DT Middle East & Africa No. 3, 2018

News / Following a simpler path from prep to crown / Industry / Checklists not just for pilots anymore / Long-term clinical success in the management of compromised intertooth spaces utilizing small-diameter implants / Oral Health / News / Large MODL Class II restoration with ceram.x® SphereTEC one, Palodent® V3 and SDR® Plus / Digital technology in dentistry / A Dentsply Sirona Predominant Practice CEREC and Single-Visit Dentistry / Tipton Training UK and CAPP Dubai: Helping young dentists get ahead / Futudent at CAD/CAM and Digital Dentistry Conference: New cameras and partnership / Clition and Irreversible Inflammatornical Management of a First Upper Molar with Invasive Cervical Resorpy Pulpitis / News / Distributors / Endo Tribune Middle East & Africa Edition No. 3, 2018 / Lab Tribune Middle East & Africa Edition No. 3, 2018 / Hygiene Tribune Middle East & Africa Edition No. 3, 2018 / Implant Tribune Middle East & Africa Edition No. 3, 2018 / Ortho Tribune Middle East & Africa Edition No. 3, 2018

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www.dental-tribune.me

PUBLISHED IN DUBAI

May-June 2018 | No. 3, Vol. 8

ENDO TRIBUNE

LAB TRIBUNE

HYGIENE TRIBUNE

IMPLANT TRIBUNE

ORTHO TRIBUNE

“No Anaesthesia”
endodontics in children

Dental Technician Int’l
Meeting was a success

M(oral) Education tested in
Dubai Youth Hub

CAPP's Clinical Implantology
Programme live surgical ...

Digital Orthodontics Symposium
addresses progressive topics

ÿA1-8

ÿB1-4

ÿC1-4

ÿD1-4

ÿE1-4

13 CAD/CAM attendance
record over 2.500 delegates
th

DENTAL TRIBUNE

Scientific Conference & Digital Orthodontics Symposium & Dental Technicians
Int’lDental
Meeting
focusesMiddle
on East & Africa Edition
The World’s
Newspaper
digital revolution in dentistry
By Dental Tribune MEA / CAPPmea
Centre for Advanced Professional
Practices (CAPP) Events recently
concluded the 13th edition of the

CAD/CAM Conference and Exhibition. Over 3,000 dental professionals, trade visitors, VIPs and students
from the MENA region, Americas,
Asia, Australia and Europe congre-

gated at the Madinat Jumeirah Conference Centre in Dubai from 4 to 5
May to share in the latest developments, innovations and ideas that
have transformed the field of den-

Delegates and visitors during the 13th CAD/CAM & Digital Dentistry Conference &
Exhibition in Madinat Jumeirah Conference & Events Centre in Dubai, UAE

tistry. The event was held in conjunction with the Digital Orthodontics
Symposium (4 May) and the Dental
Technician International Meeting (5
May) and featured various activities,
including the scientific conference
(4–5 May), multidisciplinary pre- and
post-event hands-on training courses (2–12 May), round table training
and an exhibition (4–5 May) with 26
free continuing medical education
(CME) training sessions in special
training zones.

What if your patient could have
a new crown in one visit?

MyCrown
Chairside CAD/CAM system

The scientific programme, chaired
by Dr Munir Silwadi, provided
speakers with a platform to discuss
advancements in digital dentistry,
the digital workflow and innovative practices, while sharing their
cases and research with over 2,500
attendees at the conference. Topics
covered the digital workflow, CAD/
CAM chairside and in-laboratory applications, digital and conventional
impressions (intra-oral, laboratory
and face scanners, new materials in
digital dentistry and 3-D printing),
laboratory and clinical options, digital and conventional restorations,
digital imaging, computer-guided
implantology, practice software,
one-day restorations and CAD/
CAM software. The main aim of the
conference is to provide a practical
overview of digital dentistry; to be a
stimulus for improved adoption of
the areas that have been proven and
to aid the integration of new technologies that benefit dental professionals.
One of the main highlights of the
event was that it provided dental
professionals with the opportunity
to earn up to 84 CME credit hours
over the course of 11 days. The CME
accreditations provided for these
courses included Dubai Health Authority, Health Authority Abu Dhabi
and CAPP, which is recognised by the
American Dental Association Continuing Education Recognition Program (ADA CERP) as a provider of CE
credits. Apart from this, visitors had

the opportunity to attend free CME
training sessions that were conducted by sponsors and exhibitors during the exhibition, thereby facilitating networking and the exchange of
ideas and providing exhibitors with
the opportunity to showcase their
latest technological advancements
and innovative solutions in digital
dentistry.
CAPP has always been committed
to encouraging innovative research
and advancements in the field of
dentistry that not only revolutionise dentistry, but also advance patient health. Therefore, according to
tradition, dental professionals and
students from across the world were
invited to present their outstanding
research and findings to be reviewed
by academics and industry experts
at the poster presentations event.
The plethora of innovations and a
multidisciplinary approach have always played a key role in ensuring
that CAPP’s conferences, scientific
programmes and courses are among
the most sought-after learning opportunities for dental professionals.
Dr Dobrina Mollova, founder and
Managing Director of CAPP, said:
“Such events encourage the implementation of best practices, the integration of new technologies and
the adaptation of the latest innovations in dentistry due to continuous
research and development in close
collaboration with dentists and input from across the dental profession, as they are delivered by some
of the world’s most renowned dental
experts in a quest to contribute positively to maintaining and improving
patient health.”

CAPP EVENTS
Tel: +971 4 347 6747
Mob: +971 50 4243072
E-mail: events@cappmea.com
Web: cappmea.com

[2] => DTMEA_No.3. Vol.8_DT.indd

NEWS

Dental Tribune Middle East & Africa Edition | 2/2018

13 CAD/CAM & Digital Dentistry
Conference & Exhibition Impressions
th

IMPRINT
GROUP EDITOR
Daniel ZIMMERMANN
newsroom@dental-tribune.com
Tel.: +44 161 223 1830
CLINICAL EDITORS
Nathalie SCHÜLLER
Magda WOJTKIEWICZ
EDITOR
Yvonne BACHMANN
EDITOR & SOCIAL MEDIA MANAGER
Monique MEHLER
JUNIOR PR EDITOR
Kasper MUSSCHE
COPY EDITOR
Ann-Katrin PAULICK
Sabrina RAAFF
PUBLISHER/PRESIDENT/
CHIEF EXECUTIVE OFFICER
Torsten R. OEMUS
CHIEF FINANCIAL OFFICER
Dan WUNDERLICH

Delegates and visitors during the 13th CAD/CAM & Digital Dentistry Conference & Exhibition in Madinat
Jumeirah Conference & Events Centre in Dubai, UAE

Chairman, Dr Munir Silwadi during his opening speech

Prof Dr Ahmed Adel Abdel Hakim, Egypt

Dr Roberto Molinari, Italy

Dr Eduardo Mahn, Chile

Delegates during the CME sessions at the exhibition

Delegates during the Round Table Training at DTIM

Delegates during the scientific programme

Agreement between Ajman
University and CAPP Training
Institute signed
By Dental Tribune MEA / CAPPmea
Agreement for Continuing Education and Professional Development
Programmes was signed between
Ajman University (AU) and CAPP
Training Institute. The ceremony
was held in Ajman University, UAE
on 19th of April 2018. The contract
was signed by Prof. Salem Abu Fanas,
Dean – College of Dentistry on behalf
of Ajman University and Dr. Dobrina
Mollova, Founder and Managing
Director of CAPP Events and CAPP
Training Institute.
The focus of the agreement is the utilization of Ajman University premesis with regards to the live-patient
treatment clinical days on the “Clinical Implantology Certificate and
Diploma” programme with faculty
lead Prof. Göran Urde, Sweden from
the British Academy of Dental Implantology (BADI) and British Academy of Restorative Dentistry (BARD).
For more information about the programme visit https://cappmea.com/
implant/

About Ajman University
Ajman University has been at the
forefront of UAE education since being founded as the first private uni-

From the left: Dr. Mohammad Kashif
Shaifq Khot, Prof. Salem Abu Fanas, Dean –
College of Dentistry, Dr. Dobrina Mollova,
Founder and Managing Director of CAPP
Events and CAPP Training Institute, Eng.
Tazeen Sharif and Kinga Mollov.

The contract was signed by Prof. Salem Abu Fanas, Dean – College of Dentistry on behalf
of Ajman University and Dr. Dobrina Mollova, Founder and Managing Director of CAPP
Events and CAPP Training Institute.

versity in the Gulf region 30 years
ago. With the recent addition of a
College of Medicine, the landmark
institution now encompasses 9 colleges offering 23 undergraduate and
10 graduate programs. The University’s programmes are accredited
by the UAE’s Ministry of Education.
Since opening in 1988, AU has graduated more than 36,000 students
who hail from 84 nations. Working in
a variety of professions – from dentistry to information technology;

pharmacy to law; mass communication to business administration – AU
alumni now comprise 14 alumni
chapters around the globe.

About CAPP
Centre for Advanced Professional
Practices (CAPP) was founded in
2005 in Dubai, UAE with the sole
purpose of delivering excellence in
Dental Continuing Medical Education in the Middle East and beyond.
CAPP is an American Dental As-

sociation (ADA) C.E.R.P Recognised
Provider, specialising in Continuing
Medical Education (CME) and Continuing Professional Development
(CPD) dental education programmes
– conferences, short and long term
hands-on courses leading to certificates, diplomas and fellowships,
workshops and self-instruction
programmes. For the past 13 years
CAPP has facilitated over 410 CME
programs educating over 62,000
international participants. CAPP is
also the franchise owner of Dental
Tribune Middle East (DTMEA) and
in 2016 CAPP opened its own Dental
Training Centre (CAPP Training Institute) in Dubai.

CHIEF TECHNOLOGY OFFICER
Serban VERES
BUSINESS DEVELOPMENT MANAGER
Claudia SALWICZEK-MAJONEK
PROJECT MANAGER ONLINE
Tom CARVALHO
JUNIOR PROJECT MANAGER ONLINE
Hannes KUSCHICK
Chao TONG
E-LEARNING MANAGER
Lars HOFFMANN
EDUCATION DIRECTOR TRIBUNE CME
Christiane FERRET
EVENT SERVICES/PROJECT MANAGER
TRIBUNE CME & CROIXTURE
Sarah SCHUBERT
MARKETING SERVICES
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SALES SERVICES
Nicole ANDRÄ
ACCOUNTING SERVICES
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MEDIA SALES MANAGERS
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Matthias DIESSNER (Key Accounts)
Antje KAHNT (International)
Weridiana MAGESWKI (Latin America)
Barbora SOLAROVA (Easten Europe)
Peter WITTECZEK (Asia Pacific)
EXECUTIVE PRODUCER
Gernot MEYER
ADVERTISING DISPOSITION
Marius MEZGER
DENTAL TRIBUNE INTERNATIONAL
Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 48 474 302
Fax: +49 341 48 474 173
www.dental-tribune.com
info@dental-tribune.com
DENTAL TRIBUNE ASIA PACIFIC LTD.
Room A, 20/F
Harvard Commercial Building
105–111 Thomson Road, Wanchai, HK
Tel.: +852 3113 6177
Fax: +852 3113 6199
THE AMERICA, LLC
116 West 23rd Street, Ste. 500, New York
N.Y. 10011, USA
Tel.: +1 212 244 7181
Fax: +1 212 244 7185
DENTAL TRIBUNE MEA EDITION EDITORIAL
BOARD
Dr. Aisha SULTAN ALSUWAIDI, UAE
Prof. Paul TIPTON, UK
Prof. Khaled BALTO, KSA
Dr. Ninette BANDAY, UAE
Dr. Nabeel HUMOOD ALSABEEHA, UAE
Dr. Naif Almosa, KSA
Dr. Mohammad AL-OBAIDA, KSA
Dr. Meshari F. ALOTAIBI, KSA
Dr. Jasim M. AL-SAEEDI, Oman
Dr. Mohammed AL-DARWISH, Qatar
Dr. Dobrina MOLLOVA, UAE
Dr. Ahmed KAZI, UAE
Dr. Munir SILWADI, UAE
Dr. Khaled ABOUSEADA, KSA
Dr. Rabih ABI NADER, UAE
Dr. Ehab RASHED, UAE
Aiham FARRAH, CDT, UAE
Retty M. MATTHEW, UAE
PARTNERS
Saudi Dental Society
Saudi Ortho Society
Lebanese Dental Association
Qatar Dental Society
Oman Dental Society
American Academy of Implant Dentistry
International Federation of Dental
Hygienist
British Academy of Restorative Dentistry
British Academy of Dental Implantology
DIRECTOR OF mCME
Dr. Dobrina MOLLOVA
mollova@dental-tribune.me
Tel.: +971 50 42 43072
DIRECTOR
Tzvetan DEYANOV
deyanov@dental-tribune.me
Tel.: +971 55 11 28 581
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Kinga ROMIK
k.romik@dental-tribune.me
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©2018, Dental Tribune International GmbH.
All rights reserved. Dental Tribune International
makes every effort to report clinical information and
manufacturer’s product news accurately, but cannot
assume responsibility for the validity of product
claims, or for typographical errors. The publishers
also do not assume responsibility for product names
or claims, or statements made by advertisers.
Opinions expressed by authors are their own and
may not reflect those of Dental Tribune International.

[3] => DTMEA_No.3. Vol.8_DT.indd

Solutions for better,
safer, faster dental care

Dentsply and Sirona have joined forces to become the world’s largest
provider of professional dental solutions. Our trusted brands have empowered dental professionals to provide better, safer and faster care in all fields
of dentistry for over 100 years. However, as advanced as dentistry is today,
together we are committed to making it even better. Everything we do is
about helping you deliver the best possible dental care, for the benefit of
your patients and practice.
Find out more on

dentsplysirona.com

[4] => DTMEA_No.3. Vol.8_DT.indd

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 3/2018

Following a simpler path from prep to crown
A case study by Dr. Carlos Eduardo Sabrosa, DDS, MSD, DScD featuring 3M™ RelyX™ U200 Self-Adhesive Resin Cement

Introduction
Indirect restorative procedures can
be time-consuming and complicated: many different processes from
impression taking to cementation
are carried out in the dental office,
and in each of them, different strategies may lead to success. However,
some of the available materials and

techniques will involve a lot of effort,
while others enable users to proceed
quickly and simplify the complete
procedure. A simplified workflow
from prep to crown that really make
life easier for the dental practitioner
is described below.

Comments
The described patient case shows
that it is possible to significantly reduce the number of working steps
in an indirect restorative procedure.
In this way, potential sources of error are eliminated and chair-time is
decreased. Key to success is the use
of innovative, high-quality materi-

als that offer ease of use and lead
to increased efficiency in the dental office. These include the abovementioned monophase impression
material, the bulk fill composite, the
temporization material that does
not require polishing and the selfadhesive resin cement all offered by
a single manufacturer.

Before using the products described,
please refer to the instructions for
use provided with the product packages.
The featured 3M product may be
known with an alternative name in
different regions.

Fig. 1: Initial situation. The failed composite restoration covering a large
part of the left mandibular first molar’s occlusal surface needs to be replaced.

Fig. 2: Due to the size of the restoration, the amount of remaining tooth
structure might not be sufficient to ensure the required stability for a
direct composite restoration.

Fig. 3: Upon removal of the old filling, it becomes clear that a crown is
needed to ensure the required stability. The tooth is built up with
3M™ Filtek™ Bulk Fill Posterior Restorative, which may be placed in conjunction with 3M™ Single Bond Universal Adhesive and in increments
of up to 5 mm.

Fig. 4: Following tooth preparation, a temporary crown is produced
chairside with 3M™ Protemp™ 4 Temporization Material. This material
exhibits a high strength and a natural gloss without polishing.

Fig. 5: One week after the preparation procedure, healthy soft tissue
conditions are obtained. They lay the foundation for a high-quality precision impression.

Fig. 6: In order to allow for a detailed capture of the preparation margin, the gingival tissues are retracted using the double-cord technique.
Alternatively, a single cord may be applied in combination with
3M™ Astringent Retraction Paste.

Fig. 7: Monophase impression taken with 3M™ Impregum™ Penta™
Soft Medium Body Polyether Impression Material. A very detailed representation of the preparation margin is obtained with this simple
technique.

Fig. 8: Situation at intraoral try-in of the crown. It is made of a 3M™
Lava™ Zirconia coping and an IPS e.max® Ceram (Ivoclar Vivadent) porcelain layer. Ideal intraoral conditions (smooth margins, healthy tissues)
are visible.

Fig. 9: Sandblasting of the crown’s intaglio surface to create a microretentive surface structure that is beneficial for cementation. This procedure is recommended for oxide ceramic materials.

3M, Filtek, Impregum, Lava, Penta, Protemp and RelyX are trademarks of 3M or 3M Deutschland GmbH. Used under license in
Canada. All other trademarks are owned by other companies.
© 3M 2018. All rights reserved. Dr. Sabrosa has received an honorarium from 3M Oral Care.

Fig. 10: Situation after crown placement, removal of the excess cement
and thorough cleaning. The crown blends in nicely with the surrounding tooth structure.

Fig. 11: At the check-up several days after crown placement, a
great overall picture is obtained. The patient is happy with the final
restoration in terms of aesthetics and function.

Dr. Carlos Eduardo Sabrosa, Brazil
Dr. Sabrosa is an Associate Professor at the State University of Rio de Janeiro Dental School. He received his DDS in 1992 from
the State University of Rio de Janeiro Dental School and the Clinical Advanced Graduate Studies (CAGS) in Prosthodontics
from Boston University Goldman School of Dental Medicine in 1996. He earned the Steven Gordon Research/Clinical Award
in 1995 and 1996 and the Tylman Research Grant Award in 1993 from the American College of Prosthodontics. Dr. Sabrosa
also received his MSD and DScD in Prosthodontics/Biomaterials from Boston University Goldman School of Dental Medicine
in 1997 and 1999 consecutively. He has a private practice, focused in Oral Rehabilitation and Implantology, in Leblon, Rio
de Janeiro, Brazil.

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INDUSTRY

Dental Tribune Middle East & Africa Edition | 3/2018

Futudent announces dentistry’s first miniature 4K
Camera, and a new super-lightweight POV Camera
By Futudent

for educating patients, communicating with treatment teams, and is a
superior tool for documentation. Futudent is dedicated to improving the
dental experience for doctors and
patients alike, and the proCam and
microCam fits seamlessly into everyday dental workflow in all practices.”

Helsinki, Finland: On March 29th
2018, Futudent tripled its product
portfolio by introducing two new
cameras: the microCam and proCam. These newest innovations represent Futudent’s continued commitment to bringing the benefits of
video to every dental professional.
Video helps dental care providers
explain and document more easily
than ever before. This in turn helps
patients replace fear with understanding and informs better decision-making for their treatment.
The new proCam is the world’s first
miniature 4K (3840x2160@30 fps/
13Mpix stills) dental camera and
can be mounted on loupes or chair
lights. It captures stunning video and
high quality photography without
interrupting the procedure, keeping
the doctors focus on the patient.

Benefits of video

The new microCam is a superlightweight 18 grams camera, designed for easy loupe-mounted
POV filming. It delivers clear full HD
(1080p30) images from it’s professional Sony IMX sensor. These two
new products join the eduCam to set
the new state-ofthe-art standard in

dental video technology. Futudent
founder, Lars Kåhre says, “We are
very proud to once again be changing the game and innovating new
and powerful ways to help dentists
communicate and document better
than ever before. Globally, videos are
becoming more and more popular

Video is already an integral part of
dental education today. Educators
and learners use video to demonstrate techniques, evaluate, document and present in universities, CE
and private training. Futudent supports these applications, and extends
the same benefits to private practice.
Video helps dentists visually document and explain cases and treatments to patients and colleagues
more easily than a mirror and a still
camera. Dentists know that patients
who understand their treatment
plans are much more likely to accept

the new procedure. Video is the easiest way to review treatments with
patients and even send visual advice
home straight to their smart phones.

Ease-of-use
All Futudent’s cameras are designed
to be used on either loupes, chair
lights, or a flexible arm, with each
having different advantages depending on the application. At 18
grams the microCam is optimised
for all day loupe mounting. The 26
gram proCam can also be worn on
the loupes, but it’s high 4K resolution means that digital zooming can
be used to capture clear, unpixelated
close-up video and photographs
from the chair light. The eduCam
offers a good compromise of both
price and performance.
More information at
www.futudent.com

The new Charisma® Diamond –
Welcome to the next dimension of natural beauty
Innovative chemistry provides a beautiful smile.
Charisma Diamond – Your assets at a glance.
By Kulzer

The Charisma Diamond
chemistry:
A patented matrix and newly developed nano-hybrid filler system
result in improved aesthetics, durability and handling. This means
minimum shrinkage and shrinkage
stress, a very smooth surface, elasticity optimised to tooth structure and
optimised surface hardness.

