DT India (Archived)

FDA says mercury dental fillings not harmful (entree) / WORLD ORAL HEALTH DAY / FDA says mercury dental fillings not harmful / World News / Cone Beam CT the change of paradigm in modern dentistry– clinical applications in endodontics and periodontology / Four ways to increase case acceptance / Think Out Of The Box! / The keys to early cancer diagnosis: Careful examination and timely biopsy / Worldental Communiqué: FDI Singapore 2009 / Interview with Dr. Sushil Koirala - Kathmandu - Nepal / Case report: Middle mesial canal / Miniscrews—a focal point in practice - part II / Piezosurgery—precise and safe new oral surgery technique / Papilla reconstruction revisited – A new approach

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Table of contents

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

www.dental-tribune.com

News in brief

The Government of India, to

Trends & Application
Piezosurgery-precise
and safe new oral
surgery technique

Interview
With Dr. Sushil Koirala

Technology
Cone Beam CT the
change of paradigm
in modern dentistry

Single council to regulate
medical education

VOL. 1 NO. 2

have an organised approach in
4Page

medical education, proposes to

4Page

scrap off all the regulatory bodies
and plan a single regulatory
body—National Council of Human
Resources in Health—to oversee
seven departments related to

FDA says mercury dental fillings not harmful
Reuters

medicine, nursing, dentistry, re-

gam fillings are not high enough

But Susan Runner, acting

to cause harm in patients, the

director for the FDA division

habilitation and physiotherapy,

WASHINGTON, DC, USA: The

FDA said, citing an agency

that oversees dental devices,

pharmacy, public health/hospital

US, Food and Drug Adminis-

review of roughly 200 scientific

said there was no “causal link”

management and allied health

tration recently reported that

studies.

between amalgam fillings and

sciences. The council will be

silver-coloured dental fillings

implanted as an autonomous

containing mercury are safe for

In 2006, Moms Against Mer-

available scientific evidence

body independent of governmen-

patients, reversing an earlier

cury and three other groups

supports the conclusion that

caution against their use in

sued the FDA to have mercury

patients with dental amalgam

certain patients, including preg-

fillings removed from the US

fillings are not at risk,” she told

nant women and children. While

market. Later that year, an FDA

reporters on a conference call.

elemental mercury has been

panel of outside experts said

Over the past 20 years, the

associated with adverse health

most people would not be

agency has received just 141

effects at high exposures, the

harmed but that more informa-

reports of problems in patients

levels released by dental amal-

tion was needed.

with the fillings, she added.

tal control with ample power,
including quasi-judicial.

health problems. “The best

Containers with dried amalgam waste
mud. (DTI/Photo Anke Schiemann)

‡ DT page 3

Green tea may help reduce periodontitis
Rising smoking rates among
women
The Tobacco Atlas, Third Edition
published by The American
Cancer Society and World Lung
Foundation has reported that
India has the 3rd highest number
of female tobacco users in the

caution, she further added,

of green tea providing this

“Therefore, I think that it is

benefit.

difficult to prevent periodontal

Brooke Bonds, the leading tea

disease only by drinking green

company in India has recently

tea and that conventional oral

released its green tea in the

care is the most important”.

market fueling spectulation on

This

the increasing demand for this

study,

however,

did

not confirm the mechanism

world. Study among 11.9 million

tea in the coming years. DT

female consumers of tobacco in
the rest chew it. Further, the

“e.max LITHIUM

report says that the gap in tobacco
death rates between men and

DTI/Photo courtesy of Spictex International

women is closing because of this
trend among women in many
countries including India, & particularly among young women.

Smokers have fewer and
flatter taste buds
A study based on analysis of tongues of 62 Greek soldiers says,
smokers have fewer and flatter
taste buds. A team of researchers
used electrical stimulation to
test the taste threshold and found
that application of electric current to the tongue, generates a
unique metallic taste but 28 smo-

Dr. Naren Aggarwal
DT India

nols, notably catechin, are be-

A recent research shows that

for most of these claimed health

green tea, the most popular

benefits. Lead investigator of

beverage worldwide, may help

this study, Dr. Yoshiro Shimazaki

reduce

disease.

of Kyu-shu University, Fukuoka,

Green tea refers to a variety of tea

Japan, said,” Few previous

that has during its processing

studies suggest that green tea

undergone minimal oxidation,

polyphenols inhibit the growth

& hence contains good amounts

and

of antioxidant chemicals. In

periodontal

India, tea is consumed mostly in

production of virulence factors

the CTC (cut, tanned and cured)
form that brings out strong

periodontal

lieved

responsible

IPS
1,000 N*
IPS e.max
lithium
disilicate

by these pathogens”. Increasing

The durability of lithium disilicate glassceramic crowns is higher than that of
veneered zirconium oxide. Lithium disilicate
is therefore the material of choice for single
crowns: strong, esthetic, economical. Try it
yourself.

trend of green tea consumption

*Mouth Motion Fatigue and Durability Study

adherence
pathogens

of
and

prompted her team to conduct

on the content of antioxidants

this epidemiological study that

Also on endoscopic examination

such as polyphenols. These are

shows a modest inverse asso-

smokers tongues show flatter

chemicals that are currently

ciation

fungiform papillae, with reduced

under intense research for their

of green tea and periodontal

blood supply.

cardiovascular, anticancer and
anti-aging properties. Polyphe-

disease, but the relationship
was found to be weak. Adding

worse than 34 non-smokers.

DISILICATE IS THE
MOST ROBUST
CERAMIC SYSTEM
TESTED TO DATE.” *
This changes everything.

cellular

flavors and color but loses out

kers in the study group scored

e.max

India, shows 5.4 million smoke &

between

the

intake

amic
all cer
d
u nee
all yo

Petra C Guess, Ricardo Zavanelli, Nelson Silva and
Van P Thompson, New York University, March 2009
1 90% failure by 100,000 cycles
2 No failures at 1 million cycles

350 N*
veneered
zirconium
oxide

[2] => DTAP0109_01-02_TitleNews

DeNtal tribuNe |October-December, 2009

News & Opinion

2

S

em
ept

be

t
2
1
r

h

WORLD ORAL HEALTH DAY

To commemorate the world oral health day, Indian Dental Association (IDA), announced
the launch of Tobacco Intervention Initiative and Women Dental Council
Dr. Meera Verma, Vice Chair

Isha Goel
DT India

Naren Aggarwal
DT India

person of WDC said, “The WDC

Acknowledging

sizeable

would take initiative in promot-

female

On the World Oral health Day,

presence

dentist

ing the general and oral health

the Indian Dental Association

members, the Indian Dental

of women and children.” “A lot

(IDA) launched an ambitious

Association (IDA), on the occa-

of women dentist have come

awareness program, Tobacco

sion of World Oral Health

forward and have expressed

Intervention Initiative (TII), by

Day, raised the curtains to

their desire to be part of the

pledging to engage its member

the formation of Women Dental

body to attain the vision of

dentists

Council

WDC” she added.

to

sensitize

their

(WDC)

under

its

wings, with the purpose to

patients to health hazards of
tobacco consumption, and help

of

the

DTI/Photo courtesy of Indian Dental Association

provide them with an official

Women Dental Council of

quit the addiction. The program

platform to air their views and

IDA was conceptualized and

is voluntary and interested

address their unique concerns.

inaugrated during the Nagpur,

dentists need to receive struc-

The need for such a step has

IDA annual conference in Feb

tured training at the designated

been building up for quite

2009. The launch programme

centers before they can offer

sometime considering the fact

of the WDC in Northern India

this free-of-cost service to their

that, today, almost 80 percent

was held on September 12, to

patients.

of

concide with the oral health

the

dentists

graduating

from 240 colleges are women.

day.

Dr. Ashok Dhoble, secretary-

Dental associations from US,

general, IDA said, “For dentists

UK, and Singapore already

The guest of honor at this

to start TII centers in their

have similar official bodies

function Dr. Kiran Bedi, after

in existence that represent

finding that in the present gov-

female dentists.

erning body of IDA there were

practices, they would first need

DTI/Photo courtesy of Indian Dental Association

to undergo training by experts

centers would not be offering

crops in its 11th 5-year plan.

on how to assist patients over-

nicotine replacement therapy

In this direction, the health

come

or approved drugs such as bupri-

ministry recently was able to

Dr. Sabita Ram, chairman

vailed on the general secretary

through a certificate program.”

pion

dental

make it legally mandatory to

of WDC, on this occasion, out-

of IDA, Dr. Ashok Dhoble, to

“In this, a TII centre kit consisting

professionals would emphasize

display graphic warning in

lining

objectives

commit reserving 50% of such

of technique manual kit and

the need to stop tobacco use,

large-fonts on all the tobacco

said, “the mission behind this

posts only for women dentists

CD, patient education CD and

and help their patients seek

products, after battling stiff

initiative is to create maxi-

in future. This, she felt, was

brochure, and a poster on patient

appropriate therapy to be able

resistance from the pro-tobacco

mum working opportunities

the necessary first step for

education would be provided

to kick this habit.”

groups for several years. Smok-

for women dentists, and to

IDA to show its seriousness

ing at all public spaces and

understand their unique re-

about the formation of WDC.

nicotine

dependence

or

varenicline,

to each attendee,” he added.

few women office bearers, pre-

the

main

A TII website is also slated to

In India, each year almost

offices is already prohibited in

quirements

addressing

Dr. Kiran Bedi is a well known

be launched for professionals

900000 people lose their lives

India. But, despite all such

them. Given the current chal-

social worker who has received

and public to access information

due to cancers (oral and lung),

efforts, tobacco consumption

lenges that face women dent-

the Magsaysay award for her

related to activities planned

and chest and heart problems

continues to rise in India,

ists who struggle keeping a

contributions, and was adjudged

under this initiative. Mumbai

that can be linked directly to the

while a reverse trend has been

balance between career and

the most admired woman in

took the lead by warming up to

abuse of tobacco. According

achieved in the western world.

family in a constantly changing

2002. She also hosts a popular

this campaign by opening 56

to the third National Family

With such an enormous public

work environment, the WDC

TV show on family disputes

TII centers, while Delhi began

Health Survey, a whopping

health challenge to cope with,

will act as a vehicle providing

that helps raise public aware-

with three such centers. IDA is

57% of males and 11% of

TII by dentists is one more effort

help

ness to the legal solutions

hoping to see 5000 TII centers

females use nicotine in some

to gather against tobacco, and

jobs to setting-up practices,

operating by the end of 2010,

form. The problem is more

the

this

while simultaneously looking

covering all the regions of the

worrisome

initiative will only be known

into the gender issues involved.”

country.

people between 17-22 years,

amongst

young

tangible

gains

of

and

ranging

from

finding

of such conflicts. DT

later. DT

almost half of whom are in
the habit of having tobacco.

should use every opportunity

Interestingly, almost 50% of

in their daily practices to take

tobacco

up this cause with their patients

chewable

to impress upon them the harm-

betal leaves and lime, which,

ful short-and long-term effects

in certain regions of India,

of tobacco abuse” commented

has resulted in highest rates

Dr. Mahesh Verma, who is the

of oral cancer in the world.

is

consumed
form

along

in

a

with

International Imprint
Executive Vice President
Marketing & Sales

Peter Witteczek
p.witteczek@dental-tribune.com

DENTAL TRIBUNE
The World’s Dent al Newspaper  India Ed ition

Published by Jaypee Brothers Medical Publishers (P) Ltd., India
© 2009, Dental Tribune International GmbH. All rights reserved.

dean of Maulana Azad Dental
College, New Delhi. When asked

Government of India plans

how this effort would be diffe-

to initiate a nation-wide tobacco

rent from the tobacco cessation

control

programs already in function

aim to discourage use of this

at various chest clinics in the
country, he said “although TII

product as well as encourage
farmers to shift to non-tobacco

program

that

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

will

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

Editor
Dr. Isha Goel
isha.goel@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
Chief Editor
Phone: 43574357
Dr. Naren Aggarwal
e-mail:jaypee@jaypeebrothers.com
naren.aggarwal@jaypeebrothers.com Website: www.jaypeebrothers.com

BDZ/0909/04

“Dentists as oral physicians

[3] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

World News

STA System keeps patients comfortable — even during
the injection itself
Fred Michmershuizen
DTA

at Milestone Scientific, who

SAN FRANCISCO, CA, USA:

during the recent CDA meeting,

When it comes to getting from

the Dynamic Pressure Sensing

here to there, who wants to ride

(DPS) technology used by the

around in a horse and buggy?

STA System guides the dentist

And when it comes to delivery

to the correct spot to give a

of anesthetic before a dental

comfortable

procedure, who wants to use

intra-ligamentary injection.

spoke with Dental Tribune

and

Dr. Eugene R. Casagrande says the STS System from Milestone Scientific is a “win-win-win.”
(DTA/Photo Fred Michmershuizen)

successful

160-year-old technology? Milestone Scientific, with its Single

The system provides conti-

Tooth Anesthesia (STA) System,

nuous visual and audio feed-

is changing the way local

back, so the dentist knows when

anesthesia is being delivered

the needle has left the correct

today.

site or if the needle is blocked.
a comfortable manner to anes-

the dentist because injections

return for multiple visits. Even

The STA System is also quite

thetize multiple teeth and related

are very easy and stress-free to

better, he says, it is not uncom-

frightens

versatile. Casagrande says that

tissue. Also, an interligamen-

administer. It is a win for the

mon for patients to refer others

patients and causes undue stress

despite the device’s name, STA

tary injection that is different

patient because injections are

to a particular dental practice

— and instead pick up a small

System is not just for treating

from the traditional PDL can

more comfortable, and there is

because they are pleased with

handpiece and needle that you

one tooth at a time. Any injection

be administered easily, com-

no collateral numbness to the

the way they are treated with

hold in your hand like a pen.

delivered with the traditional

fortably and successfully.

lips, face or tongue. And it is

the STA System.

