DT India (Archived)

First vaccine for treating gum disease / FDI - FOLA - and DTI launch campaign for Haitian dentists / World News / Business / The CAD/CAM evolution / Directa presents new solutions for Class II cavity preparations / Implant aesthetics / Company Promotion / A clear - fixed pressure-formed - habit breaking appliance / Minimally invasive cosmetic dentistry / An interview with Prof. Lars Hylander - Uppsala University / Implants displaced into the maxillary sinus / Early childhood caries - Preventive strategies / Miniscrews—a focal point in practice

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DENTAL TRIBUNE
The World’s Dental Newspaper  India Edition
PUBLISHED IN INDIA

www.dental-tribune.com

News in brief
Calcium plays role in taste
perception

VOL. 2 NO. 1

Technology
The CAD/CAM
evolution

Clinical
Implant aesthetics

Trends & Applications
Miniscrews —a focal
point in practice

4Page 6

4Page 9

4Page 22

A new study, published in the

Journal of Biological Chemistry,
says that various extracellular
calcium-sensing receptor (CaSR)
agonists enhance sweet, salty,
and

umami

taste,

although

they have no taste of their own.

First vaccine for treating gum disease

These characteristics are known
as “kokumi taste” and it often

“Periodontitis is a serious

appears in the Japanese cuisine.

disease and dentists face a

The researcher Yuzuro Eto

major challenge in treating it,

and his colleagues found that

because most people will not

calcium and certain calcium

know they have the disease

channel activators trigger cal-

until it’s too late and the

cium channels located on the

infection has progressed to

tongue, enhancing a specific

advanced stages,” says Prof. Eric

taste. Further, it was found that

Reynolds, CEO of the Coopera-

glutathione (a common kokumi

tive Research Centre for Oral

taste element) has no taste of

Health Science and the Head of

itself but can enhance the basic

the University of Melbourne’s

taste sensation by interacting

Dental

with these channels. The researc-

approach will provide dentists

hers believe that their study

School.

“This

new

and patients with a specific

will pave the way in creation of

treatment.”

healthy foods with minimal sugar
or salt but, can still elicit strong

Traditional periodontal ther-

taste.

apy involves manual scaling
and cleaning, and even surgery
with instruments or dental

A new vaccine could help to replace traditional periodontal treatment methods. (DTI/Photo Dmitry Naumov)

lasers in an effort to contain

Combination remedies are
best for smoking cessation

Daniel Zimmermann
DTI

ment, involves bacterial pep-

based consortium for P. gingi-

the bacterial infection. Reynold

tides and proteins that trigger

valis research, elevated levels of

said that their new line of

HONG KONG/LEIPZIG, Germany:

the immune response to peri-

the organism were found in the

vaccine products will possibly

Scientists, at the University

odontal

The

majority of periodontal lesions,

prevent the progression of the

of Melbourne, Australia, have

vaccine is currently being tested

as well as in low levels in healthy

disease, rather than managing

announced that they have part-

in mouse models and is expected

sites. In addition, the organism

its symptoms and damaging

nered with CSL Limited and

to progress to clinical trials

also produces a number of

consequences. Sanofi Pasteur

Sanofi Pasteur, the country’s

soon, the researchers said.

enzymes that have been shown

has an option, to an exclusive

to interact with and degrade

worldwide licence, to commer-

inflammation.

A study, published in the Archives

largest biopharmaceutical com-

of Internal Medicine, says that

panies, to further develop and

The new vaccine approach is

host proteins. Although the

cialise the intellectual property

the combined therapy with bupr-

commercialise a vaccine for

targeting the ‘ring leader’ of a

bacterium can be eliminated

associated with these products.

opion and nicotine lozenges, for

the treatment of gum disease.

group of pathogenic bacteria

through periodontal therapy,

smoking cessation, is better than

The programme, which has

called P. gingivalis that cause

it is often found in recurrent

been for ten-years in develop-

periodontitis. According to a US-

infections.

any monotherapy. The study

compared six-month abstinence
rates among 1,346 smokers after
treatment with five active pharmacotherapies-bupropion alone,

Painless plasma jets could soon replace dentist's drill
Claudia Salwiczek
DTI

avoided at all costs.”

Institute of Surface Modification,

Dr Stefan Rupf from Saar-

Leipzig and dentists from the

land University, who led the

Firing

Saarland University, Homburg,

research, said that the recent

Plasmas have an increasing

low temperature plasma beams

Germany, tested the effective-

development of cold plasmas

number of technical and medical

at dentin reduces the amount of

ness of plasma against common

showed great promise for use

applications. Hot plasmas are

dental bacteria by up to 10,000-

oral pathogens. The researchers

in dentistry. “The low tempera-

already used to disinfect sur-

fold, according to a new study

infected dentin from extracted

ture

degrees

gical instruments. “Presently,

published

February

human molars with 4 strains

Celsius) means they can kill

there is huge progress being

issue of the Journal of Medical

of bacteria and then exposed it

the microbes while preserving

made in the field of plasma

nicotine patch alone was found to

Microbiology. Plasma technol-

to plasma jets for 6, 12 or 18

the tooth. The dental pulp at

medicine and a clinical treat-

be least effective. These results

ogy could thus be an effective

seconds. The longer the dentin

the centre of the tooth, under-

ment for dental cavities can be

reinforce the conclusion drawn

and less painful alternative

was exposed to the plasma the

neath the dentin, is linked

expected within 3 to 5 years,”

from previous studies on efficacy

to the dentist’s drill.
Scientists at the Leibniz

greater the amount of bacteria
that were eliminated.

to the blood supply, and nerves
and heat damage to it must be

Dr Rupf added. DT

lozenge, nicotine patch, nicotine
patch & lozenge, and bupropion
& lozenge. Combined pharmacotherapy of bubropion & lozenge was found to be superior
with the abstinence rate of
29.9% followed by nicotine patch
& lozenge combination with the
abstinence rate of 26.9%. The

of such a combined approach.

LEIPZIG,

Germany:

the

(around

[2] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

News

FDI, FOLA, and DTI launch campaign for Haitian dentists
Dr Prophet said, in his email,

participating in dental teams to

that "many of our colleagues

help the most urgent needs of

have lost their practices and

the Haitian population.

we were thinking about how to
The

help them. It's very good news

president

FOLA

to know that FOLA, FDI and

said, “this tragedy is also an

Dental Tribune are trying to

opportunity to build a public

help Haitian dentists." If dentists

health service that includes

know "that help is on the way

dental care. We have asked the

they can have hope!" Dental

Pan American Health Organiza-

Tribune will publicize, in its

tion (PAHO), FDI, all Latin

worldwide print and online

American dental associations,

editions, the campaign for Haiti.

companies, and other institutions for help in putting together

FOLA president Adolfo Rodríguez, center, asking for help for Haiti at a meeting in Panama. In the image, he's surrounded
by the president, right, and vice president of the Panama Dental Association

At a meeting in Panama,

teams of dental professionals to

Dr Rodríguez of FOLA received

travel to Haiti and start working

the support of the presidents

there, and leave in place basic

of Central American Dental

dental

treatment

centers."

Javier M. de Bison
DT Latin America

health resources, but also most

the campaign for Haiti with

Associations, and made an emo-

Dr. Rodrí-guez said that this will

dental practices. In a country

the help of FDI World Dental

tional appeal to dental manufac-

be a long-term programme that

PANAMA CITY, Panama: The

were there were only 500

Federation, and Dental Tribune

turers to donate much needed

includes rebuilding the dental

president of the Haitian Dental

dentists for nine million people

International.

supplies. He said, “Colgate has

school at the university, as well

Association Dr. Samuel Prophet

before January 12th, the extent

already agreed to donate brus-

as private practices.

has told Dental Tribune Latin

of the devastation has affected

America that he and several

regular

colleagues, he was able to

professionals alike.

people

and

dental

contact in Port-au-Prince were

In addition, Dr. Rodríguez

hes and toothpaste, and that he

is putting together teams of

intended to meet with KaVo do

The Latin American dental

dental volunteers to travel to

Brasil in the upcoming CIOPS

leader said he has also asked

Haiti to attend to the dental

meeting in Sao Paulo to ask

for funding from the government

fine after the devastating earth-

The president of the Latin

needs of the population. "We

for donations of new and used

of Dominican Republic. Compa-

quake in his country. "So far,

American Dental Federation

also need to show our support

dental units.”

nies and dentists interested

we only have reports of two

(FOLA), Dr. Adolfo Rodríguez,

for our colleagues in Haiti,

missing dentists", Prophet wrote

launched a campaign after the

most of whom have lost every-

in an email.

quake asking companies and

in helping Haiti should contact
Latin

Dr. Rodriguez at arn@codetel.

thing," Rodriguez said. "We

American Dental Professionals

net.do, phone at +809 519-0789.

dental professionals to donate

need to get them back on their

from Brazil, Uruguay, and Costa

The recent earthquake not

dental instruments, materials,

feet by helping them to rebuild

Rica among others have already

only devastated Haiti’s meager

and equipment. He's organising

their practices."

expressed

Some

prominent

their

interest

Dental health meet to raise awareness in public
eases including diabetes, AIDS,

to provide dental emergency

certain cancers, eating disor-

services to the athletes and

awareness

ders, venereal disease, and sub-

delegates

program ‘Dental Health Utsav’

stance abuse can be traced

Commonwealth Games, which

for the public was organized in

through one’s oral health.” He

are to be held in the city in

Delhi that registered attendance

further added, “in recent years,

October this year. GB Pant

by about 5000 city folks. This

dozens of studies have shown

Hospital, a tertiary care facility

mass outreach gathering was

that periodontal disease may

located in the same campus

held at the Maulana Azad

contribute to cardiovascular

will offer other emergency

Institute of Dental Sciences

disorders, stroke and bacterial

services to the participants

(MAIDS) on 15th of December,

lung infection, and thus, main-

of this sports meet. DT

2009, as part of an annual public

taining good oral health is

health initiative to raise aware-

important for overall health,

ness on the importance of role

and the mouth can serve as a

of dental health to stay fit. In

looking glass.”

dental

health

the

2010

Courtesy: Maulana Azad Institute of Dental Sciences, New Delhi.

addition to providing free health
check-up and advice, the organ-

Expressing her concern at

izers conducted events to engage

the growing incidence of dental

public with lecture sessions,

problems in school-going chil-

smile competition, and a dental

dren,

quiz, to get the message across.

Mrs. Shiela Dixit said, “prevent-

the

during

chief

minister,

ing tooth decay in youngsters

International Imprint

DENTAL TRIBUNE

by intervening early should be

Published by Jaypee Brothers Medical Publishers (P) Ltd., India

by representatives of the estab-

initiated at school itself. More

lishment, including the chief

than 80 % of population is suffer-

minister, the health minister,

ing from various dental ailments

and the health secretary of Delhi.

and most of them are preventable

Dr. Mahesh verma, head of the

with early education.”

this meeting, commented, “the
first symptoms of various dis-

On the occasion, the MAIDS
was also entrusted with the task

Editor
Dr. Isha Goel
isha.goel@jaypeebrothers.com

The World’s Dent al Newspaper  India Ed ition

This assembly was well attended

MAIDS and chief orgnizers of

Publisher
Torsten Oemus
t.oemus@dental-tribune.com

Dental Tribune India makes every effort to report clinical
information and manufacturer’s product news accurately,
but cannot assume responsibility for the validity of product
claims, or for typographical errors. The publishers also do
not assume responsibility for product names or claims, or
statements made by advertisers. Opinions expressed by
authors are their own and may not reflect those of Dental
Tribune International.