The Charisma Diamond
versatility:
This is how you create beautiful
restorations. Charisma Diamond
adapts to the colour of the surrounding tooth structure for an outstandingly natural look. What’s more, the
Charisma Diamond layering technique is a distinct aesthetic advantage and ensures virtually undetect-

able restorative margins. You easily
achieve very good results with the
single-shade technique for simple
cases and first and foremost excellent results using the multilayer
technique.

The Charisma Diamond
workability:
Charisma Diamond comes with un-

compromising capabilities even for
the most challenging restorations.

livers all the ingredients for an outstandingly natural look.

It offers minimal stickiness and improved efficiency during sculpting.
It also provides an extended working time even when under operating light illumination. To top it all
off, ultrafine filler particles create a
polish that is comparable to natural
enamel. Our innovative formula de-

Aboubakr Eliwa
Area Manager Middle East
T: + 97 (1) 4 294 35 62 (Office)
F: + 97 (1) 4 294 35 63
M: +97 (1) 56506 89 76
E: aboubakr.eliwa@kulzer-dental.com
W: www.kulzer.com

[7] => DTMEA_No.3. Vol.8_DT.indd

MyCrown

[8] => DTMEA_No.3. Vol.8_DT.indd

8

INDUSTRY

Dental Tribune Middle East & Africa Edition | 3/2018

Pink & White
Aesthetics with
BEAUTIFIL II
By Shofu
BEAUTIFIL II ENAMEL and GINGIVA from Shofu are developed as
a complementary line extension of
BEAUTIFIL II series to easily create
life-like direct aesthetic restorations.
A special one-push syringe ensures
controlled dispensing of the smooth
and creamy material that is easy to
sculpt into fine details and recreate
the surface textures seen in natural
teeth & gum.
Integration of nanofillers and newly
developed organic-inorganic filler
complex into a unique silanol modified resin network imparts Beautifil
II Enamel and Gingiva with exceptional handling characteristics, longer working time, high abrasion/wear
resistance, stable shades, effortless
and superior polish with sustained
polish retention for lasting aesthet-

ics. Shofu’s proprietary S-PRG fillers
impart bioactive characteristics to
the material offering all round fluoride protection and anti-plaque benefits.
BEAUTIFIL II ENAMEL is available
in 4 naturally translucent and opalescent, Value based enamel shades
that facilitate life-like shade reproduction and value adjustment in the
final restoration to meet individual
clinical needs.
Beautifil II GINGIVA is available in 5
natural shade variations of pink to
match all ethnicities and easily mimic patient’s individual gum while
restoring areas with receded or missing gums/papilla, cervical defects,
root caries/erosion, exposed PFM
margins and abutments to achieve
red and white aesthetic harmony.

Making the move to 3D
digital imaging easy
By Carestream
3D digital imaging is particularly
valuable in dental practices when
high quality and detailed images are
needed, such as when offering dental
implants or orthodontic treatments.
The CS 8100 3D system by Carestream Dental makes the move to 3D
digital imaging easy because it provides the benefits of 3D technology
in one versatile system. As it is ultra-

compact, it can easily fit into tight
spaces within almost any practice.
Plus, it is accessible to all users and
requires minimal training.
This system is ideal for daily use and
it can capture accurate images in as
little as seven seconds. The CAD/
CAM abilities make it suitable for a
range of tasks, from traditional panoramic examinations to endodontics,
implant planning, oral surgeries and
orthodontic applications. To find out

how to incorporate 3D digital imaging into your practice, contact Carestream Dental today.
For more information, visit www.
carestreamdental.com
For the latest news and updates,
follow us on Twitter @CarestreamDentl and Facebook

Glass Ionomer Filling Cement

Glass ionomer luting cement

• For fillings of classe I, III and IV
• Excellent biocompatibility and low acidity
• High compressive strength
• No temperature rise during setting
• Enamel-like translucency
• Excellent radiopacity
• Stable and abrasion resistant

• High level of adhesion
• Highly biocompatible, low acidity
• Continuous fluoride release
• Precision due to micro- fine film thickness
• Translucency for an aesthetic result

Light-curing micro-hybrid composite
• Applicable for various indications and all cavity classes
• High translucency and a perfect colour adaption
• Polishable to a high gloss
• Excellent physical properties for durable fillings
• High filler content
• Packable consistency
(also available as Composan LCM flow)
Visit www.promedica.de to see all our products

Dental Material GmbH
24537 Neumünster / Germany
Tel.
+49 43 21 / 5 41 73
Fax
+49 43 21 / 5 19 08
eMail
info@promedica.de
Internet www.promedica.de

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[10] => DTMEA_No.3. Vol.8_DT.indd

mCME

Dental Tribune Middle East & Africa Edition | 3/2018

Checklists not just for
pilots anymore
mCME articles in Dental Tribune have been approved by:
HAAD as having educational content for 1 CME Credit Hour
DHA awarded this program for 1 CPD Credit Point

CAPP designates this activity for 1 CE Credit

By Patti DiGangi, RDH, BS, Judy Bendit, RDH, BS
With popularity of the television
show “Mad Men,” 1960's themes
such as war, racism and sexism are
memorialized, as are once-common
habits such as smoking. Women
were marketed in the 1960s with
their own cigarette brand that had
the catch phrase, “You’ve come a
long way, baby.” Following release
of Smoking and Health: Report of
the Advisory Committee to the Surgeon General of the United States,1
all smoking-related advertising was
banned from TV in 1970.2
Sit-down dentistry also evolved in
the 1960's. “You’ve come a long way,
baby” is gone from advertising, but
it remains an accurate slogan when
it comes to ergonomics in dentistry.
We have come a long way, but for
many dental professionals, that’s
still not far enough.
In 1937, pilots developed the concept
of the checklist after planes began
crashing. Dental professionals may
not be crashing in the literal sense,
but many clinicians have been
forced into early retirement because
of musculoskeletal disorders (MSD)
or they continue to try to work
through them. By incorporating a
checklist concept similar to that used
by pilots, dental professionals can be
more successful, productive — and
able to practice without pain.

Pain in dentistry
Pain of dentistry is a common fear
that keeps patients away from the
dental office. Pain in dentistry is
common, but has nothing to do with
the patient. The individuals having
pain in dentistry are the practitioners. It is estimated that more than
half of practitioners have some kind
of painful musculoskeletal disorder
that is work related.3
In 2007, the Center for Health
Workforce, funded by the American Dental Hygienists’ Association
(ADHA), conducted a sample survey
of licensed dental hygienists about a

Fig. 2. Steve Knight at LeMans. Today, as a business turnaround specialist, Knight brings lessons
from racing to dentistry. His goal is to turn around the world of seating for dental hygienists
and all dental professionals. (Race photos/Provided by Steve Knight)

wide variety of issues, including occupational injury or illness related to
their work. It was reported that just
more than one-third (33.8 percent)
indicated had experienced an occupational injury or illness. Figure 1
shows the types and percentages of
occupational injury or illness experienced. More than half (53 percent)
used medication to control the discomfort and nearly half (49.5 percent) indicated they had shortened
their work hours as a result of their
injury or illness.4
Ergonomics evolved as a recognized
field during World War II. It is the
science of adjusting the work environment to the worker.5 The Occupational Safety and Health Administration (OSHA) has links to ergonomic
information.6 The American Dental
Association (ADA) published Introduction to Ergonomics7 with suggested interventions and in 2011
published Ergonomics for Dental
Students.8 The ADA website has an
ergonomics section with links to fliers about specific problems.9 Even
with numerous articles and C.E.
courses (both in person and online)
on ergonomics in the five years since
the ADHA survey, MSDs continue to
escalate. Much of this is because of a

Fig. 1. Type of occupational injury or illness experienced by dental hygienists with employment-related injury or illness, 2007.3 (Chart/ Provided by the Center for Health Workforce and
American Dental Hygienists’ Association)

hand-me-down mentality in many
dental offices.
For the safest flight, pilots use many
checklists. In dentistry, a one-sizefits-all checklist is not enough to
evaluate how we do things because
of the wide variety of body types,
shapes and preferred work styles.
This article will develop checklists
for dental-operator seating, just one
of the many parts creating a healthy
ergonomic environment.

Checklists help find the way
In the days of early aviation, pilots
were crashing because they could
not reach the controls. Investigators
found it was pilot error as the cause.
Pilot error doesn’t necessarily mean
the pilot did something wrong; it can
mean the pilot wasn’t familiar with
the equipment or the equipment
didn’t match the pilot. For those who
work in a temporary dental situation
at multiple offices, ergonomic challenges are huge. When such practitioners walk into a new office, trying
to match their individual needs to
the available equipment is nearly
impossible.
Pilot checklists were developed to
match the steps needed for the job,
making sure that everything is done
and nothing is overlooked. Checklists have become fundamental to
the aviation industry.10 In a similar
way, checklists should become fundamental to the dental industry.
Two books, “The Checklist Manifesto: How to Get Things Right”11 by Dr.
Atul Gawande, a surgeon, and “Safe
Patients, Smart Hospitals”12 by Dr.
Peter Pronovost, discuss checklists
as an effective way to reduce medical errors. These books are not just
about the checklists, they are about
the culture of medicine and how the
checklist can foster better teamwork.
Checklists are starting to become
common in some hospital settings,
but not nearly common enough. It
takes a change of culture to adopt
something that on the surface can
seem so simple — as a core strategy
for enhancing care.
A recent success story illustrates the
difference checklists can make in
medicine. The intensive care unit
(ICU) at a hospital is a crucial part of
health care delivery and one of the

Fig. 3. Steve Knight at Laguna. In racing, perfect driver ergonomics is critical. Knight’s Goldilocks theory applies to a dental practice using existing seating simply because it was already
there: Sometimes it’s too tall or too short, and no matter how much it is adjusted, it is still not
just right.

most complex and expensive. The
Centers for Disease Control (CDC)
reported that nearly every patient
admitted to an ICU experiences
some type of complication during
his or her stay.13 Checklists were used
in the Michigan Keystone Project to
make patient care safer in more than
100 ICUs in Michigan. The project
targeted the expensive and potentially lethal catheter-related bloodstream infections that cost $18,000
when a patient contracts one and
causes 24,000 deaths per year. The
Keystone team made a checklist,
measured infection rates — and
changed hospital culture. There was
a 66 percent reduction in this type
of infection statewide, saving more
than 1,500 lives and $200 million in
the first 18 months of the program.14
It was the combination of checklists
and the culture of teamwork that
made the difference.
Race car drivers and race cars take
quite a beating during a race, both
physically and mechanically. Like pilots, race car drivers and their teams
use checklists. The teamwork of a pit
crew during a race is artistry to watch
that is fostered by checklists. Steve
Knight, once a professional Le Mans
race car driver (Figs. 2 and 3) and business turnaround specialist, has taken
lessons from racing and brought
them to dentistry. His goal is to turn
around the world of seating for dental hygienists and all dental professionals.

Seating risk factor checklist
Before Knight got into a Le Mans car
there were many considerations to
be addressed. An impression of the
driver’s body is taken to ensure a
perfect fit into the seat of the car for
optimal performance. This molding
created: proper leg-stretch to reach
the clutch, accelerator and brake;
comfort in reaching and holding the
steering wheel; and most important,
the ability to sit comfortably for
long periods of time while driving
around the race course. Success for a
top-level race car driver is driven by
a strict regimen for eating, exercise
and nearly all activities of daily life so
they can be in top shape physically.
It is the total package, including the
racing team and pit crew all using

checklists, that creates this success.
The idea of a form-fitting chair for
dental practitioners might not be
practical, yet think of the possibilities. Those same ideas can be brought
into the treatment rooms with the
“Seating Risk Assessment Checklist”
shown in Table 1. This checklist helps
to evaluate overall balance. Many
professionals have damaged themselves by repeatedly sitting, leaning,
stretching and twisting for so many
years. As Cindy Purdy, RDH, BS, consulting with Crown Seating recently
said to an online group, “Changing
stools alone will not treat medical
issues, but it can certainly offer benefits for the future.”15

Recline/incline seating
Passengers are required to sit upright
at take-off and landing on any plane
(Fig. 4). Most passengers can’t wait
to hear the announcement that the
cruising altitude has been reached
so the seats can be leaned back for
more comfort. Unfortunately, dental
professionals tend to sit in this upright position all day. When seated
in this position for long periods of
time, practitioners both elongate
and shorten different muscle groups
in the legs. Humans are not meant to
sit completely upright and especially
not for a long day in the office. 16
A more comfortable sitting position
for most is in a reclined position (Fig.
5). Think of your comfortable recliner in front of the television after
a long day of work or the experience
sitting in a first-class seat on a plane.
Reclining is so very comfortable. This
is the way race car drivers sit; but it’s
not very practical for treating dental
patients.
Now take that reclined position and
rotate the torso on its axis to create
the inverse position, called an inclined position17 (Fig 6). Incline is the
automatic position created when
sitting on a horse or a saddle stool.
It is a more balanced position. This
balance helps preserve the hips and
spine in the proper position. It is defined as an open body position that
is more comfortable, less harmful
and allows for proper lumbar cur-

ÿPage 11

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mCME

Dental Tribune Middle East & Africa Edition | 3/2018

◊Page 10
vature. The pelvis rotates downward
and forward, enabling the knees to
stay below hip level. This creates less
stress and strain on the back, neck
and shoulder muscles. A slight incline of the seat (5-15 percent) is ideal.
If you adjust more than 20 percent
out of a neutral position for an extended period of time, muscle imbalances are created, which means the
muscles are adaptively shortening
on one side and elongating on the
other. This results in misalignment
of the spine and joints, and in this
case, the hip joint. When a person sits
properly on a saddle seat, the pelvis
is properly positioned and stabilized,
so the body naturally and automatically assumes the least-stressful position.

Static vs. dynamic seating
For sitting positions, there are two
more checklist considerations. In traditional chairs, the practitioner sits
in a static position that does not provide much movement or stimulation of the muscles. A new term has
been given to some of the advanceddesign chairs: dynamic seating. The
dynamic chair offers the option of
movement, allowing the muscles to
both contract and relax while one
remains seated. Prolonged muscle contraction results in increased
pressure of the blood vessels in the
muscle, creating a decreased blood
flow through the muscle. Blood flow
assists in the repair and health of the
muscles by delivering oxygen to the
muscle and removing waste products in the muscle that might otherwise cause localized, intense pain
(ischemia). A dynamic chair allows a
period of rest and rebuilding for the
muscles needed for healthy seating.
In some dynamic stools the seat pan
moves; with others it’s the seatback
that moves forward and backward as
you move; and, with some, all parts
of the chair move. In any case, these
chairs help strengthen the body’s
core.

Seating materials
A chair can be made of rubber,
plastic, leather, mesh or other manmade materials that may or may not
breathe. These materials can make
a difference in comfort depending
on where you live. In the South, or
if there is high humidly in the office, a practitioner might complain
about the material of the seat. If
there is sweating while sitting, the
seat may not allow the legs and back
to breathe. This can be uncomfortable and/or embarrassing. Asking
the manufacturer about options for
breathability is the best choice. There
are new fabrics that control odor and
stain-causing bacteria.

With or without arms
Many practitioners wonder if they
should or shouldn’t have arms on
their chairs. The answer depends on
how that individual works. If the person’s arms are always flapping in the
breeze because the patient isn’t seated back properly, then arms on the
chair will not help. It is imperative
for the patient to either lay back in

the appropriate position, or the practitioner must stand. One suggestion
is instead of saying “Ok, let’s put the
chair back and get started,” the practitioner says, “Let’s put the chair back
and get both of us comfortable.”
They are very similar phrases with
very different meaning. Patients are
not the only ones who need to be
comfortable; the best work can happen when everyone is comfortable.
How many times during the day
do practitioners stop to get comfortable? Usually none. Health care
providers often worry more about
patient comfort and end up compromising themselves all day long, leading to pain and injury.

Goldilocks theory of seating
Chairs are often inherited from
someone else when first employed
in a different practice. Steve Knight’s
Goldilocks™ theory is like the old
story, sometimes it’s too tall or too
short and no matter how much it is
adjusted, it is still not just right. Not
getting that just-right position will
lead to pain and other issues. Many
companies can exchange the cylinder in a stool, for different heights
to make it just right. Checking with
the supplier or the manufacturer of
the stool is the best way to find out if
the cylinder can be changed to create
a better fit. The important lesson is:
Don’t just try to live with it; it hurts
the practitioner, the patients, and
eventually, the practice’s bottom
line.
Considering alternative seating
may be the best choice. Creating a
checklist for buying a new chair (Table 2) can help you find the best one
for your needs. A new chair may be
needed because some chairs can’t
be jerry-rigged enough to fit. Other
issues also play a part. Some patient
chairs are extremely wide, or our
patients can be very broad. This can
make it impossible to work close
enough when seated in a traditional
stool. The saddle stool allows much
closer access to the patient, so tasks
can be accomplished with less stress.
The professional should not have
to reach more than 15 inches. The
light, instruments on the bracket
tray, the handpieces, the computer
or anything needed for patient care
should be within arms-reach. Straining for items stresses the muscles in
the neck and shoulder. The biggest
culprit is the overhead light. A headlight attached to loupes is no longer
a choice; it is a necessary part of a
healthy ergonomic armentarium.

Checklists and the culture of
teamwork
Hospital checklists are saving lives
and money. Pilots use several different checklists for every flight
to prevent pilot error and crashes.
Winning race car teams and race car
drivers use checklists for every race.
Dentistry can use checklists to great
benefit as well. We’ve come a long
way, yet dentistry still has a way to
go. It won’t happen without a change
of culture. First, the problem must be
recognized, hopefully before there is

Fig. 4. Traditional upright seating: Notice how
this causes a stretching in the thigh muscles.
(Drawings/Provided by Crown Seating)

serious damage.
Dental professionals know that before there is a cavity, before there
is periodontitis, before there is oral
cancer; there is a risk for a cavity,
periodontal disease and oral cancer.
Preventive care and early detection
is the purpose of routine hygiene
care. Half or more of those reading
this article already have MSDs; the
other half are probably accumulating damage but haven’t reached critical mass to experience symptoms.
Dental professionals are caring individuals who don’t have to hurt themselves to help others. Ultimately not
sitting comfortably hurts the practitioners, the patients and the practice
bottom line. With simple ergonomic
seating checklists professionals can
be more successful at practicing in a
pain-free environment.

References
1. The 1964 Report on Smoking and
Health. National Library of Medicine.
1964. Available at: www.profiles.
nlm.nih.gov/ps/retrieve/Narrative/
NN/p-nid/60.
2. Nixon signs legislation banning
cigarette ads on TV and radio. Time
Magazine. April 1 1970. Available at:
www.history.com/this-day-in-history/nixon-signs-legislation-banningcigarette-ads-on-tv-and-radio.
3. Nonfatal Occupational Injuries
and Illnesses Requiring Days Away
From Work, 2010. U.S. Department
of Labor, Bureau of Labor Statistics.
Available at: www.bls.gov/news.release/osh2.nr0.htm.
4. Survey of Dental Hygienists in the
United States Executive Summary.
American Dental Hygienists Association. 2007. Available at: www.adha.
org/downloads/DH_pratitioner_
Survey_Exec_Summary.pdf.
5. Weerdmeester, B. Ergonomics for
Beginners: A quick reference guide.
2008. CRC Taylor & Francis.
6. Hazard Recognition, Control and
Prevention. Occupational Safety &
Health Administration. Available at:
www.osha.gov/SLTC/dentistry/recognition.html.
7. An Introduction to Ergonomics:
Risk Factors, MSDs, Approaches and
Interventions. A Report of the Ergonomics and Disability Support
Advisory Committee to Council on
Dental Practice American Dental

Fig. 5. Reclined seating

Association. 2004. www.rgpdental.
com/pdfs/topics_ergonomics_paper(2).pdf.
8. Ergonomics for Dental Students.
American Dental Association. 2011.
Available at: www.ada.org/sections/
educationAndCareers/pdfs/ergonomics.pdf.
9. Ergonomics. American Dental Association Alliance. Available at: www.
ada.org/4500.aspx.
10. Schamel, J. How the Pilot’s Checklist Came About. January 1, 2011.
Flight Field Service History. Available at: www.atchistory.org/History/
checklst.htm.
11. Gawande, A. The Checklist Manifesto: How to Get Things Right. New
York: Metropolitan Books, 2010.
12. Pronovost, P., Vohr, E. Safe Patients, Smart Hospitals: How One
Doctor’s Checklist Can Help Us
Change Health Care from the Inside
Out. Penguin Group, 2011.
13. Checklist for Ergonomic Risk Factors. PMA.org. Available at:
www.pma.org/osha/docs/wscchecklist.pdf.
14. Scott II, R. The Direct Medical
Costs of Healthcare-Associated Infections in U.S. Hospitals and the
Benefits of Prevention. March 2009.
Centers for Disease Control and Prevention. Available at: www.cdc.gov/
HAI/pdfs/hai/Scott_CostPaper.pdf.
15. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cos-

Fig. 6. Inclined seating

grove S, Sexton B, Hyzy R, Welsh
R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease
catheter-related bloodstream infections in the ICU. N Engl J Med. 2007
Jun 21;356(25):2660. Available at:
www.nejm.org/doi/full/10.1056/
nejmoa061115#t=articleTop.
16. Purdy, Cindy. “Ergonomics” email. E-mail to AmyRDH group. August 14, 2012.
17. Gilkey, D. Occupational Ergonomics Certificate. 2012. Available at:
www.ramct.colostate.edu/webct.