Because the injection is adminis-

dental syringe can be adminis-

tered below the pain thres-

tered more comfortably and

hold, your patient will be more

more easily with the STA.

You can set aside that scary
syringe

—

which

comfortable.
Two new, state-of-the-art
According to Dr Eugene R.

palatal injections — the AMSA

Casagrande, director of interna-

and the P-ASA — can be adminis-

tional and professional relations

tered using the STA System in

 DT page 1

President Dr John Findley said
That conclusion counters

in a statement. But Charlie

a statement the agency made

Brown, a lawyer for Consumers

last

fillings

for Dental Choice, said poorer

may cause health problems

people or those who receive

in pregnant women, children

their health care through large

and fetuses. The FDA’s decision

institutions such as the US

could impact makers of metal

military are more likely to

fillings, which include Dentsply

receive the cheaper, silver-

International Inc and Danaher

coloured fillings and are at

Corp’s unit Kerr, as well as dis-

greater risk for harm.

June

that

the

tributors such as Henry Schein
Inc and Patterson Cos Inc.

“Most consumers, and most
dentists, have already switched
to the main alternative, resin

According to the American

composite,” said Brown, whose

Dental Association (ADA), about

group was part of the lawsuit

30 per cent of fillings given

settlement

to patients are mercury-filled,

called on the agency to issue

with a growing number of pa-

more specific rules. His group

tients instead opting for lighter,

tooth-coloured

such

options, he said. Moms Against

as resin composites. The ADA,

Mercury President Amy Carson

which represents the dental in-

said

dustry, backed the FDA’s deci-

in the FDA’s reversal. Her

sion not to restrict mercury fill-

group,

ings, saying alternatives are also

others, filed a new petition with

considered “moderate risk” by

the FDA on Tuesday, again

the FDA.

calling for a ban on mercury

options

now

last

June

weighing

she

was

along

its

that

legal

disappointed
with

several

fillings, she added. DT
“The FDA has left the decision
about dental treatment right
where it needs to be—between
the dentist and the patient,” ADA

(Edited by Daniel Zimmermann)

a win for the practice because
There are also benefits for

the STA System affords an

“Patients appreciate the fact

the patient, who is able to have

efficiency factor that can result

that dentists who use the STA

a more comfortable experience,

in increased productivity.”

are going out of their way to

and to the practice itself.

make the most difficult and
As Casagrande explains, a

important part of the dental

“I call it a win-win-win,” says

patient can be treated in multiple

experience as comfortable as

Casagrande. “It is a win for

quadrants without having to

possible,” Casagrande. DT

[4] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

World News

DT Asia Pacific does well in readers poll

zig, New York, and Hong Kong—

Dentists in Asia find Dental

most interested in were science

Dental Tribune Asia Pacific

the Philippines and Australia, to

more than 20 countries that

Tribune Asia Pacific to be highly

& research (24%), followed by

was one of the first local

name a few. Their office is based

deliver the latest news & trends

up-to-date & applicable to their

world news (21%) & news from

editions published by the Dental

in Hong Kong and Leipzig in

in dentistry to over 600,000

practice, a readers poll conduc-

Asia (20%).

Tribune

Germany.

professionals worldwide. Local

ted at the FDI World Dental Con-

International

(DTI)

has publishers and editors in

issues

media group. The first edition

DTI

publications

gress in Singapore has revealed.

According to the poll, readers

appeared in April 2002. Mean-

In the last five years, DTI

are currently available in all

More than 85 per cent of those

would also like to read more

while, the newspaper reaches

has grown from a rather small

relevant

interviewed said that they would

about restorative dentistry, prac-

over 30,000 dental professionals

endeavour to a significant global

Germany, the UK, Italy, Russia,

recommend the newspaper to a

tice management, as well as pae-

in 25 countries including Singa-

publishing network. At present,

China, Japan, the US, France

colleague. Topics readers were

diatrics & special needs dentistry.

pore, Malaysia, Hong Kong,

DTI—with headquarters in Leip-

and India. DT

markets,

including

New organisation
makes dentists
‘conebeam- ready’

The International Cone Beam
Institute is a new independent
organisation of cone-beam computed tomography (CBCT) experts that aims to provide the highest level of education, training
& product information for 3-D
technology to dental professionals worldwide.
As a vendor-neutral organisation, it is an industry first for a
company to provide information
to dental professionals, future
imaging centres and vendors at
an international level. General
information, such as the various
cone-beam scanners available in
the US & international markets,
as well as general information on
available third-party software,
will be available to everyone with
out charge. ICBI also provides
in depth and customised vendor
analysis to help practitioners
understand this comprehensive
technology.
Members of ICBI’s website
(www.exploreconebeam.com)
are able to review case studies &
gain advice from CBCT experts.
They also have access to special
consulting services, online training and training seminars. In addition, ICBI offers a connection
to oral maxillofacial radiologists
who can provide reading services to aid in the interpretation
of CBCT scans. The organisation
also has a blog where users can
exchange case studies, ideas and
techniques regarding capturing
the highest quality images. The
International Congress of Oral
Implantologists, the world’s largest implant education organisation, fully endorses the ICBI.
Partners of ICBI include Dental
Tribune International and the
Dental Tribune Study Club. DT

[5] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

technology

Cone Beam CT the change of paradigm in modern dentistry–
clinical applications in endodontics and periodontology
By Prof. Dr.Liviu Steier

Panoramic radiography changed
the paradigm of diagnosis when
introduced in the early 1960s.
The limitations of two-dimensional radiography are:
1. Magnification,

Classic periapical radiography before,
during and at completion of RCT on
tooth 46.

2. Distortion,

CBCT scans of the RCT performed on
tooth 46. Very good opportunity to evaluate the cone fit (www.ct-dent.co.uk).

CBCT scans of the RCT performed on
tooth 46. (www.ct-dent.co.uk).

Classic periapical radiography before,
during and at completion of RCT on
tooth 15.

3. Superimposition,
4. Misrepresentation of struc-

a paper called: ‘Soft Tissue
Cone Beam Computed Tomo-

tures.

Due to this the use is
and was limited

graphy: A Novel Method for
the Measurement of Gingival
Tissue and the Dimensions of

Cone beam technology (CBCT)

the Dentogingival Unit’. In this

is a recent introduced technology

paper, the authors described

in dentistry which succeeded to

a simple method to diagnose

change and continues to change

the thickness of the gingiva

diagnosis, treatment indication

specially in the anterior aesth-

and treatment approach – having

etic zone. The scans were
CBCT of the same case. Upper picture demonstrating
the panoramic view while the lower shows the cepahlometric view.

CBCT scans of the RCT performed on tooth 15. Good opportunity to evaluate the successfully obturated lateral canal in
the periapical third of the palatal canal.

Clinical picture of the patient showing
a very thin periodontal biotype.

Panoramic image of the upper jaw produced by the CBCT.

CBCT image showing an almost completely resorbed buccal
alveolar plate and a very thin periodontal biotype.

doses than conventional CT.

performed

iCAT

patient was referred for the

Summary

The author has resumed this

(Imaging Science International,

completion of the diagnostic

Information provided by this

seems to be the most promising

articlefor the purpose of demon-

Inc., Hatfield, PA; USA). The

to take a CBCT at CTdent (2

modern technology represents

applications for diagnosis, treat-

stration

aided

authors positioned the subject

Devonshire Place, W1G 6HJ,

ment planning and treatment

tremendous value to routine

for the scan wearing a plastic

London, see also www.ct-dent.

diagnostic, treatment planning

dental practice.

lip retractor.

co.uk). The CBCT confirmed

as well as evaluation of treatment

the preliminary diagnosis. A

outcame specially for periodon-

CBCT images and 3D recon-

treatment plan has been elabo-

tal applications, especially in

structions allow for visualisa-

rated.

the areas of intrabony defects,

tion and exact measurement of

as such a more comprehensive
impact than the introduction
of panoramic radiography. Of
course on of the most impressive
topic is the availability of software for 3D – reconstruction.
It is of great importance to
mentione that CBCT provides
data at lower cost and absorbed

how

CBCT

1. Use of CBCT in endodontics

with

A 28-year-old female patient

2. CBCT in periodontics

was referred to our practice for

2.1 CBCT and soft tissue

evaluation and treatment plan-

invaluable

milestone

For

endodontics

CBCT

evaluation.

dehiscence and fenestration

dimensions.

ning of the periodontal status.

2.2 CBCT and hard tissue

defects, and periodontal cysts,

on the combination of clinics

In 2008 Januario et al published

No special remarks regarding

Vandenberghe and coworkers

and in the diagnosis of furcation-

and CBCT are a reliable aid in

in the Journal of of Esthetic

medical or dental history. The

researched periodontal bone

involved molars.

planning

Restorative Dentistry (J Esthet

patient has undergone ortho-

architecture using 2D CCD and

Restor Dent 20: 366-374, 2008)

dontic over a couple of years. The

full-volume

CBCT-based

imaging modalities.

Conclusion
1. For periodontology, CBCT
proves to be superior to 2D imag-

Their investigation conclu-

ing for the visualisation of bone

ded that CBCT offered a signifi-

topography & lesion architecture

cant benefit over conventional

as well as for the covering.

and

Diagnosis built

execution

simple as well as advanced
dental procedures. DT
References are available on request.

About the author

radiography. The authors concluded that CBCT can be used
to diagnose the bony support as
well as surrounding soft tissue
and may reveal valuable inforPanoramic view CBCT image showing the advanced bone resorption at the
level of the first upper molars.

mations for example regarding
furcation involvement. A 53
old human patient was referred

The CBCT centre sent along as 3D
reconstruction of the left side.

to our practice for evaluation,
treatment planning and execution. Of major concern was
the first upper molars. After
performing the routine diagnostic approaches such as BOP,
periodontal probing, etc, the
The CBCT confirms the class III furcation involvement.

patient was referred to CTdent
for a CBCT.

The CBCT centre sent along as 3D
reconstruction of the right side.

Dr. med.dent.LiviuSteier is a
visiting professor at the School of
Dental Medicine in Florence;
visiting professr at Tufts School of
Dental Medicine on its endodontic
postgraduate programme; and an
honorary clinical associate professor at Warwick Medical School.
He is a registered specialist in
endodontics (GDC) and spezialist
fuer Prothetik (www.dgzpw.de).
He can be reached at
l.steier@msdentistry.co.uk

[6] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

Practice Management

Four ways to increase case acceptance
Roger Levin, DDS

l Do you emphasize patient

dwell on the negative. We’re

current needs and treatment.

assuming which patients may

starting a new year — a time

Yes, practices should address a

or may not be able to afford

brimming with possibilities — so,

patient’s immediate concerns,

certain cases. Case acceptance

l How up-to-date are your

let’s focus on the one indis-

but there also should be a focus

dramatically increases when

marketing materials? Do they

putable fact that I can’t empha-

on lifelong dentistry that takes

patients see the value in the rec-

promote all of your services,

size enough to dentists every-

a comprehensive view of the

ommended treatment and are

especially cosmetic dentistry

where: Your practice is the best

patient’s dental future needs

presented with a variety of

and implants?

investment you ever made.

and wants. Unfortunately, a high

flexible financial options that suit

percentage of dental appoint-

their budget. Levin Group rec-

Now is the time to re-invest

ments are still single-tooth treat-

ommends that practices use

in your practice by improving

ments. Offering comprehensive

these options:

benefits

‘A pessimist sees the difficulty
in every opportunity; an
optimist sees the opportunity
in every difficulty.’
—Winston Churchill

right

from

the

get-go?

Everyone wants new year to

l Do you offer flexible financial

be better than last one. Well,

options to every patient?

here’s how: improve your system
for presenting treatment to

As you can probably guess,

your system for case presenta-

care to all patients can result

l 5 percent discount for full

patients — especially larger

the majority of the responses

tion. Levin Group helps our

in a significant increase in

payment in advance for larger

need-based and elective cases.

are in the negative. That’s

clients increase case acceptance

production and profitability.

cases,

When I say that to dentists at

because most people, including

with a systematized approach

my Total Practice Success™

dentists, have difficulty accu-

called Greenlight Case Presenta-

seminars, a few attendees will

rately evaluating their perform-

tion. These four “green light”

Focus on benefits right
from the start

inevitably respond, “I’m doing

ance. We all want to believe that

action steps can help you do

Dentists love the technical as-

everything I can, but nothing

we’re doing the best that we

the same.

pects of treatment, but most

seems to work. About the same

can. Of course, we often are,

patients couldn’t care less. They

percentage of patients accept

but sometimes we are not.

Conclusion

treatment year-to-year no matter

Admittedly, changing can be

ment will benefit them. Let’s

Case acceptance drives practice

what I do.”

difficult. It often takes a major

Promote comprehensive
dentistry

just want to know how treattake implants, for example.

success. These four action steps

event, such as the worst eco-

Successful practices take a long-

Patients want to hear how

can help you and your team get

nomy since the Great Depres-

term view of patients’ oral health.

implants will improve their

more patients to say “yes” to rec-

sion, to shake us out of our

Most patients are potential can-

smile, prevent bone loss, in-

ommended treatment. Combat a

complacency.

didates for any number of tradi-

crease their quality of life, etc.

tough economy by increasing

tional and elective procedures,

It’s not that clinical explanations

your case acceptance and give

several

yet too many practices take a

should be avoided entirely,

the green light to more success

educate patients about all

months have certainly been a

shortsighted view and focus

but it’s just that they should be

in 2009!

practice services?

wake-up call, this is no time to

exclusively on the patients’

de-emphasized. Save technical

This is when I start asking
questions

about

their

case

presentations:
l Is

your

team

involved?

Does your hygienist regularly

While

the

past

l credit cards,
l half upfront, half before
completion of treatment,
l outside or third-party financing.

details for later in the case pres-

Dental Tribune readers are

entation, and keep them to a

entitled to receive a 20 percent

minimum unless the patient asks

courtesy on the Levin Group’s

specific questions. Remember,

Total Practice Success™ Seminar

patients generally have one thing

held for all general dentists on

in mind: “What’s in it for me?”

