - Horseley - Tel: 2889 1218
Sri Lanka - Yu & Co - Tel: + 94 11 269 1740
India - Dental Avenue - Tel: + 91 22 6699 7599
Pakistan - Al Qiam Traders - Tel: + 92 423 732 3049
Vietnam - Vietdan - Mobile Tel: + 84 9095 04034
Malaysia - Indra Sari Trading - Tel: + 603 5121 7193
Thailand - Shanghai Dental - Tel: + 66 2 866 3477

Pola Ofﬁce+: The world’s fastest bleach: Based on the total treatment time compared to that of all other competitor’s printed literature. THE DENTAL ADVISOR, Vol. 25, No. 9, November 2008.

[20] =>

7+( 32:(R 2) 7+( 3(R)(&7 FIT

Dental health is the cornerstone of your well-being.
Restorations created with Planmeca FIT™ have
been individually crafted to ȴt your uniTue needs
Ȃbensuring durability that will stand thebtest of tiPe.

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[cover] => DT Asia Pacific No. 6, 2015

[toc] => Array ( [0] => Array ( [title] => Asia News [page] => 01 ) [1] => Array ( [title] => Dental implantology: Evolution or the road to ruin? [page] => 04 ) [2] => Array ( [title] => World News [page] => 05 ) [3] => Array ( [title] => Business [page] => 09 ) [4] => Array ( [title] => Interview: “We need to congratulate Singapore” [page] => 10 ) [5] => Array ( [title] => Peri-implantitis: Is it a crisis? [page] => 12 ) [6] => Array ( [title] => All-ceramic restorations with IPS e.max [page] => 16 ) [7] => Array ( [title] => Treatment of an unusual presentation of radicular cysts [page] => 18 ) ) [toc_html] =>

Table of contents

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