Judy Bendit, RDH,
BS, Patti DiGangi,
RDH, BS. They are
national speakers
who created and
present Creating
a Flight Plan Beyond the Routine.
The one-of-a-kind
program includes
topics such as electronic health records, risk assessment, instrumentation and ergonomics to name
a few. They are presenting “Flight Plan:
Checklists” in its new format during the
Yankee Dental Congress, www.yankeedental.com, in January. Contact DiGangi
at pdigangi@comcast.net or Bendit at
JZBeducate@aol.com.

mCME SELF INSTRUCTION PROGRAM
CAPPmea together with Dental Tribune provides the opportunity with
its mCME - Self Instruction Program a quick and simple way to meet your
continuing education needs. mCME offers you the flexibility to work at your
own pace through the material from any location at any time. The content
is international, drawn from the upper echelon of dental medicine, but also
presents a regional outlook in terms of perspective and subject matter.
Membership
Yearly membership subscription for mCME: 1,100 AED
One Time article newspaper subscription: 250 AED per issue. After the
payment, you will receive your membership number and allowing you to
start the program.
Completion of mCME
•
mCME participants are required to read the continuing medical
education (CME) articles published in each issue.
•
Each article offers 2 CME Credit and are followed by a quiz
Questionnaire online, which is available on www.cappmea.com/
mCME/questionnaires.html.
•
Each quiz has to be returned to events@cappmea.com or faxed to:
+97143686883 in three months from the publication date.
•
A minimum passing score of 80% must be achieved in order to claim
credit.
•
No more than two answered questions can be submitted at the same
time
•
Validity of the article – 3 months
•
Validity of the subscription – 1 year
•
Collection of Credit hours: You will receive the summary report
with Certificate, maximum one month after the expiry date of your
membership. For single subscription certificates and summary
reports will be sent one month after the publication of the article.
The answers and critiques published herein have been checked carefully
and represent authoritative opinions about the questions concerned.
Articles are available on www.cappmea.com after the publication.
For more information please contact events@cappmea.com or
+971 4 3616174

Table 1. Seating Risk Assessment Checklist (Table adapted from the
Occupational Safety and Health Administration’s ‘Checklist for Ergonomic Risk Factors’)

Table 2. Checklist for buying a new chair

FOR INTERACTION WITH THE AUTHORS FIND THE CONTACT DETAILS AT
THE END OF EACH ARTICLE.

[12] => DTMEA_No.3. Vol.8_DT.indd

mCME

Dental Tribune Middle East & Africa Edition | 3/2018

Long-term clinical success in the
management of compromised intertooth
spaces utilizing small-diameter implants
mCME articles in Dental Tribune have been approved by:
HAAD as having educational content for 1 CME Credit Hour
DHA awarded this program for 1 CPD Credit Point
By Paul S. Petrungaro, DDS, MS
Management of edentulous sites in
the oral cavity with dental implants
has been well documented in dental literature during the past 25-plus
years.1-3 Patients seeking tooth replacement for partial or totally edentulous situations have been able to
enjoy natural appearing and functioning prostheses that are fixed, stable and, in some cases, so natural it’s
difficult to ascertain a dental implant
restoration from a tooth restoration.
Using dental implants to replace
the natural tooth system in the esthetic zone has also seen an increase
in restorative treatment plans and,
with the advent and perfection of
immediate restoration protocols
initially reported in the literature,4-7
achieving natural soft-tissue esthetics around dental implants can be
predictable and successful. However, certain clinical situations can
complicate or negate the procedure
altogether.
One of these complications is insufficient intertooth spacing between
natural teeth and, most commonly,
with congenitally missing lateral
incisors following orthodontic treatment.8 Often as a solution to this, the
dentist chooses a removable partial
denture or some type of resin-bonded bridge, both of which may not be
appealing to younger individuals. In

extreme cases, the dentist may elect
to proceed with a fixed bridge, which
would cause excessive destruction
to the natural teeth serving as abutments and, for a young individual,
this could be devastating to these
teeth during a 40-50 year period, if
not sooner.8
To properly form an ovate pontic
type emergence profile in the soft
tissue, which is required for a fixed
bridge to have a natural clinical appearance, consideration must be
given to the intertooth edentulous
space.9-12 This is also very important
when choosing dental implants for
natural tooth replacement. Wallace,
Misch and Salama, et al,9-11 stated that
for a normal two-piece implant, the
implant should be placed at least 1.5
mm from the adjacent teeth.
As a result, using a 3.5 mm diameter
implant, the minimum inter-tooth
space to support interproximal bone
and natural soft-tissue papillary contours should be 6.5 mm, and with a
3.0 mm diameter implant, 6.0 mm
for the edentulous space. Often, the
intertooth space in these types of
cases is smaller than 6.0 mm.
Taking these parameters into account, small-diameter implants (3.0
mm is the smallest from most dental
implant manufacturers) should not
be used in cases with less than 6.0
mm of inter-tooth space, to prevent

potential tooth root damage, crestal
bone loss and unnatural-appearing
gingival tissues and papillae.
Small-diameter, or mini, implants
were developed more than 20 years
ago and, initially, the recommended
use was to support temporary removable prostheses during the healing phase for advanced bone-grafting procedures and/or conventional
implant placement.12-13
Their use was later expanded into
immediate conversion of full dentures into implant-supported dentures, support for partially edentulous cases and for anchorage of
single tooth implant restorations in
compromised intertooth spaces.14-15
Implants are available from 1.8 mm
diameter to 2.8 mm diameter and
offer a fixed permanent tooth replacement option for patients who
otherwise would not be able to have
implants placed and restored. Their
ease of use and atraumatic placement utilizing a flapless approach,
with only one coring procedure, as
well as simplistic abutment transfer
and provisional construction make
the use of these implants in the
aforementioned sites a must for the
dental implant practice.
The following case report will demonstrate the use of the Dentatus
ANEW (Dentatus USA, Ltd, New York,

CAPP designates this activity for 1 CE Credit

N.Y.) implant for the management
of the compromised, congenitally
missing lateral space in a 17-year-old
young woman with a 10-year clinical
follow up.

Case report
A 17-year-old, non-smoking female
presented for tooth replacement in
the congenitally missing maxillary
left lateral incisor site (Fig. 1). The patient had recently completed orthodontic therapy, and the orthodontist
and general practitioner had agreed
this was the final obtainable result in
regard to the remaining intertooth
space between the maxillary left central incisor and maxillary left canine
(Fig. 2).
The resultant intertooth space was
less than 5.0 mm, and conventional
two-stage implants with abutment
options were ruled out. The patient
and her parents ruled out conventional tooth-replacement options
and chose the minimally invasive
procedure: a small-diameter implant, 1.8 mm in diameter, which
would allow for natural papillary
contours to be developed.
After administration of an appropriate local anesthetic, an ovate
pontic contour was created utilizing a football-shaped diamond in
the attached, keratinized tissue of
the edentulous site (Fig. 3). This scalloped-type tissue contour helps in
the creation of the natural-appearing
papillary contours.
The small-diameter implant chosen,
a 1.8 mm x 14 mm Dentatus ANEW
Implant was then placed after a
single coring of the site with a 1.4
mm needlepoint CePo to full depth,
within the sculpted tissue emergence profile previously created (Fig.
4). Conversion to an esthetic provisional restoration was completed
by placing an abutment coping with
a delrin retention screw (Dentatus
USA, New York, N.Y.).
An ion shell provisional crown was
then hollowed out and retrofitted
to the abutment coping with flow-

Fig. 1. Pretreatment clinical view. (Photos/Provided by Dr. Paul S. Petrungaro)

Fig. 2. Preoperative periapical radiograph.

able composite. The margins of the
provisional were corrected and provisional contoured out of the mouth.
The restoration was polished and
seated with the set screw from the
palatal. The immediate postoperative clinical view is seen in Fig. 5. The
immediate postoperative periapical
view is seen in Fig. 6.
The patient then went through the
three-month healing and observation phase prior to construction of
a lab-processed provisional restoration (Fig. 7). One year later, the patient underwent final restoration
fabrication at the left lateral incisor
site. A 10-year postoperative clinical image can be seen in Fig. 8 and a
10-year postoperative CT scan of the
implant in Fig. 9.
Please note the beautiful soft-tissue
esthetic result obtained and excellent maintenance of the crestal and
lateral contours.

Conclusion
The management of compromised
intertooth spaces presents a challenge for the contemporary dental
implant team. These spaces have
limits on how they are handled and
require implants 3.0 mm wide or
less, as was demonstrated in the text
of this article. Availability of smallerdiameter implants allows patients
who normally would have to proceed with a fixed bridge, or resinbonded bridge, the luxury of dental
implants with no preparation and/
or reduction to the adjacent natural
dentition.
Proper placement procedures and
restorative techniques can lead to
very esthetic results, allowing for
natural tissue contours and emergence profile formation, reminiscent
of the natural tooth.

Acknowledgement
Originally published in Inside Dentistry. © 2014 to AEGIS Publications,
LLC. All rights reserved.
Reprinted with permission from the
publishers.

References
1) Branemark P-I, Zarb GA, Albrektson
T, eds. Tissue-Integrated Prosthesis:
Osseointegration in Clinical Dentistry. Carol Stream, IL: Quintessence
Publishing: 1985:11-81
2) Adell R, Lekholm U, Rockler B, et al.
A 15-year study of osseointegrated
implants in the treatment of the
edentulous jaw. Int J Oral Surg. 1981;
10(6):387-416.
3) Babbush CA. Dental Implants: The
Art and Science. Philadelphia, PA: WB
Saunders Co. 2001:201-216.
4) Kan JY, Rungcharassaeng K. Immediate placement and provisionalization of maxillary anterior single
implants: A surgical and prosthetic
rationale. Pract Periodontics Aesthet

Fig. 3. Ovate pontic type defect created

Fig. 4. Dentatus ANEW implant seated minimally invasive protocol

ÿPage 13

[13] => DTMEA_No.3. Vol.8_DT.indd

Dental Tribune Middle East & Africa Edition | 3/2018

mCME

◊Page 12

Fig. 5. Immediate postoperative clinical view

Dent. 2000; 12:817-824.
5) Saadoun AP. Immediate implant
placement and temporization in extraction and healing sites. Compend
Contin Educ Dent. 2002; 23:309-323.
6) Petrungaro PS. Immediate implant placement and provisionalization in edentulous, extraction and
sinus grafted sites. Compend Contin
Educ Dent. 2003; 24:95-113.
7) Petrungaro PS. Immediate restoration of implants utilizing a flapless
approach to preserve interdental
contours. Pract Proced Aeshtet Dent.
2005; 17:151-158.
8) Misch CE. Treatment options for a
congenitally missing lateral incisor.
A case report. Dentistry Today. 2004;
Vol 23, No.8 pp 92-95.
9) Wallace SS. Significance of the
“biologic width” with respect to root
form implants. Dent Implantol Update. 1994;5:25-29.
10) Misch CE. Early bone loss etiology
and its effect on treatment planning.
Dent Today. Jun 1996; 15:44-51.
11) Salama H, Salama M, Garber D, et
al. Developing optimal peri-implant
papillae within the esthetic zone:
guided soft-tissue augmentation. J
Esthet Dent. 1996; 8: 12-19.
12) Petrungaro PS. Fixed temporization and bone-augmented ridge stabilization with transitional implants.
Pract Periodontics Aesthet Dent.
1997;9(9):1071-1078
13) Froum S, Emtiaz S, Bloom MJ, et
al. The use of transitional implant

Fig. 6. Immediate postoperative radiograph

Fig. 7. Lab-processed, long-term provisional restoration

for immediate fixed temporary
prosthesis in cases of implant restorations. Pract Periodontics Aesthet
Dent. 1998; 10(6):737-746.
14) Petrungaro PS. Management of
the Compromised Implant Site with
Small-Diameter Implants. Inside
Dent. March 2006, 78-80.
15) Petrungaro PS. Management of
the Compromised Intertooth Space
with Small-Diameter One-Piece Implants in the Esthetic Zone. Funct Esthet & Rest Dent; 1 (2):70-75.

Paul S. Petrungaro, DDS, MS, FICD, FACD,
DICOI. He is internationally recognized for
his educational and clinical contributions
to modern dentistry. He graduated from
Loyola University Dental School in 1986,
where he completed an independent study
of periodontics at the Welsh National Dental School in Wales, U.K. He completed his
residency in periodontics and has a specialty certificate in addition to a master’s of
science degree in periodontics from Northwestern University Dental School. He is
the former coordinator of implantology,
Graduate Department of Periodontics,
Northwestern University Dental School.
Petrungaro has been in the private practice of periodontics and implantalogy since
1988 and holds a license in both Illinois and
Minnesota.

Fig. 8. 10-year postoperative clinical view

Fig. 9. 10-year postoperative CT serial view

[14] => DTMEA_No.3. Vol.8_DT.indd

14

ORAL HEALTH

Dental Tribune Middle East & Africa Edition | 3/2018

Beverly Hills Formula Black Toothpastes Proven to Give the Whitest Smile
Beverly Hills Formula Black toothpaste range ranks highest in stain removal after
5 minutes of treatment against other leading brands
By Beverly Hills Formula
Having a beautiful white smile is
something most people aspire to
achieve through the use of advanced
whitening products and treatments,
and more and more people are looking for in-expensive, safe and reliable products to help them acquire a
cleaner, brighter smile for home use.
Beverly Hills Formula (BHF) is a
brand synonymous with that perfect ‘Hollywood smile’. In existence
for over 20 years, the company has
dedicated itself to giving customers
healthy and effective oral hygiene
products which actually do the job
of making teeth whiter through the
use of its powerful stain removal ingredients.
Recent independent research has
indicated just how effective Beverly
Hills Formula products are at stain
removal with several of its leading
‘black’ whitening products rated
highest in stain removal compared
with other brands; SEE CHART
A game changer for the oral hygiene
market, the introduction of Beverly
Hills Formula Perfect White Black
Toothpaste in 2013 was the first ever
black whitening toothpaste to hit
UK shelves. Scientifically formulated with Activated Charcoal which
is known for its love of tannins – a
compound found in coffee, tea, wine,
berries and spices, all of which stain
your teeth. This toothpaste also helps
eliminate bacteria which causes bad
breath and neutralises remaining
odours, leaving breath feeling fresh
all day long. Most importantly, Beverly Hills Formula’s products are de-

Professional Range chart

signed to provide maximum stain
removal without damaging enamel,
by using hydrated silica combined
with Activated Charcoal it offers a
high-performance whitening boost
that is safe for daily use.
Following the overwhelming success of Perfect White Black, Perfect
White Black Sensitive was launched
and also scored highly for its stain removal properties. Designed specifically for teeth with extra sensitivity
this stain removal toothpaste combines the advanced hydrated silica
for high performance whitening and
potassium citrate for rapid sensitivity action. So, Perfect White Black
Sensitive toothpaste allows people
to enjoy rich, acidic foods and drinks
whilst leaving teeth looking whiter
and brighter.
Beverly Hills Formula then ventured
into new territory when they created the first black mouthwash. The
‘shake to activate’ charcoal mouthwash keeps breath fresh for up to 12
hours, whilst removing stains. Perfect White Black mouthwash was acknowledged at the Grocer Magazine
Awards as the Best New Personal
Care product in 2016. The highly
prestigious Grocer Awards celebrates
and rewards outstanding innovation
in the UK’s Fast Moving Consumer
Goods sector in non-food and food
categories.

New Professional White
The recently launched Professional
White range that was showcased at
this year’s International Dental Con-

ference and Arab Dental Exhibition
(AEEDC) in Dubai, also came out on
top of the chart for stain removal. Incorporating their latest black toothpaste, Black Pearl, the new products
have been in development for two
years and aim to provide premium
professional oral hygiene products
that offer superior results.
The new Beverly Hills Formula Professional White range includes, Black
Pearl whitening toothpaste, Pink
Pearl Sensitive whitening toothpaste, Precious Pearl Enamel rem-

ineralising toothpaste and Fresh
Pearl mouthwash containing chlorhexidine and xylitol to combat bad
breath and neutralize the bacteria.
In addition, is their first Professional
White teeth whitening kit consisting
of strips and a whitening pen which
will help people achieve a whiter
smile, safely and easily in their own
home using proven whitening ingredients.
Chris Dodd, CEO of Beverly Hills
Formula, which is based in Ireland

and distributed in over 30 countries,
said: “We are very excited about our
new Professional White range which
has taken over two years in development, but it’s been well worth it
because we believe we’ve created
the best teeth whitening products
which aren’t harmful to enamel and
are aimed at consumers who expect
superior results from a whitening
toothpaste.”

[15] => DTMEA_No.3. Vol.8_DT.indd

Dental Tribune Middle East & Africa Edition | 3/2018

ORAL HEALTH

Fluoride varnish
in primary dentition
positively affects caries
prevention
By DTI
COLOGNE, Germany: Whereas
caries in adults and adolescents
in Germany is declining, research
has found that about 14 per cent
of 3-year-olds in the country have
cavities in their primary dentition. According to a report by the
Institute for Quality and Efficiency in Health Care (IQWiG), fluoride
varnish is effective in remineralisation of the tooth surface and
prevents the development and
progression of caries.

benefit of fluoride varnish application.
The report, titled “Assessment of
the application of fluoride varnish
on milk teeth to prevent the de-

velopment and progression of initial caries or new carious lesions”,
was published online by IQWiG on
26 April 2018.

Permanent teeth may be affected
by caries at an early stage in the
case of caries-affected primary
teeth, as the enamel has not yet
fully hardened. Because oral hygiene and caries prevention can
be challenging in young children,
the use of fluoride varnish can be
beneficial.
For this reason, the IQWiG researchers investigated whether
the application of fluoride varnish
to primary dentition has advantages in comparison with standard care without fluoride application by comparing the findings of
15 randomised controlled trials.
In these, a total of 5,002 children
were treated with fluoride varnish, and 4,705 children received
no such treatment, being the control group. Children aged up to
6 years with or without caries of
their primary teeth were included
in the research.
In several of the studies, further
measures for caries prevention in
addition to the application of fluoride varnish were offered. These
included training on oral hygiene,
instruction on the correct toothbrushing technique, and the provision of toothbrushes and fluoridated toothpaste. The follow-up
observation period was mostly
two years.
The development of caries was
investigated in all 15 studies; sideeffects were investigated in nearly
all of the studies. However, owing to a lack of conclusive data,
it is unclear whether fluoride application also has advantages regarding further patient-relevant
outcomes, such as tooth preservation, toothache or dental abscesses. There was no data on oral
health-related quality of life.
A clear advantage of fluoride varnish was determined despite the
very heterogeneous study results.
After the application of fluoride
varnish, caries in primary teeth
was less frequent. More precisely, the fluoride treatment could
completely prevent caries in approximately every tenth child
and would at least reduce progression of caries in further children.
Apparently, whether the children
already had caries or whether
their teeth were completely intact
made no difference regarding the

HAAD 7.25 CME
DHA 5.5 CME

Fluoride varnish prevents the development and progression of caries, research has
shown. (Photograph: collusor/pixabay)

[16] => DTMEA_No.3. Vol.8_DT.indd

NEWS

Dental Tribune Middle East & Africa Edition | 3/2018

Core Build-Up using Dentsply Sirona’s SDR® Plus
By Dentsply Sirona
The SDR® technology from Dentsply Sirona provides an unmatched combination of flowable consistency, excellent cavity

adaptation, unique self-leveling and minimal shrinkage stress.
With more than 50 million applications and superior performance in 5 and 6-year clinical studies, the SDR® Plus flowable
material is the world’s most researched and clinically proven
bulk-fill flowable technology.
Dentists can bulk-fill up to 4mm deep to perform faster, easier
Class I and II procedures without affecting the durability and
longevity of the restoration. The handling properties of SDR®
technology in SDR® Plus also make it ideal for several indications including core build-up. With three additional shades (A1,
A2, and A3) simplifying aesthetic matching and enhanced wear
resistance with a modified glass filler package that significantly
increases durability, it is no surprise that SDR® Plus is clinically
proven for indirect crown restorations.

Case Study
This case below shows a posterior tooth with an endodontic
treatment followed by an indirect crown restoration. SDR® Plus
is used as a core build up material before the crown was seated.