May 28 & 29 in Nashville. To reg-

Only by focusing on benefits

ister and receive your discount,

can

truly

call (888) 973-0000 and mention

motivated. Without motivation,

“Dental Tribune” or email cus-

it’s doubtful patients will move

tomerservice@levingroup.com

forward with treatment.

with “Dental Tribune TPS” in

patients

become

Educate patients

the subject line. DT

Just as billion-dollar corporations run the same TV commercials repeatedly to create product awareness, a practice must

About the author

also educate patients about all
of its services multiple times during each and every visit. Case
presentation shouldn’t be solely
the doctor’s responsibility, each
team member must do his or
her part to educate and motivate
patients about practice services.
In addition, marketing materials
— brochures, posters, infomercials on monitors, etc. — should
be featured in patient areas
throughout the practice.

Present flexible financial
options
Practices can dramatically increase case acceptance by offering a broad array of financial
options to all patients. Many
doctors make the mistake of

Dr. Roger P. Levin is chairman
and chief executive officer of Levin
Group, the leading dental practice
management firm. Levin Group
provides clients with Total Practice
Success, the premier comprehensive consulting solution based on
the implementation of high performance systems. A third-generation dentist, Levin is one of the
profession’s most sought-after
speakers, bringing his Total Practice Success Seminars to thousands
of dentists and dental professionals
each year.

[7] => DTAP0109_01-02_TitleNews

[8] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

Clinical

8

Think Out Of The Box!
Dr. Sujata Goyal, MDS
India

able maturation since its intro-

percussion. Intra-oral periapical

resins or even cast metal frame

ment, but also ease of use and

duction to dentistry in the early

x-rays revealed severe bone loss

works.3-8 However, these materi-

an assortment of widths of the

Teeth have people attached to

1950s by pioneers in the field. In

and a periodontal abscess. The

als could never be chemically

fibers to manage a wide variety

them! And it is never easy to

the last decade only, however,

tooth had a hopeless prognosis

incorporated into the dental

of

break the news about an impe-

our knowledge of adhesive

and a mutual decision to extract

resin and as a result could not

research has demonstrated that

nding loss of a tooth, especially

materials has grown exponen-

it was taken. Nevertheless, the

withstand the repeated loading

the fiber reinforcement architec-

a front tooth, to our patients. The

tially and consequently, there

young patient was heartbroken

in function and parafunction.

ture with RibbondTM enhances

cause of tooth loss or the hope-

has been a significant increase

and didn’t want to let go of her

More bulk was necessary to pre-

flexural strength and flexural

lessness of the situation not

in the role adhesives play in

with-standing, the decision to

daily dental practice. With the

sacrifice the natural tooth alw-

advent of minimally-invasive

ays seems very cruel to the

dentistry, there has been a

patients. Moreover, if the loss

paradigm shift, moving away

is inevitable, every patients want

from metal restorations towards

natural tooth. Idea of a RPD was

vent the failures, which resulted

modulus of the composite resins

an immediate replacement to

adhesive dentistry for the con-

devastating to her. Adjacent

in

and hence resists cracking.9-11

escape the social embarrass-

servation of tooth structure.

teeth didn’t fulfill requirements

collection of plaque, leading

ment of a ‘window’, in their

When minimal tooth structure

of ideal abutment so we couldn’t

to further progression of perio-

smile. And as clinicians we are

is removed, bonded composite

promise her a conventional

dontal disease.

expected to meet patients’ expec-

resins can be placed, which

tooth-retained FPD as well.

tations who seek a fixed, non-

restore the tooth to 90-95% of

Implant was an expensive option

The challenge here was to

extracted (Fig. 2) and the site

invasive, highly esthetic, non-

its original strength and 100%

for her at that time, so we had to

place a thin, but strong natural

allowed to heal for two days.

metallic restoration, which should

of its original appearance.

think out of the box! There are a

looking restoration that was

Complete isolation of the site free

number of reports in the litera-

non-invasive. I’ve been using

of oozing or any moisture is

not also be expensive! All of

clinical

situations.

Also,

“Using the natural tooth as a pontic offers the
benefits of being the right size, shape and color”
difficulty

to

clean,

and

As part of the therapy, complete prophylaxis was carried
out, the tooth in question was

us have faced this challenging

The use of adhesive tech-

mandatory for bonding, so this

situation many a times in our

niques and composite materials

delay was considered necessary.

clinical practice.

reinforced with fiber systems

When the crown of the tooth

allows clinicians to respond to

is in good condition, it can be

Fiber-rein-

easily bonded temporarily to the

rative options to replace missing

forced materials have highly

adjacent teeth with light-cured

teeth are: removable partial

favorable mechanical proper-

restorative material. This tech-

dentures; porcelain fused to

ties, & their strength-to-weight

nique has been used several

metal or all ceramic fixed resto-

ratios are superior to those of

times by us in the past producing

ration; resin-bonded fixed par-

most alloys. When compared to

satisfying results. Using the

tial dentures; or implant-sup-

metals they offer many other

natural tooth as a pontic offers

ported prostheses. However,

advantages as well, including

these restorative alternatives

noncorrosiveness, translucency,

size, shape and color. Moreover,

carry their own limitations

good bonding properties, and

the positive psychological value

such as:

ease of repair. Since they also

to the patient by using his or her

bone

offer the potential for chair-side

natural tooth is an added benefit.

support for abutment teeth

and laboratory fabrication, it is

Extracted tooth to be used as

or placing the implants

not surprising that fiber-rein-

pontic was first of all trimmed

Excessive removal of healthy

forced composites have potential

into the size as per the space

tooth structure for abutment

for use in many applications in

available. The open root canal

preparation, which is consid-

dentistry. Polyethylene fibers

was sealed with composite and

ered to be further mutilation

improve the impact strength,

polished after being shaped

by many patients

modulus elasticity, and flexural

into a modified ridge lap design

Dependence or delay invol-

strength of composite materials.

as this design will meet both

ved in the fabrication which

Unlike carbon and Kevlar fibers,

is not acceptable to people

polyethylene fibers are almost

ments. It was decided that all

who have an active social life.

invisible in a resinous matrix

remaining

lower

They will also need a provi-

and for these reasons, seem to

would

splinted

sional restoration

be the most appropriate and

RibbondTM extending from one

Multiple appointments which

esthetic strengtheners of com-

canine to the other canine as

is normal for the fabrication

posite materials.2

all the remaining mandibular

Various conventional resto-

•

•

•

•

Lack

of

adequate

these

demands.1

the benefits of being the right

Fig. 1

esthetic and hygiene require-

Fig. 2

Repair is difficult and expensive in case of a failure.

The case presented here

to periodontal disease.

illustrates an alternative solution to every day clinical problem

Increased patient demands
cause thus clinicians to seek

Two

days

later

patient

in an attempt to meet rising

reported back with a nicely

demands of our patients.

healed site ( Fig.3). Teeth were

materials and techniques that
enable minimally-invasive ap-

using

incisors were also mobile due

of indirect prostheses
•

be

incisors

thoroughly cleaned on the facial,

Fig. 3

lingual and interproximal sur-

proaches for chair-side applica-

Case report

ture for splinting of the mobile

one brand of fiber reinforce-

faces with pumice paste, finish-

tions. Adhesive dentistry permits

A 38-year-old female patient

teeth and adding a natural tooth,

ment ribbon, RibbondTM for

ing strips and a prophylaxis cup

dental treatment that were pre-

reported to our practice with

an acrylic resin tooth or a tooth

almost ten years with good

to remove any traces of surface

viously considered impossible

pain in the left lower lateral

carved out of composite as a

success. RibbondTM is a bond-

impurities, which could affect

with conventional techniques,

incisor (Fig. 1). On clinical exam-

pontic, connected to the adja-

able, polyethylene, lock-stitch

the adhesion adversely. Requi-

opening new frontiers in mod-

ination the tooth had grade 4

cent teeth with various means

multidirectional reinforcement

red length of the fiber was

ern dental restorations. Adhesion has undergone consider-

mobility, was partially avulsed,
and sensitive to palpation and

such as wire meshes of nylon or
metal, wire ligatures, composite

ribbon that offers not only excellent composite resin reinforce-

measured with the help of well
adaptable soft tin foil provided

[9] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

Clinical

Fig. 6

Fig. 4

9

according to the manufacturer’s

ent but also act as a splint for

instructions (Fig. 5). Then, com-

the adjacent mobile teeth. These

posite resin was placed on the

res-torations are esthetic, non-

middle one-third of the lingual

invasive,

surface from canine to canine.

long-lasting if there is a judicious

Fiber ribbon was embedded

case selection and protocol of

into the composite resin adapting

adhesive dentistry is followed. DT

biocompatible

and

it well onto the teeth surfaces
with the help of a plastic filling

References available on request.

instrument (Fig. 612 and 7).
Excess resin was removed and
then cured for 20 seconds at

About the author

least for each tooth. The ribbon
should remain completely covered with the resin during this
process. Then, composite resin
was shaped, finished and polished to achieve an esthetic
restoration. To ensure longFig. 5

Fig. 7

lasting functional restoration,
occlusion was checked to rule

in the pack. At all times,
plasma-treated

time of use (Fig. 4).

polyethylene

to block the gingival embrasures

out any contact of the opposing

so that excess composite does

teeth in function or at rest.

fiber should be handled with c

All surfaces in the canine to

not flow into the gingival embra-

The restoration done for the

are to avoid contamination. It

canine region were etched for 30

sures. The unfilled adhesive

patient was found to be stable and

should be taken out of the pack

seconds with a 32% phosphoric

resin applied on etched surfaces

functional even after five years.

with clean cotton pliers and cut

acid gel. Teeth were then rinsed

was cured at this point. After

with special RibbondTM scissors.

with air-water spray and gently

this, the extracted trimmed

Conclusion

Another alternative to cut this

dried. The lower anterior area

lateral incisor was placed and

Many a times there is a need

tough fiber cleanly is using a

was isolated with cotton rolls

adjusted in its final position be-

for quick and direct replace-

wire-cutter. After wetting the

and adhesive resin was applied

tween central incisor and canine

ment for a single lost anterior

fiber is wetted with adhesive

with the help of a brush on all

to stabilize it using few drops

tooth. For such cases a fiber

resin, it should be covered to

the etched surfaces. At this point

of flowable resin on its proximal

reinforced restoration not only

avoid light exposure till the

LC block-out resin was used

sides. The resin was cured

meets the demands of the pati-

Dr. Sujata Goyal is a professor and
heads the department of prosthetic
dentistry at Luxmi Bai Institute of
Dental Sciences, Patiala, India and
also conducts courses on implantology. She is practicing since 1988
with special interest in the field of
esthetic dentistry & implantology.
She has published internationally
on bone manipulation techniques
and is a member of the editorial
review board of International
Journal of Clinical Implant
Dentistry. She can be contacted at
seth1964@gmail.com .

[10] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

10 education

The keys to early cancer diagnosis: Careful examination
and timely biopsy
Sara Gordan
DDS, MSc, FRDCDC

oral cavities of sexually active

likely to generate squamous

young adults.1 Nevertheless, the

cell carcinoma.

The young man was just 19

most common risk factors for

A lichenoid drug reaction,

when he came in to see his dentist

oral cancer remain tobacco and

for example, is a reaction to a

after Halloween because of a

alcohol use.

systemic medication that disap-

sore on the side of his tongue. A

pears when the medication is

non-smoker and non-drinker,

The dentist should routinely

withdrawn. Lichenoid reactions

he did not seem to be at risk for

depress the tongue and examine

also can result from contact

cancer, so his dentist decided

the soft palate and oropharynx

with an allergenic material,

to re-check the lesion before

while the patient says “ah.” Even

such as a metal, in susceptible

Christmas. By then the lesion

the act of gagging presents

patients (Fig. 3), and for other

was bigger. When he finally

a momentary opportunity to

reasons.

had a biopsy in January, it was

glimpse the oropharynx and

an

soft palate.

invasive

squamous

cell

There are many reports in

carcinoma.

the literature of cancer arising in
About 90 percent of oropha-

a patient previously diagnosed

Oropharyngeal cancer con-

ryngeal malignancies are squa-

with lichen planus5,6, but some

tinues to claim the life of about

mous cell carcinoma of the

retrospective analyses have con-

one American every hour, ac-

surface mucosa.2 Precancerous

firmed that the original clinical

counting for 7,590 deaths in

mucosal lesions are often white

or even microscopic diagnosis

2008, according to the American

and may appear slightly rough;

of lichen planus was incorrect.7

Cancer Society. Oral cancer

unexplained white lesions are

Apparent malignant transfor-

takes a terrible toll if it is not

often called leukoplakia. Lesions

mation of oral lichen planus

caught early as it can rob its

such as that shown in Figure 1

(OLP) may represent “red and

survivors of the ability to eat,

look rough because the proli-

white lesions that were dysplas-

speak and taste.

ferating epithelium piles up

tic from their inception but that

on the surface, and the thick-

mimic OLP both clinically and

Dentists often fail to detect

ened epithelium hides the red

histologically.”8 Figures 4 and

oral cancer until it has invaded

color of the underlying blood

5 demonstrate this concept.

deeply because it can mimic

vessels.
Warty-looking

common traumatic, infectious

Fig. 1: This rough white lesion was diagnosed on biopsy as moderate epithelial
dysplasia.

verrucous

surface

conditions also may confuse

cancer is detected early enough,

tissues, as seen in Figure 2, are of-

dentists. Many diseases in this

it can be cured; recognized in

ten red and enlarged, and

group are caused by HPV. Benign

its precursor stages, it can even

unexplained red lesions are

members of this group include

sometimes be prevented.

often

erythroplakia.3

verruca vulgaris, the common

Unexplained red lesions are

wart (Fig. 6), which is self-

they have not been shown by

lesion and preserve it en route

The cancer screening exami-

more likely than white lesions

limiting in most patients, and

rigorous

analysis

to the oral pathology laboratory

nation includes looking at and

to be diagnosed as malignancies

condylomata,

warts

to either help or hinder early

(Fig. 8). At the lab, the specimen

palpating the neck, scalp and

when they are biopsied because

(Fig. 7), which can be wide-

cancer detection in the general

is processed on a glass slide

face as well as the mouth and

the

spread in the immuno-sup-

population. Even visual screen-

and diagnosed microscopically.

oropharynx. About two-thirds

causes inflammation & secretes

pressed patient.

ing programs have not been

Usually it takes a week or less

of oral cancers arise in the

molecules that stimulate the

proven to help reduce oral can-

for the oral pathologist to

lateral/ventral tongue and the

formation of new blood vessels.