Chairman DT India
Jitendar P. Vij
jaypee@jaypeebrothers.com

Editorial Consultants
Dr. Gurkeerat Singh
Dr. Amit Garg

Dental Tribune India

Published by : Jaypee Brothers Medical
Director
Publishers (P) Ltd.
P. N. Venkatraman
4838/24, Ansari Road, Daryaganj,
venkatraman@jaypeebrothers.com New Delhi 110002, India
Phone: 43574357
e-mail:jaypee@jaypeebrothers.com
Chief Editor
Website: www.jaypeebrothers.com
Dr. Naren Aggarwal
naren.aggarwal@jaypeebrothers.com

BDZ/0909/04

Dr. Isha Goel
DT India

[3] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

World News

3

Oral bacteria linked to stillbirth
system takes care of the bacteria

By Case Western Reserve University
School of Dental Medicine

in the blood before it reaches
the placenta. In this case, the

CLEVELAND, OH, USA:

mother had experienced an

Researchers at the Department

upper respiratory infection and

of Periodontics at Case Western

a low-grade fever just a few

Reserve University School of

days before the stillbirth. The

Dental Medicine reported the

baby died from a septic infection

first documented link between

and inflammation caused by

a mother with pregnancy associ-

the bacteria.

ated gum disease to the death
of her fetus. The studies find-

The study underlines the

ings will be discussed in the

growing importance of good

February issue of Obstetrics

oral health care. In addition

& Gynecology.

to this direct link from the
mother to her baby, oral bacteria

Approximately 75 per cent

have been associated with heart

Pregnant women should take extra care of their oral health. (DTI/Photo Yuri Arcurs)

disease, diabetes and arthritis.

of pregnant women experience
gum bleeding due to the hor-

pregnancy,” said Yiping Han,

Due to pregnancy-associated

to match the bacterium found

monal changes during preg-

lead researcher of the study.

gingivitis, Fusobacterium nucl-

in the mother’s mouth with

(Edited by Claudia Salwiczek,

nancy. “There is an old wives’

“But if there is another underly-

eatum, a bacteria commonly

the bacterium in the baby’s

DTI) DT

tale that you lose a tooth for

ing condition in the background,

found in the mouth, entered

infected lungs and stomach.

each baby, and this is due to

then you may lose more than

the blood and worked its way

the underlying changes during

a tooth but a baby.”

to the placenta. Han was able

Normally a mother’s immune

Museum dispels myth about George Washington’s teeth

George Washington’s teeth are on display at the National Museum of Dentistry in
Baltimore. (DTI/Photo Fred Michmershuizen)

Fred Michmershuizen
DTA

and his tooth troubles. His

BALTIMORE, MD, USA: Did you

made of ivory — are on display,

know that George Washington’s

as well as forceps made to pull

false teeth were not really

his teeth on the Revolutionary

made of wood? Those who visit

War battlefield and examples of

the National Museum of Den-

presidential portraits that show

tistry, located here, can see

how tooth loss affected Washing-

first president’s famous chop-

ton’s appearance.

dentures — which were actually

pers on display, & they can find
out more about his tooth trou-

According to the museum,

bles. The story about wooden

Washington lost his first tooth

teeth is a myth.

when he was 22 years old.
Despite the fact that he brushed

“Many people are surprised

with tooth powder daily, he

to find out that George Washing-

would have only one tooth in

ton never had wooden dentures,”

his mouth by the time he was

said Museum Curator Dr. Scott

inaugurated president in 1789.

Swank, in a recent press release.

Washington had many illnesses

“We think the myth arose since

during his life, including small-

ivory dentures tend to stain like

pox and malaria. Treatments

wood after years of eating and

included remedies like mer-

drinking.”

curous

chloride,

which

is

known to destroy the teeth.
The National Museum of
Dentistry features a gallery
devoted to the first president

His favorite dentist, John
Greenwood, would make several

sets of dentures for Washington

museum. In fact, they were

gold and held in place with

during his lifetime — and

carved

springs that held the upper and

none of them would be made

ivory and elephant ivory. Some

from wood, according to the

of the dentures were set in

from

hippopotamus

lower teeth together. DT

[4] => DTAP0109_01-02_TitleNews

4

DeNtal tribuNe | January-March, 2010

business

AMD updates laser for soft tissue surgery Customized implant abutments: Sirona launches
release. Picasso Lite aims speciftitanium bases
ically at dental hygienists and
dentists who have no or little
experiences with dental lasers.
Dentists can use Picasso
Lite for all kinds of soft tissue
surgery, including troughing,
gingivectomies, frenectomies,
exposing implants/teeth/ortho
brackets, and treating aphthous
ulcers and herpetic lesions.
According to the company, it

The Sirona TiBase, shown here with the abutment screw and scan body,
is compatible with numerous popular implant systems. (DTI/Photo Sirona)

cuts and coagulates tissue with
reduced trauma, bleeding, and

by Sirona Dental Systems, Inc.

using the inEos scanner is
acquired, a fully anatomical

necrosis of tissue.
BENSHEIM, Germany: Since

crown can be designed in only

Picasso Lite, which is priced

December 2009, the Sirona

one step. The mesostructure

Alan Miller, President/CEO of AMD LASERS. (DTI/Photo courtesy of AMD Lasers, USA)

NEW YORK, USA/LEIPZIG,

this new and improved soft

at US$2,495, comes with a

inLab system is capable of pro-

is created automatically by

Germany: The US-based manu-

tissue dental laser will be able

set-up DVD, online laser certifi-

ducing customised zirconium

reducing the crown. Optimum

facturer

has

to use convenient disposable

cation, accessories and a world

oxide abutments for a wide

flexibility is ensured by various

recently launched the Picasso

tips or a low-cost strippable fiber

power adapter. AMD LASERS

range of popular implant sys-

adjustable parameter settings,

Lite to the worldwide dental

for a wide range of applications,

offers a two-year warranty on

tems. Following the successful

e.g. telescope angle, shoulder

markets. As first in the industry,

the company said in a press

all its products. DT

launch with CAMLOG, Sirona

width and gingival pressure.

AMD

LASERS

has now introduced its own

Countries in Asia less than average in
health care spending

implant

Both components i.e. the

systems from Nobel Biocare,

zirconium oxide abutment and

Straumann, Astra Tech, Fri-

the feldspar or glass-ceramic

adent, Biomet 3i and Zimmer.

crown

The matching TiBase connector,

inLab MC XL unit. Alternatively,

titanium

bases

for

can be milled on the

care report by the Organisation

Turkey and Mexico is less than

supplied in a set with the scan

users have the option of applying

for Economic Co-operation and

one-third of the OECD average.

body and abutment screw, is

a veneer facing directly to a

adhesively bonded to the milled

partially reduced abutment, as

and sintered zirconium oxide

is the case with a conventional

mesostructure.

crown stump. The prefabricated

Development (OECD) in Paris,
only New Zealand provided

The latest edition of Health

more money for health care

at a Glance demonstrates that

than the average of all observed

all the countries observed could

countries. Japan, Korea and

do better in providing good

With the aid of the new in

Australia, however, spent less

quality health care. Key indica-

Lab 3D for Abutments V3.65,

secured. They are available in

than the OECD average of

tors presented in the report

it is now possible to design a

two different shades and in two

8.9 per cent of GDP.

provide information on health

zirconium oxide abutment and

connector sizes, which speeds

status and the determinants of

matching crown in one single

up the milling process. DT

The US currently spends

health, including the growing

step. After the implant position

more on health care than any

rates of child and adult obesity,

other country—almost two and

which are likely to drive higher

a half times greater than the

health spending in the coming

OECD average of US$ 2,984,

decades. Based on new data on

adjusted for purchasing power

access to care, the report demo-

DELHI,

countries have been found to

parity.

France

nstrates that all OECD countries

installed its 9500 3D cone-beam

spend less of their GDP’s for

and Switzerland also spend far

provide universal or near-uni-

computed tomography (CBCT)

health care than most other

more than the OECD average.

versal coverage for a core set

machine for dental imaging at

countries in Europe and the

At the other end of the scale,

of health services, except the

Diwan Chand Imaging Center

US. According to a new health

health-care

US, Mexico and Turkey. DT

in Delhi, India. This is the first

Health care spending has improved
in Asia but still is below average. (DTI/
Photo Sean Prior)

Daniel Zimmermann
DTI

LEIPZIG,

Germany:

Asian

Luxembourg,

expenditure

in

inCoris ZI meso zirconium
oxide

blocks

are

rotation-

Cone-Beam CT in India
India:

Kodak

has

machine from Kodak in India.

Europe’s Swiss Smile enters India
DELHI,

CBCT designed for imaging

India: Swiss Smile

Dr. Sathya Kallur, CEO and

Dental Clinics – Europe’s leading

Director of clinical operations

dental service brand has chosen

of India, speaking on the plan

Medical tourism, in India, is

imaging of a focused area, with

India for its business expansion

said, ‘‘starting from Bangalore,

estimated to grow 29 per cent

relatively low radiation expo-

outside Europe. Swiss Smile has

we are planning to set up ten

by 2009-12 to become a $2.4

sure. CBCT technology pro-

tied up with Global Tech Park to

dental clinics in major cities of

billion industry. India Brand

mises to change the paradigm

launch a chain of clinics in India

India like NCR, Hyderabad,

Equity Foundation (IBEF) quo-

in dental radiology by providing

at a total investment of around

Chandigarh, Mumbai, Ahmed-

ted a market research report

clear and clean view of the

US$ 30 million. The planned

abad, Chennai, Kolkata and

“Booming Medical Tourism in

entire field determining bone

dental clinics will provide state-

Pune within next three years.’’

India” to claim that despite the

structure,

of-the-art facilities and trained

Dr. Sathya added that this

economic slowdown, medical

nerve canals and pathology, and

consultants offering specialized

venture will also attract medical

tourism in India is the fastest

to aid dental professionals in

dental care to customers, all
under one roof.

tourism in India by offering
quality services at leaner costs

growing segment of the tourism
industry. DT

making accurate diagnosis and
in treatment planning. DT

to overseas patient.

hard tissues of the maxillofacial
region allows three-dimensional

tooth

orientation,

Courtesy: Diwan Chand Satyapal
Aggarwal Diagnostic Imaging Research
Centre, New Delhi.

[5] => DTAP0109_01-02_TitleNews

[6] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

technology

The CAD/CAM evolution
Computers in practice and laboratory will determine action
Prof. Albert Mehl
Switzerland

Impression-free practice, virtual

more powerful computers and

construction models and articu-

effective measuring techniques

lation on Windows desktops,

developed in the 1990s, it was

biogeneric

surface

possible to adapt 3-D recording/

design with intelligent software,

imaging systems to the needs

as well as rapid prototyping,

of dentistry and simplify their

and 3-D printing are just some

operation. Continued develop-

of topics increasingly mentioned

ment of CAD software enabled

in lectures and publications

a multitude of construction

dealing with CAD/CAM. Already,

options (Fig. 1) and an improve-

‘conventional’ CAD/CAM tech-

ment in the quality of the grind-

nology is in use in dental offices

ing/milling units. Economic

and laboratories, and now the

efficiency, combined with high

next step in CAD/CAM evolution

quality

is anticipated. Only a few years

current hallmark of CAD/CAM

ago,

technology. It is not only dentists

pointment

treatment

exactness of fit, the reduced

and dental engineers who bene-

time-saving

benefit

costs for dentists and patients,

fit from standardised and excel-

patient and eliminates provi-

and user-friendliness. The qual-

lently-controlled treatment and

sional restoration, which addi-

ity of CAD/CAM restorations

manufacturing methods, the

tionally minimises the risk of

was viewed with cynicism, and

patient does as well.

cusp fracture, enamel-margin

systems

has

clearly improved. Based on

occlusal

discussion

CAD/CAM

focused

restorations,

Fig. 2: The remaining tooth substance determines the morphology of the occlusal surface in the defect region,
largely through, for instance, the position of the cusp tips, the cusp slopes, and the course of fissures. The natural
rules governing the biogeneric occlusal surface can be found through the analysis of many thousands of occlusal
surfaces of natural teeth. (DTI/Photo A.Mehl)—Fig. 3: Using the natural laws thus found, an occlusal surface is
calculated that replaces the defect as naturally as possible, by adapting it to the remaining tooth structure.
(DTI/Photo A. Mehl)

the

only a few pioneers gave scien-

has
for

a
the

chipping, and weakening of the

tific attention to this technology.

What is the latest in CAD/

dentine bond. The biogeneric

At present, the situation is quite

CAM development? Anyone well

formation of occlusal surfaces

different. The hesitant & doubt-

acquainted with the field pre-

enables the reconstruction of

ful attitude towards computer-

dicted early on that manufactur-

missing occlusal surfaces for

manufactured dental prostheses

ing centres would play a crucial

inlays,

has been discarded, and an

role: high capacity utilisation,

crowns according to nature’s

accepted, standard procedure

specialised staff, centralised

designs (Figs. 2, 3).

has

material purchasing, and high

taken

its

place.