Conclusion
This case involves the use of SDR® Plus composite as a core
build-up material. The outstanding flowability of SDR® Plus
composite allows complete filling of the pulp cavity, even in
the smallest recesses; the composite was placed in two stages
to ensure thorough polymerisation. The periphery of the tooth
was then prepared, preserving a layer of enamel at the preparation margin to ensure effective bonding of an all-ceramic crown.
This was bonded with the Calibra® system. This protocol thus
avoids iatrogenic mechanical strains on the tooth roots during
core build-up. This treatment, involving a tooth/restoration
monoblock with SDR® Plus composite and crown using only adhesive techniques, provides for outstanding biomechanical and
aesthetic results.
For more information or to request a demo, please contact your
local Dentsply Sirona representative.

Fig. 1: Tooth with a temporary restoration after endodontic treatment

Fig. 2: After removal of the temporary cement and etching with phosphoric
acid.

Fig. 3: Application of the etch&rinse adhesive Prime&Bond Universal™

Fig. 4: First layer of SDR® Plus was placed at the cavity bottom. SDR® Plus selflevels within a few seconds and can be applied to 4mm.

Fig. 5: SDR® Plus first increment was light-cured for 20 sec, before a second
layer of SDR® Plus was placed and light-cured.

Fig. 6: View of the tooth – with the SDR® Plus core prepared for crown seating..

Fig. 7: Impression taking with Aquasil® Ultra Putty soft and Aquasil® Ultra
Light LV.

Fig. 8: The ceramic crown was etched with hydrofluoric acid.

Fig. 9: Calibra® Silane was applied and dried.

Fig. 10: After having etched tooth surfaces, Prime&Bond® universal was applied and dried.

Fig. 11: Before seating the crown, a homogeneous and thin film of Calibra®
Automix was placed on the inner surfaces of the crown.

Fig. 12: The crown was light-cured from each side.

Fig. 13: Final result.

[17] => DTMEA_No.3. Vol.8_DT.indd

[18] => DTMEA_No.3. Vol.8_DT.indd

NEWS

Dental Tribune Middle East & Africa Edition | 3/2018

Investing in better dentistry
Tony Beale of Optident advises young dentists to use their limited equipment budgets
wisely, suggesting to put personalised loupes at the top of any wish list
By Young Dentist
Perhaps one of the most difficult
decisions that students and newly
qualified dentists have to make before and upon venturing into dental
practice is to prioritise their buying
requirements. As budgets will be
extremely tight, they will obviously
need to be very cautious, not wishing to invest in any dental items
that are anything less than practical.
It is sensible, therefore, to consider
instrumentation that they can use
literally every day, and for many varied procedures. Ideally, items should

not be expendible, and should have a
relatively long service life.
Loupes are a product that definitely
fall into this category, and for dental students and the newly qualified
practitioner, they can prove to be a
very worthwhile investment.

Essential kit
Loupes can now be regarded as an
essential piece of kit. They are invaluable in many ways; not only as an
aid to enhance the user’s visionary
requirements, but to combat poor
or incorrect working posture, thus

Fig 2: The Univet range of loupes offers the best choice for young dentists made from
lightweight, but tough, carbon fibre materials at affordable prices

reducing the chances of inducing
acute back, neck and shoulder pain,
and ensuring a more comfortable
and efficient way of working.
However, loupes have never been
regarded as cheap! But having said
this, ‘cheap’ can often turn out to be
costly! Although low-cost loupes can
be purchased off the shelf, there really is no substitute for loupes that are
custom made to suit the users exact
requirements. After all, why would
you buy a pair of ready-made spectacles in the hope that your eyesight
will adjust to them when you can
have a detailed and concise optical
prescription for loupes to suit you?
Personalised loupes will take into account and accommodate the correct
magnification, lens, angle of working, inter-pupillary distance fit, style
of frame and colour, together with
the option of upgrading at a later
date.
The Optident Vision Boutique offers
all young dentists the opportunity to
invest in loupes that will be tailored
to suit the individual’s prescription,
but at reasonable cost. The Univet
range of loupes offers the best choice

for young dentists with ‘cool’ Italian
designer frames made from lightweight, but tough, carbon fibre materials, through-the-lens (TTL), Galilean
and prismatic lenses, together with a
personalised prescription service to
match all the users requirements, all
at an affordable price.

Let there be light
Having made the decision to purchase the right loupes, newlyqualified dental practitioners should
also then consider illumination as
an optional accessory that will significantly enhance the use of their
custom-made loupes. Lightweight,
battery-powered LED lighting, such
as the Optilume POV light, can easily be attached to virtually all loupe
types. LEDs permit a clear view of
difficult-to-access intraoral areas, enable accurate colour determination
and effective shade taking, which is
so important in all restorative and
cosmetic procedures. Their use in
the correct determination of gingival
margins in both restorative and periodontal work is also essential.
Those operators who undertake endodontic work will appreciate the ad-

vantages that loupes, together with
effective lighting can provide. They
are an absolute must if optimum
operatory results in root canal work
is to be achieved without stress or
straining.
Dentistry, together with the introduction of continually improved
materials and techniques, now enables dental practitioners to offer a
wide range of treatment options to
their patients. It is therefore of paramount importance that students
and newly-qualified practitioners
are able to undertake successful
treatment programmes, knowing
that their skills will be fully utilised
by access to the best products and
services available.
For further information or to purchase loupes, please contact SWAN
info@swanmedsupply.com or visit
www.swanmedsupply.com

Editorial note: The article was originally published in Young Dentist
Magazine.

Ivoclar Vivadent
launches new product portal to round
off its online services
By Ivoclar Vivadent AG
Ivoclar Vivadent has announced the
go-live of a new portal. Under the
heading of "Highlights", the portal
offers dental professionals and laboratory professionals the latest news
about the company's products.
The new online portal is now operational. It complements the well-established and successful Dentist and
Dental Technician blogs, which focus

on topics and issues concerning everyday work in the dental practice and
the dental lab.

Update on
new developments
In the new Highlights portal, not
only new product innovations will
be presented, but readers will also be
provided with the most recent findings from Research & Development
to keep them up to date. Dentists
and laboratory technicians who subscribe to the newsletter of this gateway will automatically be informed
about new publications once per
month.

Available in five languages
Similarly to the existing blogs, the
new product portal will be available in the following five languages:
English, German, Italian, French and
Spanish. The portal features two sections, which are in line with the company's relevant target groups: One
section is dedicated to dentists, the
other one to laboratory technicians.
Both target groups will thus be supplied with relevant information to
their profession.

The new Highlights portal from Ivoclar
Vivadent

Link:
https://highlights.ivoclarvivadent.
com

[19] => DTMEA_No.3. Vol.8_DT.indd

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[20] => DTMEA_No.3. Vol.8_DT.indd

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 3/2018

Large MODL Class II restoration with ceram.x®
SphereTEC one, Palodent® V3 and SDR® Plus
By Dr. Clarence Tam, New Zeland
A 43 year old female came to my practice
with a history of non-attendance. She was
concerned about generalised sensitivity
with her heavily-restored dentition, many
teeth of which featured extensive composite restorations with recurrent caries
detectable both clinically and radiographically. Certain teeth with extreme structural
compromise were planned for bonded
porcelain restorations, however, restorations like this large MOD were planned to
be restored with direct composite due to
financial constraints.

shade to umbrella a cluster of shades, by
its distinct chameleon effect, permitting a
minimalised armamentarium.
The Palodent® V3 matrix permitted efficient reconstruction and placement of
initial layers in the extended proximal box
situation, obviating the need to free-hand
sculpt line angles prior to placement of the
sectional matrix assembly.
All in all, the Class II Solution™ offered by
Dentsply Sirona is elegant, efficient and
precise; three features I strive to achieve in
every restoration.

Conclusion and references
Following the total etch bonding technique, Dentsply Sirona’s SDR® Plus was
placed against the base of the proximal
box floor as liner in very thin layers and
cured, in an effort to ensure hybridisation
and marginal integrity in this sensitive area
before building the marginal ridge.
The body composite chosen, Dentsply Sirona’s ceram.x® SphereTEC™ one, features
SphereTEC™ technology using spray granulation to produce spheres with a mean
size of 15 µm out of primary submicron filler glass. These spheres minimise frictional
forces when under stress. On the other side,
the irregularly shaped primary particles
ensure high slump resistance, thus leading
to excellent sculptability. The Cloud Shading Concept adopted by Dentsply Sirona’s
ceram.x® SphereTEC™ one allows a single

Dr. Clarence Tam
Auckland, New Zealand.
Clarence is the Chairperson and Director of the
New Zealand Academy of
Cosmetic Dentistry. She is
currently one of only two
individuals in Australasia to hold Board-Certified
Accredited Member Status with the American
Academy of Cosmetic Dentistry. Clarence is a Key
Opinion Leader for multinational dental companies Kuraray Noritake, J Morita Corp, Hu-Friedy,
Henry Schein, Ivoclar Vivadent, Dentsply Sirona,
Kerr, GC Australasia, SDI, Coltene, Triodent and is
the only Voco Fellow in Australia and New Zealand. She holds Fellowship status with the International Academy for DentoFacial Esthetics. She
sits on the Board of Smiles For the Pacific, an educational trust and charity for dental professional
development across the South Pacific.

Before - Intraoperative situation showing extent of large
MODL Class II restoration. Resin-modified calcium silicate
liner placed against area of deeper dentin with near-carious pulp exposure. Wedgeguards will protect against accidental adjacent tooth grazing during preparation, and
also double as the wedge for the Palodent® V3 sectional
matrix assembly.

Zoomed out view showing diametrically-opposing Palodent® V3 rings with Palodent® V3 matrices overlapping
each other in a one-step solution driving the rebuilding of
proximal and axial contours predictably.

Buccal lobe placement using A2 ceram.x® SphereTEC™
one. Fissure stain placed in interlobar position.

Palodent® V3 sectional matrix set-up showing a re-creation of an ideal line angle anatomy all in one solution.

Marginal ridge formation using A2 ceram.x® SphereTEC™
one. Removal of sectional matrix assembly after this
stage. Finish like a Class I restoration.

After - Final result after placement of lingual lobe and
characterisation. This result demonstrates the superb
handling, sculptability and chameleon effect of the universal, cloud-shaded ceram.x® SphereTEC™ one composite featuring spherical fillers for ultimate control of placement. Note the precision of line angle and bucco-lingual
embrasure formation with Palodent® V3.

[21] => DTMEA_No.3. Vol.8_DT.indd

INTERVIEW

Dental Tribune Middle East & Africa Edition | 3/2018

Digital technology
in dentistry
By Dental Tribune MEA / CAPPmea

Dental Tribune MEA /
CAPPmea: Would you please
introduce yourself?
Martin Serck: I am Martin Serck,
I am based here in Dubai—a resident of the Emirates. For 30 years, I
worked for Sybron Kerr in the consumables business. Six years ago, I
switched to Carestream due to my
passion to know more about equipment, and, in particular, specialised
radiology equipment and now today, also scanning cameras, which is
the opening to the digital world for
us.

world is completely changing
everything?
I think it’s the dental practice, in a
general way, that is changing. We
saw some lectures this morning with
beautiful images showing how dentistry is changing from an analogue
matter to a digital matter and this
facilitates the dental practice on a
daily basis. And yes, there is a continuation from that. Manufacturers are
working permanently on research
for software and we develop the soft-

ware in a sense that they can offer
real support in easing the practice of
dentistry.

Do you find that the dentists
that are at this event are a
small minority or do you think
this is the way the industry is
now?
Certainly, the intention and the attention for the future is big and I
think from all the customers and

Carestream booth at the 13th CAD/CAM & Digital Dentistry Conference & Exhibition

dentists that we can see in the field—
they all consider it. Of course, the
cost towards a more modern, digital
practice is great for some doctors.
Not all of them decide immediately
or can decide to make purchase, but

we see that all practices, according to
their size and their needs, are moving
in that direction.
Thank you for your time and we’ll
see you at the next event.

Tell us more
about Carestream.
Carestream was formerly known as
Kodak and the medical and the dental divisions were sold to Carestream
in a consolidation of Trophy and
Kodak to form a new company. Their
speciality is radiology and scanning
camera devices for scanning and for
taking impressions digitally.

*/5&--*(&/5&/06()
TO IMPRESS A GENIUS

And, obviously this is the perfect event for you. Here, we’re
talking about digital dentistry at the 13th edition of the
CAD/CAM & Digital Dentistry
Conference & Exhibition.
I have been impressed, because the
size of this congress is an important volume and concentration of
dentists who are introduced to a
wide range of aspects that can be
applied to their daily practice. You
have the workshops, you have two
ballrooms—it’s a nice way to approach dentistry. And, we get a lot
of customers visiting us to get more
appropriate details when something
was missed during the workshop
sessions.

Are you finding that the
people that are coming to this
event are more cutting-edge?
That they want to adopt new
technology?
I need to congratulate the organisers of the event, because it surely is
very hard work, first of all, to get all
the lecturers and the audience together and to ensure that it works so
perfectly and runs smoothly. Everything, including the entertainment,
the lunches, everything is very well
organised.

You’ve mentioned briefly,
you’ve moved into scanners
now as well. Tell me why your
scanner is better than everybody else’s?
Well, this will of course be a debate
and each manufacturer will tell his
own story, but for us, it is a matter
of precision. Laboratories that are
providing final work to the dentist
need to give the guarantee that,
time after time, the scan is a precise
one. Not that you take one scan and
the second time you take the same
scan; you have different results. It’s
our focus to have a constant, highprecision scan.

And do you think that digital
technology in the dentistry

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tAutomatically fills in holes with appropriate colour for the optimal aesthetic outcome
t Warns users in real time about areas that require additional scanning
and indicates the ideal direction to scan in
tFacilitates patient occlusion analysis with automatic occlusion mapping
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soft tissue
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*
“Accuracy of Four Intraoral Scanners in Oral Implantology: A Comparative In-Vitro Study,”
Imburgia et al., BMC Oral Health (2017) 17:92 DOI 10.1186/s12903-017-0383-4.

For more information
visit carestreamdental.com

[22] => DTMEA_No.3. Vol.8_DT.indd

22

INTERVIEW

Dental Tribune Middle East & Africa Edition | 3/2018

A Dentsply Sirona Predominant Practice
CEREC and Single-Visit Dentistry
"For me, CEREC is like the iPhone – it’s the leader in its industry."
What would you say are
the advantages to your
workflow and the practice by
using CEREC?

By Dr. Hubert de Grully, UAE
Dr. Roze and Associates Dental Clinic
is located in Jumeriah 3, Dubai. The
clinic comprises of predominately
Dentsply Sirona equipment as part
of their commitment to offer the
best possible service to their patients,
with CAD/CAM technology at the
heart of their practice. Dr. Hubert has
been working at Dr. Roze for 4 years,
specialising in CEREC. We caught up
with him to find out how CEREC has
benefited his workflow, his patients
and the practice.

It changes your way of working
definitely. If you don’t have the CAD/
CAM technology in house, usually
you see one patient every 30 minutes but now with the CEREC I have
fewer patients but bigger sessions.
So I can take more time to perfect
my work and have less stress - no
patients waiting in the waiting room.
At the end of the day it’s beneficial to
everyone.

Please briefly explain your
background in digital
dentistry.
My university in the South of France,
Montpellier first introduced me to
digital dentistry. They had a CEREC
BlueCam machine which they allowed students to practice on and
discover the workflow. As soon as I
used this machine, I believed that
CAD/CAM technology would be the
future of dentistry – and now it’s
everywhere! In order to stay relevant

How has CEREC, and
single-visit dentistry, affected
the satisfaction of your
patients?
in the market, you have to keep upto-date with the latest technology
otherwise you will fall behind your
competitors. We want to offer our
patients the best, and CEREC is the
best.

Why did you choose
CEREC over other CAD/CAM
systems?
I chose CEREC naturally as this is
what we had at the university and

www.celtra-dentsplysirona.com

were taught with. But even when I
had the chance to discover other systems, I felt more comfortable with
the CEREC workflow. Everything is
so smooth, well synced, and works
well together. So why would we need
to use a different system other than
CEREC? For me, CEREC is like the iPhone – it’s the leader in its industry.
This is because of the quality and the
intuitive relationship that the customer has with the CEREC machine.

Can you explain your
experience with the support
you receive from Dentsply
Sirona?
We have strong support from Dentsply Sirona from A-Z. Our clinic is
actually predominately Dentsply
Sirona - treatment chairs, imaging
units, CEREC, and consumables.
Our service engineers and our CAD/
CAM consumables sales representative Joseph Magdy really help to
ensure a smooth and easy life with
CEREC.

How do you find the CEREC
workflow?
Honestly it’s perfect. It does take
more time than the regular process for one restoration it can take around
an hour and a half, or two hours if its
highly aesthetic. But the end result is
worth it – I’m happier as I deliver a
better result and the patient is happier as everything is completed within
a single session.

CEREC® CAD/CAM Solutions

Designed to simply work better together

What are the types of cases
you do with CEREC?

Celtra® Duo (ZLS) blocks, Prime&Bond universal™ Adhesive, and Calibra® Ceram Cement
were designed to enhance and strengthen the individual benefits each of them
provides, resulting in an easy-to-use system that streamlines the restoration process.

Everyone in our practice uses the
Omnicam for scanning the teeth,
especially our 2 orthodontists. Some
are not comfortable with milling or
shading and glazing, but I spent a
lot of time using it in the past so I’m
comfortable with the whole procedure. I mainly do single restorations,
because for one restoration you
have to anticipate at least an hour
maybe more with the patient. Everyone is using the Omnicam at the
clinic, from our general dentist with
the single visit restorations, to our
2 orthodontic specialists scanning
the arches for the Invisalign®1 cases
or for creating in-house immediate
digital surgical guides with our 2 surgeons.

Celtra Duo (ZLS) blocks
• Restoration longevity of Celtra Duo (ZLS) is ensured when used with
Prime&Bond universal Adhesive and Calibra Ceram Cement
• Firing is optional: choose either fire and seat or polish and seat
Prime&Bond universal Adhesive
• No need to use a self cure activator when used with Calibra Ceram Cement
• Low film thickness to allow passive seating of the crown
Calibra Ceram Cement
• One-step curing when used with Prime&Bond universal Adhesive
• 10-second tack cure window and 45-second gel phase ensures an easy, no-stress cleanup

358 CAD CAM Flyer V1.indd 1

04/05/2017 11:40

It’s very good as the patient sees the
whole process from start to finish,
even the chairside workings. It’s nice
to share what we are doing with the
patients when they are in the chair,
they love it. They enjoy seeing the
milling machine working – this is
why we keep it in the patient waiting
room so they can take pictures!
By doing everything in one session
we avoid using multiple anesthesia
and temporary crowns. We also get
more accuracy with digital impressions as CEREC trains us to do good
prep. Aesthetically, we can achieve
a better colour by working chairside
with the patient. If I use a lab, I have
to send pictures to my technician –
the quality of the pictures is never as
good as in real life.

In your opinion,
can you achieve a high return
on investment with CEREC?
I am not involved directly in the
figures but I know that there are 6
doctors here using the equipment
– 2 orthodontists and 4 general dentists.
There is a huge demand for another
Omnicam machine now! In terms of
the full CEREC system, I know that in
the long term we our reducing our
lab costs overall.

What would you say was your
goal with CEREC, and would
you say you have achieved
this yet?
First and foremost my goal was to
deliver highly aesthetically pleasing
restorations to my patients. I have
only reached my goal because of
CEREC.
When I work with the labs either
in France or Dubai there is always
something that needs changing with
the restorations. With the CEREC machine it allows us to design the tooth
ourselves, so we can create the shape,
colour and details that we want.
There’s no comparison – why send
the work to the lab who doesn’t know
how we work or what we want!

[23] => DTMEA_No.3. Vol.8_DT.indd

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[24] => DTMEA_No.3. Vol.8_DT.indd

INTERVIEW

Dental Tribune Middle East & Africa Edition | 3/2018

Tipton Training UK and CAPP Dubai:
Helping young dentists get ahead
Modern dentistry is presenting unique challenges for young professionals. In this article, Professor
Paul Tipton, Clinical Director, Tipton Training and Dr. Conor O'Loughlin (Tipton Alumni) share their
experience of preparing for a successful career in dentistry.

By Tipton Training

Time To Differentiate
Young dental professionals that
want to reach the pinnacle of the
industry must act to ‘differentiate’
themselves in an increasingly competitive jobs market.
That’s the message from Tipton
Training, a dental training centre
that has fast-tracked the careers of
many ambitious dentists.
“I think it’s important that newly
qualified dentists recognise that
they’ve just been taught the basics,”
explains Professor Paul Tipton, Clinical Director at Tipton Training.
“University is there to get dentists
qualified. But it’s important that
young dentists realise that there is so
much more to learn.
“It’s a little like passing a driving test.
Doing so allows a person to drive on
the road - but they only become an
accomplished driver with hands-on
experience. The same principle applies in dentistry, which is why we
help dentists navigate this process.”