There are also premalig-

cer deaths, and more study is

finalize the biopsy report.

floor of the mouth, but other

However, both red and white

nancies and malignancies in this

needed in this field.9 Table 1

common sites include the retro-

lesions are capable of represent-

group. Proliferative verrucous

summarizes the currently avail-

molar pad, the tonsillar pillars,

ing malignancy. Malignancies

leukoplakia (PVL) is a multifocal

able adjunctive technologies.

the soft palate & the oropharynx.

may also cause spontaneous

verrucous disease that eventu-

The dentist should thoroughly

pain or paraesthesia. The gen-

ally turns into carcinoma in a

This leaves the dentist with a

moved from the oral cavity

examine the lateral tongue by

eral rule of thumb is that

substantial proportion of cases.

very powerful tool: the biopsy,

should be sent to an oral patho-

gently pulling it forward with

unexplained red, white and/or

Figure 1 may represent a case

which is still the only technique

logist as a biopsy, unless it

gauze, and check the floor of

ulcerated lesions that persist

of PVL. Verrucous carcinoma

that definitively diagnoses oral

results from a routine procedure

the mouth when the patient

for more than 10 days should

is a large warty malignancy

cancer. When coupled with a

such as a gingivectomy for es-

rolls the tongue back against

be biopsied.

that is slow to invade but can

thoughtful patient history as

thetic and functional reasons.

degenerate into squamous cell

well as a thorough head and neck

Most oral pathologists’ services

carcinoma.

examination, it can allow the

are covered by the patient’s

dentist to diagnose oral lesions

medical

with as much confidence as

pathologists will also accept

possible.

biopsies from dentists, but oral

or immune diseases. When oral

Malignancies

called

expanding

of

malignancy

the palate.
Lichen planus, or lichenoid

genital

Fig. 2: This large red mass was a squamous cell carcinoma. The lateral tongue
is the most common site for oral cancer.

Cochrane

The American Academy of
Oral and Maxillofacial Pathology
recommends that all tissue re-

The gagging dental patient

mucositis, has generated heated

is a perennial problem, but it

debate about its premalignant

A number of commercial

is more important than ever to

potential for years.4 It is now

chairside applications such as

make the effort to inspect this

recognized

are

toluidine blue staining, tissue

difficult region. There has been

several conditions that can share

reflectance, fluorescence imag-

A biopsy is simply the removal

three years of specialty training

a recent increase in human

the clinical appearance of lacy

ing and brush tests have ap-

of tissue from a living patient

after dental school and are

papillomavirus

(HPV)-associ-

white lines on a red background

peared on the market in the

for the purposes of diagnosis.

truly specialists in oral disease.

ated squamous cell carcinoma

and also the microscopic feature

past decade, and they are

Whether the dentist uses a

of the base of the tongue and ton-

of a dense T-lymphocyte infil-

intended to help the dentist

scalpel, surgical scissors or

By routinely examining every

sils in young patients, a change

trate along the basement mem-

with early cancer detection.

a surgical punch, the aim is

patient thoroughly for signs of

that is attributed to a rise in
high-risk HPV infection in the

brane. Lichenoid conditions
are probably not all equally

Despite their attractive marketing and their convenience,

to retrieve a piece of tissue that
is representative of the entire

head and neck cancer, and
ensuring that any potentially

that

there

insurance.

General

pathologists receive at least

[11] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

education 11

Table 1: Commercial techniques intended to aid oral cancer detection.

suspicious lesion that persists

Technique

for more than 10 days is appropri-

Example of common

How it works

ately biopsied and sent to an oral

brand name
Toluidine blue vital dye

Orascan

Dyes proliferating tissues blue

pathologist for diagnosis, den-

Tissue reflectance

Vizilite

Enhances the appearance of white areas

tists may indeed save lives.

Tissue autofluorescence

Velscope

Abnormal tissue loses normal green autofluorescence, looks black

Brush test

Oral CDx

Superficial epithelial sample is classified as
positive, negative or atypical

Fig. 3: This lesion looks much like lichen planus, but it arose when the
orthodontic brackets were placed and disappeared when they were removed.
Lesions such as this are called lichenoid mucositis.

Literature
1. Ryerson AB, Peters ES, Coughlin
SS, Chen VW, Gillison ML, Reichman ME, Wu X, Kawaoka K. Bur-

Fig. 6: Verruca vulgaris, the common wart, is a benign discrete warty lesion
that is usually self-limiting. It is caused by some types of HPV. It is more familiar
on the skin, and may spread to the mouth by direct contact.

den of potentially human papillomavirus-associated cancers of
the oropharynx and oral cavity in
the US, 1998-2003. Cancer. 2008
Nov 15; 113(10 Suppl): 2901–9.
2. Marur S, Forastiere AA. Head &
neck cancer: Changing epidemiology, diagnosis and treatment.
Mayo Clinic Proceedings April
2008 vol. 83 no. 4 489– 501.
3. Pindborg JJ. World Health Organization Collaborating Center
for Oral Precancerous Lesions:
definition of leukoplakia and
related lesions: an aid to studies
on oral precancer. Oral Surg
(1978) 46: pp 518–39.
4. Greer RO, McDowell JD, Hoernig
G, Oral lichen planus: a premalignant disease. Pathology Case
Reviews (1999) 4: pp 28–34.
5. Bornstein MM, Kalas L, Lemp S,
Altermatt HJ, Rees TD, Buser D.
Oral lichen planus & malignant
transformation: a retrospective
follow-up study of clinical & histopathologic data. Quintessence
Int. 2006 Apr; 37(4): 261–71.
6. Eisen D. The clinical features,
malignant potential, and systemic associations of oral lichen
planus: a study of 723 patients J
Am Acad Dermatol. 2002 Feb;
46(2): 207–14.
7. Fatahzadeh M, Rinaggio J,
Chiodo T. Squamous cell carcinoma arising in an oral lichenoid
lesion. J Am Dent Assoc. 2004
Jun; 135(6): 754–9; quiz 796.
8. Lovas JG, Harsanyi BB, El
Geneidy AK. Oral lichenoid dysplasia: a clinicopathologic analysis. Oral Surg Oral Med Oral
Pathol. 1989 Jul; 68(1): 57–63.
9. Kujan O, Glenny AM, Oliver R,
Thakker N, Sloan P. Screening
programmes for the early detection and prevention of oral cancer. Cochrane Database of Systematic Reviews 2006, Issue 3.
Art. No.:CD004150. DOI:10. 10 0 2
/14651858.CD004150. pub2. DT

About the author

Fig. 4: This rough white lesion was initially to be lichen planus, but on biopsy
it proved to be a microinvasive squamous cell carcinoma.

Fig. 7: Condylomata (genital warts) are also caused by HPV and may be florid
in immunosuppressed patients such as this one. They are benign.

Dr. Sara Gordon is an associate
professor in the College of Dentistry at the University of Illinois
at Chicago in the Department of
Oral Medicine and Diagnostic
Sciences. At UIC, she is director of
the Oral Pathology Biopsy Service
and director of Oral Pathology
Graduate Education. She is a diplomate of the American Board of
Oral and Maxillofacial Pathology,
a fellow in Oral Pathology and
Oral Medicine of the Royal College
of Dentists of Canada, and president of the Canadian Academy
of Oral & Maxillofacial Pathology
and Oral Medicine. Before becoming an oral pathologist, she p
racticed general dentistry for
nearly a decade.

Fig. 5: This photomicrograph of squamous cell carcinoma demonstrates an
area in which lymphocytes are attacking the overlying dysplastic epithelium,
giving a microscopic appearance that is similar to lichen planus. Such an
inflammatory reaction to dysplasia may explain why some cases are initially
misdiagnosed as lichen planus and later prove to be squamous cell carcinoma.

Fig. 8: Biopsy specimens should be of adequate size (3 mm or larger) and should
be taken from a representative area of the lesion. The dentist should place then
informalin fixative immediately, and then transport them to the oral pathologist
for microscopic diagnosis.

Department of Oral Medicine
and Diagnostic Sciences
801 S. Paulina (M/C 838),
Room 525B
Chicago, Ill. 60612
E-mail: gordonsa@uic.edu

[12] => DTAP0109_01-02_TitleNews

Message from the president

2009 FDI elections

The 2009 FDI Annual World

the need to continue working in

There were two seats open for

available positions, with four

Dental Congress in Singapore

collaboration across the region.

election on the FDI Council,

nominations for Council posi-

has come to a close for another

I will forever cherish the moment

including

tions and 22 nominations for

year. This year’s event ran seam-

I received the presidential chain

and ten seats open for election

lessly thanks to the tireless ef-

from my distinguished collea-

on the Committees at the 2009

Congratulations & welcome

forts of the Local Organising

gue, Past-President, Dr Burton

FDI Annual World Dental

to the following FDI Council

Committee (LOC) & volunteers.

Conrod, in a symbolic change of

Congress. In total, 26 nomina-

and Committee members who

I would like to make a special

FDI presidency. During his term

tions were received for the

were elected in Singapore.

mention of the FDI staff, which

as president, Dr Conrod has sup-

has been working in collabora-

ported important FDI initiatives

FDI President-Elect

tion with the Singapore LOC in

to increase global awareness

FDI Council

addition to relocating the FDI

about oral health issues, inclu-

Councillors

head office from Ferney-Voltaire, Dr Burton Conrod passes the presidential ding Live.Learn.Laugh., the
chain to incoming FDI President
France, to Geneva, Switzerland. Dr Roberto Vianna. (DTI/FDI)
publication of ‘The Oral Health
Atlas’ and the Global Caries Ini-

President-Elect,

Committee positions.

Dr Orlando Monteiro da Silva (Portugal)
Dr Norberto Lubiana (Brazil)

FDI Committees
Communications &
Member Support Committee

Dr Jun-Sik Moon (Korea)
Asst Prof. Dr Nikolai Sharkov (Bulgaria)
Prof. Dr S.M. Balaji (India)
Prof. Dr Vladimer Margvelashvili (Georgia)
Dr Ward van Dijk (The Netherlands)
Dr Armando Hernandez Ramirez (Mexico)
Prof. Dr Georg B. Meyer (Germany)
Dr Claudio Pinheiro Fernandes (Brazil)

The AWDC brought together

Hobdell. The congress provided

tiative. In my Welcome Cere-

107 speakers from many disci-

an ideal forum to further streng-

mony speech, I affirmed my

plines of the dental profession

then FDI’s relationships with

commitment to the continuation

to share knowledge & best prac-

member associations, corporate

of these and other FDI activities.

tices on treatment advances

partners & contributing special-

Later we enjoyed a colourful

with colleagues from around the

ists. During the National Liaison

performance that took the audi-

world. Congress participants

Officer (NLO) Lunch on 2 Sep-

ence through Singapore’s his-

were dazzled with the latest de-

tember, three of four contribut-

tory, represented through dance

velopments in products & equip-

ing authors to “The Oral Health

and music.

ment at the Exhibition, which

Atlas” made a brief presentation

featured more than 130 interna-

about the research involved in

Looking at the year ahead we

tional vendors. During the week,

compiling this new FDI advocacy

have many exciting projects on

The FDI General Assembly

important business meetings

tool, which was officially relea-

the horizon, including upcoming

adopted three new and nine

designed to set the agenda for

sed later that day. I was delighted

events for the Global Caries Initi-

revised FDI Policy Statements

global health advocacy took

to learn as well about the Uni-

ative & the FDI Regional Contin-

at the 2009 Annual World Dental

place, as well as the 2009 FDI

lever announcement: Unilever

uing Education Progra-mme. I

Congress.

Elections. Congratulations to

has renewed its partnership

feel proud to have been given

Council & Committee members

with FDI on the Live.Learn.

this opportunity to serve as FDI

New Policy Statements

who were appointed during the

Laugh. programme for another

President, particularly at a time

• Dentin Hypersensitivity

General Assembly B and Council

three years, to continue develop-

when next year’s AWDC will be

• Edentulism & General Health

C meetings (see 2009 FDI Elec-

ing oral health projects for

in my home country. The 2010

tions). And thank you to outgoing

communities in need.

AWDC Local Organising Com-

• The Use of Academic, Profes-

Tuberculosis and the Practice

mittee has been working steadily

sional and Honorary Titles

of Dentistry were withdrawn at

representatives who have dedi-

Dental Practice Committee
Science Committee
World Dental Development &
Health Promotion Committee

Dr Jo E. Frencken (The Netherlands)
Dr Kevin S. Hardwick (United States) FDI

FDI Policy Statements

Problems of the Elderly

cated their time and expertise

The Welcome Ceremony this

towards welcoming us all in

to the organisation: Dr William

year was a special evening for

Salvador da Bahia next year & I

Revised Policy Statements

O’Reilly, Dr Neil Campbell, Dr

me. Singapore’s Health Minister,

look forward to seeing you there!