Many

onlays,

and

partial
Fig. 4: In the future, intra-oral camera scanners will enable optical impressions
of the entire jaw, thus preparing the way for the impression-free practice.
(DTI/Photo K. Wiedhahn)

CAD/CAM and all-ceramics
are often mentioned in conjunc-

& abrasion, periodontal change,

universities. But because the

tion with each other, which

or inter ventions is possible.

technology is relatively new
and the performance potential

is understandable given the
discussion above, but this doesn’t

Fig. 1: Virtual automatic reconstruction: the scanned data of the antagonist,
functional movement, adjacent teeth and the preparation can be considered in
toto, in order to create a fitting occlusal surface that follows all the rules of
dentistry and dental engineering. (DTI/Photo A. Mehl)

companies now invest immense

quality standards for ‘standard

resources in the further develop-

care’ facilitate an economical

ment of this technology.

throughput,

distinct

advantage

enormous potential in milling

over the conventional wax-up

change in the next few years,

procedures and, just recently,

technique

the

which in turn will influence

in the laser sintering of metals

functional and morphological

the training of dental students

is often completely forgotten.

occlusal surface design. Com-

and indirectly the treatment

The

plex algorithms can store an

possibilities

restorations (eg, non-precious

immense

as well, in the interests of

metals, titanium, or gold alloys)

knowledge about tooth struc-

will thus eventually become a

tures and individual genetic

domain of CAD/CAM technology.

contexts. Virtual articulators can

manufacture

metal

also

lies

amount

basic

simulate any programmable
What does the future of

movement, so that considerably

Intra-oral 3-D measuring will

well as individual parameters,

What impelled this rapid

investment in highly developed

at least in part make the impres-

can be integrated into the resto-

change? On the one hand, the

manufacturing machines, while

sion-free practice possible (Fig.

ration surface than has been

value of zirconium dioxide

increasing economic efficiency.

4). The speed, operation, and

possible up to now.

ceramic in particular, which

Mid-sized and smaller labs will

precision of the images are

can only be processed with

use their core competence in

being

computer-assisted techniques,

the computer-assisted manufac-

and the measurement range

technology

became evident. This material

ture of high quality, aesthetic

expanded. Once a 3-D data set

basic research to new heights

made all-ceramic fixed partial

restorations and special fabri-

of tooth surfaces has been

and thus advanced other areas

dentures possible for the first

cation of partial prostheses.

stored,

novel

of dentistry. Through coopera-

form of dental diagnostics can

tive ventures, universities and

time. Other ceramics, too, ex-

tremendous, this is certain to

enables the amortisation of the

turn

technology

computer-assisted procedures

more natural laws and limits, as

CAD/CAM

represent all the options. The

hold?

which

CAD/CAM

technology

continually

improved

completely

practices

our patients. DT

Contact Info

The needs of CAD/CAM
have

propelled

hibited better material proper-

Another important current

be conducted, by comparing

industry can form a useful

ties after automated milling

trend is the chairside manufac-

data that were recorded at

symbiosis to promote and shape

because the blanks used could

ture of inlays, onlays, partial

different time points. Thus,

this exciting development. Until

be industrially manufactured

crowns, and single crowns. The

quantitative, 3-D progression

now, CAD/CAM or computer-

under optimal conditions. On
the other hand, the technology

dentist is this CAD/CAM procedure’s target group. The one-ap-

control of orthodontic treatment, the analysis of erosion

assisted dentistry has not been
a central subject at the

Prof. Albert Mehl is currently
guest professor at the Center for
Dentistry and Oral Medicine,
University of Zürich, Switzerland. He can be reached at
info@ag-keramik.de.

[7] => DTAP0109_01-02_TitleNews

[8] => DTAP0109_01-02_TitleNews

8

DeNtal tribuNe | January-March, 2010

World News

Directa presents new solutions for Class II cavity preparations
Daniel Zimmermann
DTI

and

LEIPZIG, Germany: Placing a

procedure

According to the Swedish

The contact point is created by

a

company, the combined matrix

the dual curvature of Fender-

matrix band to attain a good

separating plastic wedge with

and wedge are inserted as

Mate so that further burnishing

contact point and avoiding inter-

a stainless steel matrix. The

one piece. A new technology

will not be necessary.

proximal overhang after exca-

Fendermate

in

contours and compliments the

vation for Class II fillings has

regular and narrow width and

curvature of the patients tooth

With the combination of

always been a time consuming

for left or right application and

and holds its shape without

FenderMate and Fender Wedge,

& laborious procedure. Directa

will be colour coded for better

having to use a retentive ring

Directa also offers a tissue

preparation

has announced to offer a unique

identification.

that inhibits access to a cavity.

friendly

Class II cavities. DT

easy

solution
by

is

for

this

combining

available

approach

for

the

and

filling

of

Rice University
to work on oral
cancer test
Daniel Zimmermann
DTI

NEW YORK, NY, USA/LEIPZIG,
Germany: Researchers at the
BioScience Research Collaborative at Rice University in
Houston in the US have received
a US$2 million grant from the
US National Institutes of Health
for the development of a new
test for detecting oral cancer.
The test, which utilises latest
LED and nano microchip technology, aims to provide an accurate diagnosis in less than 30
minutes and can be performed
in the dental office. Additional
tests for the detection of cardiovascular

diseases

and

HIV

are also in development, the
researchers said.
Oral cancer affects about
300,000 people per year worldwide, and most cases are diagnosed in the late stages. If
oral cancer is detected early,
the prognosis for patients is
excellent, with a 5-year survival
rate of more than 90 per cent.
Unfortunately, the actual 5-year
survival rate for oral squamous
cell carcinoma is only about
50 per cent, amongst the lowest
rates for all major cancers.
“We want to provide an
accurate diagnosis for oral cancer using a minimally invasive
test that requires no scalpels or
off-site lab tests,” said principal
investigator Prof. John McDevitt,
Rice’s Brown-Wiess Professor
of Chemistry and Bioengineering. “The payoff for this
could be tremendous because
oral cancers today are typically
diagnosed much too late in
their development.”
According to McDevitt, the
test is being developed in
collaboration with other scientists from universities in the
US and the UK. DT

[9] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

Clinical

Implant aesthetics
Prof. Porus S. Turner & Team
India

Table 1. Hurdles in placing implants in the pre-maxillary zone
 High incidence of missing labial plate of bone

Since 1980s, osseointegration

 High potential loss of interdental papillae leading to black triangles

with dental implants has become

 Less than optimal bone quality

a predictable dental procedure
with high success rate of over

Implant should be tapered

earlier. After preparation of

97%.1-5 Today making a fixed

with a progressive thread design,

the osteotomy as per the protocol

partial denture after reducing

i.e. the implant threads get

of ‘ANKYLOS’, a 4.5 mm diameter

two adjacent teeth is not the

progressively deeper towards

and 14 mm long implant was

treatment of choice, and, ins-

the apical end engaging more

motor driven into place (Fig 7a ).

tead, a single tooth replace-

bone in the soft spongy area

The final ratcheting was done

ment with an implant-supported

of the apical region. This ensu-

by hand to place the implant 3

crown has become the most

res primary stability even in a

mm away from the free gingival

frequent indication in implant

compromised bone. However,

margin (Fig 7b). We achieved

therapy.6 In the posterior areas

for implant stabilization, its

of the oral cavity, the most

crestal part should have shal-

important objective of a single

lower threads to prevent exces-

tooth replacement is to allow

sive stress in the dense cortical

adequate mastication, while the

bone of the region.7-10

Fig. 1: Although this implant is surviving and is functional to the patient, aesthetically
it is not a success due to the labial placement of the implant.

aesthetic outcome is of lesser
concern. In contrast, replacing

Implant should not have

the anterior teeth in the pre-

any polished collar and should

maxillary zone - often referred to

be surface-treated (roughened)

as the ‘aesthetic zone’ - requires

right up to its top. This allows

a cosmetic finish to patient’s

bone to grow right up to the

satisfaction. This presents a

platform of the implant resulting

major challenge for implant

in minimal bone loss due to

clinicians & technicians (Fig 1).

remodeling (figs 4 and 5).

Fig. 2a, b & c: Atraumatic extraction of the tooth starting with microsurgical no 15 blade followed by periotome in fig. 2b:
and finally a thin luxator in fig. 2c. The periotomes and luxators should apply pressure on the mesio-distal surfaces and
the palatal surfaces only. The microsurgical blade may be used to severe the periodontal ligament fibers on the labial aspect.

There are major difficulties in
placing the implants because

The implant abutment con-

of various local risk factors

nection should be a conical-

that can compromise the final

tapered one to prevent micro-

aesthetic outcome (Table 1).

movement and microleakage.
This will help lead to stability

From our experience, the
following criteria are important

of the peri-implant hard and
soft tissue.

to prevent loss of hard and soft
tissues to achieve optimum
aesthetics:

Implantation should be de-

Fig. 3: Correct labio-palatal placement of the implant in
the extraction socket with space of about 2-3mm on the
labial aspect, which may be grafted with particulate synthetic
bone like Algipore (Dentsply, Friadent Germany).

Fig. 4: Shows the unique ‘ANKYLOS’ implant (Dentsply
Friadent, Germany) with progressive thread design and
conical tapered connection.

layed, if the tooth to be extracted
is infected and loss of the labial

All attempts should be made

plate of bone is expected. After

to place an implant immediately

waiting for 3 weeks for the soft

after extraction and definitely

tissue closure, implant can be

not more than four weeks

placed with guided bone regen-

after extraction, to minimize

eration along with a modified

resorption of the labial plate

Maryland bridge (Fig 6a-f).

of bone.

To better explain the concepts
for achieving optimum aesthet-

Extraction should be carried
out with minimal damage to
bone and soft tissues. The use

Fig. 5: Although the implant is placed
sub-crestally, observe the excellent
preservation of crestal the bone.
Implant in service since last 2 years.

Fig. 6a: Healing of soft tissue after three
weeks of extraction.

Fig. 6b: Buccal defect on labial aspect
after the removal of cover screw and
placement of sulcus former.

Fig. 6c: Grafting of the defect with mineralized red algae (Algipore, Dentsply
Friadent).

Fig. 6d: Covering of grafted bone
with absorbable collagen membrane
(BioGide, Geistlich, Switzerland).

Fig. 6e: Excellent primary closure
achieved due to waiting for three
weeks after extraction.

ics, we here are providing two
case reports.

of microsurgical blades, peri-

Case report 1

otomes and, finally, very thin

A male, aged 62 years, reported

luxators is highly recommended

with a fractured central incisor

(Fig 2a-c).

and requested to be rehabilitated urgently with a fixed

Correct 3D placement of the

restoration. It was decided to

implant should be achieved,

do an immediate implantation

especially in the bucco-lingual

with a fixed provisional restora-

region, taking care not to touch

tion on a final abutment. The

good primary stability in the

torque. An alginate impression

the fragile buccal plate. It is not

‘ANKYLOS’ implant system was

region of 35 Ncm and therefore

was taken of the abutment

necessary to fill the complete

selected for using in this patient

we removed the cover screw

and a crown was fabricated on

socket labio-palatally with a

due to its numerous advantages

and placed the final ‘ANKYLOS’

the prepared cast using the

lar-ge diameter implant; rather

in immediate implantation and

Balance Abutment tightening

unique shading system of the

a space may be left labially,

provisionalisation.

it only by hand pressure. The

composite Ceram–X (Dentsply)

conical-tapered connection of

to match the color of the adjacent

the ‘ANKYLOS’ system can be
friction-locked with very little

lateral incisor (Fig 7c). After a
period of 4 weeks to allow heal-

which can be grafted by autogenous
(Fig 3).

synthetic

bone

The tooth was extracted
atraumatically as described

Fig. 6f: IOPA radiograph of the ‘ANKYLOS’
implant with sulcus former in place to
further support the soft tissue.

[10] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

10 Clinical

tially edentulous patients: A

ing, the same abutment was

5-year follow-up report. Int

torqued with a hand wrench to

J Oral Maxillofac Implants

only 15 Ncm. The abutment

2000; 15: 633-645.

was prepared for a crown and

5.

bridge impression and the final

Belser UC, Lussi A, Buser D.