Real-world Knowledge Gaps
Conor O’Loughlin is one young dentist that Tipton Training has helped.
Inspired by his father to enter the
world of dentistry, Conor opted to
study the field at university.
“I had always wanted to follow in my
father’s footsteps as a dentist. He was
passionate about dentistry, but my
lack of self-confidence held me back,”
explains Conor.
“It wasn’t until my mid-20’s when
I had a burning desire to take action and send myself off to university. When I finished my studies, I
thought I had all the tools under my
belt to make a real impact in my chosen profession.
“But this wasn’t the case. I felt my
fundamentals were somehow not
refined enough, simply because I
was seeing dental work fail. I then
decided to speak to the professionals and find out where things were
going wrong and how I could correct
them.”

Investing In Training
This led to Conor enquiring and reg-

istering for a series of Tipton Training courses. Specifically, Conor enrolled onto The Restorative Course
in 2016.
“I wanted a solid grounding in restoring teeth. Where better than The
Restorative Course? I soon realised
how naive I had been in my early
years. Professor Paul Tipton opened
my eyes to occlusion and how the
mouth works as a whole,” says Conor.
“Rules and ideas which I overlooked
were explained precisely. Some
things can be learnt from a textbook
- but to actually get involved in chats
and seminars was a much better way
for me to learn.”
The Level 7 Postgraduate Certificate
in Restorative Dentistry explores the
theoretical, scientific and engineering principles behind restorative
dentistry.
Consisting of six units over 14 days,
delegates learn through a combination practical sessions, lectures and
demonstrations.
“The most important topic we cover
on The Restorative Course is occlusion,” adds Professor Paul Tipton.
“Most newly qualified dentists are
unfamiliar with the concept because
universities don’t tend to teach it.
However, occlusion is the major factor which determines whether restorations succeed or fail. It’s this kind
of learning that helps many dentists,
just like Conor, start to deliver treatments that exceed expectations.”

Further Practical Learning
After successfully completing The
Restorative Course, Conor wanted a
means of testing his knowledge in a
practical environment.
With this in mind, he enrolled onto
The Phantom Head Course in 2017.
The course consists of six units delivered over 10 face-to-face days and
two days of e-learning.
“I wanted some hands-on experience before putting my knowledge
into practice. The Phantom Head
Course was just perfect,” says Conor.
“The days spent drilling teeth over
and over again were exhausting - but
what better way to improve? Practice
really does make perfect! I can safely
say my preparations improved ex-

ponentially.
“Plus, I had a lot of fun along the way.
I was very lucky to have some great
colleagues and mentors to make the
days exciting! I now consider them
lifelong friends.”
An integral part of The Phantom
Head Course concerns two-handed
tooth preparation, a skill which Professor Paul Tipton views as essential.
“Most dentists don’t know how to
‘prepare to prepare’. I know that may
sound trivial, but most dentists don’t
know the best means to prepare
teeth.
“For example, I see a lot of dentists
prepare with just one hand. Tipton
Training teaches two-handed tooth
preparation, which involves holding
the turbine in both hands.

“Within months, I was producing
beautiful restorative work from various crowns, onlays/inlays, veneers
and many variations in bridgework.
Literally days after a course, I was
able to apply my new-found knowledge to everyday problems.
“I’ve had several makeover cases
where I’ve combined veneers with
crowns, implants and bridgework
- and patients have cried in happiness!”
What’s more, Conor has found that
his ability to take on more complex
cases has more than covered his original course fees.

“Of course, revenue is important, but
now I can go to work and really look
forward to more challenging cases.

Improved Confidence
& Treatment Delivery

“Who wants to spend the next 30
years just drilling and filling? The
job’s not worth doing without satisfaction - and that is exactly what I
have now.”

“Doing The Restorative Course and
The Phantom Head Course has immensely improved my self-confidence,” explains Conor.

Plus, these Enhanced CPD compliant
qualifications give dentists the skills
to provide first-class treatments to
patients, maximising their earning
potential.
Dentists who want to establish a
clear career path should consider
registering for one of Tipton Training’s Postgraduate Certificate or Diploma courses.

“I would recommend Tipton courses
- 110%. My courses, one year later,
have paid for themselves,” says
Conor.

“The Phantom Head Course also explores how to use the speed increasing handpiece, select the right type
of burs, correctly use a mirror and
adequately prepare a dental nurse.”

The skills Conor learnt on The Restorative Course and The Phantom Head
Course were immediately applied
in his practice setting - meaning he
could complete complex cases confidently.

ter’s level National Vocational Qualification (known as a Level 7 qualification), which can help dentists stand
out in a competitive jobs market.

Postgraduate
Certificates & Diplomas
As an approved EduQual centre,
Tipton Training gives delegates an
opportunity to learn advanced dentistry principles through engaging
theoretical and practical sessions.
Successful completion leads to Mas-

CAPP-Tipton Dental Academy offers
3 Diploma programmes in Dubai
UAE, namely:
1. Restorative & Aesthetic Dentistry
Certificate & Diploma
www.cappmea.com/capptipton
2. Clinical Endodontics Certificate &
Diploma
www.cappmea.com/endo
3. Clinical Implantology Certificate &
Diploma
www.cappmea.com/implant
For more information visit the
above mentioned websites or Call/
WhatsApp +971528423659 or e-mail:
p.mollov@cappmea.com

[25] => DTMEA_No.3. Vol.8_DT.indd

[26] => DTMEA_No.3. Vol.8_DT.indd

INTERVIEW

Dental Tribune Middle East & Africa Edition | 3/2018

Futudent at CAD/CAM and Digital Dentistry
Conference: New cameras and partnership
By Dental Tribune MEA / CAPPmea

Dental Tribune MEA / CAPPmea: Please would you
introduce yourself.
Brian Forth: Sure, I am Brian Forth,
I’m the Head of Sales and Marketing
at Futudent. We are the global leader in dental video technology and
we’re very happy to be here at the
13th CAD/CAM & Digital Dentistry
Conference in Dubai. Thank you for
having us. We were very proud to
donate one of our cameras for this
event. Also, we were very excited
about a lot of new things that we did
at this show. We donated a camera,
we have premiered two brand new
cameras that we have just launched,
here at your event. And, then we also
began working with our new partner,
SWAN, here in the UAE. So, we had a
lot of new and exciting things happening over the last two days.

Could you tell us a little bit
more about the two new
cameras that you have
launched? What are their main
advantages compared to the
previous generation?
The two cameras that we launched
are the proCam and the microCam.
The proCam is the first 4K camera in
dentistry, a miniaturized 4K camera.
It can be used either on the loupes
or on the light to film dental work in
amazing detail. So, we’re very excited

about that product. And, at the same
time, we launched a product called
the microCam. Now, the microCam is the smallest loupe-mounted
dental camera. It’s only 12g, it feels
like almost nothing, because doctors already have a lot of weight on
the bridge of their nose, with their
loupes and their light, so if you want
to add a camera there, you want to
keep the weight as low as possible.
So, the microCam is a great camera
for filming from the loupe to get that
perfect shot from the point of view
of the doctor,but without adding too
much extra weight.

What is the main advantage
for a dentist to actually make
a video of the procedures?
And, what is the main advantage for patients themselves?
That’s a great question. So, we’ve
been doing this for a long time. We
started seven years ago and we’ve
seen the evolution of the use of video in general dentistry. It began as a
technology that was primarily used
by academics and key opinion leaders who needed to get great videos of
their procedures for education to be
able to show people in their presentations what they’re doing. But, what
we’ve done, since we’ve started this,
is we’ve taken those tools of video
and we found ways to make it useful
for a general practitioner. So, a corner doctor, even hygienists are able
to film their work and show their

patients and their colleagues in different cases. So, one of the most interesting uses for our video is really
patient education—helping the patient see and understand the dental
work that’s being done. It helps with
treatment acceptance and then of
course, within the team as well, to be
able to share difficult cases. You can
do a certain amount of still photography, but a video is so much richer,
you can do a lot more with video. So,
we’re seeing more and more applications for video all the time and we
are very excited to be sitting at the
front of that wave.

Brian, what do you think about
the 13th edition of the CAD/
CAM and Digital Dentistry
Conference and Exhibition and
about your partnership with
SWAN, who is now your local
distributor here in the UAE?
Well, I can say this has been a fantastic two days. We’ve had a lot of very
exciting conversations in our little
booth around the corner. I spend
my life travelling around to dental
shows—a lot of big ones—and this
show was just very focused. So, the
doctors who came here to talk about
digital dentistry, they’re already in
the right headspace, they're technological savvy, they’re interested in
using digital technology to enhance
the way they communicate; the
way they document their cases and
they’re looking to do that with CAD/

Brian Forth, Head of Sales and Marketing at Futudent presenting the newly launched
camera to one of the winners of poster presentation during the 13th CAD/CAM & Digital Dentistry Conference in Dubai.

CAM and other technologies as well.
We just offer another and unique
way to do that, that is new for a lot
of them. So, we’re still educating the
market at the same time as we’re
here talking with doctors.
Brian, thank you very much for the
great interview. We hope to see you
next year at the 14th edition of the

event, which will be on the 12th and
13th of April 2019.
If you’d like more information about
the Futudent cameras or our conference go to www.futudent.com or
www.cappmea.com. Thank you and
have a great day.

Prof. Daniel Wismeijer on
the importance of 3-D printing in dentistry
By Dental Tribune MEA / CAPPmea

3-D printing. This can be a very easy
and simple book to help you understand the technologies behind 3-D
printing. When you understand the
technologies, then you can also find
a way of implementing these technologies into the workflow. It’s not
just plug-and-play, it’s not “here you
have a machine and now you can get
to work”. No, you have to understand
the role the machine plays in the total digital workflow in dentistry.

We’re here at the 13th CAD/CAM
Conference in Dubai. This is the second time I’m here, the first time I was
here was about three years ago at the
tenth edition. The CAD/CAM conference is focusing on the digital workflow in dentistry.
And what is interesting about the
digital workflow is, it’s showing us
how dentistry is going to be changing in the coming years. What we
see is that we’re getting away from
the analogue and going full digital.
Digital diagnostics, lets us look at our
patients from a virtual perspective..
We do the CAD, the planning; we go
into CAM; we have the milling; we
have the 3-D printing. And then we
can execute the total treatment, as
we go to the patients ourselves. So,
looking around here at this conference, we see a lot of industry that
understands the change that we are
up against in dentistry. They’re here
presenting the technologies that
they all have in portfolio.
One of the problems however is that
these technologies are all in verticals.
The technologies are not horizontally connected together. So, what we’re
looking for is a horizontal connec-

Prof Daniel Wismeijer from the Netherlands during the 13th CAD/CAM & Digital Dentistry Conference in Dubai on the importance of
3-D printing in dentistry.

tion between all these vertical technologies to get the digital workflow
to really work for dentists.
Questions are directed to me all the
time: “How are we going to do this?”
“Could you explain how I can integrate this into my workflow?” But, if
you don’t have the proper software
and you haven’t learnt how to use it,

then you’re going to get into trouble
when you try to implement it. So, the
credo here is that you have to learn,
unlearn and relearn to understand
what’s happening in digital dentistry.
Today, I gave a presentation on 3-D
printing in dentistry. Some of the

questions that were posed to me
after my presentation told me that
people do not fully understand yet
what 3-D printing actually is. And
they’re asking me: “Can I use that
printer for printing metals?” No,
you can’t. “What can I read to learn
more about digital dentistry?” Well,
my idea would be to get a book on

You have to understand which machines you need to make the digital
workflow work for you. So, it’s not
just about reading up on the end solutions; it’s also reading up on the basics, the technology itself, and learning about subjects that you need
to first understand i.e.; what digital
dentistry is and what 3-D printing is.
If you don’t understand the basics,
it’s going to be very difficult to understand the final execution of all
these technologies in your workflow.
My advice is: be humble, be prepared
to learn, be prepared to unlearn everything that you have learnt in the
past and relearn the new technologies to be able to function properly
in the new digital workflow.
Thank you.

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GENERAL DENTISTRY

Dental Tribune Middle East & Africa Edition | 3/2018

Clition and Irreversible Inflammatornical
Management of a First Upper Molar with Invasive
Cervical Resorpy Pulpitis
By Prof. Dr. Leandro A. P. Pereira
External cervical tooth resorption is
characterized by an irreversible loss
of dentin tissue due to the action
of odontoclasts (Patel et al 2007).
It may also be called invasive cervical resorption (ICR). It is an inflammation of the tissues supporting
the tooth. Initially, there is no pulp
involvement (Mavridou AM, Pyka
G, Kerckhofs G, et al 2016). Generally, this type of resorption begins
immediately below the union epithelium in the cervical region of
the tooth. While there is no bacterial invasion in the pulp cavity, the
pulp's vitality is maintained. Thus,
the pre-dentin layer will be present.
The ICR does not progresses into
the pulp cavity possibly due to the
presence of inhibitory factors in
this pre-dentin layer (Wedenberg
1987, Mavridou et al. 2016, Mavridou AM, Pyka G, Kerckhofs G, et al
2016). Its diagnosis and treatment
are not always easy and the prognosis depends on the location and degree of severity of the lesion when
diagnosed.
Several etiological factors may be
involved in ICR. These include the
following:
- Physical: dental trauma, surgical
procedures, orthodontic movements, periodontal scaling and
bruxism (Heithersay 1999).
- Chemical: internal bleaching
agents, especially in cases of heating and high concentrations of
hydrogen peroxide (Harrington &
Natkin 1979, Cvek & Lindvall 1985,

Schroeder & Scherle 1988, Gold &
Hasselgren 1992, Neuvald and Consolaro 2000).
- Anatomical variation: the type of
cementoenamel junction seems to
play a key role in external cervical
resorption. In 10% of teeth, there is
no juxtaposition of the sealing to
the enamel (Schroeder & Scherle
1988). Thus, an area of the dentin
has no sealing or enamel (Cvek &
Lindvall 1985, Neuvald and Consolaro 2000). This dentin exposure is
a risk factor for the development of
ICR (Neuvald and Consolaro 2000).
In cases where the cementoenamel
junction is not continuous, physical and/or chemical irritants can
cause damage to the bone and
dentin. This aggression may lead
to biochemical changes in the affected tissues, leading to the formation of multinucleated giant cells.
These cells are clastic cells. In these
clinical situations, they may act by
reabsorbing the dentin. In the resorption process, monocytes and
macrogens are present, as well as
complex enzymatic and hormonal
events.
Cervical reabsorption begins on the
outer surface of the root and progresses toward the pulp. However,
when it still presents vitality, the
pre-dentin layer is maintained and
the ICR does not invade the pulp
cavity. Predentin, which is a nonmineralized tissue, changes the direction of resorption progression
by making it settle circumferentially to the pulp cavity (Fig. 4-7).

The diagnosis of ICR can be performed by clinical examination
when it is in a more advanced
stage, allowing its direct visualization. Clinically, at the beginning of
the process, the tooth condition is
asymptomatic since no pulp pathophysiological changes are involved.
In these cases, diagnosis by image is
the most effective method. For this
reason, direct visual clinical diagnosis is not possible in the early stages.
Imaging examinations such as periapical radiographs and/or CT scans
are efficient methods of diagnosis.
Among these, the conical beam tomography is more accurate than
the periapical radiography (Patel et
al 2016, Vaz de Souza D et al 2017).

purpose. However, none of these
presented desirable characteristics
and results. Only bioceramic materials have the desirable characteristics for this purpose. Among bioceramic materials, MTA is the most
used material and has the highest
scientific evidence of its results (Pitt
Ford et al 1996, Torabinejad & Parirokh M 2010, Parirokh M & Torabinejad 2010).

Clinical Case

The treatment of ICRs aims to protect the affected dentin from exposure to the patient's immune system. For this, cleaning the affected
area and restoring the cavity with
biocompatible material is the indicated treatment. As these areas are
in direct contact with tissue and salivary fluids, they are wet and irregular due to the destructive aspect of
the resorption process. Therefore,
the material of choice for the closure of this cavity, besides being
biocompatible, must be able to fill
irregular cavities and have good
physicochemical behavior in a wet
environment.

A 52-year-old female patient, ASA I,
came to the clinic with complaints
of spontaneous pain exacerbated
by hot and cold foods in the right
maxilla. On clinical examination,
tooth 16 responded to thermal
tests with high-intensity, pulsating
pain and taking long to cease. She
did not present positive responses
to lateral and vertical percussion
tests, nor to apical palpation. The
clinical diagnosis was symptomatic
irreversible pulpitis with normal
periapex. In addition, a radiolucent
image was visualized on the radiographic examination involving the
cervical and coronary region of
tooth 16, leading to the suspicion of
a Cervical Invasive Resorption (Fig.
1-3). In order to have a confirmation of the diagnosis and assess the
extent of the lesion, a concomitant
computed tomography scan was
performed.

Throughout the history of dentistry, several materials such as resins, amalgam, resin-modified glass
ionomer, hydroxyapatite and endodontic sealers were used for this

In the tomography, we could observe the three-dimensional extension of the ICR around the pulp
cavity. As previously described,
the ICR does not invade the pulp

cavity when the pulp is alive due
to the presence of the pre-dentin
layer. This imaging characteristic is
present in cases of external dental
resorption where the pulp is still
alive with consequent preservation
of the pre-dentin non-mineralized
layer (Fig. 4-7).
The endodontic treatment was
performed according to the pulpal
diagnosis. However, a complementary approach was required in the
resorption area (FIGURE 8). The
marked curvature of the mesial
root led to the selection of a reciprocating nickel - titanium instrument
with shape memory control (Reciproc Blue - VDW) for mechanical
preparation.
After accessing the pulp chamber,
5 ml of sodium hypochlorite were
used for initial irrigation (FIGURE
9). Afterwards, a Reciproc Blue 25
instrument was progressively introduced into each of the canals,
in cycles of 3 slight incoming and
outgoing movements in the canals followed by irrigation of 3 ml
Hypochlorite between each cycle,
until they reached 2/3 of the radiographic length of the tooth. At this
time, the actual working length was
established using an electronic foraminal locator. Subsequently, the
Reciproc Blue 25 instrument was
taken to the working length. With
a Reciproc Blue 40 instrument, the
diameter of the apical preparations
was increased (FIGURE 10, FIG-

ÿPage 26

Fig. 1: Initial periapical radiograph

Fig. 2: Initial periapical radiograph at different horizontal angulation

Fig. 3: Interproximal radiograph

Fig. 4: Computed tomography showing
the shape of the resorption around the
pulp chamber

Fig. 5: Computed tomography showing
the Invasive Cervical Resorption

Fig. 6: Invasive Cervical Resorption around
the pulp chamber

Fig. 7: ICR Area and Location

Fig. 8: Live pulp

Fig. 9: Connective tissue filling the area of
resorption

Fig. 10: Location of mesiobuccal canal 2

Fig. 11: Root channels prepared with
Reciproc Blue 40

Fig. 12: Final radiograph

Fig. 13: Clinical aspect 8 months later color preservation

Fig. 14: Control periapical radiograph
(8 months later)

Fig. 15: Horizontal angulation variation
of the periapical control radiography
(8 months later)

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GENERAL DENTISTRY

Dental Tribune Middle East & Africa Edition | 3/2018

◊Page 24
URE 11). Due to the shape memory
control of the Reciproc Blue files,
it was possible to perform the apical preparation of the mesiobuccal
root with marked curvature, even
with an instrument of 40 apical diameter and 5% taper.
The irrigation protocol of 3 ml of
solution per canal at every 3 incoming and outgoing movements of
the reciprocating instrument was
maintained until the end of the
preparation. After finishing the
chemical/mechanical preparation
of the canals, the irrigation was performed with 17% EDTA associated
to passive ultrasonic irrigation in
3 cycles of 20 seconds per cycle in
each canal. The canals were then
re-irrigated with 2.5% Sodium Hypochlorite.
For endodontic filling by the cold
vertical compaction technique,
MTA Fillapex (Angelus - Londrina,
Brazil) and pre-calibrated guttapercha cones were selected.
In the resorption region, an intracoronary (non-surgical) sealing approach was chosen. This choice was
made due to the small extent of the
area of communication between
the resorption and the external
dental surface (FIGURE 9). For sealing the resorption area including
the communication between the
external/internal surface, the material of choice was MTA-HP and
not the conventional MTA. As the
conventional MTA contains Bismuth Oxide as radiopacifier, it may
lead to a darkening of the tooth
crown when used near the cervical region or in the dental crown.
Bismuth Oxide may react with the

dentin collagen, causing a graying
of the dental structure (Marciano
MA et al 2014). This color alteration
may also occur due to the interaction between Bismuth Oxide and
Sodium Hypochlorite (Camilleri et
al 2014, Marciano MA et al 2015).
Thus, using bioceramic materials
containing Bismuth Oxide as a radiopacifier should be avoided.
With the concern for preserving
the aesthetics of the clinical cases
treated with bioceramic materials,
new formulations of these materials have been proposed by the
industry. As an example, MTA HP
Angelus has Calcium Tungstate as
radiopacifier. This new formulation
does not lead to chromatic changes
in dental structure (Marciano Ma et
al 2014). Thus, HP MTA can be used
in areas close to the tooth crown
without the chromatic impairment
of the treated tooth. Furthermore,
the addition of an organic plasticizer to the liquid component of
this new material significantly improved its clinical management. As
this clinical case involves the placement of bioceramic material near
the coronary cervical area of tooth
16, we chose MTA HP to preserve
the original color of the tooth (Fig.
12). In the 8-month clinical control
it is possible to observe the maintenance of the original color of tooth
16 (Fig. 13) as well as the normality
of the periapical tissues (Fig. 14-15).