• The Association between Oral

Mark Goodhew, Dr Claus Munck,

Mr Khaw Boon Wan, delivered an

Health and General Health

Dr Howard Jones, Prof. Martin

inspiring account of the positive

• Dental Bleaching Materials

Tyas, Prof. Reiner Biffar, Mr

improvements to oral health in

Dr Roberto Vianna

George Weber & Prof. Martin

his country, emphasising as well

FDI President

• Fluoride in Restorative
Materials
• Infection Control in Dental
Practice
• Post-Exposure Prophylaxis for
HBV, HCV and HIV
• Research
The FDI Policy Statements
on Dental Unit Water Lines and

General Assembly B and Open
Forum 1, respectively. FDI

• Effect of Masticatory Efficiency on General Health

FDI launches new Oral Health source book

‘The Oral Health Atlas’ is
published by Myriad Editions

Participants and delegates of

memoration of World Oral

designed to illustrate oral health

lease at congress, the Singapore

(www.myriadeditions.com),

the

Health Day (WOHD) on 12

globally.

texts,

Dental Association announced

which is known for its award-

September, 2009.

colourful maps, graphics and

it would purchase copies of

winning State of the World Atlas

images, along with statistics

‘The Oral Health Atlas’ for

series. More information about

2009

congress

joined

incoming FDI President, Dr
Roberto Vianna, FDI Executive

Using

short

Director, Dr David Alexander,

The annual WOHD is an op-

and facts, the atlas presents a

distribution to public libraries

the atlas, including how to

and authors Roby Beaglehole,

portunity for diverse segments

global picture of oral health in

across the city-state. Other mem-

purchase a copy, is available at

Habib Benzian and Jon Crail,

of the population to reflect upon

a visually intuitive and easy-to-

ber associations have demon-

the official website:

at the FDI Pavillion for the

their own situations when it

understand format.

strated interest in translating

www.oralhealthatlas.org. FDI

official release of FDI’s new
‘Oral Health Atlas’, in com-

comes to managing oral health
and ‘The Oral Health Atlas’ is

Following the official re-

the atlas for readers within their
regions.

[13] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

Worlddental Communiquè 13

FDI head office relocates to Switzerland

Alexander, reported on the
progress of the initiative: “The

The FDI has relocated its global

fied management accounting

and the International Council

response to the Sponsor a Win-

headquarters to Geneva, Swit-

on commercial activities.

of Nurses, which facilitates

dow programme has been signif-

collaboration

icant and I would like to thank

zerland, completing the final

Switzerland was a top con-

integrated

stage of a plan that has been

tender due to its proximity to

several years in the making. The

the FDI’s previous head office,

The new office is walking dis-

driving forces for the move were

which allowed the possibility of

tance from the Geneva Airport,

their generosity.”

logistical and financial: the FDI

keeping the majority of existing

making it convenient for out-

New address of FDI head office:

sought to be in a country where

staff. Furthermore, the city is a

of-town visitors. It has 475 sqm

FDI World Dental Federation

it could conduct business as a

hub for international govern-

of space and has been renovated

single entity—versus the current

mental and non-governmental

to create an open concept

structure of six distinct compa-

organisations such as the United

nies—which could also offer
favourable taxation and simpli-

health promotion.

contributing member associations and individual donors for

New FDI head office in Geneva, Switzerland. (DTI/FDI)

Tour de Cointrin

workspace, with 360 degrees of

Window” programme as a way to

Case Postale 3

Nations, World Health Organiza-

windows. Earlier this year,

raise funds for the move. FDI

1216 Cointrin – Genève

tion, World Heart Federation

FDI introduced a “Sponsor a

Executive Director, Dr David

Switzerland FDI

Avenue Louis Casai 84

What makes dental
professionals smile

FDI/Unilever Poster Award Competition

The Wm. Wrigley Jr. Company has partnered with the FDI World Dental Federation
in the second consecutive edition of the FDI & Wrigley Photographic Award.

tion were announced at a recep-

and Wrigley Photo-

associations in Singapore on 3

graphic Award was

September. They are:

Richard from Tacoma,

• Sagar Abichandani (India)

Washington (also the

— “Evaluation of the Quality of

North America Regio-

Root Canal Fillings in Mumbai,

nal Winner). Richard

India”

The six winners of the 2009 FDI/
Unilever Poster Award Competition hosted by the two organising

Representatives from the FDI and Unilever and the winners of the 2009 Poster
Award Competition. (DTI/FDI)

was awarded an ex-

• Myat Nyan (Japan)—“Effects

• Manisha Kukreja—“Compar-

then invited to present their pos-

pense-paid trip to the

of simvastatin and alpha-

ative evaluation of hand wrist

ters & research to a panel of jud-

tricalcium phosphate combi-

radiographs

cervical

ges, followed by a question &

nation on the early healing of

vertebrae for skeletal matura-

answer session at the congress.

bone defects”

tion in 10–12 yr old children”

All winners received a free regis-

Dr William O’Reilly, Dr Burton Conrod and FDI
and Wrigley Photographic Award regional 2010 FDI World Dental
winner for Asia-Oceania, Pujan. (DTI/FDI)
Congress in Salvador

with

Earlier this year, dental pro-

da Bahia, Brazil.

fessionals from 63 countries

he received a regional prize: a

• Yun-Ching Chang (Chinese

• Mohanad Al-Sabbagh—“Gen-

tration to a future FDI Annual

around the world submitted

voucher worth $1,000 US for

Taipei)—“Study of invasion

etic variations in periodontally

World Dental Congress & 1,500

photographs to the 2009 FDI

photographic equipment, a one-

patterns of oral squamous cell

involved smokers”

& Wrigley Photographic Award

year subscription to the Inter-

carcinoma with a new device

competition, which ran from 16

national Dental Journal, and

of modified grading system”

March to 8 July. The photographs

a year’s supply of Wrigley sugar-

were reviewed by a panel of

free chewing gum.

Additionally,

judges & winners were selected

The other five regional win-

based on their creativity in addr-

ners of the 2009 FDI & Wrigley

essing “what makes you smile ”.

Photographic Award are:

towards his or her participation in the congress.

A FDI/

More than 120 submissions

Unilever Poster Award Competi-

• Victor T.W. Fan—“Alveolar

were received by the FDI for the

tion will be held once again in

Bone Preservation and Aug-

competition this year. The best

2010. More information can be

mentation with scaffold for im-

posters were selected as finalists

found on the FDI website once

plant therapy”

prior to the congress & they were

it becomes available. FDI

Meeting of the Section Defence Forces
“Oral healthcare professionGauteng, South Africa
als play a significant role in
• Asia-Oceania region: Pujan
Dental Services (SDFDS) in Singapore
• Africa region: Sandy from

creating healthy smiles around

from Singapore

the world, and we were thrilled

• Europe region: Jan Eric from

On 31 August, Brigadier Gen-

dental officers to discuss scien-

lenges, this meeting offered

that professionals took the op-

Altstätten, SG, Switzerland

eral (Dr) Benjamin Seet, Chief

tific and military dental issues.

participants an opportunity to

portunity to share what makes

• Latin America region: Gun-

of the Singapore Armed Forces

In his opening address, Brig.

network and share knowledge

them smile”, said Maureen

ther from Cartago, Costa Rica

Medical Corps, officiated at

Gen. (Dr) Benjamin Seet empha-

about advancing military den-

Jones, Wrigley Oral Healthcare

• Middle East region: Neda

the Opening Ceremony of the

sised the relevance of this year’s

tistry and providing better oral

Military Programme for the

theme: Dental Healthcare for

care for soldiers and servicemen.

2009 FDI Annual World Dental

the Next Generation of Armed

Program

Manager.

Winning

from Tehran, Iran

photographs from this year’s
competition were displayed at

Each regional winner re-

Congress. The meeting, which

Forces. With healthcare services

Among the speakers present-

the FDI Pavillion during the

ceived the same regional prize

attracted more than 60 military

of many armed forces transform-

ing at the congress were Colonel

Annual World Dental Congress

noted above. Also, in addition to

dentists from 18 countries,

ing to meet a wider spectrum

(Dr) Tan Peng Hui, Commander

in Singapore. The grand prize/

the regional winners this year,

provided a forum for military

of geopolitical and military chal-

of the Singapore Armed Forces

overall winner of the 2009 FDI

50 other names were chosen at

Military

random from the remaining en-

Major General Zhao Yimin, Vice-

About the publisher

tries to receive a year’s supply

Dean of the School of Stomatol-

Publisher

of Wrigley’s sugarfree chewing

ogy, China Fourth Military Med-

gum (approx. 144 packs). Fin-

ical University; Colonel Robert

ally, for each entry received,

Hale of the US Army Institute of

Wrigley’s Oral Healthcare Pro-

Surgical Research; and Police

gram

donating

Colonel Peter Sahelangi. A wide

$25 US per submission, or up to

range of topics were discussed

Aimée DuBrûle

$25,000 US total, to the FDI

during the two-day Military Pro-

FDI Worldental Communiqué is published by
the FDI World Dental Federation. The newsletter and all articles and illustrations therein are
protected by copyright. Any utilisation without
prior consent from the editor or publisher is
inadmissible and liable to prosecution.

World

Development

gramme, including facial trauma

Fund (WDDF), which supports

care, forensic remains identifi-

Tour de Cointrin, Avenue Louis Casai 84,
Case Postale 3
1216 Cointrin – Genève, Switzerland
Phone: +41 22 560 81 50
Fax: +41 22 560 81 40
E-mail: info@fdiworldental.org
Web site: www.fdiworldental.org

FDI Communications Manager

(WOHP)

Dental

oral health education and projects in low-income countries. FDI

Opening Ceremony of the 2009 Military Programme in Singapore. (DTI/FDI)

Medicine

Institute;

cation, field dentistry and dental
fitness of soldiers. FDI

[14] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

14 interview

“Minimally Invasive Cosmetic Dentistry is
an emerging trend”

first and then only you should
concentrate on the aesthetic
part, which has

again three

areas normally guided by the
patient’s desires.

Interview with Dr. Sushil Koirala, Kathmandu, Nepal
the dental patients have increa-

tistry, hence demand proper

or make-over, we need to start

Although, composites have by

sed drastically and now a glow-

case selections, minimal tooth

treatment by knowing patients’

and large replaced non-tooth

ing, healthy and vibrant smile

preparation (preservation of

PSYCHOLOGY,

colored materials, their long-

is

exclusive

tooth enamel) and selection of

perception,

and

term strength has been an area

domain of millionaires, models

correct luting cements for its

desires. Next job is then to

of concern. In your opinion,

and movie stars only. Therefore,

long-term aesthetics and func-

establishing proper HEALTH

can this issue be addressed

most of the general dentists

tional success. Aesthetically,

(general, specific and dento-

adequately to allow the dentist

are now forced to incorporate

veneers are one of the most

gingival), and after establishing

to use them with confidence

various aesthetic enhancement

acceptable treatment modali-

normal or acceptable health

and assurance?

dental treatment modalities in

ties by the patients.

status of the patient, we should

With my 17 years of clinical

proceed to establish FUNCTION

practice

and involvement in
international

no

longer

an

their daily practices to meet

especially the

personality

the recent aesthetics demands

In addition to the color, shape

(occlusion, phonetic and com-

various

of their patients.

and alignment of teeth, what

fort). In the last, we need to

programs, I have found that,

are the other attributes that

address the AESTHETICS com-

most of the practitioners are not

One of the significant break-

should be evaluated by a cosme-

ponents of smile, and for better

willing to learn or accept the

Dr. Sushil Koirala is the founding

throughs in cosmetic dentistry

tic dentist when planning a smile

understanding of the clinician,

newer developments in dental

president of Vedic Institute of

has been the development of

makeover?

I have divided it into three divi-

material science. By and large,

Smile Aesthetics (VISA) and the

dental veneers. How do you see

When we talk about treatment

sions, namely. Macro-Aesthetics

we follow what we study in

Nepalese Academy of Cosmetic

the acceptance of veneers both

planning for any smile make-

(Facial), Mini-Aesthetics (Dento

our graduations, but it is a

and Aesthetic Dentistry & South

among dentists and users?

over case, there are a couple of

–Facial) and Micro-Aesthetics

fact that development in dental

Dr. Sushil Koirala

Asian Academy of Aesthetic Dentistry. He maintains a private
practice emphasising on minimally invasive cosmetic dentis-

“The case selection is very important
while using composite resins”

CDE

materials sciences is very rapid
and we must have proper
information about it to provide
better patients care.

try. Dr. Koirala has developed
the “Vedic Smile Concept”,

It is not the dental veneers that

things that we need to keep in our

(Dento-Gingival). Then the sub-

There are composites resin

the “Smile Design Wheel” and

is the breakthrough, I believe

minds before we start the proce-

jective choice of the patient

restorative materials with better

various clinical techniques for

it is the development of dental

dure. It’s been almost two years

plays a vital role and as per his/

physical and aesthetics proper-

direct aesthetic restorations.

adhesives in dentistry, which

now that I have developed a

her desires, we should carry

ties available now in the market.

He has

authored “A clinical

have opened up the doors for

“Smile Design Wheel” concept

out the necessary aesthetic

The case selection is very impo-

guide to Direct Cosmetic Resto-

various treatment modalities

which explains about simple

enhancement procedures. So

rtant while using composite

rations with Giomer” and also

in aesthetic dentistry.

steps in smile design or make-

the “Smile Design Wheel” proto-

resins. In the posterior heavy

over. I hope you have heard

col guides you to design a

load bearing areas, I still prefer

about PHFA-Pyramid of smile

healthy, well-balanced (force

to go for indirect tooth-colored

components) & aesthetic smile

onlay or inlay, however, in most

with high patient satisfaction.

of the anterior aesthetic cases

conducts hands-on programs
and delivers lectures, globally.

Dental veneers are one of

DT India Editor Isha Goel

the most technique-sensitive

design. If

spoke with Dr. Sushil Koirala

procedures in aesthetic den-

you a bit here. In smile design

not, I will explain

about aesthetic dentistry.

direct composite resins are a

What advice would you have

good alternative to ceramic

Isha Goel: How’s aesthetic den-

for clinicians who often are

restorations.

tistry evolving as an application

perplexed about how to balance

to become a necessary aspect

aesthetics with function?