PFM

Early loading of non-sub-

crown

was

cemented

merged

(Fig 7d). Note the excellent

results of a prospective study in

cent to the left central incisor

partially edentulous patients.

has regenerated avoiding the

Clin Oral Implants Res 2005;
16: 631-638.

black triangle observed during
provisionalisation.

implants

etched surface. Five year

tissue. In fact the papilla adjaFig. 7b: Apico-coronal placement of implant 3 mm from
the free gingival margin.

titanium

with a sandblasted and acid

preservation of hard and soft

Fig. 7a: Placing of the implant with motor.

Bornstein MM, Schmid B,

6.

Belser UC, Buser D, Hess D,
Schmid B, Bernard JP, Lang

Case report 2

NP. Aesthetic Implant restorations in partially edentulous

A Japanese male, aged 50 years,

patients – A critical appraisal.

requested for a match to the

Periodontol 2000 1998; 17:
132-150.

color, anatomy and texture of
the adjoining central incisor

7.

influence of implant design,

incisor

application, and site on clinical

with

an

implant-

performance and crestal bone,

supported crown.
Fig. 7c: Provisional crown custom made with Ceram-X
(Dentsply, Detrey Germany).

a multicenter, multidiscipli-

Fig. 7d: Final PFM crown cemented. It was decided not
to duplicate the color of the left central incisor since the
later it was discolored.

After

placement

of

nary clinical study. Dental

the

Implant

implant and waiting for 6
importantly, the soft tissue to

Research

49-55.
8.

Weng D. Different microgap

stabilize, an implant-level trans-

designs and their influence

fer impression was taken. The

on Peri Implant Bone levels.

technician with the aid of a

Abstract EOA Vienna. Journal

soft tissue model very accurately

of periodontology 2003; 141.

prepared the abutment in the
laboratory. It was then transFig. 8b: Exact duplication of contralateral central incisor
with PFM crown due to excellent laboratory support.

Clinical

Group. Implant Dent 1992; 1:

months for the hard and, more

Fig. 8a: Exact position of the abutment transferred from
the model to the patient mouth using an accurate resin
transfer jig.

Morris HF and Ochi S. The

for his missing right central

ferred with the aid of a resin
transfer jig to the patient’s oral
cavity (Fig 8a). The final PFM
is cemented.

9.

Nentwig G.A. The Ankylos
Implant System concept and
clinical application. J Oral

Implantol 2004; 30: 171-177.
10. Baggi L et al. The influence of
Implant Diameter and Length
on Stress Distribution of Oseio
Integrated Implants Related

Note the exact duplication

to Crestal Bone Geometry.

of color, anatomy and texture

A three dimensional Finite

of the adjacent central incisor

Element Analysis. J Prosthet

due to the excellent laboratory

Dent 2008; 100: 422-431. DT

support (Fig 8b).

References
1.

Buser D, Weber HO, Lang NP.
Tissue integration of non-

About the author

submerged implants. 1 year
results of a preospective study
with 100 ITI hollow-cylinder
and hollow-screw implants.

Clin Oral Implants Res 1990;
1: 33-40.
2.

Lekholm U, van Steenberghe
D, Herrmann I, Bolender C,
Folmer T, Gunne J. Osseointegrated implants in the treatment of partially edentulous
jaws: A prospective 5-year
multicenter study. Int J Oral

Maxillofacial Implants 1994;
9: 627-635.
3.

Buser D, Mericske-Stern R,
Bernard JP, et al. Long-term
evaluation of non submerged
ITI implants. Part 1:8 year life
table analysis of prospective
multi-center study with 2359
implants. Clin Oral Implants

Res 1997; 8: 161-172.
4.

Behneke

A,

Behneke

N,

d’Hoedt B. The longitudinal
clinical effectiveness of ITI
solid-screw implants in par-

Dr. Porus S. Turner is a professor
in the department of prosthodontics at A. B. Shetty Institute of
Dental Sciences, Mangalore, India.
He has 30 publications in national
and international journals to his
credit and contributed to two books
on dentistry. He has authored a
book entitled “Art and Science of
Aesthetic Dentistry”. He lectures
extensively in India and abroad
on restorative dentistry and
implantology. He can be contacted
at porusturner@ hotmail.com.

[11] => DTAP0109_01-02_TitleNews

[12] => DTAP0109_01-02_TitleNews

[13] => DTAP0109_01-02_TitleNews

[14] => DTAP0109_01-02_TitleNews

[15] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

trends & applications 15

A clear, fixed pressure-formed, habit breaking appliance
Dr. Deepak Rai, Dr. Gurkeerat Singh
New Delhi

Introduction
Digit sucking habit, usually
referred to as thumb or finger
sucking habit, can cause adverse
effect on normal pattern and
direction of the skeletal and
dentoalveolar growth.1 During

Fig. 1: Dental study models of patient with thumb
sucking habit.

Fig. 2: Working model, molar bands with soldered
buccal and lingual buttons.

Fig. 3: Working cast scored with three bur holes in
palatal area.

Fig. 4: Othodontic stone used to create spikes.

Fig. 5: Wax relief for guidance to erupting incisors.

Fig. 6: Working model in MinistarR *unit to form the
appliance.

Fig. 7: Labial view of vacuum-formed habit breaking
appliance.

Fig. 8: Inside view of appliance.

Fig. 9: Spikes filled with wax, relief wax over incisors
removed.

thumb sucking, due to lowered
position of the tongue in the
oral cavity, maxilla tends to grow
in an abnormal protrusive direction with the mandible growing
in downward and backward
direction.2 It causes maxillary
anterior teeth protrusion while
mandibular teeth are retroclined.3-5 The lowered position of
tongue as well as the increased
cheek pressure may also result
in posterior cross bite.
Moyers has concluded, that
the thumb sucking habit creates
undue pressure on immature
highly malleable alveolar ridge,
and can lead to malposition of
the teeth, aberrant breathing

Appliance design and
fabrication

guidance, the

nate thumb sucking habit before

appliance can be cut back on

arch is deformed sufficiently, to

Habit breaking appliances

1. Patient’s molar bands with

lingual aspect of incisors, with a

require

make thumb sucking meaning-

soldered buccal and lingual

flowable composite flown into

action during deglutition.

Graber, in his classic work,

less by breaking suction, pre-

buttons, on a working cast

labial, for applying pressure on

states that the muscle activity is

venting displacement of incisors

(Fig. 2). Button soldered to

erupting incisors to be guided

This, new pressure-formed fixed

normal in Class I malocclusion

and reposition the tongue.7 Habit

provide retention of molar

lingually.

clear appliance, helps in elimi-

except in case of Class I maloc-

breaking appliances, generally,

bands into pressure-formed

clusion with the anterior open

have an associated problem

sheet.

bite. The most common cause of

of compliance wear, especially

2. The cast was scored with

anterior open-bite

with the commonly used removable cribs with little success.10

pattern, speech abnormalities,

pattern is achieved (Fig. 1).

facial muscular imbalances,
and psychological problems.6

problems

is thumb or finger sucking
habit. It is considered normal

To provide

homeostatic

muscle

nating deleterious thumb suck-

Discussion

ing habit with passive guidance
fashion

to incisors in eruption, allowing

three deep bur holes along

flourish in orthodontics as they

correction of the open bite,

the line joining cuspid tips

do in interior decorating and

especially

on the rugae area (Fig. 3).

clothes designing, with time-

patients.

Graber

mentioned

in

noncompliant

orientation.7

for children to engage in non-

Haskell and Mink introduced

3. Orthodontic white stone was

nutritive sucking during infancy

Blue-grass appliance having

used to create spikes with

Current popularity of pressure-

*MINISTARR, SCHEU-DENTAL GmbH,

which mostly disappears sponta-

hexagonal teflon roller on the

stone flowing and anchoring

formed appliances, after Sheri-

P.O. BOX 7562 D-58613 ISERLOHN

neously by 6-18 months of age.

cross-palatal bar.11 Chris Baker

into retention holes on cast

dan’s

**DURANR,

modified Blue-grass appliance

(Fig. 4).

ances13 for corrective orthodon-

Proffit states that most of

by replacing roller with two

4. Wax relief was given along

thermo-formed

appli-

claiming more

erupting

sucking habit is discontinued

stimulation of tongue.12 All these

(Fig. 5).

before eruption of the permanent

modifications

required some

5. Working model in Ministar

to fabricate with no wire parts,

teeth erupt”. In cases of persist-

wire bending skills, with solder-

R unit* & DuranR** pressure

and are less costly. Clear and

ent thumb sucking habit with

ing procedures in some designs

moulding foil were used to

transparent appearance of these

sufficient intensity,

frequency

for cross-palatal bar-bearing

form the appliance (Fig. 6).

appliances

duration, maxillary ante-

cribs, spikes, beads or rollers,

6. Labial view of the appliance

rior segment is deformed lead-

but without any passive guid-

ing to adaptive forward thrust

ance

of tongue, which accentuates

deflected or erupted incisors.

elements

for

labially

open bite, preventing adequate
eruption of maxillary incisors

This article introduces a

and forcing them labially.7 When

new

maxillary incisors move labially,

formed habit breaking appli-

lip enters in to picture and joins

clear,

fixed

pressure-

P.O. BOX 7562 D-58613 ISERLOHN
DT

have encouraged development

References available on request.

promotes

early

patient acceptance especially
in the prepubertal children with

7. Inside view of the appliance

low ego strength. 14

with sheet cut out over

About the authors

molar band’s occlusal sur-

The thumb sucking habit,

face, ready to be cemented

leading to open bite malocclu-

in patients mouth (Fig. 8).

sion

spikes

GmbH,

of appliances which are easy

(Fig. 7).

8. The

SCHEU-DENTAL

tics and retention purposes,

acrylic

and

path

subject

the dental changes resolve if

beads

incisor

linked

of

is,

generally,

the

first

pressure

assault on the integrity of denti-

ance, which is easy to fabricate

formed appliance can be

tion and the adaptive and com-

the tongue in nature’s adaptive

and is clear, for early patient

filled with

wax, cement,

pensatory activities of tongue

attempt to create oral seal

acceptance, & overcomes non-

or colored acrylic to provide

and lip, which later may team-

during swallowing.8,9 Open bite

compliance

associated

with

additional rigidity.

up to provide a more significant

is accentuated by this vicious

removable

appliances

with

9. Wax relief over erupting

deforming mechanism. Thus, it

cycle unless normal activity
is restored and mature somatic

passive eruption guidance to
incisors.

incisors can progressively be
removed (Fig. 9).

is essential that an interceptive
appliance is provided to elimi-

Dr. Deepak Rai is an associate
professor in the department of
orthodontics at Sudha Rastogi
College of Dental Sciences and
Research, Faridabad, India.

Co-author
Dr . Gurkeerat Singh is a professor
and heads the department of
orthodontics at Sudha Rastogi
College of Dental Sciences and
Research, Faridabad, India.