Conclusion
Invasive cervical resorptions are pathologies of immunological character. When early diagnosed, where
the extent of tooth destruction is
still small and easily accessible, the

prognosis is favorable. Bioceramic
repair materials are indicated to
seal the communication between
the endodontium and the external surface of the root. As invasive
cervical resorptions involve aesthetic areas, bioceramic materials
containing Bismuth Oxide should
be avoided because they cause
chromatic changes in the crown
of the impaired tooth. Therefore,
traditional MTAs are not indicated
in these cases. However, new formulations of MTA such as MTA
HP do not contain Bismuth Oxide.
This characteristic does not lead to
changes in tooth color. Hence, this
is the most suitable material for
sealing these areas of resorption.

References
Patel S, Pitt Ford T. Is the resorption
external or internal? Dent Update.
2007;34:218–29.
Wedenberg C, Lindskog S. Evidence
for a resorption inhibitor in dentin.
Scand J Dent Res 1987;95:270–1.
Heithersay GS. Invasive cervical resorption: An analysis of potential
predisposing factors. Quintessence
Int. 1999;30:83–95.
Harrington, G. W. & Natkin, E. (1979)
External resorption associated with
the bleaching of pulpless teeth.
Journal of Endodontics 5, 344–348.
Cvek, M. & Lindvall, A. M. (1985)
External root resorption following
bleaching of pulpless teeth with
oxygen peroxide. Endodontics and
Dental Traumatology 1, 56–60
Torabinejad M, Parirokh M.
Mineral trioxide aggregate: a
comprehensive
literature
review--part II: leakage and biocompatibility investigations. J Endod.
2010 Feb;36(2):190-202

Parirokh M, Torabinejad M. Mineral
trioxide aggregate: a comprehensive literature review--Part III: Clinical applications, drawbacks, and
mechanism of action. J Endod. 2010
Mar;36(3):400-13.
Schroeder, H. E. & Scherle, W. F.
(1988) Cemento-enamel junction
revised. Journal of Periodontal Research 23, 53–59.
Gold, S. I. & Hasselgren, S. (1992) Peripheral inflammatory root resorption. A review of the literature with
case reports. Journal of Clinical Periodontology 19, 523–534.
Pitt Ford TR, Torabinejad M, Abedi
HR, Bakland LK, Kariyawasam SP.
Using mineral trioxide aggregate:
As a pulp-capping material. J Am
Dent Assoc. 1996;127:1491–4.
Marciano MA, Costa RM, Camilleri J,
Mondelli RF, Guimarães BM, Duarte
MA. Assessment of color stability of
white mineral trioxide aggregate
angelus and bismuth oxide in contact with tooth structure. J Endod.
2014 Aug;40(8):1235-40.
Camilleri J. Color stability of white
mineral trioxide aggregate in contact with hypochlorite solution. J
Endod. 2014 Mar;40(3):436-40.
Marciano MA, Duarte MA, Camilleri
J. Dental discoloration caused by
bismuth oxide in MTA in the presence of sodium hypochlorite. Clin
Oral Investig. 2015 Dec;19(9):2201-9.
Patel K, Mannocci F, Patel S. The
Assessment and Management of
External Cervical Resorption with
Periapical Radiographs and Conebeam Computed Tomography:
A Clinical Study. J Endod. 2016
Oct;42(10):1435-40
Daniel Vaz de Souza, Elia Schirru,
Francesco Mannocci, Federico Foschi, Shanon Patel. External Cervical
Resorption: A Comparison of the

THE SAME EFFICIENCY
WITH BETTER PLASTICITY

Diagnostic Efficacy Using 2 Different Cone-beam Computed Tomographic Units and Periapical Radiographs. Journal of Endodontics, Vol.
43, Issue 1, p121–125
Mavridou AM, Pyka G, Kerckhofs G,
et al. A novel multimodular methodology to investigate external cervical tooth resorption. Int Endod J
2016;49:287–300.
Mavridou AM, Hauben E, Wevers
M, Schepers E, Bergmans L, Lambrechts P. Understanding External
Cervical Resorption in Vital Teeth. J
Endod. 2016 Dec;42(12):1737-1751.
Lilian Neuvald, Alberto Consolaro.
Cementoenamel Junction: Microscopic Analysis and External Cervical Resorption. Journal of Endodontics, Vol. 26, Issue 9, p503–508.
September 2000

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

Endodontics

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NEWS

Dental Tribune Middle East & Africa Edition | 3/2018

A practice of firsts and high standards in Kuwait
Eschmann exploring infection control in different countries
By Dr Praveen Chandra L.P, Kuwait

unprocessed, biological monitoring
indicators to confirm the eradication
of spores, and with the vacuum sterilisers, Bowie-Dick test packs to verify
steam penetration.

When Maidan Clinic – Sharq branch
opened in 1987 in the central business district, it was the first private
dental practice in Kuwait. The aim
was to provide a first class dental
experience to patients by meeting
the highest standards and using the
latest technology and innovations.
Now, there are six other centres that
belong to the Maidan group, though
Sharq remains the biggest, both in
team and physical size (the centre is
spread over roughly 10,000 square
feet). Maidan Clinic – Sharq branch is
very popular with VIP patients.
Including me there are 10 dentists
in the Sharq branch, 16 dental assistants, 5 infection control specialists, 4 hygienists and 4 receptionists
that work across 12 surgeries in shifts
between 0900 and 2030. Together,
we are able to provide a comprehensive list of treatments from general
dentistry to implants, orthodontics,
sedation dentistry and more thanks
to the broad skill set of the team and
variety of qualifications. I specialise
in conservative dentistry and endodontics, but my scope of practice
also includes placing implants and

Ultimately, it is the expert team of
infection control specialists that are
responsible for ensuring all protocols are followed to the letter, but I
am very passionate about the infection prevention and control within
our practice, as it ensures we are able
to provide a quality level of care. Not
only is it a legal requirement, but
our patients trust us to provide an
excellent service, and it’s what they
deserve to receive.

minimally invasive anterior alignment using the Invisalign appliance
(though only in select cases). I was
instrumental in arranging the first
certification programme for Invisalign in Kuwait, an honour that was
observed by the then United States
Ambassador to Kuwait, Matthew H.
Tueller.

Each dentist – myself included – will
see approximately 10 patients each
day, though of course this can vary
depending on the types of treatment
required. The practice is open Saturday to Thursday, which is a half-day,
and we have Friday off as this is considered our weekend in Kuwait.

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As part of our service, we also offer a
state of the art mobile dental clinic
designed especially for corporations,
private senior management consultations, schools and to treat patients
with additional needs that are unable to attend the practice for treatment. This service is usually offered
around twice a month, but at peak
times of the year it can be as many
as four.
Altogether, our patients receive a
high standard of care across all aspects of dentistry, not only with
treatments but infection prevention
and control too, which is regulated
by the Ministry of Health. As well as
our personal benchmark that we set,
there are specifications that we’re
required to meet in line with ‘Infection Control Guidelines in Dental
Practice’. The instructions include
information on all aspects of infection control from hand hygiene
to the use of personal protective
equipment, surface disinfection and
equipment asepsis, waste disposal,
and instrument decontamination.
On top of that we follow both OSHA
standards (Occupational Safety and
Health Administration) and Universal Precautions, which along with
our state-of-the-art infection control
department ensures complete compliance and patient safety.
We have two rooms – one for the
dirty, used instruments and cleaning
and disinfection, and one for sterilisation, packing and storage, which
are interconnected by a hatch to
minimise recontamination. Equipment wise we use an ultrasonic
cleaner before the instruments are
packed, sealed and sterilised using either dry heat sterilisation or
steam under pressure (autoclave).
For best results all loads have either
dry-heat or steam indicator tape to
distinguish between processed and

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To ensure I stay up to date with all
the latest regulations, techniques,
equipment and so on I regularly attend conferences and workshops all
over the world such as the Midwinter
Meeting in Chicago, the IDS Cologne
and AACD (American Academy of
Cosmetic Dentistry) event. Any new
changes or innovations that I come
across I always take back to my practice, and where possible we always
try to incorporate to make our service that little bit better.
For more information on the highly
effective and affordable range of
decontamination equipment and
products from EschmannDirect,
please visit www.eschmann.co.uk or
call 01903 753322

Dr Praveen Chandra L.P details a day in
the life as a senior dentist and associate
in Maidan Clinic – Sharq branch, Kuwait,
where he’s been for 15 years. Dr Praveen
graduated in 1992 with a BDS degree
from the University of Mysore, India before gaining his Master’s degree from
Kuvempu University, India in 1996. He
has been an opinion leader many times
for Dentsply Endodontics, and has trained
with people like Dr Gary Carr and Dr John
Stropko in micro-endodontics. His mentor
was Dr William Ben Johnson, the inventor of Thermafil and pioneer of rotary
endodontics. Previously, Praveen was an
associate professor in endodontics and
conservative dentistry.

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33

NEWS

Dental Tribune Middle East & Africa Edition | 3/2018

Study finds acupuncture could
help with dental
anxiety
By DTI
YORK, UK: Fear of the dentist is
something some people suffer
from more than others. With multiple reasons for dental anxiety
and its effects, there is however
limited research on its impact and
possible treatment methods. In an
effort to look deeper into the topic, researchers from the University of York have recently reviewed
a number of studies on treating
dental anxiety with acupuncture,
and the results show it could be a
helpful tool.
For the systematic review and
meta-analysis, six trials with a
total of 800 patients were chosen
from almost 130 eligible trials. The
researchers used a points scale to
measure anxiety, and in the studies included, anxiety was shown
to be reduced by eight points
when dental patients were given
acupuncture as a treatment. According to the researchers, this
level of reduction is considered to
be clinically relevant, indicating
that acupuncture could be a possibility for treating dental anxiety.

Researchers from the University of York have found that acupuncture could help with dental anxiety.
(Photograph: acupuncturebox/pixabay)

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Co-author Dr Hugh MacPherson,
Professor of Acupuncture Research at the University of York’s
Department of Health Sciences,
said: “There is increasing scientific
interest in the effectiveness of acupuncture either as a standalone
treatment or as an accompanying treatment to more traditional
medications.”

“If acupuncture is to be integrated
into dental practices, or for use
in other cases of extreme anxiety, then there needs to be more
high-quality research that demonstrates that it can have a lasting
impact on the patient. Early indications look positive, but there is
still more work to be done,” said
MacPherson.
The study, titled “Acupuncture
for anxiety in dental patients:
Systematic review and meta-analysis”, was published in the June
2018 issue of the European Journal of Integrative Medicine.

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Of the six studies, those that
compared anxiety levels between
patients that received acupuncture and those that did not show
a significant difference in anxiety scores during dental treatment. However, the researchers
noted that no conclusions could
be drawn between patients that
received acupuncture as an intervention and those that received
placebo treatment, and suggested
that larger controlled trials are
needed to increase the robustness
of the findings.

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[34] => DTMEA_No.3. Vol.8_DT.indd

34

NEWS

Dental Tribune Middle East & Africa Edition | 3/2018

Sipping hot fruit teas and
snacking can lead to tooth erosion
By King's College London
An acidic diet has long been associated with erosive tooth wear. However,
some people who consume dietary
acids develop erosive tooth wear and
some do not.
Scientists at King’s College London
have examined the risk factors and
damaging habits associated with the
consumption of acidic foods that result in the loss of tooth enamel and
dentine.
Drawing on a previous study at
Guy’s Hospital, London, that compared the diet of 300 people with severe erosive tooth wear and 300 people without, researchers identified
how different behaviours increased
the risk of developing the condition
that affects more than 30% of adults
in Europe.
The King’s team found that eating
and drinking acidic food and drinks,
particularly between meals, carried
the greatest risk. Those who consumed acidic drinks, including water with a slice of lemon or hot fruit
flavoured teas, twice a day between
meals, were more than 11 times more

likely to have moderate or severe
tooth erosion. This figure was halved
when drinks were consumed with
meals.
The research, reviewed in the British Dental Journal, also identified a
range of foods, drinks and medications that have the potential to be
erosive. Drinks with added fruit or
fruit flavourings were dominant and
massively increased the erosive potential of the drink, putting them on
a par with cola drinks.

voured sweets, lozenges or medications have large erosive potential
when consumed regularly
- The increase in patients with tooth
erosion may be linked to changing
patterns of eating, such as increased
snacking in both children and adults
- Drinks are more likely to cause
tooth erosion when served hot
- Vinegars and pickled products can
also lead to tooth erosion

Researchers found that sipping,
holding or rinsing drinks in the
mouth prior to swallowing increases
the risk of tooth erosion, as these
habits increase the duration and/
or force of the contact between the
acidic drink and surface of the teeth.
Wine tasters, for example, swish and
hold wine in their mouths for prolonged periods and multiple times
a day, while long distance drivers or
video gamers may sip acidic drinks
over long periods of time.

Lead author, Dr Saoirse O’Toole said:
‘It is well known that an acidic diet is
associated with erosive tooth wear,
however our study has shown the
impact of the way in which acidic
food and drinks are consumed. With
the prevalence of erosive tooth wear
increasing, it is vitally important that
we address this preventable aspect of
erosive tooth wear. Reducing dietary
acid intake can be key to delaying
progression of tooth erosion. While
behaviour change can be difficult
to achieve, specific, targeted behavioural interventions may prove successful.’

The study also found:
- Sugar-free soft drinks are as erosive
as sugar-sweetened ones
- Fruit flavoured teas and fruit fla-

See Saoirse on BBC News here:
http://www.bbc.co.uk/news/av/
health-43165233/the-truth-aboutfruit-tea

Postgraduate studies
at the Dental Institute

By King's College London

Enhance your skills with blended learning
courses designed for working dentists.
Delivered mostly online, our
distance learning master’s and
• remote study via the King’s
Virtual Learning Environment
•
of clinical cases from your daily
practice
• face-to-face training weeks to
gain hands-on experience from
expert teachers

12 annual Senior
Dental Leaders
programme held
in London
th

Advanced Minimum Intervention Dentistry MSc: 3-years, part-time,
face-to-face training in London
Aesthetic Dentistry MSc: 3-years, part-time, face-to-face training
in London
Dental Cone Beam CT Radiological Interpretation Postgraduate
Certificate: 9-months, part-time, face-to-face training in London
Endodontics MSc: 3-years, part-time, face-to-face training in London
Fixed & Removable Prosthodontics MClinDent: 4-years, part-time,
face-to-face training in London or Dubai
Maxillofacial Prosthetic Rehabilitation MSc: 3-years, part-time,
face-to-face training in India

Another cohort of accomplished
delegates gathered in London in
March for the 12th annual Senior
Dental Leaders programme (SDL), an
international conference designed
to develop high-level leadership
and management capabilities in
oral health leaders from around the
globe. Over 200 participants from
over 43 countries now count themselves as part of the highly connected senior dental leader network.
First conceptualised by Professor
Raman Bedi in 2007 at King’s College London, the SDL programme
is organised by the Global Child
Dental Fund, King’s College London
Dental Institute and the Harvard
School of Dental Medicine, and is cosponsored by Henry Schein, Inc. and
Colgate-Palmolive.
The intensive multi-day conference brought together dental policy
makers, national Chief Dental Officers, representatives from NGOs and

RANKED NUMBER ONE IN EUROPE FOR
DENTISTRY QS WORLD UNIVERSITY
RANKINGS 2018

All courses start in January 2019
and are open for applications now.
Find out more: visit kcl.ac.uk/distancedentistry
or email distancedentistry@kcl.ac.uk
KCL DI A5 PRESS AD APR 2018 v2.indd 2

RANKED NUMBER TWO IN THE
WORLD FOR DENTISTRY QS WORLD
UNIVERSITY RANKINGS 2018

26/04/2018 16:30

members of clinical and academic
communities, who work to forge an
international collaborative network
with the goal of advancing the mission of a cavity-free world for children. Speakers included Professor
Mike Curtis, Dean of King’s College
London Dental Institute; Dr Bruce
Donoff, Dean of the Harvard School
of Dental Medicine; Dr Marsha Butler, Vice President of Oral Health and
Professional Relations, Colgate-Palmolive; and Mr Stanley M Bergman,
Chairman & Chief Executive Officer,
Henry Schein, Inc.
Professor Raman Bedi, Chairman of
the Global Child Dental Fund, said:
“Leadership training in oral health
is just as important as gaining clinical skills. It is not only necessary for
dentists but a whole range of other
health professionals such as doctors,
nurses and health visitors. Leadership development is also crucial for
schoolteachers around the world to
advocate for better child oral health."

[35] => DTMEA_No.3. Vol.8_DT.indd

Planmeca Emerald intraoral scanner
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come in small packages
The brand new intraoral scanner Planmeca Emerald™ is a small, lightweight,

and exceedingly fast scanner with superior accuracy. Taking digital impressions has never
been as easy. It is the perfect tool for smooth and efficient chairside workflow.

It is a true game-changer!

Find more info and your local dealer!
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Planmeca Oy Asentajankatu 6, 00880 Helsinki, Finland. Tel. +358 20 7795 500, sales@planmeca.com

[36] => DTMEA_No.3. Vol.8_DT.indd

NEWS

370 Class II Inforgraphic FINAL.qxp_Layout 1 14/09/2017 07:30 Page 1

Dental Tribune Middle East & Africa Edition | 3/2018

Researchers
ciently, you can be more
c
PROPER EXECUTION develop
OF EACH STEP OF THE CLASS II PROCEDURE
drug-filled
IS ESSENTIAL FOR SUCCESS.
3-D printed
OF EACH STEP OF THE CLASS II PROCEDURE
dentures

PROPER EXECUTION

By addressing the most vulnerable interface and delivering esthetic results efficiently, you can be more
confident that the result will positively impact patient experience and the bottom line of your business.

IS ESSENTIAL FOR SUCCESS.
ciently, you can be more

1
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ciently,
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PROFESSIONALS’
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ciently, you can be more
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82%

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DENTAL PROFESSIONALS’ PRIMARY CONCERNS WHEN PERFORMING POSTERIOR RESTORATIONS1 :

CLINICAL LONGEVITY

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82%

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THE MOST VULNERABLE INTERFACE
Dentsply
Sirona products
work together to
Studies show that the #1 reason for composite failures is recurrent. caries.
Dentsply
Sirona products
2
protect
the floor of
the
proximal
the
vulnerablebox,
interface.
Protect
it with the
THE
power of2 four
VULNERABL
proven
products.
E
INTERFACE
Protect
it with
work MOST
together
to
protect
thebox,
floor
ofmost
the proximal
the most
vulnerable
interface.
the power
of three
products.
Studies
show that
the #1 proven
reason for
composite failures is recurrent caries. Dentsply Sirona products work together to
protect the floor of the proximal box, the most vulnerable interface.2 Protect it with the power of four proven products.

1. ISOLATE the restorative
field with a tight gingival
seal—
the restorative
first with
step in
protecting
the seal field
a restorative
tight
gingival
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ISOLATE
the
most
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interface.
field with a tight gingival seal—

1. ISOLATE

the first step in protecting the

the first step in protecting the
most
vulnerable
most
vulnerable
interface.interface.

Palodent V3
®

cient esthetics
Sectional Matrix
System with a s

2. CREATE a strong bond

with an adhesive
2. CREATE
a strong
thatbond
gives you
high
bond strength
and low
with
an
adhesive
that
gives
you
2. CREATE
a strong
bond
film
thickness.
with
an
adhesive
that
gives
you
high bond strength and low film
high bond strength and low
thickness.
film thickness.

3. MAINTAIN

3. MAINTAIN
marginal integrity while

also achieving
excellent
marginal
integrity
while also
3. MAINTAIN
cavity
adaptation.
marginal
integrity
while
achieving
excellent
cavity
also achieving excellent
adaptation.
cavity adaptation.