As aesthetic dental procedures

of the general dental practice?

Personally I see, nowadays in

are highly technique sensitive,

Dr. Koirala: Today, with an

cosmetic dental practice, the

do you think that the selection of

increased media coverage and

function and health is being over

dental material play a significant

availability of free web-based

shadowed by the aesthetics

role in success of these treat-

information on cosmetic den-

component, and it is a great

ment? If so, can you please

tistry, the public awareness on

concern to many of us, who

suggest some guidance which

smile aesthetics has increased

advocate healthy and functional

can

a lot. People now know that

aesthetics in cosmetic dentistry.

product selection?

smile aesthetics play a key role

It is to be noted that aesthetics

You are very correct that, aes-

in their sense of wellbeing,

without health and function is

thetic dental procedures are

social acceptance by others, suc-

a case failure in dentistry. So

highly technique sensitive, and

cess at work and in relationships

when you take up any cases

selection of dental materials

and the level of their self-confi-

for

as per the case type plays a

dence. The aesthetic expecta-

you must follow the sequences

tions, desires, and demand of

of – Psychology-Health-Function

aesthetic

enhancement,

help

practitioners

in

significant role.
If you go through the literature about physical properties
of dental hard tissues and
corresponding biomaterials, it
suggests,

dentin structure of

the natural tooth

has similar

physical (elastic modulus, thermal expansion coefficient and
ultimate tensile strength) and
optical properties as that of

[15] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

interview 15

“Aesthetic procedures are highly
technique sensitive”

hybrid composites and natural
enamel with fieldspathic ceramics. Whenever possible, I

smile aesthetics, then learn
basic aesthetic dentistry skills
and always start with a simple
case and move towards more

suggest clinicians to follow the
above findings, but in practice

Do you have any suggestions

ponent. We must understand

so that one day your practice

complex one. I wish you success

it may not always be possible, so

for our readers, who have

that there is no shortcut in

will have beautiful Smile Art

and joy. DT

the natural optical properties

interest in incorporating cos-

the art; i.e. cosmetic dentistry

Gal-lery which will give you

and load-bearing status of the

metic

requires a lot of dedication. I

full satisfaction in future. As far

Thank you very much for the

tooth lesion need to be analyzed

practice?

think that any work related to

as incorporating the cosmetic

interview.

properly to select the appro-

Cosmetic dentistry is a science-

the cosmetic dentistry is a piece

dentistry in your practice is

priate aesthetic bio-restorative

based creative work, which is

of art, and, hence suggest you to

concerned, first you need to up-

materials.

dominated much by the art com-

document each of your artwork,

grade your knowledge about

How’s the use of lasers in cosmetic dental practice being
perceived by dentists as a more
comfortable and convenient tool
they could possibly offer to their
patients?
Personally I feel that, there are
many

treatment

modalities

available in cosmetic dental
practice and you can use various
techniques and protocols as
well as various equipments
as per your comfort and affordability. The major concern area
is the evidence that you need to
search for before you use any
new equipment, protocols or
techniques. Certainly, laser has
some definite advantages over
conventional techniques, but I
suggest the clinicians to perform
a need analysis before buying
any costly new equipment for
the practice.

From your experience, what
are the recent trends in the field
of cosmetic dentistry? What
expectations do you have for
the future?
Thank you very much for asking
one of the most relevant questions in cosmetic dentistry. If I
have to reply to this question
in a simple and short manner,
I will just say Minimally Invasive
Cosmetic

Dentistry

(MiCD)

is an emerging trend. This is
the reason that the South Asian
Academy of Aesthetic Dentistry
(SAAAD) has accepted the MiCD
as an emerging

trend and is

keeping it as its conference
theme for first biennial scientific
meeting to be held in Nepal on
November, 28-29. I think we
have to

move

towards the

minimally invasive technology
in dentistry and respect the
long-term health, function and
aesthetics of the oral tissue.
In future, I expect more digital
technology

available for the

early assessment of the oral
diseases, defects (functional and
aesthetics) to match patient’s
desires alongwith more options
in aesthetic biomaterials.

dentistry

into

their

[16] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

16 Clinical

Case report: Middle mesial canal
Siju Jacob shows why it pays to be aware of the possibility of a third mesial canal when treating mandibular molars
Abstract

rate portal of exit. The incidence

Failure to recognise and treat

of middle mesial canals varies

aberrant canal anatomy can af-

from 1 to 15 per cent 3. (See

fect the prognosis of endodontic

Table. 1).

therapy. This case report shows
a variation in conventional ana-

This article will illustrate the

tomy in mandibular first molars.

clinical management of the mid-

A third mesial canal may be

dle mesial canal.

present between the Mesiolin-

Fig. 1

Fig. 2

gual and Mesiobuccal canal in

Case report

Mandibular molars. A clinician

A 27-year-old male patient re-

Table 1: Prevalence of a third canal in the mesial root of Mandibular Molars according to different authors.

should be aware of the possibi-

ported to the clinic with chief

(Courtesy Navarro et al3 )

lity of this extra anatomy when

complaint of food impaction in

Authors

Year

No. of teeth

Method

Three Canals (%)

treating mandibular molars.

the right mandibular posterior

Skidmore and Bjorndol

1971

Vitro

tooth for the past four months.

Pineda and Kuttler

1972

300

Vitro

There was no history of pain.

Vertucci

1974

100

Vitro

A comprehensive knowledge of

His past medical history was

Pomeranz

1981

100

Vivo

canal anatomy and its variations

non-contributory.

Martinez-Berna and Badanelli

1983

1418

Vivo

1.5

Fabra-Campos

1985

145

Vivo

2.1

Fabra-Campos

1989

760

Vivo

2.6

Goel

1991

Vivo

Introduction

is essential to ensure consistency
in endodontic therapy. Variations
from

conventional

Clinical examination revea-

anatomy

led a large carious lesion in the

are encountered occasionally in

right mandibular first molar

all teeth. Inability to recognise,

tooth (see Fig. 1). The tooth was

access cavity was prepared. Ini-

detect and treat this additional

not tender to percussion and

tial access revealed two mesial

anatomy can lead to failure

probing depths were within

canals and one distal canal (see

All canals were cleaned

with a layer of Cavit (3M ESPE,

of endodontic therapy.1

normal

Radiographic

Fig, 3). On closer examination

and shaped (see Fig. 8) using

Germany) followed by glass

examination revealed a large

with a surgical microscope

Protaper (Dentsply Maillefer,

ionomer cement (Fuji VII, GC,

In mandibular first molars,

radiolucent lesion in relation to

(Zeiss Germany) a ledge of

Switzerland) and hand files.

Japan).

the normal anatomical pattern

the first molar (see Fig. 2). A

dentin was found between the

The Middle mesial canal was

The patient was recalled

consists of two mesial canals and

diagnosis of chronic apical

mesio- buccal and mesio-lingual

confluent with the Mesio buccal

two weeks later. The calcium

one or two distal canals.2 How-

periodontitis was made. Treat-

canals (see Fig. 4). The ledge was

canal. Canals were irrigated

hydroxide was removed (see

ever, a third mesial canal may

ment options were discussed

removed

ultrasonics

with 5.2 per cent sodium hypo-

Fig.

be occasionally present between

with the patient and Endodontic

(Proultra, Maillefer, Switzer-

chlorite, 17 per cent EDTA and

obturated using gutta percha

the mesio-buccal and the mesio-

therapy

land) (see Fig. 5). Removal of

two per cent Chlorhexidine.

and AH plus sealer (Dentsply

lingual canal. This is referred

of choice.

the dentinal shelf revealed an

Canals were dried using paper

De- Trey, Germany) in warm

isthmus (see Fig. 6). Troughing

points and a calcium hydroxide

vertical condensation. The ac-

limits.

was

the

treatment

to as the middle mesial canal.

using

middle mesial canal (see Fig. 7).

canals (see Figs. 9 a and 9b).
The access cavity was sealed

10).

The

canals

were

The middle mesial canal maybe

After local anesthesia and

of this isthmus with ultrasonics

paste (Apexcal, Ivoclar Vivadent,

cess cavity was sealed and the

confluent or may have a sepa-

rubber dam application, an

under magnification revealed a

Switzerland) was placed in the

core buildup done using a dual

Fig. 3

Fig. 4

Fig. 5

Fig. 6

Fig. 7

Fig. 8

Fig. 9a

Fig. 9b

Fig. 10

Fig. 11

[17] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

Clinical 17

Fig. 13

Fig. 14

About the author

missed anatomy.10
Fig. 12

The use of the surgical operAn extra mesial canal known

ating microscope has vastly en-

as the middle-mesial canal has

hanced the quality of Endodontic

been documented by numerous

therapy.11,12 Magnification cou-

researchers.3-9 The percentage

pled with coaxial lighting gre-

The biologic objectives of endo-

varies from one to 15 per cent.

atly enhances visualisation and

dontic therapy include removal

The majority of middle mesial

the potential to discover addi-

of all potential irritants from

canals will merge with either

tional anatomy.

the root canal space and the

the

control of infection and peri-

lingual canals. Rarely, they may

The use of ultrasonic tips

in Mandibular molars is one

apical inflammation. Complex

have a separate apical portal

for precise cutting has gained

such variation. Knowledge of

root canal anatomy can pre-

of exit.

favour among clinicians in the

anatomical variations and the

last decade. Ultrasonics in con-

techniques to discover and man-

cured resin (Luxacore, DMG,
Germany) (see Figs. 11 to 15).

Discussion

mesiobuccal

or

canal anatomy can occur in any
teeth. The middle mesial canal

mesio-

vent achievement of endodontic

Fig. 15

goals. It is important to debride,

Numerous techniques enable

junction with the surgical micro-

age these variations will signifi-

disinfect and obturate as much

the clinician to look for the

scope (Microsonics) greatly enh-

cantly enhance the prognosis

anatomy as possible. A missed

middle mesial canal. It is impor-

ances the clinician’s ability to

of endodontic therapy. DT

canal can lead to failure of

tant to have an adequately

locate extra canals.13

Endodontic therapy.1 Therefore

flared access cavity to visualise

every effort must be made to

the anatomy of the chamber.

Conclusion

locate additional canals if any.

Constricted access can lead to

Variations in conventional root

References available on request.

Dr Siju Jacob BDS MDS maintains
a private practice limited to Endodontics in Bangalore, India. In
addition, he conducts handson courses in Endodontics and
Microscopes for general practitioners and Endodontists at his
center at Bangalore. He can be
reached at drsiju@gmail.com or
through his website, www.rootcanalclinic. com.

[18] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

18 trends & applications

Miniscrews—a focal point in practice
Six-part series by Dr Björn Ludwig, Dr Bettina Glasl, Dr Thomas Lietz & Prof. Jörg A. Lisson—Part II
Basic information
on the insertion of
miniscrews

noted that this information is

Preparing for insertion

General notes on insertion

The insertion of a miniscrew

Accurate pre-operative planning

is a very simple and rapid thera-

is a basic requirement for suc-

peutic measure. Although there

cessful treatment with mini-

are several methods that will

screws. Such planning includes

yield good results, successful

a comprehensive anamnesis and

insertion requires adherence

an accurate assessment of the

to a few important principles.

findings. It is essential that

The following text details those

the treatment be thoroughly

insertion steps that offer a high

explained to the patient. Pro-

degree of safety for both patient

per hygiene must be ensured

and dentist (see checklist for

throughout the entire opera-

insertion below). It should be

tion. Both the dental chair and

generalised and must be adapted
to individual circumstances.

Fig. 2.1: X-ray positioning aid (X-ray pin, FORESTADENT) shown in situ in relation
to the adjoining tooth axes.

the treatment process must be

must be at least 2.6 mm from

depending on the positioning

Checklist for insertion

prepared with this in mind.

each other. Thus, the bone

of the X-ray tube, object, film,

Pre-operative planning and pre-

During

status and the longitudinal

and/or sensor, all types of

paration:

miniscrew, adherence to all

axis of the insertion site must

X-ray

• planning documentation (X-ray,

hygiene

be carefully evaluated.

may yield some optical distor-

situational models);

the

insertion

measures

required

for an invasive procedure, such

devices

and

images

tion. Interpretation of images

• marking of the muco-gingival

as a sterile work environment

Basic information regarding

can thus lead to false-negative

line and tooth axes on the model,

and gloves, must be ensured.

this is obtained by carrying

or false-positive results (Figs.

determining the site of insertion;

All instruments required for

out

the

2.2a–c). Therefore, the place-

and

insertion must be checked for

model. It often helps to mark

ment of a miniscrew should

completeness,

functionality,

the vertical axis of the teeth

always be based on the clinical

preparation of the workstation.

and sterility. The patient may

and the progression of the

findings. If a miniscrew is

Anaesthetic and assessment of the

rinse with a disinfectant solu-

muco-gingival

insertion site:

tion, or a suitable disinfectant

model, based on the clinical

area in which there is no

• anaesthetic;

can be locally applied. The

and radiological findings. This

risk

• use of X-ray aids; and

patient should then be positioned

will allow for an improved

nerves, or blood vessels (e.g.

• control image.

to ensure a clear view of the

assessment of the spatial cir-

into the palate just behind

Selection of the screw:

operational area and ergo-

cumstances

the

• measuring of the thickness of the

nomically facilitate insertion

with the X-ray image. To assist

the two canines), the position

for the treating dentist.

the accurate determination of

of the screw may be freely

of the adjoining teeth should

the insertion site, X-ray aids

chosen (Figs. 2.3a–c).

be retained. For this reason,

• sterilisation of the instruments &

mucous membrane (optional);
• determination of the length; &

measurements

line

the

combination

be
of

inserted
damage

transverse

into
to

line

roots,

linking

Figs. 2.2a–c: The top image shows
the initial situation. An X-ray
pin was inserted into the first and
second quadrants of the upper
jaw (in the 6–5 region) to check
the bone site, followed by the miniscrew. Both screws were inserted
in a manner that is clinically safe,
but the X-ray images show damage
to the adjoining root in the righthand quadrant, indicating a falsepositive initial interpretation of the
situation.