[16] => DTAP0109_01-02_TitleNews

trends & applications

Minimally
dentistry

invasive

cosmetic

A concept and treatment protocol for general practice
Dr. Sushil Koirala
Nepal

its replacement.15 Thus far, the

management of dental cari-

focus of MI dentistry has been

ous lesions. It has failed to

on caries-related topics16 and

give the necessary attention

Increased media coverage and

has not been comprehensively

to the problems that nega-

the availability of free web-

adopted

of

tively affect smile aesthe-

based information has lead to

dentistry. Dr Miles Markley, one

tics, for example non-cari-

heightened public awareness

of the great leaders of preven-

ous dental lesions, or deve-

and thus to a dramatic increase

tive dentistry, advocated that

lopmental

in patients’ aesthetic expecta-

the loss of even a part of a human

malocclusion.

tions, desires and demands.

tooth should be considered a

Today, a glowing, healthy and

serious injury & that dentistry’s

of contemporary cosmetic

vibrant smile is no longer the

goal should be to preserve

dentistry are trending to-

exclusive domain of the rich

healthy and natural tooth struc-

wards more invasive pro-

and famous and most general

ture. His words are much more

cedures with an over-utili-

practitioners are forced to incor-

relevant in today’s cosmetic

sation of crowns, bridges,

porate various aesthetic treat-

dental practice, in which the

thick full veneers, and inva-

ment modalities in their daily

demand for cosmetic procedures

sive periodontal aesthetic

practices to meet this growing

is rapidly increasing. With the

surgeries, while neglecting

demand.

treatment approach trend to-

long-term oral health, act-

wards the more invasive pro-

ual aesthetic needs and

The treatment modalities

tocols, millions of healthy teeth

the characteristics of the

of any health-care service are

are aggressively prepared each

patient.

aimed at the establishment of

year in the name of smile

health and the conservation of

makeovers and instant ortho-

degrading, owing to the

the human body with its natural

dontics, neglecting the long-

trend of fulfilling the cos-

function and aesthetics. The

term

metic demands of patients

concept of minimally invasive

aesthetics of the oral tissues.

in

other

health,

fields

function

and

(MI) treatment was initially
introduced in the medical field





defects

and

The treatment modalities

Social trust in dentistry is

without ethical consideration and sufficient scientific
background (the more you

in the early 1970s with the

The need for a new
concept

application of diamine silver

Contemporary aesthetic dentis-

fluoride.1 This was followed by

try demands well-considered

In this article, I introduce

the development of preventive

concepts and TPs that provide

a concept and TP for minimally

resin restorations (PRR)2 in

a simple, comprehensive, pa-

invasive cosmetic dentistry (MI

the 1980s and the atraumatic

tient-frien-dly and MI approach

CD), in order to

resto-rative treatment (ART)

with an emphasis on psy-

appro-ach3 and Carisolv4 in the

chology, health, func-

1990s. The major components

tion and aesthetics

of MI dentistry are the risk

(PHFA; Fig. 1). The

assessment of the disease with

need for a holis-

a focus on early detection and

tic concept and

prevention; external and inter-

basic treatment

nal remineralisation; use of a

guidelines was

range of restorations, bio-com-

expressed

patible dental materials and

concerned pra-

equipment; and surgical inter-

ctitioners, aesth-

vention only when required and

etic dentistry ass-

only after any existing disease

ociations and aca-

has been controlled.5–11

demics around the

and was adapted in dentistry

Current basic treatment pro-

replace, the more you earn;
more is more mentality).

address
these

by

facts
prop-

world for the following Fig 1
basic reasons:

erly and integrate the evidence-based MI

tocols (TPs) and approaches


Owing to an increased aes-

philosophy and its application

air abrasion, laser treatment

thetic demand, aesthetic

into aesthetic dentistry.

or sono abrasion to gain cavity

dentistry is becoming an

access and excavate infected

integral part of general

Defining MICD

carious tooth tissue through

dentistry.

aesthetic

As the perception of aesthetics

selective caries removal or laser

outcome of any dental treat-

and beauty is extremely sub-

treatment;12,13 cavity restoration

ment plays a vital role in

jective and largely influenced

by applying ART, PRR, or sand-

the

by personal beliefs, trends,

wich restoration; and the use

satisfaction criteria.

fashion, and input from the

MI

media, a universally applicable

in MI dentistry are the use of

of computer controlled local



The

patient’s
dentistry

treatment
currently

anaesthesia delivery systems14

focuses on prevention, re-

definition

with emphasis on the repair of
a failed restoration rather than

mineralisation and minimal
dental intervention in the

Hence, smile aesthetics is a
multifactorial issue that needs

is

not

available.

[17] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

trends & applications 17
and desires of the patient are

health, function and aesthetics

cations, treatment limitation,

explored. The primary goal of

as follows:

and tentative costs should be
established during this step.

this first step is a better patient–
dentist understanding. As the



Grade A: The established

aesthetic perceptions of the

parameters of oral health,

For easy application, the

dentist and the patient may

function and aesthetics are

aesthetic treatments in MICD

differ, it is imperative to under-

within normal limits and

are categorised as follows:

stand the subjective aesthetic

aesthetic enhancement is

perception of the patient. Various

required only to fulfil the

types of questions, personal

patient’s cosmetic desires.

interviews and visual aids can



Grade B: The established



Type I: Micro-aesthetic components;



Type II: Mini-aesthetic components; and

be used as supporting tools. In

parameters of oral health

this step, the practitioner should

and function are within

ask the patient to complete the

normal limits; however, the

components: facial and den-

MICD

smile-evaluation

aesthetic parameters are

tal midline relation, facial

reduction of treatment fear

form. The information obtained

below the accepted level.

profile, symmetry of facial

and increased patient confi-

will help estimate the perceived

Aesthetic enhancement can

thirds and hemi-faces.

dence;

smile aesthetic score (a-score)

further improve the aes-

As the treatment modality

promotion of trust and en-

and will be used as the base-line

thetic parameters.

depends on the professional

in this article I define MICD

hancement of professional

data in the evaluation step.

Grade C: The established

capability and experience of the

as “a holistic approach that

image.

parameters of oral health or

practitioner, simple and practi-

function or both are below

cal

Fig 2

to be adequately addressed
during aesthetic treatment.

3.

17

MICD deals both with subjective
and objective issues. Therefore,

explores the smile defects and

4.

self



Next, diseases, force ele-



Type III: Macro-aesthetic

methods

are

used

to

at an early stage and treats

The MICD treatment
protocol

smile are explored. Information

them using the least inter-

In my experience, the TPs that

on the medical and dental

vention options in diagnosis

are currently in use in aesthetic

history, general health and

and treatment technology by

dentistry are mostly based on

specific health (oral-facial) of

considering

psychology,

more invasive techniques and

the patient is collected and com-

health, function and aesthetics

procedures. With the use of

plete dental and periodontal

of the patient.”18 The core MICD

such protocols, cosmetic dentists

charting is performed. In order

principles are:

are knowingly, or unknowingly,

to understand the force ele-

1.

application of the-sooner-

heading

over-

ments, the existing occlusion,

the-better approach and

utilisation of invasive techno-

comfort, muscular activity, spe-

exploration of the patient’s

logies in their practices, which

ech and phonetics are thor-

establishment treatment is

categorise the MICD treatment

smile defects and aesthetics

is becoming a professional and

oughly examined with the evalu-

mandatory prior to aesth-

complexity:

desires at an early stage in

ethical concern. The basic aim

ation of para-functional and

etic enhancement.

order to minimise invasive

of the MICD TP is to guide practi-

other oral habits, comfort during

treatments in the future;

tioners in achieving optimum

mastication and deglutition,

From the above, the practi-

require consultation with a

smile design in considera-

results with as little intervention

and temporo-mandibular joints

tioner will obtain a smile aes-

specialist (preventive, sim-

tion of the psychology, hea-

as possible. The intervention

(TMJ) movements. The neces-

thetic grading in terms of the

ple oral surgery/endodon-

lth, function and aesthetics

level of the treatment in MICD

sary diagnostic tests, photo-

patient’s health, function and

tics/periodontics/implants,

(Smile Design Wheel ) of

depends on the type of smile

graphic documentation and the

aesthetics, as well as a complete

short orthodontics);

the patient;

defects and the aesthetic needs

diagnostic study models are

overview over the smile aesthe-

adoption of the do-no-harm

(objective measurement and

prepared during this step for

tic problems and the macro-,

requires

strategy in the selection

subjective perception) of the

the further exploration of exis-

mini- and micro-smile defects.

involvement of other dental

of treatment procedures

patient.

ting diseases, force elements

aesthetic desires of a patient

2.

the

18

3.

towards

the

and the maximum possible
preservation of healthy oral

the

ments and aesthetic defects of

and aesthetic defects.
The basic framework and

normal

limits.

An

Fig 3





Grade I: Treatment that may

Grade II: Treatment that
the

procedural

specialists (complex endoThe patient’s PHFA factors

dontics/periodontics/ortho-

are the four fundamental compo-

dontics) but not oral and

tissues;

pathway of the MICD TP are

In the following step, the

nents of aesthetic dentistry18

maxillofacial surgery or

selection of dental materials

illustrated in Figures 2 and 3.

data collected is analysed in

and must be respected to achieve

plastic surgery; and

and equipment that support

It is to be noted that the TP in

relation to the accepted normal

healthy, harmonious and beau-

MI treatment options in an

medical and dental sciences

values of a patient’s sex, race

tiful smiles. The design step

requires

evidence-based approach;

must be dynamic in nature and

and age (SRA) factors. The

depends on the information

involvement of oral and

encouragement of the keep-

should be flexible to incorporate

aesthetic components of the

obtained from exploration and

maxillofacial surgery or

in-touch relationship with

evidence-based facts. I have

smile are analysed in detail

analysis. The information on

plastic surgery.

the patient to facilitate regu-

therefore outlined the MICD

grouped into macro-(facial and

psychology is subjective in na-

lar maintenance, timely

core principles that are required

dental midline relation, facial

ture; however, health, function

With the aid of this simple

repair and strict evaluation

to achieve the optimum result

profile, symmetry of the facial

and aesthetic analysis provides

grading system, any practitioner

of

in terms of health, function and

thirds and hemi-faces), mini-

the objective information that

can determine the complexity

aesthetics with minimum inter-

(visibility of upper anterior

will guide the design with the

of the treatment involved for the

vention and optimal patient

teeth, smile arc, smile symmetry,

various established and basic

accomplishment of a new smile

The main MICD benefits include:

satisfaction. However, it is the

buccal corridor, display zone,

principles of smile aesthetics

design for an individual patient

1.

promotion of health, func-

practitioner’s duty to incorporate

smile index and lip line) and

and also the feasible & practical

and can plan for the necessary

tion and aesthetics of the

all the necessary guidelines,

micro-aesthetics (dental: central

extent of the aesthetic desires

multidisciplinary support.

oral tissues and positive

protocols and regulations of

dominance, teeth proportion,

of the patient. The aesthetic

impact on the quality of life

the authority concerned (state

axial inclination, incisal embra-

mock-up, manual tracing, digital

The last step of this phase is

of the patient;

or affiliated professional organi-

sure, contact-point progression,

makeover and smile catalogues

the most important in MICD TP

preservation of sound tooth

sations) into the MICD TP.

shade progression, surface tex-

are some of the popular tools

because in this step the patient

ture; gingival: shape, contour,

used in this step. A new smile,

is presented with an image of

4.

5.

the

aesthetic

work

performed.

2.

structures

(banking

the



Grade III: Treatment that
the

procedural

tooth structure), while ach-

Phase I: Understand

embrasure and zenith height).

alternative designs, types of

his or her future smile. Visual

ieving the desired aesthetic
result;

In the first step of Phase I, the
perception, lifestyle, personality,

The practitioner can now grade
the smile in terms of the patient’s

treatments involved, complexity,
possible risk factors and compli-

aids, such as a smile catalogue,
aesthetic mock-ups, manual

[18] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

18 trends & applications

Fig. 4a: Gummy smile with lack of
upper central dominance.

methods are given, as well

Table 1: MICD treatment options

as protective devices. Self-

NI treatment options

MI treatmet options

care should focus on regular

Smile training

Micro- and macro-abrasion

tooth brushing, flossing,

Tooth whitening

Selective contouring (gums/teeth)

the use of prescribed protec-

Re-mineralisation of white spots

Direct restorations with minimal tooth preparation

tive devices and other perti-

Short orthodontics (sectional)

Minimal Preparation

nent professional advice

Fig. 4b: Harmonised smile with proper
central dominance. Treated with MI
approach.



Adhesive Brigdes

for maintaining general

Non-preparation veneers

Veneers, inlays and onlays

health.

Enamel augmentation

MI implants

Professional care: The oral

Adhesive pontic

habits, health of the oral

(long-term temporary restoration)

tissues, and the functional

Oral appliance

and aesthetic status of the
Professional factors: exist-

sively in every field of the

documented during each

ing knowledge and skills,

dentistry. For this reason, I have

follow-up visit, and neces-

and attitude towards devel-

explained the MICD concept

sary maintenance repair

oping these.

and its TP, which integrates the

work preformed are well

Fig. 5a: Smile after establishment
treatment.

Fig. 5b: Smile aesthetic enhancement
with non-invasive veneers treatment.