SDR® Plus

Prime&Bond universal™

Universal Adhesive

Posterior Bulk Fill Flowable Base

cient esthetics is where artistry and effi

Achieve efficientESTHETICS
esthetics with a simplified
EFFICIENT
cient esthetics with a s shade selection process, utilizing your preferred viscosity

EFFICIENT ESTHETICS

(high orefficient
low), and
finishing
single step.
Efficient
esthetics
where artistry
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Achieve
esthetics
withina asimplified
shade
selection
process,isutilizing
your preferred
viscositymeet. Deliver
cient
esthetics
is
where
artistry and effi
smooth,
contoured
surfaces
and
simplified
shadeesthetics
matching
for your
Classand
II restorations.
(high
or low),
and
finishing
in aa
single
step. Efficient
is where
artistry
efficiency meet. Deliver
cient
esthetics
with
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esthetics
with
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smooth,
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and
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Efficient esthetics is where artistry and efficiency meet. Deliver smooth, contoured surfaces and
simplified
shade matching for your Class II restorations.
FINISHING
AND
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AND

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uptime
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procedure. 3
a Class II procedure.3

RESTORATIONS

APPEARANCES MATTER

THAT LAST Clinicians
RESTORATIONS
THAT
can
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can increase
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THAT
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Class II restorations with
proper finishing technique.4

SIMPLIFY shading and preferred

handling, for lifelike results in less time.

handling, for lifelike results in less time.
SIMPLIFY shading and preferred handling,
ceram.x®
SphereTEC™
SphereTEC™
forceram.x®
lifelike results
in less time. one one

restored and adjacent natural
teeth.5

FINISH and improve your likelihood
of success while saving time.

FINISH and improve your likelihood
of success

saving time.
FINISH and while
improve your likelihood of
success while saving time.

Universal
Nano-Ceramic
Restorative
Universal
Nano-Ceramic
Restorative

ceram.x® SphereTEC™ one
Universal Nano-Ceramic Restorative

CHAMELEON
CHAMELEON
EFFECT
EFFECT
CHAMELEON
EFFECT

SURFACE
SURFACE
IRREGULARITIES
IRREGULARITIES
SURFACE
IRREGULARITIES

Plaque Accumulation

Helps dentist
more accurately
match match
Helps dentist
more accurately
the shade,
tooth shade,
the tooth
Helpsoffsetting
dentist more
accurately
match
theincluding
tooth shade,
variables
in shade
selection
offsetting variables
in shade
selection
including
extrinsic staining,
lighting,
andselection
shade availability.
offsetting
variables
in shade
including
extrinsic staining, lighting, and shade availability.

extrinsic staining, lighting, and shade availability.

Gingival Irritation

Plaque Accumulation

DENTSPLY Caulk procedure timing breakdown study. Data on file.

Christensen, G J. (2014). Simplifying your Class II Composite Finishing Technique.
Clinicians
Report, Colum 7 Issue 4
5

Joiner A. Tooth colour: a review of literature. JDent. 2004; 32(Suppl. 1): 3-12

Staining

By
By reducing
reducing surface
surfaceirregularities
irregularitieswith
withproper
properfinishing,
finishing,
By
reducing
surface
irregularities
with proper finishing,
you
can
avoid
things
like
staining,
plaque retention,
you
can
avoid
things
like
staining, plaque retention,
gingival irritation
recurrent
you canand
avoid
thingscaries.
like staining, plaque retention,
gingival irritation and recurrent caries.

gingival irritation and recurrent caries.

SOURCES
1
Dental Products Report April 2015 posterior composite survey.
2
Durable Bonds at the Adhesive/Dentin Interface. Braz Dent Sci. 2012; 15(1): 4-18
3
DENTSPLY Caulk procedure timing breakdown study. Data on file.
4
Christensen, G J. (2014). Simplifying your Class II Composite Finishing Technique. Clinicians Report, Colum 7 Issue 4
1
Dental5Products Report April 2015 posterior composite survey.
Joiner A. Tooth colour: a review of literature. JDent. 2004; 32 (Suppl. 1): 3-12
2
Durable Bonds at the Adhesive/Dentin Interface. Braz Dent Sci. 2012; 15(1): 4-18.

SOURCES

Staining

Gingival Irritation

By DTI
NEW YORK, U.S.: It is not uncommon
for denture wearers to suffer fungal infections that cause inflammation, redness and swelling in the mouth. Seeking
to avoid or better treat such denturerelated stomatitis, researchers from
the University at Buffalo have used 3-D
printing to create dentures filled with
microscopic capsules that periodically
release amphotericin B, an antifungal
medication. They found that the dentures reduced fungal growth.
“The major impact of this innovative 3-D
printing system is its potential impact
on saving cost and time,” said the study’s
senior author, Dr. Praveen Arany, an assistant professor in the Department of
Oral Biology in the university’s School of
Dental Medicine.
Using PMMA for the denture material,
the researchers sought to determine if
the dentures could both maintain their
strength and effectively release antifungal medication contained in biodegradable, permeable microspheres. The
microspheres protect the drug from the
heat of the printing process and allow
the release of medication as they gradually break down. With a flexural strength
testing machine, the scientists found
that, while the flexural strength of the
3-D printed dentures was 35 percent less
than that of a conventional laboratoryfabricated denture used as a control, the
printed dentures never fractured.
To examine how well the dentures could
release the antifungal medication, the
dentures were tested with one, five and
ten layers of material to learn if additional layers would allow the dentures to
hold more medication. The researchers
found that the dentures with five and
ten layers were impermeable and thus
not effective at dispensing the medication.
With the new approach, Arany believes
the antifungal application could prove
invaluable among those highly susceptible to infection, such as the elderly and
hospitalized or disabled patients. Additionally, unlike current treatment options, such as antiseptic mouthwashes,
baking soda and microwave disinfection, the new means of controlled drug
release can help prevent infection while
the dentures are in use.
Arany and his colleagues are now looking to further research how to reinforce
the 3-D printed dentures with glass fibers and carbon nanotubes to achieve
greater mechanical strength and to focus on denture relining.
The study, titled “Functionalized prosthetic interfaces using 3D printing: Generating infection-neutralizing prosthesis
in dentistry,” was published in the June
2018 issue of Materials Today Communications.

[37] => DTMEA_No.3. Vol.8_DT.indd

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[38] => DTMEA_No.3. Vol.8_DT.indd

SMILE IS
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NO MORE RUBBER CUPS
NO MORE BRUSHES
NO MORE PASTE
LESS USE OF POWER AND
HAND INSTRUMENTATION
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MAKE ME SMILE.

[39] => DTMEA_No.3. Vol.8_DT.indd

[40] => DTMEA_No.3. Vol.8_DT.indd

[41] => DTMEA_No.3. Vol.8_DT.indd

www.dental-tribune.me

PUBLISHED IN DUBAI

May-June 2018 | No. 3, Vol. 8

“No Anaesthesia”
endodontics in children

SUBSCRIBE NOW
www.me.dental-tribune.com/e-paper/
Vol. 13 • Issue 4/2017

issn 2193-4673

roots
international magazine of

endodontics

2017

By Dr Imneet Madan, UAE
“Laser Popping Sound” in dentistry
for children is one of the best approaches that can help us to overcome the initial fear of the unknown
when it comes to first treatment appointments in children. Its uniqueness lies in the fact that the need for
numbing is completely exempted.
Today’s children like technology
playing at its best. Lasers definitely
meet that perception of technology.
The routine first visit appointments
are usually not a concern as children
do not anticipate any intervention.
Since they are not in pain, their
mindset of approach is not defensive. Rather when there is no prebiased opinion or fear, there is a
pleasant sense of adaptation that

allows the smooth flow of the appointment. Any different kind of behavioural exhibit occurs only when
kids are anticipating an intervention,
when they had been in pain or when
in general they come fatigued.
The discussion of needles is considered to be the most common subject
just prior to the visit to the dentist.
This discussion can become even
more intense when there is already
a perceived treatment need. Very
young children can have the fear of
the unknown, anxiety with strange
and new places.
The older ones develop extreme
fear by talking to peers who have
been to the dentist before. Some
of them might have had good and
some others not so good experience.

Sometimes, past unpleasant parental experience can distort the child’s
adaptability to the dental appointment. They enter the clinic with
the preformed image of the dentist
which is not very convincing and
helpful to the child. These external
experiences can lay the foundation
of the child’s coping ability in the
dental chair.

How can lasers help?
Since laser is not commonly available at all practices, there could be
a possibility that there had been no
real discussion on the use of lasers in
the treatment. Another possibility of
having a good experience with lasers
can change the perception of the
child who is in for the first time.
When laser is introduced to the

parents, they are informed about
details on the functioning of laser
and its benefits. While explaining
euphemisms to the child, the laser is
shown as “Popping Light”. There is a
significant number of children who
go awe-inspired to come back and
get there teeth fixed.

research
Photodamage of dental pulpa stem cells
during 700 fs laser exposure

case report
Apexification treatment with MTA REPAIR HP

interview

The whole mindset of the child
changes when they are told that
treatments do not involve any needles approach.

“No Anaesthesia”
Procedures that can be done without
anaesthesia are:
– Restorations: Decays involving occlusal, labial, palatal, buccal or proximal surfaces of the teeth.
– Deep restorations on teeth with decays close to the pulp.

Understanding sonic-powered irrigation

– Pulpotomies in primary teeth.
– Pulpectomies in primary teeth.
– Pulpectomies in primary teeth
with abscess, fistula or swellings.
The term “No Anaesthesia” is a misnomer as the procedure is accom-

ÿPage A2

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[42] => DTMEA_No.3. Vol.8_DT.indd

ENDO TRIBUNE

Dental Tribune Middle East & Africa Edition | 3/2018

◊Page A1
plished with few drops of anaesthesia in between, especially when
endodontics is involved. The “No Anaesthesia” approach for enamel dentine restorations are the erbium laser
Prep mode for restorative dentistry:
MX7, 3.25 W, 25 Hz, air, water. There
are two commercial settings that can
be followed for the most acceptable
cavity preparation:
– Rapid Prep: MX7, 5 W, 20 Hz, air 80,
water 50. This setting is usually used
for enamel caries removal as water
content is lesser. Since there is less
water in the enamel, higher power
is needed for appropriate absorption
of laser.
– Comfort Prep: MX7, 3.75 W, 25 Hz,
air 60, water 30. This setting is usually advised when we have reached
the level of the dentine as the water
content in the dentine is higher in
comparison to enamel.
Once complete excavation of the decay has been attempted with laser,
gentle hand excavation, low speed
excavation is attempted. This step
should be followed with Bond prep:
MX7, 3.25 W, 50 Hz, air 60, water 30.
Following this step, the tooth is isolated and restored with composite
(Figs. 1 & 2).

Pulpotomy procedure
with erbium laser
When the carious decay is found
deep and in close proximity to pulp,
exposure of the pulp canals can happen while removing this decay. In
such situations, exposed pulp needs
to be treated by removing the affected coronal pulp contents. This procedure is referred to as Pulpotomy.
Deep caries are excavated with preadjusted rapid prep settings: MX7, 5
W, 20 Hz, air 80, water 50; and then
comfort prep settings: MX7, 3.75 W,
25 Hz, air 60, water 30 are used as we

ing and composite restoration.

Pulpectomy procedure
in primary tooth with abscess
or fistula
In cases where there are long standing infections o
chronic irreversible pulpitis, it becomes invariable to use both diode
and erbium laser sterilisation after
the laser assisted access and further
steps as described above.
Figs. 1 & 2: The laser is a helpful tool in the dental treatment of children that can be used
for various procedures.

approach deep into the dentinal caries. As soon as there is pin point pulp
exposure, few drops of Lignospan
are dropped inside the coronal pulp
chamber. This step is followed by
opening partial access into the coronal pulp chamber. As we go further
deep into the coronal chamber, more
anaesthetic intrapulpal infilteration
is used followed by complete laser
access opening.
After removing the coronal pulp
contents, the chamber is irrigated
and dried followed by diode laser
sterilisation and coronal pulp filling
with zinc oxide eugenol. The tooth is
then filled with base Fuji IX and final
restoration is done with composite
or stainless steel crown.

Pulpectomy procedure
with erbium laser
Teeth that have chronic profound
caries, active signs and symptoms,
and radiographical signs of pulp involvement, are indicated for Pulpectomy. Pulpectomy involves the removal of both coronal and radicular
pulp contents.
When the tooth is indicated for
pulpectomy or root canal procedure,

deep caries are excavated with preadjusted rapid prep settings: MX7, 5
W, 20 Hz, air 80, water 50; and then
comfort prep settings: MX7, 3.75 W,
25 Hz, air 60, water 30 are used as we
approach deep into the dentinal caries. As soon as there is pin point pulp
exposure, few drops of Lignospan
are dropped inside the coronal pulp
chamber. This step is followed by
opening partial access into the coronal pulp chamber.
As we go further deep into the coronal chamber, more anaesthetic
intrapulpal infilteration is used
followed by complete laser access
opening. Once access has been done
with laser, coronal pulp contents are
removed. Before gaining access into
radicular pulp chamber, few more
drops of anaesthesia are dropped in.
Complete extirpation of radicular
pulp contents is done with rotary
instruments.
Continuous copious irrigation is
done with saline and chlorhexidine.
Canal measurement is done, and as a
final step before obturation, both the
erbium and diode laser are used for
sterilisation. Final step is zinc oxide
eugenol obturation, Fuji IX base fill-

TIME & LOCATION:

Thursday - Friday 05 - 06 July 2018
CAPP Training Institute, Dubai, UAE

Practicing contemporary dentistry
in children with the appropriate usage of technology and the key tools,
is the way forward. The benefits of
the “No Anaesthesia” erbium approach far outweighs the existing alternatives. This kind of professional
approach can certainly become the
gold standard for dentistry in children in the very near future.

Benefits of
“No Anaesthesia” dentistry
– No risk of children having traumatic bite after the procedure is completed. The times when anaesthesia
in children was a common practice,
it was imperative to let the child and
parents know about the numbing
effect that would stay for few hours
after the procedure. Cotton roll is
given to bite on so that it serves as a
reminder for the child.
– Despite all these precautions, children may still land up in biting there
lip or cheek. Once there is a traumat-

Dr Imneet Madan
Specialist Pediatric Dentist
MSc Lasers Dentistry (Germany)
MDS Pediatric Dentistry
MBA Hospital Management
Children’s Dental Center, Dubai
Villa 1020 Al Wasl Road
Umm Suqeim 1, Dubai
United Arab Emirates
Tel.: +971 506823462
imneet.madan@yahoo.com
www.drmichaels.com

(Management of Endodontic Failure)

(Management of Endodontic Failure)
PRICE:
4,400 AED (1198USD)

This procedure has been practiced
as an alternate to pre-times extraction of primary teeth that has to be
then replaced with a space maintainer. Most of the parents prefer
this approach when compared to
extraction, as they do understand
that having the natural tooth as the
space maintainer is indeed the best
approach.

Conclusion

Endo Micro Surgical Retreatment

Endo Non-surgical
and Surgical Retreatment
Dr. Antonis Chaniotis, Greece

Until the point that canals are found
completely dry, obturation is deferred. Usually it takes one or two
visits to complete the final step of
obturation in teeth with abscess or
fistula. The entire treatment is completed with intrapulpal drops of anaesthesia when required. No infiltrations or blocks are used in the entire
procedure.

ic bite, there is nothing much that
can be done as the traumatized tissue has to self-heal. This can be quite
painful for the child, thereby defeating the entire purpose of pain free
dental approach.
– Multi-quadrant dentistry can be
practiced on the same day, same appointment.
– There is actual saving of chairside
time, as there is no waiting period for
local anaesthesia to work.
– Children can eat a few minutes after the procedure, which is not the
case with dental local anaesthesia.

CONTACT:
Email: events@cappmea.com
Mob: +971 50 2793711

CAPP designates this activity for 14CE Credits

| 09:00 – 18:00

COURSE OUTLINE:
DAY 1 - To understand the rational behind non surgical retreatment approaches and the
aitiology of initial root canal treatment failure. To present an evidence based framework
for the safe and effective dissasembly of non obturation and obturation materials.
DAY 2 - To understand the factors related to the long term outcome of non surgical
endodontic retreatment and to develop a rational diagnostic and decision making
framework. To appreciate the importance of magnification and illumination for the
management of complicated non surgical retreatment cases.

Prof. James Prichard, UK

PRICE:
4,400 AED (1198USD)

TIME & LOCATION:

Saturdy - Sunday 07 - 08 July 2018
CAPP Training Institute, Dubai, UAE

CONTACT:
Email: events@cappmea.com
Mob: +971 50 2793711

CAPP designates this activity for 14CE Credits

| 09:00 – 18:00

COURSE AIMS:
DAY 1 - To understand the rational behind micro surgical retreatment approaches and
acquire basic surgical knowledge.
DAY 2 - To understand the importance of magnification in endodontic microsurgery
and acquire basic microsurgical skills.

14 CE
Credits

Est.
14 CME
HAAD

Est.
12 CME
DHA

[43] => DTMEA_No.3. Vol.8_DT.indd

[44] => DTMEA_No.3. Vol.8_DT.indd

ENDO TRIBUNE

Dental Tribune Middle East & Africa Edition | 3/2018

Root canal therapy and coronectomy

Fig. 1: Partially erupted third molar and inflammation of the gingiva
distally

Fig. 2: Pre-op radiograph showing a hook-like curve of the mesial root,
as well as the relationship between the pulp chamber position and the
bone level.

Fig. 3: CBCT scans showing the intimate relation between the mesial root
and the IAN and confirming the bone level relative to the pulp chamber.

and evidence-based minimum. The
alternative solution in such cases is
coronectomy.

Fig. 4: File in a mesial canal showing the abrupt curvature.

By Drs Mirna Hobeika, Ali Hajj Hassan, Edgard Jabbour & Philippe Sleiman, Lebanon
Coronectomy is a procedure that
generally spares the vital coronal
pulp and is performed to avoid the
risk of damaging the inferior alveolar nerve (IAN) during the surgical
rocedure when extraction of mandibular third molars is indicated or
needed. Coronectomy is the removal
of the crown of the mandibular
third molar without exposing the
pulp.1 The coronectomy procedure
is performed only on the third molar
crown, leaving the roots in the socket. This procedure is now known for
its benefits and success rate, in contrast to the contemporary belief that
the roots left behind will be a source
of problems.2 Risk factors for nerve
injury include root proximity, the
surgeon’s experience, surgical pro-

Fig. 5: A complete root canal therapy was performed.

cedures, the patient’s age and preexisting disease. Several studies have
shown that coronectomy significantly decreases the risk of iatrogenic injury to the IAN and lowers the
complication rate.3 Coronectomy
has been associated with a low incidence of complications in terms of
IAN injury (0.0–9.5 %), lingual nerve
injury (0.0–2.0 %) and pulp disease
(0.9 %),4 in addition to other rare
events, such as swelling, fever, alveolitis, pulpitis and root exposure.5
Coronectomy to prevent IAN damage was first proposed by Ecuyer and
Debien in 1984,6 and it remained
controversial owing to the possibility of infection and other pathologies
arising from the roots left behind.2
Potential complications include
deep dry sockets, local postoperative
infections, postoperative pain, pulpitis, root canal necrosis and infection,

Fig. 7: A small field of view CBCT scan confirmed the outcomes of the
surgical procedure and root canal therapy.

Fig. 6: Bitewing radiograph taken during the surgical procedure, showing the level of the surrounding bone and
the remaining part of the tooth.

and an increased risk of IAN infection, which is known as failed IANI.7
The point of discussion is whether
it is necessary to perform root canal
therapy simultaneously with coronectomy if the pulp is going to be exposed during the surgical procedure.
A new method combining coronectomy with root canal therapy, when
necessary, in order to decrease the
risk of infection, pain and other complications is introduced in this paper.

Case presentation
A female patient in her mid-twenties
was suffering from typical partially
erupted third molar complications
(Fig. 1). Extraction was advised in order to relieve the patient. A preoperative radiograph was taken (Fig. 2)
for the surgeon and endodontist to
discuss the shape of the roots and

the IAN proximity. At the request
of the endodontist, a CBCT scan was
performed (i-CAT), as is advised prior
to any surgery (Fig. 3). The cross sections revealed an intimate relation
between the mesial root and the
nerve, and thus indicated that any
surgery at this point could cause
some trauma to the nerve.
The situation was explained to the
patient, who was very concerned
about the potential injury to the
IAN. However, the patient presented
with acute pain, which would require treatment, possibly antibiotic
therapy, which in the future would
be her go-to in case of a flare-up.
This was definitely not an ideal solution, especially in view of the efforts
currently being undertaken by the
European Society of Endodontology
to limit antibiotic prescription for
root canal therapy to a reasonable

Fig. 8: Two-year follow-up radiograph.