• determination of the type of screw.

Pre-operative planning

(Fig. 2.1) are available. Although

Transgingival penetration:

To function correctly, a mini-

their use facilitates the selection

Anaesthetic

are recommended:

• excision of the mucous membrane

screw requires firm anchorage

they

During the interradicular inser-

a) a

or perforation with the screw.

in the bone (primary stability)

cannot replace other diagnostic

tion of a miniscrew, the sensitiv-

approximately 0.5 ml anaes-

Preparation of the bone site:

and the positioning of its head

measures. This is because,

ity of the periodontal tissue

thetic (Figs. 2.4a & b); and

• optional marking of the bone; and

in the denser gingival tissue

• perforation of the cortical bone

(gingiva alveolaris). The selec-

or deep pilot drilling, depending

tion of the insertion site must

on the type of screw.

take clinical and para-clinical

Insertion of the miniscrew:

findings into account (X-ray

• manually or by machine.

image, model), as well as the

Start of orthodontic measures:

goal of the treatment and the

• attaching & fixing of the linking el-

resulting

ements.

orthodontic

the

insertion

site,

the following two procedures
low-dose

injection

appli-

ance. For interradicular inser-

Post-operative care:

tion, a bone thickness of at

• notes on care and behaviour; and

least 0.5 mm around the minis-

• check-up dates.

crew is required. This means

Removal of the miniscrew:

that

• removal of the linking elements; &

an—for many reasons—optimal

• removal of the miniscrew.

diameter of 1.6 mm the roots

for

miniscrew

with

Figs. 2.4a & b: Injection pen with needle and anaesthetic cartridge, and injection
of anaesthetic.

Figs. 2.3a–c: The clinical image shows two miniscrews inserted into the palate in the safe zone to the distal side
of the transversal line linking the two canines. The FRS and the PA image confirm the bone support in the insertion region.

Figs. 2.5a & b: Superficial anaesthetic device in pen form with cartridge, and
application of superficial anaesthetic.

Fig. 2.6: Measuring of the thickness
of the mucous membrane in the direction of insertion. (Photo: Dr Pohl)

[19] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

Figs. 2.7a & b: Diagrams showing the thread mechanisms: self-cutting and selftapping.

trends & applications 19

Figs. 2.8a & b: Pre-drill with a 4 mm long blade and limit stop: Drill
(FORESTADENT) and tomas-drill SD DENTAURUM.

Fig. 2.9: Sterile miniscrew supplied in
pin-holder (tomas-pin, DENTAURUM).

b) the induction of superficial
anaesthesia of the mucous
membrane at the insertion
site, for which a topical
anaesthetic gel is suitable
(Figs. 2.5a & b). No general
anaesthetic is ever required
for this procedure.

Figs. 2.10a–d: Preparation of the work rack and removal of the blades.

Choice of screw

part outside the bone. The

6, 8 or 10 mm; and

through gingival tissue, which

rotational speed (at approxi-

Measuring of the thickness

various dimensions must be

• in the lower jaw: usually

must thus be perforated during

mately 30 rpm–1) and with as

of

taken into account.

insertion. Two methods are

uniform a torque as possible.

the

mucous

membrane

6 mm or 8 mm.

(optional).

used for the perforation of the
The thickness of the bone

Determination of the type of
thread

gingival tissue:
tissue; or

Manual insertion

A pointed sensor with an

in the direction of insertion

attached rubber ring is used to

determines the required length

Self-cutting miniscrews require

measure the thickness of the

of the miniscrew:

pre-drilling (also known as

b) direct insertion of the screw

several lengths for the manual

gingival tissue in the direction

• bone thickness > 10 mm:

pilot drilling) appropriate to

through the gingival tissue.

insertion of the screws. Because

of insertion (Fig. 2.6). This

miniscrews with a length

the length and diameter of

information

of up to 10 mm are to

the screw, as well as to the

There are currently no pub-

pose the risk of attaining a very

be used;

quality of the bone. A self-

lished studies that investigate

high torque during insertion.

may

be

useful

when determining the final

a) excision

of

the

gingival

Manufacturers supply various
screwdrivers and blades in

of their dimensions, long blades

length of the screw and possibly

• bone thickness < 10 mm and

tapping miniscrew will find its

the effect of these two methods

Thus, insertion must be carried

when inserting the miniscrew.

> 7 mm: miniscrews with

own way into the bone and

on post-operative problems,

out carefully to avoid breaking

When choosing the length, the

a length of 8 mm or 6 mm

requires no pre-drilling (Figs.

histological effects, and/or the

the miniscrew. Torque ratchets

bone repository and the thick-

are to be used; and

2.7a & b). Bone is more or less

loss rate of miniscrews.

are available for use with some

ness of the mucous membrane
in the direction of insertion

• bone thickness < 6 mm:
miniscrews cannot be used.

play a role; in the retromolar

systems (e.g. tomas, DENTAU-

elastic depending on site, age,
and structure. However, the

Preparation of the bone site

screw diameter, the thickness

Protection

is

which provide a certain amount

of

the

bone

RUM; and LOMAS, Mondeal),

section of the lower jaw and

The following guidelines aid

of the cortical bone, and the

an important aspect. Insertion

of control over the insertion

in the palate, the thickness of

in selecting the length:

hardness of the bone at the

without pre-drilling results in

torque.

the mucous membrane is often

• in the buccal region of the

insertion site limit the extent

tensional

more than 2 mm. The part of

upper jaw: 8 mm or 10 mm;

to which this method can be

bone, which may lead to post-

Machine insertion

the miniscrew inside the bone

• in the palatinal region (de-

used.

pre-drilling,

operative complications. Partic-

Machine

the bone will be strongly com-

ularly in the case of crestally

a surgical treatment unit (the

pressed during insertion and

placed screws, bone displace-

torque of which can be con-

thus suffer a related tension

ment may result in a severe

trolled) or at least a low-rpm

stress. This may result in the

expansion of the periosteum.

dual green handpiece. Accurate

cracking of the bone around

The thickness of the cortical

setting of the torque and the

the insertion site. When the

bone, especially in the lower

number of rotations is required;

screw is screwed into the bone,

jaw, can have a significant effect

the rotation rate should not

it is subjected to high loads.

on the torque of the screw. To

exceed 30 rpm–1, & the torque

Depending on the bone quality,

ensure that the screw is not

must be restricted to the maxi-

the resistance against insertion,

overloaded during insertion,

mum load limit of the screw.

and the continuity of the rota-

the

tional movement, high torsional

anterior lower jaw should be

forces can result. In regions

perforated by pre-drilling as

to achieve a consistent torque

with thick cortical bone and

mentioned earlier. Pre-drilling

during insertion but means

a much looser bone structure

should be done at a maximum

that the operator loses percep-

(e.g. the upper jaw), the use of

of 1.500 rpm–1, using a short

tion of the bone. During manual

self-tapping screws is recom-

pilot drill and water-cooling

insertion, it is possible to per-

mended. In regions where the

to reduce the risk of damaging

ceive the interaction between

cortical bone is thick and the

the root (Figs. 2.8 a & b).

the screw & the bone by tactile

must be at least as long as the

pending

on

the

region):

Without

stress

compact

within

bone

of

the
requires

the

bone structure is dense (e.g.

Figs. 2.11a–f: Preparation of the instruments and insertion of two miniscrews
into the palate by machine.

insertion

Machine

insertion

helps

senses. Insertion by machine is

the anterior lower jaw) both

Insertion of the miniscrew

self-cutting and self-tapping

The miniscrew must be removed

screws may be used, in each

from its sterile packaging (Fig.

case following perforation of

2.9) or the work rack (Figs. 2.10

the compact bone.

a–d) without contamination.

As no healing phase is required,

The thread of the screw may

load may be placed on the

Transgingival penetration

not be touched. The screw

The miniscrew must penetrate

should be inserted at a constant

shown in Figures 2.11a–f.
Attaching the orthodontic
linking elements

‡ DT page 21

[20] => DTAP0109_01-02_TitleNews

trends & applications

Piezosurgery—precise and safe
new oral surgery technique
Dr Markus Schlee Germany

high demands on the prosthetic
finalisation of dental implants.

site preparations.

Piezosurgery is a new and

Its precision allows excellent

Sinus floor elevation

modern bone surgery technique

results and tissue conservation

Bone ridge splitting, harvesting

for periodontology and implan-

accelerates the healing process.

techniques, and sinus elevation
are particularly important tech-

tology. Piezosurgery has thera-

niques

for

implantologists.

peutic features with several

Piezo-electrical surgery is a

advantages over conventional

relatively new surgical tech-

Sinus floor elevation is usually

surgical methods. The technol-

nique and offers considerable

the most effective therapy for

ogy enables a micrometric cut

advantages over conventional

augmenting the atrophic poste-

methods of bone surgery. Based

rior maxilla with bone mass.

on adjustable, two-dimensional

Perforation of the Schneiderian

ultrasonic oscillation, the tech-

membrane is a risk with tradi-

nology

tissue-specific

tional procedures during prepa-

cutting characteristics. With an

ration of the window or during

operating frequency of 25–30

the elevation stage. Piezosurgery

kHz, the device cuts hard tissues,

can reduce this risk to a mini-

while preserving sensitive soft

mum. An intact membrane is a

tissues. Adjusting the working

precondition for stabilising the

tip OT 1

tip OT 5

tip EL1

tip EL2

offers

tip EL3

Fig. 1

Fig. 2

Fig. 3

Fig. 4

Fig. 5

Figs. 1-5: Sinus floor elevation: initial dissection of the membrane with the tip ElI.

that is uniquely precise and

frequency settings and different

graft. Different tips are there-

secure, limiting tissue damage,

tips, helps to adapt the system to

fore available for performing

especially to surrounding soft

different surgical techniques,

various surgical procedures, to

tissues. A selective cut is possible

such as dental extraction, bone

achieve an optimal result. The

because of different ultrasonic

grafting, osteogenic distraction,

selective cut makes it impossible

frequencies, which only affects

endodontic surgery, alveolar

to injure the membrane while

hard (mineralised) tissues, spar-

nerve decompression, and cyst

preparing the window. In prac-

ing fine anatomical structures.

removal. In particular, dental

tice, the osteoplasty OT5 tip is

The intra-operative field re-

implants often require precise

recommended for the prepara-

mains almost free of blood. With

osteoplastic

to

tion of the window in case of a

piezoelectrical surgery tech-

guarantee proper positioning.

thin bone wall. In cases with

niques, bone harvesting (chips

Owing to its high accuracy

thick bone, the osteoplasty

and blocks), crestal bone split-

(micrometric cut) and tissue-

OT1 tip is indicated for bone

ting, and sinus floor elevation

conserving properties (selective

reduction, and the OT5 tip

can be performed easily and
safely. Piezosurgery meets the

cut), Piezosurgery is the method
of choice for critical implant

thereafter for bone cutting. After
elevation of the membrane

restoration,

[21] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

tip OP1

trends & applications 21

tip OP3

Fig. 6: Harvested bone chips with a size of 500 mm show best results in bone
regeneration.

Fig. 7

Fig. 8

limits. In these cases, bone

pressure trauma, especially in

blocks achieve better results.

D1 bone. Therefore, Piezosur-

Classical donor areas for the

gery is also beneficial when used

blocks are the chin, linear

for preparations of dense mine-

oblique, and crista iliaca. The

ralised bone.

osteotomy has a disadvantage

tip OT7

Fig. 9

tip OT8L

tip OT8R

Figs. 7-9: Prepared bone block.

when using conventional proce-

Conclusion

dures: the horizontal osteotomy

With Piezosurgery, an innovative

needs a large area to be uncov-

technique for dental surgery is

ered, to provide the clinician

available. It can be used as a

with good access to the opera-

concomitant procedure or, to

tional site and to protect sur-

some extent, to displace conven-

rounding soft tissue. With Piezo-

tional techniques. It is espe-cially

surgery, this approach is easier,

useful for implant procedures,

as the low operational ampli-

which

tude of the tip requires only

actions and benefit from the high

a small access area. The optimal

accuracy and tissuepreserving

cooling effect and the selective

properties of this method.

demand

precise

cut protect neighbouring soft
Fig. 10

tissues and ensure that no

Fig. 11

injury occurs (Figs. 7–9).
(Fig. 6) are the perfect material

Fig. 12
tip OT7

Figs. 10-12: Piezosurgery is also successfully used in bone splitting.

2 mm around the limits of

helps to dissect the membrane

the window, the Piezosurgery

(Figs. 1–5).

EL2 and EL3 elevation instrumatic pressure of the elements

Bone harvesting (chips
and blocks)

applied via the cooling solution

Bone chips with a size of 500 m

ments are used. The hydropneu-

for osteoconductive bone regen-

Bone splitting

eration & show the best results.

For the placement of dental

The chips serve as a guiding

implants, the bone splitting

structure and thus facilitate

technique can be used in cases

bone regeneration. Piezosurgery

in which there is sufficient bone

is well suited for harvesting

height but insufficient bone

appropriate autogenous bone

width. In this case, Piezosurgery

chips. Gently scratching along

shows good results as well. With

the surface of the bone, using

an osteotomy tip OT7, the bone

osteoplasty OP1 to OP3 tips, can

can be separated non-traumati-

harvest sufficient bone chips.

cally (Figs. 10–12). An extension

About the author

can be completed by the use of
Bone chips are not in any

osteotomes. Piezosurgery lowers

case the best material for bone

the risk of bone fractures and

regeneration. In horizontal or

the bone becomes more elastic

vertical augmentation proce-

after extension. However, during

dures, bone chips show their

bone splitting there is a risk of

Dr. Markus Schlee can be reached
at mectron@mectron.com

Editorial note: The next edition of Dental Tribune India will feature Part III - Miniscrews - a focal point in practice.