–

evidence-based MI philosophy

jobs are carried out.
Detailed clinical documen-

into aesthetic dentistry, in the

Evaluation is the final step

tation of the case during main-

hope that it will help practition-

ment of the patient’s aesthetic

of MICD TP. Any ‘completed’

tenance and evaluation can

ers achieve optimum results

as presentation tools. The results

desires, which can be grouped

treatment without a proper

provide various cues to the

in terms of health, function

of the design step are systemati-

into two categories based on

evaluation is considered incom-

practitioner in the evaluation of

and aesthetics with minimum

cally presented to the patient

the patient’s needs and wants.

plete in MICD protocol. The

his or her clinical success in

treatment

with professional honesty and

Even though it is sometimes

following components need to

terms of case planning, material

optimum patient satisfaction.

ethics. All pertinent queries of

difficult to draw a clear line

be evaluated:

and protocol selection, as well

the patient related to the pro-

between the two & their related



Global patient satisfaction:

as his or her existing restorative

Acknowledgements

posed smile need to be addressed

treatment, in MICD they are

After receiving aesthetic

skills. I believe that a thorough

In formulating the MICD TP, I

during presentation. The treat-

categorised as follows:

dental treatment, the patient

evaluation can support any

discussed the concept with sev-

ment complexity, its limitations,



needs: objective restorative

is requested to complete

practitioner in initiating prac-

eral national and international

the risks involved, possible

needs of the patient in har-

the MICD exit form, in which

tice-based research and keep-

colleagues in order to ensure

complications, treatment cost

mony with the SRA factors

the patient evaluates his

ing up-to-date with the recent

that it is simple, practical and

estimation and maintenance

and due emphasis on health

or her new smile, gives a

trend of evidence-based den-

comprehensive. I would like

responsibility must properly be

and function of oral tissues

second

tistry (Figs. 4a–5b).

to extend my gratitude to Dr

explained to the patient. The

(naturo-mimetic smile enh-

aesthetic score (b-score),

patient is thus involved in

ancement)

and indicates his or her

wants: subjective desires of

will sign the written informed

sketches, modified digital pic-

The enhancement step of

tures, computer-designed make

MICD is focused on the fulfil-

overs or animations can be used

perceived

smile

intervention

and

Akira Senda (Japan), Dr Didier
Dietschi

global satisfaction score.

MICD treatment
modalities

the patient, which may not

The b-score is compared

Various

Oliver Hennedige (Singapore),

consent form before proceeding

be in harmony with the

with the previous a-score.

modalities

to Phase II.

SRA factors (cosmetic smile

This process helps deter-

MICD.

enhancement)

finalising the treatment plan and



Phase II: Achieve

types

of

(Switzerland),

Dr

Hisashi Hisamitsu (Japan), Dr

treatment
in

Dr Dinos Kountouras (Greece),

use

Dr Mabi L. Singh (USA), Dr

mine the patient’s actual

depends on the level of smile

Ryuichi Kondo (Japan), Dr So-

satisfaction status. In MICD,

defects, type of smile design,

Ran Kwon (Korea), Dr Prafulla

this is the main parameter

proposed treatment type and

Thumati (India), Dr Vijayarat-

for evaluating a patient’s

the treatment complexity grade.

nam Vijayakumaran (Sri Lanka),

aesthetic satisfaction.

There is only one principle in

as well as Dr Suhit R. Adhikari,

Clinical success: Clinical

selecting treatment modalities

Dr Rabindra Man Shrestha, Dr

are

Their

available
effective

As per the TP, which is finalised

During

during the presentation step, all

aesthetic

necessary preventive intercep-

healthy oral tissue is treated with

tive and restorative (curative)

no direct benefit to health or

dental treatments are conducted

function, the treatment modali-

success is a multifactorial

in MICD: always select the

Binod Acharya and Dr Dinesh

in order to establish the proper

ties should be within the scope

issue. Selection of proper

least invasive procedure as

Bhusal

health and function of the oral

of non-invasive (NI) or MI

cases (the patient), restora-

the choice of the treatment.

valuable

tissues. Owing to the complexity

procedures.19

patient’s

tive materials, TPs and their

of the treatment, a multidis-

cosmetic desires alone should

correct and skilful applica-

The two categories of MICD

ciplinary

be

not be the rational for the treat-

tion are the key factors for

treatment are NI and MI treat-

necessary for a good result.

ment.20 Do no harm! should

clinical success. Therefore,

ment (Table 1). However, con-

Once the case is stable in terms

always be the credo pertinent to

MICD TP suggests self-

ventional invasive treatment

of health (controlled disease)

all dental treatment procedures.

evaluation of the following

modalities may also be required,

approach

may

any

want-based

treatment,

The

where


and function (balanced force

four factors (4Ps) using the

depending on the complexity of

elements) with good oral habits,

MICD clinical evaluation

the case.

the patient is requested to

Regular maintenance, compli-

form:

re-evaluate his or her smile in

ance and timely repair play a

terms of aesthetics with the

crucial role in the long-term

maintenance status, compli-

MI dentistry was developed

help of the MICD self smile

success of aesthetic enhance-

ance issues and attitude of

over a decade ago by restorative

re-evaluation form. This is

ment procedures. Hence, MICD

the patient towards aes-

experts and founded on sound

important, because in some

emphasises the keep-in-touch

thetic treatment;

evidence-based principles.21–30

cases the patient is fully satisfied

concept and encourages patients

Product factors: bio-comp-

In dentistry, it has focused

with the results of the establish-

to go for regular follow-up visits.

atibility, mechanical and

mainly on prevention, re-miner-

ment step alone and may modify

Responsibility for maintenance

aesthetic quality of the

alisation and minimal dental

his or her idea of further aes-

is grouped into two categories:

products

intervention in caries manage-

thetic enhancement. In MICD



treatment;

ment and not given sufficient

Protocol factors: TP used

attention to other oral health

–

Self-care: Patients are ad–

Patient

factors:

used

regular

for

the

Nepal,

for

comments,

their
advice

and feedback. DT

Phase III: Keep in touch

–

of

References available on request.

About the author

Conclusion

TP it is considered unethical

vised to continue their

should the practitioner not

normal oral hygiene proce-

in terms of its simplicity,

problems. I believe that the

collect self smile re-evaluation
information from the patient.

dures. If necessary, special
care and precautionary

predictability & its evidencebased nature;

MI philosophy should be the
mantra adopted comprehen-

Dr. Sushil Koirala is the founding
president of the Vedic Institute of
Smile Aesthetics and maintains
a private practice focusing primarily on MI cosmetic dentistry
(MICD). He can be contacted at
skoirala@wlink.com.np.

[19] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

interview 19

“Allergic reactions from amalgam fillings in
some patients have been acknowledged”

There was a focus on the
oral cavity, which thus ignored
the

environmental

aspects

such as mercury emissions
from crematoria and leakage of

An interview with Prof. Lars Hylander, Uppsala University

mercury into wastewater from
In November, 2009, an agree-

What has been decided regard-

country. Thus far, nothing has

There was some consensus

dental clinics and the wearing

ment in concept was reached

ing dental amalgam?

been decided, but the WHO can

that mercury use in dentistry

of amalgam surfaces due to

by a World Health Organization-

The WHO has not been as quick

hardly ignore the decision made

should be phased down. A

everyday chewing. The Ameri-

convened international expert

as Norway, who instituted a ban

by the world’s governments

suitable way to do this is to begin

can Dental Association demon-

group meeting, supporting the

on dental amalgam in less than

within the UNEP to negotiate

teaching alternative restoration

strated this most clearly in

phase-out of dental mercury

six months after the proposal

a mercury treaty, which will

techniques, other than dental

use worldwide.

of a ban was presented in the

begin in Stockholm next June.

amalgam, in dental schools.

Dental Tribune Group Editor
Daniel
with

Zimmermann
Prof.

Associate

Lars

spoke

Hylander,

Professor

at

the

University of Uppsala in Sweden
who attended the meeting,

EMS-SWISSQUALITY.COM

about the agreement and strategies for future biomaterials
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Zimmermann:

Prof.

Hylander, you recently attended
a joint meeting of the World
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the United Nations Environment
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to assess the latest clinical
evidence on dental restorative
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at least phased down. Dr Poul
Erik

Petersen,

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WHO, however, raised several
good questions, such as what to
tell people in poor countries
who cannot even afford dental
amalgam fillings. At this point,
the room grew rather silent.

A similar consultation was held
more than ten years ago. What
has changed since then concerning the manner in which
dental

restorative

materials

are perceived?
Allergic reactions from amalgam

DEEP DOWN, between tooth and gingiva, billions of bacteria managed to
proliferate under the cover of malicious
biofilm – until now.

fillings in some patients have
been acknowledged by proamalgamists. Mercury leakages
and

emissions

from

dental

amalgam into the environment
have been fully acknowledged,
particularly after dental amalgam was banned in Norway
and Sweden, and restricted in

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 DT page 20

[20] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

20 Clinical

Implants displaced into the maxillary sinus
By Dov M. Almog, DMD, Kenneth
Cheng, DDS & Mohammad Rabah,
DMD

outcomes in dental implant
treatment

and

CBCT-based

retrieval basket through the

maxillofacial problems, such

eral wall of the maxilla, thereby

dental imaging is unknown

endoscopic working channel

as retained roots, decay and

gaining access to the maxillary

and awaits discovery through

port. The advent of endoscopic

missing teeth, to name a few.

sinus. Antral currettes and a

large prospective clinical trials,

As some have predicted,1 the

techniques has made it the

the authors strongly believe

growth in dental implant-based

preferable choice, especially for

that using CBCT-based dental

procedures increased consider-

patients with chronic sinusitis.

imaging is becoming a reliable
procedure from a precautionary

ably in recent years. As a result,
there has been a rapid increase

The most commonly used

standpoint based on a series

in the number of practitioners

technique for retrieval of foreign

of recent preliminary clinical

involved in implant placement,

bodies displaced into the maxil-

studies and case reports.

including specialists and gener-

lary sinus is the Caldwell-Luc

alists, with different levels of

procedure. In contrast to the

expertise. At the same time,

endoscopic technique, which

although at a low frequency,

involves accessing the maxillary

we are witnessing a diversity of

sinus via the nose, the Caldwell-

unusual complications associ-

Luc procedure involves gaining

ated with these procedures,

access to the maxillary sinus by

some of which are displaced im-

the fenestration of the anterior

plants into the maxillary sinus.

lateral wall of the maxillary sinus

Fig. 1: Pre-operative diagnostic conebeam CT revealing, among other
things, two implants displaced into the
right and left maxillary sinuses. By
utilizing the i-CATTM 3D CBCT
(Imaging Sciences International, Hatfield, Pa.), which includes clear-cut
panoramic and cross-sectional slices
of any desired location, one obtains
precise anatomical information.

Fig. 2: Axial slice is useful for revealing
the two displaced implants from a
different angle.

or canine fossa.11,12
Nevertheless, the chief com-

A literature search revealed
several published reports of

The Caldwell-Luc procedure

plaint noted by the patient, and

displaced foreign bodies into the

offers better direct visual access

most profound clinical finding,

sinus.2–6 Generally

to the maxillary sinus as com-

was “two implants displaced

speaking, foreign bodies in the

pared to the endoscopic ap-

into the right and left maxillary

maxillary sinus include multiple

proach, but is considered more

sinuses” (Figs. 1–3). The medical

displaced objects. These include

aggressive with potentially more

history was non-contributory.

teeth, roots, impression materi-

serious complications. Some of

als, dental instruments, broken

the possible complications are

Proceeding with careful asse-

burs and, more recently, dental

dysesthesia of the infraorbital

ssment of all the available diag-

implants.

foreign

nerve, numbness of the maxil-

nostic information, and upon fur-

bodies in the maxillary sinus

lary teeth, injury to the floor

ther discussion with the patient,

are not common, it behooves

of the orbit and facial edema.

several treatment options were

hemostat were used to retrieve

us to familiarize ourselves with

This older and perhaps less

developed in association with his

the displaced implants (Fig. 4).

Therefore, the authors stro-

such an unusual complication

conservative

for

retained roots, caries & missing

The sinuses were then irrigated

ngly believe that by making

and its management. Displace-

accessing the maxillary sinus

teeth. As far as the patient’s chief

and

a CBCT-based

ment of such foreign bodies

was first introduced by two

complaint, one treatment option

gauze, which was later removed.

placing dental implants, dis-

into the maxillary sinus occurs

otolaryngologists (American and

was offered to him, that is, the

The incision was closed. Post-

placement of dental implants

following dental procedures that

French) in 1893.11

Caldwell-Luc

to

operatively, the patient did well

into

remove both displaced implants

and no complications were

be avoided. DT

in his maxillary sinuses. After

reported.

maxillary

Although

create an unplanned oroantral
perforation.

The

procedure

technique

Case report

procedure

Fig. 3: Three-dimensional virtual
rendering (3-DVR) of the displaced
implants provides the surgeon feedback as to the surgical approach.
In this case, a Caldwell-Luc procedure
was performed using a bur to
create an access window through the
lateral wall of the maxilla, there by
gaining direct access to the displaced
implant.

packed

with

iodoform

A 50-year-old African-American

careful consideration, the pati-

foreign bodies from the maxil-

male Vietnam veteran presented

ent chose to proceed with the

Conclusions

lary sinuses is considered very

to the VA New Jersey Health Care

proposed treatment plan.

As described in this case report,

invasive. In this case report,

System Dental Service at East

the authors describe a syste-

Orange seeking dental care.

A Caldwell-Luc procedure

ciated with the removal of dental

matic approach to the removal

A comprehensive oral and max-

was performed bilaterally under

implants displaced into the

of two implants displaced into

illo-facial examination included

general anesthesia. Specifically,

maxillary sinuses is considered

the right & left maxillary sinuses.

an intraoral and extraoral exam,

the Caldwell-Luc procedure

very invasive. While numerous

including cancer screening, full-

involved making an incision in

dental reports described patients

Currently, there are two ac-

mouth X-rays, and a cone-beam

the bucco-gingival sulcus in the

treated for displaced implants

cepted methods for removing

CT (i-CAT™ 3D CBCT Imaging

area of the maxillary canine and

into

foreign bodies displaced into the

Sciences Inter-national, Hat-

bicuspid teeth, exposing the

none illustrated those from a

maxillary sinus. One method is

field, Pa.) revealing, among other

anterior lateral wall of the

preventive standpoint, that is,

the endoscopic transnasal maxi-

things, two implants displaced

maxilla. Care was taken to avoid

the use of CBCT-based dental

llary sinus surgery.7-10 Access to

into the right and left maxillary

injury to the infraorbital nerve

imaging before placing dental

the maxillary sinus is achieved

sinuses.

as it exits in the infraorbital

implants.

the clinical management asso-

maxillary

sinuses,

foramen. Using a bur and Kerri-

through the nose via the ostium.

study prior to

the maxillary sinus can

References available on request.

associated with the removal of

the

Fig. 4: Caldwell-Luc procedure is useful
in gaining access to the maxillary
sinus by the fenestration of the anterior
lateral wall of the maxillary sinus.
Note successful retrieval of implant
from the maxillary right sinus through
the access window.

About the authors
Dov M. Almog, DMD, Chief of
the Dental Service, VA New
Jersey Health Care System
(VANJHCS)
Kenneth Cheng, DDS, Oral and
Maxillofacial Surgeon, VANJHCS
Mohammad Rabah, DMD, Oral
and
Maxillofacial
Surgery
Resident, VANJHCS

For reprints:
Dov M. Almog
Chief, Dental Service (160)
VA New Jersey Health Care
System
385 Tremont Avenue
East Orange, N.J. 07018
Tel.: (973)-676-1000, ext. 1234
Fax: (973) 395-7019
E-mail: Dov.Almog@va.gov

The foreign body is captured

Ultimately, the exam revea-

son’s rongeurs, a window was

While the quantitative rela-

and removed using an urological

led a diversity of oral and

made through the anterior lat-

tionship between successful

 DT page 19

Which

materials

out any ban, such as in Japan,

Composites and glass ion-

promising alternative, not only

were considered to have the

less than four per cent of the

omers are also widely used in

for developing countries. In

the presentation by Dr Daniel

most

in

fillings are now fabricated with

many developing countries. The

countries in which glass iono-

Meyer, in which it was stated

developed

developing

amalgam, for aesthetic reasons.

question of why such develop-

mers or composites are pro-

that of the thirty-five tons of

countries?

In addition, many patients do

ments progress so slowly in the

duced locally, the cost of these

amalgam

in

Composites and other white fill-

not find it sensible to have as

big nations of the rich world was

fillings is lower than that of

the US, only a few hundred

ing materials have replaced

toxic an element as mercury

raised. Atraumatic restorative

amalgam. DT

kilograms are emitted into the
environment.

amalgam in several developed
nations. Even in countries with-

just a few centimetres from
their brains.

treatment with glass ionomers
and using only hand tools is a

Thank you very much for the
interview.

used

annually

restorative
potential
and

for

use

[21] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

Clinical 21

Early childhood caries - Preventive strategies

transmission of mutant strepto-

coccus mutan from mother to

Dr. Usha Mohan Das, MDS
India

the application of fluoride var-

child. This goal can be achieved

nish at this first visit will help

by cutting the main routes

Introduction

reduce future disease (Fig. 3).

of transmission (egg, pacifiers,

If applied twice a year, fluoride

spoons) and by suppressing

Early childhood caries (ECC)

varnish can reduce decay in

the levels of mutant S. mutan

is a virulent form of dental

baby teeth by 33% & by 46% in

in highly infected mothers.

caries that can destroy the

the permanent teeth. It is usual

primary dentition of toddlers

to apply fluoride varnish to the

Preventive programs targe-

teeth of children who already

ting mothers have been imple-

have decayed teeth or are consi-

mented during pregnancy or

and preschool children (Fig. 1).
Fig. 1: Four-year-old child with ECC

ECC is a syndrome with both

of their infants. One can also

ting dental caries in children

dered to be at increased risk of

when the infants were 3 to 8

disease and behavioral compo-

examine and provide preventive

from low socio-economic groups

developing tooth decay.

months of age, with evaluation

nents. The colloquial term for

care to the children in private

which are at high-risk of devel-

ECC is “Baby Bottle Tooth

clinics.

oping ECC.

Decay” because it is common in

on a long-term basis. The conOne approach is to prevent

trolled studies have generally

S. mutans from accumulating

included dental treatment, oral

young children; a baby bottle,

It is assumed that an increase

While the preventive strate-

to pathologic levels through

health information, and coun-

filled with liquids containing

in the knowledge, of mothers

gies, at the professional and

the topical application of anti-

seling as well as topical treat-

sugar, is used as a pacifier

and caregivers at the community

home level, are not well known

microbial agents. The high-risk

ments of the mothers with

in aiding sleep or quietness.

level basis, will influence their

by the parents and caregivers,

groups could benefit from the

various antibacterial agents,

Untreated caries may lead to

self-care habits and dietary

all infants should receive an

application of chlorhexidine

such as chlorhexidine, fluoride

early loss of the primary denti-

practices in turn, improve the

early dental examination at or

varnishes. A varnish, containing

for the bacterial suppression.

tion and affect the growth and

dietary and oral hygiene habits

before the age of 1 year as

1% chlorhexidine and thyme,

maturation of the secondary,

of the infants leading to the

recommended by the American

was found to reduce dental

Conclusion

adult dentition.

prevention of the ECC. Many

Academy of Pediatric Dentistry.

caries in the fissures of perma-

ECC is characterized by severe

cross-sectional

have

Early screening could help

nent molars by 50%. Chlorhexi-

decay in the teeth of infants or

been done to determine the

in the early identification of

dine varnishes may be useful

young children. As we know,

Caries is a common, complex,

efficacy of educating people at

incipient carious lesions on

in preventing the transmission

ECC is a multifactor disease

and chronic disease resulting

this level which concluded

smooth tooth surfaces. Addition-

of cariogenic bacteria from

like any other form of caries

from an imbalance of multiple

with a modest positive change

ally, early dental visits provide

mothers to infants. A chlorhexi-

involving three primary factors.

risk factors & protective factors

achieved in the dietary and

an opportunity to review feeding

dine varnish could be easily

To prevent development of any

over time. Fundamentally, caries

personal health behaviors of

and oral hygiene practices and

applied to infants and toddlers

carious lesions, the primary

is biofilm (plaque)-induced acid,

infants at risk of developing ECC.

to plan professional fluoride

and does not require the same

caretakers are advised to check

applications.

level of moisture control as sea-

their baby’s mouth regularly

lants. Bimonthly topical applica-

by lifting the lips and cheeks

Etiology

studies

demineralization of enamel or
dentin, mediated by saliva. Car-

All infants and toddlers,

ies is regarded as an infectious,

regardless of their risk status,

Study findings support the

tion of a 10% providence–iodine

on both the sides. Also, parents

contagious, and multifactorial

could benefit from water fluori-

use of fluoride varnish to prevent

solution, to the dentition of

should be educated about the

disease produced by three pri-

dation. Water fluoridation has

ECC and reduce caries incre-

babies at high risk for ECC,

feeding habits and the precau-

mary individual factors: cario-

been found to be highly effective

ment in very young children.

increased disease-free survival.

tions to be taken while feeding

genic microorganisms, cario-

(40-60%) in a cross-sectional

Fluoride varnish efficacy, in this

genic substrate, and susceptible

study in preventing the dental

age group, provides the addi-

Finally, for high-ECC-risk

host (or tooth) (Fig. 2). These

caries in the primary dentition.

tional rationale for an early

infants and toddlers, a special

factors interact for a certain

Furthermore, it has been found

dental visit, especially for the

pacifier containing fluoride (0.25

feeding

period of time, causing an im-

to be more effective in preven-

high-caries-risk children, since

mg), xylitol, and orbital could be

approach

balance in the demineralization

efficacious in controlling dental

Always clean the baby’s teeth

and remineralization between

caries. Xylitol-containing gum

with warm-wet-clean cloth after

tooth surface and the adjacent

is effective in preventing dental

feeding, and begin brushing

plaque (biofilm).

caries in primary teeth, though

teeth as soon as the first tooth

it is impractical for use in infants

erupts. And most importantly,

and toddlers. For infants and

if the mother or caretaker first

Dental caries is still the most

toddlers, a pacifier, containing

notices any discoloration of

common

disease

xylitol, is a novel idea that could

teeth, they should immediately

among children. It is a prevent-

be used as a temporary substitute

approach the dentist for timely

able disease and its prevention

for feeding at night or bed time

intervention. DT

begins at the pediatrician’s

or for a pacifier laced with sugar.

Prevention
infectious

their baby.

clinic. The dentists encourage
oral health care providers and

Another promising approach

caregivers to implement preven-

toward primary prevention of

tive practices that can decrease

ECC is to develop strategies

a child’s risks of developing

that target the infectious compo-

the

acquisition

of

of

cariogenic

behaviours
to

is

one

prevent

ECC.

About the author

nent of this disease, for example,

this devastating disease. Understanding

Prevention

Fig. 2: Caries etiology triad

by preventing or delaying pri-

cariogenic microbes is necessary

mary acquisition of S. mutans

to improve prevention strategy.

at an early age through suppression of maternal reservoirs of

Prevention of ECC is done

the organism. There is evidence

at different level, e.g. it can be

that cariogenic bacteria (mutant

done at community level which

streptococcus mutan) are trans-

relies on educating mothers in

mitted from mothers to infants.

the hope of influencing their
dietary habits as well as those

Fig. 3: Tray with fluoride foam

The goal of primary prevention
is to decrease or postpone the

Dr. Usha Mohan Das is principal
and head of the department of
pedodontia & preventive dentistry
at Vokkaligara Sangha Dental
College and Hospital, Banglore.
She can be reached via email at
ushymohandas@gmail.com

[22] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

22 trends & applications

Miniscrews—a focal point in practice

or functional reasons;


Six-part series by Dr. Björn Ludwig, Dr. Bettina Glasl, Dr. Thomas Lietz & Prof. Jörg A. Lisson—Part III

a short-term treatment or
partial treatment is required
that does not involve correc-

Clinical examples (1)

tion and realignment of the

Horizontal tooth displacement

basic dental arch;


Lack of space is one of the main

asymmetrical

treatments

reasons for the oblique position-

are associated with the risk

ing of teeth. One way to solve this

of midline displacement and

problem is to create the neces-

the possibility of compensa-

sary space. Conversely, premature loss of teeth or anatomical
abnormalities may result in

Figs. 1a–c: Distalisation of the upper molars. Mesial positioning of teeth 16 and 26, showing clear displacement of the
canines (a). Walde Frog Appliance (FORESTADENT) anchored to two miniscrews (b). Distalisation by approx. 6 mm after three
months’ treatment, providing sufficient space for the correct repositioning of the canines (c).

tory extraction;


or a suitable dental baseline
situation is to be created for

gaps that require modification

successful molar distalisation,

pre-prosthetic treatments.

for various reasons. For the

they can be used to stabilise

It is important to note that in

correction of horizontal tooth

the situation achieved for the

cases in which space closure

displacement, miniscrews can

remainder of the treatment.

treatment is proposed, it must

be used, as these produce no

Thirdly, there is no risk of dam-

be ensured that the patient is

undesirable reactive effects.

aging other teeth because of an

aware of not only the costs and

unfavourable spatial situation

risks of the treatment, but also

Distalisation

and/or incorrect insertion.

of the available alternative

markedly reduced.