 DT page 19

the linking elements have been
removed, the miniscrew may
be removed with the same
tools used for insertion. The
resulting wound requires no
special care & usually heals
within a short time. DT
Fig. 2.12: Linking of the miniscrew
to the orthodontic appliance.

Figs. 2.13a–c: Miniscrew in place, after removal, and following a four-week healing period.

miniscrew immediately after

linking

insertion must be regularly

cheeks

insertion. The selected linking

between 0.5 and 2 N (about 50

reviewed during the entire

otherwise the screw may be

element must be prepared acco-

and 200 g).

time that the miniscrew remains

prematurely lost.

Contact Info
element

should

rdingly and attached to the

in place. The patient must be

should

avoided,

Removal of the miniscrew

head of the screw (Fig. 2.12).

Basic post-operative care

informed that any manipulation

To avoid damage to the teeth

The healing of the gingival

of the screw head with the

A miniscrew can be removed

to be moved, the load on the

tissue and hygiene status after

fingers, tongue, lips, and/or

under local anaesthetic. After

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@kieferorthopaed
i e- mosel.de

[22] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

22 trends & applications

Papilla reconstruction revisited – A new approach
Dr. Mahesh Lanka, Dr. Sangeeta Dhir
India

and associated blood vessel

3-5 mm to achieve ideal implant

branch. The branches from

localization & appropriate space

Optimal esthetics for implant-

the bone and oral soft tissues

for the peri-implant sulcus to

supported restorations in the

only provide blood supply to the

form.7

anterior maxilla may be more

peri-implant mucosa. In natural

difficult to obtain than implant

teeth the gingival vasculariza-

Soft tissue quantity and quality

osseointegration. The ability

tion is derived from the branches

The documented literature una-

to predictably preserve or repro-

originating from the interdental

nimously states that sufficiently

duce inter-implant papilla is

septa, periodontal ligament and

extremely important in the

oral mucosa. Further, the peri-

replacement of maxillary ante-

implant mucosa contains a high

rior teeth. The presence of

amount of collagen and low

inter-proximal papilla around

number of fibroblasts. There-

implant-supported restorations

fore, the peri-implant mucosa

allow symmetrical soft tissues

can also be considered as “scar-

margins and a state of harmony

like tissue”.

between

natural

teeth

and

dental implant components.1
This harmony & tissue symmetry
lead to natural looking restoration that does not obscure

Fig. 1: Preoperative

Fig. 2: Orthodontic treatment done to
prepare the site for implant

Fig. 3: Stage 1 implant surgery: Force
direction indicator (FDI) in position

Fig. 4: Implant in position

Fig. 5: Flat gingival architecture at
4 months

Factors influencing
the outcome of papilla
reconstruction

vision. On the contrary, slightest

Blood supply
It’s the key factor in predicting

change in the level of the inter-

the treatment outcome, as suffi-

proximal papilla can lead to

cient blood supply should be

major esthetic and phonetic

maintained in any flap design.

Fig. 6: Stage 2 implant surgery: Palatal
site de-epithelialized

Fig. 7: Papilla preserving flap incision,
flap reflected buccally

Fig. 8: Palatal flap rolled under the
buccal flap

interproximal papilla leads to

Implant positioning

broad cuff of keratinized mucosa

restorations in the esthetic zone

ease. Radiographic findings of

black triangles interproximally

Well-placed implants lead to an

is necessary to allow for pre-

should mimic the emergence

the mouth revealed normal

(black hole disease), this makes

esthetically successful implant

dictable manipulation of the

profile (flat) of the natural tooth.

bone levels. Orthodontic treat-

the periimplant-supported tis-

restoration.4 Three different

soft tissue surrounding the

The vertical length of the sub-

ment was started with the aim

sues a delicate clinical issue to

directions govern the positioning

implant and also leads to long-

gingival portion of the resto-

of preparing the edentulous

handle.

of the implant: apico-incisal,

term success of oral endosseous

ration is extremely important

site for receiving an implant-

mesio-distal, and labiopalatal.

implants and maintenance of

as the guided gingival growth

supported prosthesis (Fig. 2).

the integrity of interproximal

is indirectly proportional to the

complications. Since losing the

Biological truth

Preoperative assessment

Engquist et al, 1995,2 stated that

Periodontal biotype

papilla.8-10 Of all the methods

submergence

tooth extraction leads to the

Periodontal biotype thick or thin

used for soft tissue augmenta-

implant.14

emergence

The concerned site revealed

interdental papilla remodeling

affects the dimension of the

tion and the flap designs used,

profile of the final prosthesis

buccolingual width measuring

in a sloping fashion from the

periodontal tissue and should

the underlying concept is to

should be carefully created. If

4.8 mm in the middle 1/3rd and

palatal to the more apical facial

be carefully evaluated during

preserve the blood supply to

the profile is too narrow, no

3 mm in the crestal 1/3rd regions

osseous plate and becomes

pre-surgical planning. Thick

the adjacent papilla and to

contralateral pressure or sup-

and papilla height index of

depressed in comparison with

bio-type is more prone to pocket

minimize recession.

port for the gingival will exist

5.5 mm (Tarnow’s index). Patient

the healthy adjacent marginal

formation but reconstruction

depth

The

of

the

and the interdental papilla will

had a thick flat periodontal

diminish. If the profile is too

biotype in the area.

tissue. Unfortunately, the lost

procedures seem to be more

Implant size selection

interdental papilla cannot reg-

predictable due to sturdy nature

Selection of an implant for an

wide papilla will be vertically

enerate to regain its original

of the soft tissue and osseous

esthetic zone depends on the

compressed, oral hygiene will

The technique

dimensions.3

structure. Thin biotype is more

dimensions of the edentulous

be difficult or impossible to per-

Stage 1 surgery was performed

prone to gingival recession

crest and proximity of adjacent

form & the papilla will collapse.

and a 3.8/10.5 mm (tapered

following mechanical & surgical

roots. Implants with larger

manipulation.

diameter are of limited use as

Biology
mucosa

of

the

peri-implant

There is a significant difference

internal, Biohorizon, AL, USA)

Case report

implant was placed following
manufacturer’s protocol (Fig. 3

they compromise the interim-

between the tissues surroun-

Bone quality and quantity

plant distance of 3 mm leading

A 21-year-old female patient

ding the natural teeth and the

The bony support between a

to increased crestal bone loss.11

presented for routine examina-

implants. In implants, due to

tooth and an implant or between

Hence implants 3.75-4 mm in

tion with a desire of replacement

After 4 months (Fig. 5), Stage

lack of cementum-like structu-

two implants has been shown

diameter are preferred in the

of missing anterior tooth. Patient

2 surgery of uncovering the

res, the connective tissue fibers

to be an important criterion

anterior restoration.12 Platform

was healthy with no significant

implant was performed along

of the peri-implant mucosa are

in creating or preserving the

switching to a smaller diameter

medical history.

with the desired soft tissue aug-

stretched parallel to the implant

papilla.5,6 Tarnow & colleagues

at the interface level favors

surface rather than perpendi-

reported a mean papillary height

the biologic width development

Intraoral examination revea-

thesia, an esthetic flap design

cularly attached to the root

between two adjacent implants

in the horizontal direction to

led congenitally missing lateral

was planned preserving the

surface as seen in natural teeth.

as 3.4 mm. One difficulty in

compensate for vertical one

incisor in relation to left maxil-

interdental papilla along the

Most groups of surpracrestal

maintaining or reforming a

henceforth,

the

lary quadrant (Fig. 1), leading

adjacent teeth. A 15c scalpel

fibers (dentogingival and trans-

papilla between two implants is

postoperative bone resorption

to the mesial migration of

(HU-FRIEDY, CH, USA) was used

septal fibers) do not exist

that the biologic width around

and maintaining soft tissue

canine. Patient’s oral hygiene

to mark the vertical incision

status was found to be adequate.

extending

A thorough oral examination,

aspect towards the palatal side.

around the implant abutment.

an implant usually is located

minimizing

13

margins.

apically to the implant abutment

and Fig. 4).

mentation. After securing anes-

from

the

buccal

Another, important vital dif-

junction. In the esthetic zone

Emergence profile

including cha-rting of oral hy-

The palatal extent was marked

ference is the restricted blood

the distance from the alveolar

A proper emergence profile is

giene scores (plaque index, gin-

about 5-7 mm from away the

supply, which is due to the
absence of periodontal ligament

crest to the adjacent tooth Cementoenamel Junction should be

important for hygiene, gingival
health, and appearance. Implant

gival bleeding index) revealed
no significant periodontal dis-

‡ DT page 23

[23] => DTAP0109_01-02_TitleNews

DeNtal tribuNe | October-December, 2009

Off time 23

Ford gears up to launch a small car in India
Ford Motor Company President
and CEO Alan Mulally revealed
the much anticipated new car
to be produced in India, the new
Ford Figo. “The new Ford Figo
is designed and engineered to
compete in the India’s small car
segment” Mulally commented.
Figo leverages Ford’s small-car
platform architecture, sharing
underlying technology with the
Ford Fiesta, already familiar
to Indian drivers. Press conference held in Delhi on September
23 was the first public preview
of the exterior design of the
new Ford Figo. Ford is reserving further details about the
vehicle

until

production

closer

launch

to

its

early

in

2010. Design-conscious Italy
inspired the new Ford Figo’s
name. Figo is colloquial Italian

Quality, substance and gener-

and chamfered window shape at

is another key kinetic design

ous proportions are clearly

the rear, Ford Figo is filled with

feature hinting at the comfort

evident in the design of the new

kinetic design touches. These

& spaciousness awaiting occu-

“We’re confident that the new

Sharing key elements of

Ford Figo, which features a

also include sculpted shapes to

pants' front and rear. The side

Ford Figo will be extremely

Ford’s kinetic design language

solid stance, an invitingly large

the body side – chiseled front

window graphic is executed

attractive to Indian car buyers,”

with vehicles like the globally

interior and a vibrant, youthful

fenders, a ‘comet tail’ undercut

with a blacked-out B-pillar, an

said Michael Boneham, presi-

renowned Ford Focus, Ford

character. Its package is right-

in the doors & additional light-

elegant design touch that unifies

dent and managing director,

Mondeo & the Ford Fiesta, Ford

sized for the market, which

catching sculpting in the lower

the side windows into one shape

Ford India.

Figo features a fresh, contem-

is predominated by congested

bodyside – which combine to

visually.

porary shape that will be a

urban driving conditions.

communicate the solidity, sub-

for "cool”.

distinctive alternative to traditional brands in this segment.

stance and protective safety of
From its modern headlamps,

its design.

solidity.

For more information log-on
to www.ford.com. DT

With its wheels positioned at
the four corners of the vehicle

Source: Corporate Communication,

with minimal overhang, Ford

Ford India.

The design language conveys

grille

a dynamic spirit of energy in

bonnet of its distinctive face to

The bold graphic of Ford

Figo's bold wheel arches self-

motion.

the subtle integrated spoiler

Figo’s large side window shape

assuredly signal its agility and

using

Conclusions

obtaining reconstructing pap-

sutures (Osteogenics Biomed-

Reconstruction of the gingival

illa. This approach of papilla

ical TX-USA). Simple interrupted

esthetics is an important issue

reconstruction and buccal soft

sutures were placed at the

in modern esthetic implants

tissue

mesial and distal interproximal

dentistry. Ideal treatment plan-

alone till duplicated. DT

part of the pedicle graft that

ning and sound preoperative

forms the future papilla and

assessment of soft and hard

simultaneously maintains the

tissues form the baseline for

shapes

and

sculpted

 DT page 22

Fig. 9: Temporary crown - at insertion

Fig. 10: PFM prosthesis 18 months post
operative buccal view

4-0

ePTFE

cytoplast

augmentation

stands

References available on request.

buccal fullness. Impression was
recorded at the same visit

About the author

About the author

Dr. Lanka Mahesh is a leading
expert in the field of implantology.
He heads the department of dental
surgery at Modi Hospital, New
Delhi, India. He has MS in Implant
Dentistry from UCLA (USA) and
CUFD (Thailand). He is a fellow,
diplomate and board member
of ICOI. Dr. Lanka has authored
a text book “Practical guide to
Implant Dentistry” & has lectured
extensively in India & abroad on
implants. He can be contacted at
drlanka.mahesh@gmail.com.

Dr Sangeeta Dhir is an associate
professor in the department of
periodontics at Sudha Rastogi
Dental College, Faridabad near
Delhi, India. She maintains a
private practice focusing primarily
on perioplastic surgery and implantology. She has published
many articles and has lectured
extensively across the country.
Dr. Dhir is also a fellow of the ICOI
(USA). She can be contacted at
sangeeta_dhir @hotmail.com.

for the fabrication of the temporary crown. Two weeks later,
sutures were removed and a
screw-retained full composite
crown was given (Fig. 9). Five
months later, an impression
was taken and a screw-retained
porcelain fused to metal crown
was fabricated (Fig. 10).
Fig. 11: Post operative x-ray

Results

crestal tissue. Palatal site was

the palatal tissue of the pedicle

The patient achived complete

marked and deepitheliallized

graft was then rolled and posi-

fill of the interproximal papilla

with scalpel or diamond bur

tioned into the buccal pouch and

(both mesial and distal) with

(Fig. 6 and Fig. 7). Full thickness

under the buccal flap (Fig. 8)

buccal soft tissue augmentation

flap was elevated from the

followed

of

(crestal augmentation = 5 mm,

palatal side. This elevation

narrow diameter healing abut-

middle 1/3 = 6.5 mm). Consistent

extended towards the buccal

ment. The pedicle graft was

results were obtained by us in

side as pouch dissection. After
completion of buccal dissection,

meticulously sutured around
the emerging healing abutment

seven other cases.

by

placement

[24] => DTAP0109_01-02_TitleNews

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