The first case (Figs. 1a–c) pre-

options, such as the use of

sented involves a frequently en-

One disadvantage of the cou-

countered problem: the patient’s

pling necessary between the

molars had migrated in a mesial

Walde Frog Appliance used

direction. This resulted in a

(FORESTADENT) and the mini-

marked loss of space in the

screws (see Figs. 1a–c) is that

region of the canines. The two

cleaning becomes difficult. As

treatment options in such a case

large areas of the mucous

are extraction or distalisation.

membrane are covered, there is

In this case, distalisation was a

the risk of the development of

bridges or implants. There are
three types of space closure.
Anterior space closure (e.g. in displacement of the lateral incisors)
Figs. 2a–d: Distalisation of the upper laterals. Miniscrews were inserted in
the paramedian region (OrthoEasy, FORESTADENT) (a). OrthoEasy with attached
laboratory abutments (b). The Frog Appliance was lashed to the laboratory
abutments (c). Lateral X-ray showing the ideal positioning of miniscrews,
laboratory abutments and Frog Appliance (d).

Orthodontic space closure is
frequently indicated if there is a
gap in the anterior row of teeth,

interception of the opposing

particularly in the region of the

forces is a major consideration

lateral incisors. The undesirable

viable option and extraction was

peri-mucositis. If this develops

Space closure

unnecessary. Conventional tech-

further into peri-implantitis,

Owing to the availability of

within the therapeutic strategy.

effects of conventional thera-

niques for distalisation (apart

premature loss of the miniscrews

miniscrews, new therapeutic

The orthopaedic closure of

peutic techniques are the dis-

from the use of headgear) req-

could result. A possible future

techniques can now be used,

dental spaces using miniscrews

placement of the midline and/

uire support from other groups

alternative could be the use of

particularly for the management

is highly recommended if:

or negative inclination of the

of teeth. Creating anchorage in

‘laboratory abutments’ (Figs.

of the partially edentulous situa-

this way has negative reactive

2a–d), which contain no plastics

tion that obviates the need for

effects. In the example under

and can be used to couple the

consideration, it is highly probable that protrusion of the anterior
teeth

would

have

used for the stabilisation of the

compensatory extractions and

able conventional methods

median incisors (Figs. 4a–c),

appliance with the miniscrews

the problem of the loss of stabi-

and/or there is insufficient

such effects can be avoided. A

entirely hygienically.

lity of the units used for anchor-

certainty that these will be

stable, rigid steel arch with a

age support. It is here that the

effective;

size of at least 0.48 mm by 0.64

the extensive use of braces

mm (19 x 25) attached to two

is to be avoided for cosmetic

miniscrews inserted in the

resulted,
Mesialisation

effect of Newton’s Third Law is

for

been

One of the most problematic

particularly apparent, and the

employed. Such negative results

areas of orthodontic therapy is

can be avoided by the use of

the correction of the anterior

miniscrews.

displacement of teeth, and par-

have



there are no alternative, vi-

should a conventional method
distalisation

anterior teeth. If miniscrews are



ticularly of jaw segments. It
Miniscrews can be inserted in

could seem that the availability

the vestibular and—as in this

of miniscrews means that con-

example—palatinal areas. Vesti-

ventional appliances no longer

bular insertion of a miniscrew

need to be used at all. However,

(e.g. between the premolars) is

depending on the baseline situa-

always

the

tion and the nature of the re-

miniscrew’s eventual interfer-

quired correction, the use of a

ence with tooth migration. When

combination of devices and ap-

this occurs, the miniscrew must

pliances is recommended. This

be extracted and a conventional

is often advisable and may even

form

anchorage/blocking

be necessary for biomechanical

(e.g. a ligature) must then be

reasons, such as in a Class III

used. In this case, the presence of

situation. In the case shown in

the primary molars represented

Figures 3a to c, forced transverse

a contraindication for insertion

expansion of the palatine suture

on the vestibular side of the pre-

was used in combination with

molar region. The paramedian

mesial traction, applied by mean

insertion of two miniscrews has

of a Delaire facial mask. The sup-

several advantages. Firstly, the

port provided by two miniscrews

miniscrews provide a very solid

inserted in the paramedian

basis for anchorage of the distal-

region redirected the forces of

isation appliance. Secondly, they

sagittal and transverse move-

will never impede the movement
of the lateral teeth. Even after

ments almost entirely onto the
bones. Dental side effects were

associated

with

Figs. 3a–c: Mesialisation of the upper molars. Miniscrews inserted in the paramedian region with laboratory abutments
(FORESTADENT) and transverse screw with hook for a Delaire facial mask (a). Status after transverse expansion and formation
of a median diastema (b). Extra-oral view of the appliance with a Delaire mask (c).

Figs. 4a–c: Space closure in the region of the upper anterior teeth. Diagram showing the anchorage principle (a). Baseline situation: The central frontal teeth were held in place using a steel arch (19 x 25) fixed to a miniscrew with additional frontal dental
torque (b). After nine months the anchorage is stable (c).

Figs. 5a–c: Space closure in the region of the upper anterior teeth. En masse retraction with the aid of miniscrews and a Power
Arm (FORESTADENT), which has been crimped here (a). Status after extraction of the premolars, showing OrthoEasy miniscrew (b). The Power Arm is used as a sliding mechanism, in order to distalise the canine further (c).

[23] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | January-March, 2010

trends & applications 23

Figs. 6a–c: Space closure in the region of the upper laterals. Baseline situation: Teeth 25 and 27 are free of caries (a). Using
miniscrews (OrthoEasy), it is possible to provide ‘invisible’ treatment (b). Very few elements are required for mesialisation (c).

returned to its original position

in each case between the canine

within three months by means

and

of the indirect anchorage of

Titanol

tooth 23 to a miniscrew using a

(FORESTADENT) was attached

straight wire appliance. In the

to the capstan of the miniscrew,

case of a bite that exposed tongue

and the screw was set to intru-

and bone (Figs. 8a & b), the

sion. There was even some

approach adopted was to provide

overcorrection of the positioning

transverse expansion and extru-

of the first molars on both sides

sion of the anterior teeth. Inter-

after five months’ intrusion,

maxillary rubber traction braces

resulting in closure of the

connected to miniscrews in the

frontal bite.

lower jaw were used. If the

extrusion of these would have

pists to overcome logistical and

resulted (every action has an

emotional barriers before they

Vertical tooth displacement

equal and opposite reaction).

can begin to employ miniscrews,

Any displacement of the teeth

Because of the small root surface,

but it is only when they are used

along the vertical axis can pres-

this process would have occu-

that their versatility becomes

ent a cosmetic and/or functional

rred in a much shorter space of

apparent. Miniscrews make our

problem. The solution is extru-

time than in the case of the upper

routine work that much simpler.

sion or intrusion using skeletal

anterior teeth. The opposing

They enhance the efficiency and

anchorage. This technique is

bone in the lower jaw prevented

effectiveness of many dental

very simple to implement and

this undesirable reactive effect.

appliances, resulting in an overall improvement in treatment

(Fig. 6a–c). What should the

rior teeth. Using the standard

patient be offered—implants,

vestibular

bridges

mechanical

tech-

space

closure

niques, the gap can be closed

treatment? With a view to the

without altering the position of

realistic long-term prognosis

the incisors.

for the anchorage teeth, conser-

En masse or canine retraction
(e.g. where the premolars are
missing)

vation of the surviving natural
teeth, and the minimisation of
the effects on the existing
materials, a prosthetic solution

Miniscrews can also be used as

would not appear to be appro-

an aid in this form of treatment

priate. The basic concept of

(Figs. 5a–c). In contrast with the

restorative

conventional appliances, there

destroy, in order to reconstruct—

is no loss of anchorage but

is frequently not the best solu-

rather a biomechanical benefit

tion. Let us assume that the

in terms of more favourable

strategy adopted is to mesialise

direction of forces. If the mini-

tooth 27, in order to compen-

screw and the fitting for the

sate—using a natural method—

active element (traction spring

for the loss. The skeletal anchor-

or elastic chain) are positioned

age means that undesirable

at the same level as the resistance

side effects, such as reciprocal

centre of the canines, physical

space closure, are avoided.

movement of the tooth (or teeth)

Only a few elements (brackets,

is possible.

springs etc.) are needed to

dentistry—first

support the mesial movement.
Space closure in the molar region
(e.g. to avoid the need for
prosthetic measures)

The treatment remains invisible
to the casual observer, while in
comparison with the stated

Premature loss of the primary

alternatives, it is very cost-

molars has not yet been eradi-

effective and provides for a

cated despite all the advances

high level of conservation of

made in prophylactic treat-

the

ments. There may be a need

prognosis for the long-term

for appropriate therapy, particularly in cases in which the

preservation of the natural
teeth is very good.

natural

elements.

The

quality. DT

This open bite with extrusion of
miniscrews

the tongue (Figs. 9a & b) was

may be used for single teeth

treated by means of intrusion of

(Figs. 7a–c) and for groups of

the molars and consequent

teeth (Figs. 8a & b). Trauma had

caudal rotation of the maxilla.

caused the intrusion of tooth

Miniscrews were inserted in

22 (Figs. 7a–c). The tooth was

the first and second quadrants

Extrusion

can be used to stabilise the ante-

Spring

It may be necessary for thera-

Extrusion

adjacent teeth are not carious

Uprighting

lower anterior teeth, undesirable

Intrusion

median or paramedian region

premolar.

Conclusions

very cost-effective.

Figs. 9a & b: Intrusion in order to close a tongue and skeletal open bite. Intrusion
of the molars was effected using a Titanol Uprighting Spring (FORESTADENT) (a).
Status after six months (b).

first

braces had been connected to the
Figs. 7a–c: Extrusion of a single tooth. Viable lateral incisor following intrusion due to trauma (a). Miniscrew with indirect anchoring of the canine and straight arch technique, in order to extrude tooth 22 (b). Status after three months (c).

Figs. 8a & b: Extrusion in order to close an open bite caused by tongue thrust, with
deterioration of the upper jaw. The aim was to extrude the upper frontals over the
miniscrew in the lower jaw (a). Status after twelve months (b).

the

using

Contact Info
Dr. Björn Ludwig
Am Bahnhof 54
56841 Traben-Trarbach, Germany
Tel.: +49 65 41 81 83 81
Fax: +49 65 41 81 83 94
E-mail: bludwig@
kieferorthopaedie-mosel.de

[24] => DTAP0109_01-02_TitleNews

) [page_count] => 24 [pdf_ping_data] => Array ( [page_count] => 24 [format] => PDF [width] => 842 [height] => 1191 [colorspace] => COLORSPACE_UNDEFINED ) [linked_companies] => Array ( [ids] => Array ( ) ) [cover_url] => [cover_three] =>

[cover] => DT India (Archived)

[toc] => Array ( [0] => Array ( [title] => First vaccine for treating gum disease [page] => 01 ) [1] => Array ( [title] => FDI - FOLA - and DTI launch campaign for Haitian dentists [page] => 02 ) [2] => Array ( [title] => World News [page] => 03 ) [3] => Array ( [title] => Business [page] => 04 ) [4] => Array ( [title] => The CAD/CAM evolution [page] => 06 ) [5] => Array ( [title] => Directa presents new solutions for Class II cavity preparations [page] => 08 ) [6] => Array ( [title] => Implant aesthetics [page] => 09 ) [7] => Array ( [title] => Company Promotion [page] => 11 ) [8] => Array ( [title] => A clear - fixed pressure-formed - habit breaking appliance [page] => 15 ) [9] => Array ( [title] => Minimally invasive cosmetic dentistry [page] => 16 ) [10] => Array ( [title] => An interview with Prof. Lars Hylander - Uppsala University [page] => 19 ) [11] => Array ( [title] => Implants displaced into the maxillary sinus [page] => 20 ) [12] => Array ( [title] => Early childhood caries - Preventive strategies [page] => 21 ) [13] => Array ( [title] => Miniscrews—a focal point in practice [page] => 22 ) ) [toc_html] =>

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