From discussing this option with
the surgeon and studying carefully
the radiographs and CBCT data, it
was clear that, if the surgeon was to
cut the crown below bone level, pulp
exposure and partial pulpectomy
were inevitable. Therefore, in order
to minimise postoperative complications, the decision was made to
perform a root canal therapy on the
third molar to reduce the risk of pulpitis or infection in the apical part.
The patient agreed to this solution.
Endodontic treatment was performed using the TF Adaptive SM
(small/medium) procedure pack
(Kerr) for root canal shaping. During the treatment, one periapical
radiograph was taken (Fig. 4) and
it showed the curve on the mesial roots. Irrigation was performed
very safely with the EndoVac unit
(Kerr), as any extrusion of sodium
hypochlorite could have severe
consequences for the nerve and the
apical area. The root canal therapy
was completed in a single visit (Fig.
5), following which the surgeon performed the coronectomy. A bitewing
radiograph was taken to check the
level of the coronal part after the excision and confirm that it was completely under the bone level (Fig. 6).
A reinforced glass ionomer was used
to seal the roots, and sutures were
placed and left for one week. A small
field of view CBCT was taken to check
the postoperative outcome of the
procedure (Fig. 7).
Two years after the treatment, the
patient returned to the clinic complaining of some pressure sensations in the area. A CBCT scan allowed us to investigate the situation,
and it revealed a pleasant surprise:
the tooth had migrated coronally
and gone above the nerve (Figs. 8 &
9). We explained to the patient that
the remaining part of the tooth had
moved towards the gingival level,
which was why she was feeling pressure, and now it would be safe to remove the remaining tooth. The surgeon performed the intervention.
Figure 10 shows how much the tooth
had migrated over the two years and
demonstrates the absence of any infection under the roots.
Editorial note: A list of references is
available from the publisher.

Fig. 9: CBCT scans showing the root migration above the nerve, allowing for safe extraction
to be performed.

Fig. 10: Comparison of the immediate post-op situation and the situation at the
two-year follow-up.

Dr Philippe Sleiman
is an assistant professor at the Faculty of
Dentistry of the Lebanese University in
Beirut in Lebanon. He can be contacted at
profsleiman@gmail.com.

[45] => DTMEA_No.3. Vol.8_DT.indd

ENDO TRIBUNE

Dental Tribune Middle East & Africa Edition | 3/2018

Fig. 1

When an idea turns into innovation
By Marc Chalupsky, DTI
Although the headquarters of COLTENE are in Switzerland, its endodontics plant is in southern Germany. At
the factory, located in Langenau, a
town between Stuttgart and Munich,
155 employees produce treatment
auxiliaries and endodontic equipment in a fully automated and camera- and laser-controlled process. The
German location houses an impressive logistics department thanks to
the office’s central location. Dental

Fig. 2

Tribune was invited to learn more
about the company’s endodontic
products.
A now well-known expert in endodontics, Dr Barbara Müller has been
responsible for the company’s endodontics business unit for over 20
years. She takes pride in the company’s achievements. Today, COLTENE is an international leader in
the development and manufacture
of dental consumables and solutions for a variety of applications.

Fig. 3

The company operates worldwide,
with subsidiaries and distributors
in over 120 countries. With the 1990
introduction of the ParaPost X System, COLTENE came to be known as
a provider of endodontic solutions.
This position has been further entrenched in recent years as the company’s portfolio of endodontic products has continued to grow.

Fig. 4

An impressive
endodontic range
The CanalPro line, for example, features a cordless endodontic motor,
a fully automated electronic apex
locator and a variety of rinsing solutions, which are colour-coded for
procedural safety. ROEKO and HYGENIC paper points are sterile and
highly absorbent, and being nonadhesive, allow for reliable and easy
drying of the root canal. Fast and
safe obturation can be conducted

Fig. 5

with GuttaFlow bioseal, a bioactive
three-in-one obturation material
that combines cold free-flow guttapercha with a sealer and bioceramic
in one outstanding filling system
and with HYGENIC and ROEKO Guttapercha points. Recent studies have
evaluated the in vitro toxicity of endodontic sealers such as GuttaFlow
bioseal and GuttaFlow 2, as well as
Angelus’s MTA-FILLAPEX and Dent-

ÿPage A6

[46] => DTMEA_No.3. Vol.8_DT.indd

ENDO TRIBUNE

Dental Tribune Middle East & Africa Edition | 3/2018

◊Page A5

Fig. 6

sply Sirona’s AH Plus, on stem cells
from the periodontal ligament. It
was found that especially GuttaFlow
bioseal and also GuttaFlow 2 showed
lower toxicity levels and higher
cell viabilities than the competing
sealers did. In addition, GuttaFlow
2 demonstrated a better result in
terms of microleakage and sealing
ability than the competing sealers
did.
COLTENE’s HyFlex instrument, probably its best-known product, has set a
new benchmark for NiTi rotary files.
HyFlex EDM, the latest generation,
integrates the controlled memory
effect of its predecessor, HyFlex CM.
Furthermore, owing to an innovative manufacturing process using
electrical discharge machining, HyFlex EDM has a specially hardened
surface that makes the files stronger
and more fracture-resistant. The
controlled memory of both HyFlex
CM and HyFlex EDM gives the instruments a number of important
properties, including extreme flexibility, superior canal tracking, regeneration after repeat autoclaving and
strong fatigue resistance.
To achieve these characteristics,
HyFlex CM and HyFlex EDM are

manufactured using a special thermomechanical process whereby
the crystallographic phase transition from austenite to martensite
at room temperature results in an
advanced controlled memory of the
material, making both files extremely flexible. “We successfully managed to give our NiTi material shape
memory properties,” said Müller.
“We did this by changing the DNA of
the material through a switch from
low to room temperature. Our idea
became not only an innovation, but
a product many of our competitors
have tried unsuccessfully to copy.”
Introduced at the International
Dental Show in Germany two years
ago, the new HyFlex EDM reduces
the number of files needed to two
to three, particularly in straight and
larger canals.

Proven clinical experience
According to Müller, a number of
clinical studies have demonstrated
the efficacy of both systems. For
example, Goo et al. compared the
bending stiffness, cyclic fatigue and
torsional fracture resistance of NiTi
rotary instruments, including VTaper 2, V-Taper 2H (both SS White),
HyFlex CM, HyFlex EDM and ProTa-

Fig. 7

Fig. 8

Fig. 9

per Next X2 (Dentsply Sirona). HyFlex EDM showed the highest cyclic
fatigue resistance of the group, with
V-Taper 2H and HyFlex CM coming
in next. Overall, they showed high
torsional resistance. In comparison
with HyFlex CM, the EDM version
demonstrated a higher fracture resistance.

it to remain usable for longer when
shaping severely curved canals.

joen.2017.01.001. Epub 2017 Mar 23.
https://www.ncbi.nlm.nih.gov/pubmed/28343929
Mechanical Properties of Various
Heat-treated Nickel-Titanium Rotary Instruments, J Endod. 2017 Sep
23. pii: S0099-2399(17)30703-3. doi:
10.1016/j.joen.2017.05.025.
[Epub
ahead of print] https://www.ncbi.
nlm.nih.gov/pubmed/?term=mech
anical+properties+of+various+heat
+treated+Goo+et+al.

In another study, Kaval et al. aimed
to evaluate these properties in novel
NiTi rotary files, including HyFlex
EDM OneFile from COLTENE, ProTaper Gold and ProTaper Universal
(both Dentsply Sirona). The results
showed that HyFlex EDM OneFile
demonstrated significantly higher
cyclic fatigue resistance and higher
distortion angle to fracture, but
a lower torsional resistance than
both ProTaper options. In addition,
Pedulla et al. sought to measure
the torsional and cyclic fatigue resistance of HyFlex EDM OneFile in
comparison with VDW’s RECIPROC
R25 and Dentsply Sirona’s WaveOne
Primary. HyFlex was found to have a
significantly higher cyclic fatigue resistance and higher angular rotation
to fracture.
Furthermore, Lacono et al. aimed to
measure the wear of HyFlex EDM after clinical application. No fractures
were registered, no wear or degradation was reported, and the increased
fatigue resistance of HyFlex EDM
(compared with HyFlex CM) allowed

A case from the Philippines
Dr Margaret Tui, a clinician based in
the Philippines, agrees that the increased fatigue resistance and strong
flexibility of both HyFlex systems
allowed her to manage an S-shaped
case more easily. At a recent COLTENE Train the Trainer event, she
presented a mandibular first molar case with four canals that was
referred to her by another dentist
who could not negotiate the canal
owing to its difficult anatomy. After
utilising the crown-down technique
and the HyFlex CM files to flare the
coronal third of the distobuccal and
distolingual canals, Tui then continued to use HyFlex EDM to negotiate
the mesiobuccal and mesiolingual
canals, as she had discovered a slight
curvature in the middle third of the
canals. As for the S-shaped distobuccal and distolingual canal, she
continued with the Hyflex CM files.
Post obturation radiograph showed
properly shaped canals with proper
healing.

References
Cytotoxicity of GuttaFlow Bioseal,
GuttaFlow2, MTA Fillapex, and
AH Plus on Human Periodontal
Ligament Stem Cells, J Endod. 2017
May;43(5):816-822. doi: 10.1016/j.

Evaluation of the Cyclic Fatigue and
Torsional Resistance of Novel Nickel-Titanium Rotary Files with Various Alloy Properties. J Endod. 2016
Dec;42(12):1840-1843. doi: 10.1016/j.
joen.2016.07.015. Epub 2016 Oct
21. https://www.ncbi.nlm.nih.gov/
pubmed/?term=Evaluation+of+the
+Cyclic+Fatigue+and+Torsional+Re
sistance+of+Novel+Nickel-Titanium
+Rotary+Files+with+Various+Alloy
+Properties
Torsional and Cyclic Fatigue Resistance of a New Nickel-Titanium Instrument Manufactured by Electrical Discharge Machining. J Endod.
2016 Jan;42(1):156-9. doi: 10.1016/j.
joen.2015.10.004. Epub 2015 Nov
14. https://www.ncbi.nlm.nih.gov/
pubmed/?term=Torsional+and+Cyc
lic+Fatigue+Resistance+of+a+New+
Nickel-Titanium+Instrument+Man
ufactured+by+Electrical+Discharge
+Machining

Root canal treatments with the EndoSystem by VDW – Peace of mind included
By VDM
MUNICH, Germany: Deliver root
canal treatments with an opti-mally
integrated concept from a single
source. This claim is be-hind the
campaign ‘Peace of mind included –
the Endo-System’ by VDW.
‘Peace of mind included’ with the
Endo-System by VDW means that
dentists have a holistic system for
simplified, individualised work processes. They also benefit from safety
in use, time and cost efficiency and
long-term treatment success.

Endodontics in four steps
The key drivers to success with VDW
are products and services linked
through all treatment steps:
1. Preparation
File systems such as RECIPROC® blue
combined with VDW drives can be
used to prepare the root canal with
only one instrument.
2. Irrigation
The sonic-powered EDDY® irrigation

tip cleans even complex root canal
anatomies safely and efficiently.
3. Obturation
GUTTAFUSION® can be used for
homogeneous, wall-adapted obturation of the root canal.
4. Post-Endo
DT Post quartz fibre posts with double taper design contribute to preserving more dentine during postendodontic treatment.

Education and services
for treatment success
The Endo-System by VDW is backed
up by almost 150 years of experience in endodontics. Dentists can
take advantage of this expertise with
the VDW education programme.
Comprehensive service and consulting offers help to set up the optimal
Endo-System and integrate it into
the practice routine – with peace of
mind included.
More about ‘Peace of mind included
– the Endo-System’ by VDW can be

The VDW Endo-System

found at vdw-dental.com/endosystem and at congresses and trade fairs.

About VDW
VDW GmbH based in Munich, Germany is one of the most well-known
manufacturers working in the den-

tal field of endodontics. For almost
150 years, VDW has been a pioneer in
shaping the evolution of root canal
treatment significantly. VDW focuses on offering the dentist a holistic
solu-tion covering the entire endodontic treatment process including
prepara-tion, irrigation, obturation

and post-endodontic care as well as
service and training.
For more information about the
com-pany, the VDW brand and products, please visit www.vdw-dental.
com/en/

[47] => DTMEA_No.3. Vol.8_DT.indd

Membership in mCME Program
20 CME

credit hours
per year

quick and
easy way to
meet your
needs

flexibility
to work at
your own
place

» mCME participants are required to read the Continuing Medical Education (CME) articles published in each issue
» Each article offers 2 CME Credit and is followed by a questionnaire online
» Participants will receive the summary report with Certificate

For more information please contact

marketing@cappmea.com or call +97143616174

www.cappmea.com/mCME

[48] => DTMEA_No.3. Vol.8_DT.indd

WaveOne Gold
®

Now with WaveOne® Gold Glider

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

*compared to WaveOne
© 2018 Dentsply Sirona, Inc.

Rx Only

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

[49] => DTMEA_No.3. Vol.8_DT.indd

PUBLISHED IN DUBAI

May-June 2018 | No. 3, Vol. 8

www.dental-tribune.me

Dental Technician Int’l
Meeting was a success
By Dental Tribune MEA / CAPPmea
DUBAI, UAE: This May CAPP (Centre
for advanced Professional Practices)
hosted another meeting that was
dedicated to the dental technicians
from the MEA region and beyond.
The meeting was a part of the annual
congress, 13th CAD/CAM & Digital
Dentistry Conference & Exhibition
that was held in beautiful arena of
Madinat Jumeirah Conference Centre on 04-05 May 2018. Dental Technician Sessions were an accomplishment not only for dental laboratory
owners and dental technicians but
also for the entire dental technology
profession.
The event was spread over two very
active days for all participants and
welcomed 154 dental technicians.
On the first day there were seven
various tables where the hands-on

SUBSCRIBE NOW
www.me.dental-tribune.com/e-paper/
Vol. 8 • Issue 4/2017

issn 1616-7390

CAD/CAM
international magazine of

digital dentistry

2017

immediately and ask their personal
questions. The practical demonstrations, at the same time, provided inspiration and offer means of trouble
shooting.

interview
“Dentistry has finally arrived in the digital age”

case report

Aiham Farrah, CDT from Syria during his lecture presentation at the Dental Technician
Int’l Meeting.

trainings took place. The tables operated simultaneously with a rotation
of several groups for each table. The
trainings were help in small groups
(10 seats available per session) in or-

der to have the highest impact. Outstanding dental technicians presented various topics of a great interest
to the dental technicians. The participants had an opportunity to interact

On the second day Saturday 05 May
2018, Dental Technician International Meeting scientific programme
took place and a line-up extraordinary dental technicians who provided their best interpretations of the
latest novelties in the dental technicians profession. Aiham Farrah,
CDT, from Syria spoke about Flawless Lab-Fabricated Dental Restorations, followed by Philippe De Moyer
from Belgium who had a lecture on
Innovative Method in Guided Surgery to Prepare Immediate Loading
and Place Dental Implant. Rik Jacobs
from the Netherlands introduced 3D
Printing on the Edge of Conversion
and Eric Berger from France finished

Screw-retained implant-supported restoration
in the edentulous maxilla

cone beam supplement
Dynamic navigation for reliable
and predictable flapless implant placement

the day with his lecture on “Aesthetic
Realization with VITA: Cut Back on
VITA Block”.
The next edition of Dental Technician Meeting will be held on 12-13
April 2019 in Madinat Jumeirah Conference Centre.
For more information contact CAPP:
Tel: +971 4 347 6747
Mob: +971 50 2793711
Web: www.cappmea.com

Hossein Basaeri from Iran representing Dentium during his hands-on
training at the Dental Technician Int’l Meeting

Aiham Farah from Syria representing Ivoclar Vivadent during his handson training at the Dental Technician Int’l Meeting

Rik Jacobs from the Netherlands representing Next Dent during his
hands-on training at the Dental Technician Int’l Meeting

3shape hands-on training at the Dental Technician Int’l Meeting

Eric Berger from France during his lecture presentation at the Dental
Technician Int’l Meeting

Philippe De Moyer from Belgium during his lecture presentation at the
Dental Technician Int’l Meeting

Materials and systems for all
ceramic CAD/CAM restorations
By Drs. Christian Brenes, Ibrahim
Duqum & Gustavo Mendonza, USA
Dental crowns have been used for
decades to restore compromised,
heavily restored teeth, and for aesthetic improvements. New Computer Aided Design/Computer Aided

Manufacturing (CAD/CAM) materials and systems have been developed and evolved in the last decade
for fabrication of all-ceramic restorations. Dental CAD/CAM technology
is gaining popularity because of its
benefits in terms of time consuming,
materials savings, standardisation of

the fabrication process, and predictability of the restorations.
The number of steps required for
the fabrication of a restoration is
less compared to traditional methods (Fig. 1). Another benefit of CAD/
CAM dentistry includes the use of

new materials and data acquisition,
which represents a non-destructive
method of saving impressions, restorations and information that is
saved in a computer and constitutes
an extraordinary communication
tool for evaluation.

The incorporation of dental technology has not only brought a new
range of manufacturing methods
and material options, but also some
concerns about the processes involv-

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similar to IPS Empress but with a
finer particle size; this material was
designed to be use with the CEREC
system (Sirona Dental) and was
available in different shades.2 More
recently, the introduction of IPS
Empress CAD (Ivoclar Vivadent) and
Paradigm C that according to the
manufacturer (3M ESPE) is a 30 to 45
percent leucite reinforced glass ceramic with a fine particle size.10

Fig. 1: Number of steps comparison between traditional methods of all-ceramic restorations and CAD/CAM restorations.

Fig. 2: Vita Mark II block.

To overcome esthetic problems of
most CAD/CAM blocks having a
monochromatic restoration, a different version was developed as a
multicoloured ceramic block, which
was called VITA TriLuxe (Vident) and
also IPS Empress CAD Multiblock;
the base of the block is a dark opaque
layer, while the outer layer is more
translucent; the CAD software allows
the clinician to position or align the
restoration into the block for the desired outcome of the restoration.11,12

Fig. 3: In-house milled crown from an E-max block.

onto an enlarged die that is fabricated from the scanned data.[16]
The enlarged fabricated core shrinks
to the dimensions of the working
die when sintered at 1,550 °C; this
material offers a very high strength
core for all-ceramic restorations; the
crown is finished with the application of feldspathic porcelain.17 More
recently, In-Coris AL (Sirona Dental) has been introduced as a highstrength aluminum oxide block
with similar mechanical properties
as Procera.18

Lithium disilicate
Lithium disilicate is composed of
quartz, lithium dioxide, phosphor
oxide, alumina, potassium oxide
and other components. According to
Saint-Jean (2014) the crystallization
of lithium disilicate is heterogenous
and can be achieved through a two or
three stage process depending if the
glass ceramic is intended to be used
as a mill block (e-max CAD) or as a
press ingot (e-max press). Lithium
disilicate blocks (Fig. 3) are partially
sintered and relatively soft; they are
easier to mill and form to the desired
restoration compared to fully sintered blocks; after this process the
material is usually heated to 850 °C
for 20 to 30 minutes to precipitate
the final phase. This crystallization
step is usually associated with a 0.2
percent shrinkage accounted for
the designing software.19 Nowadays,
blocks of lithium disilicate are available for both in-office and in-laboratory fabrication of all-ceramic restorations; monolithic blocks require
layering or staining to achieve good
esthetic results.8 Different in vitro
studies that evaluate the marginal
accuracy of milled lithium disilicate
reveal that these restorations could
be as accurate as 56 to 63 microns.20
According to the manufacturer specifications, the designing principles
for lithium disilicate are produced
by default in the designing software,
but in full all-ceramic crowns structures the minimum thickness must
be applied in the preparation design
(Table I).

Fig. 4: Full arch implant supported prosthesis milled from a
partially sintered sintered (green state) zirconia puck.

ing restorations’ fit, quality, accuracy, short and long-term prognosis.1
The purpose of this document is to
provide a review of the literature regarding the different materials and
systems available up until 2015 in
the USA.

CAD/CAM materials
Glass ceramics
The first in-office ceramic material was Vitablock Mark I (Vident);
it was a feldspathic-based ceramic
compressed into a block that was
milled into a dental restoration. After the invention of the Mark I block,
the next generation of materials for
CAD/CAM milling fabrication of
all-ceramic restorations were Vita
Mark II (Vident) and Celay, which
replaced the original Mark I in 1987
for fine feldspathic porcelains primarily composed of silica oxide and
aluminum oxide.2,3 Mark II blocks
are fabricated from feldspathic porcelain particles embedded in a glass
matrix and used for single unit res-

Fig. 5: STL file of an intraoral scan.

torations available in polychromatic
blanks nowadays. On the other hand,
Celay ceramic inlays have been considered clinically acceptable by traditional criteria for marginal fit evaluation.4
Dicor-MGC was a glass ceramic material composed of 70 percent tetrasilicic fluormica crystals precipitated
in a glass matrix; but this material
is no longer available on the market.[5] Studies from Isenberg et al.
suggested that inlays of this type of
ceramics were judged as clinically
successful in a range from 3–5 years
of clinical service.6-8 In 1997, Paradigma MZ100 blocks (3M ESPE) were
introduced as a highly filled ultrafine
silica ceramic particles embedded in
a resin matrix; the main advantage
of this material is that it can be use
as a milled dense composite that was
free of polymerisation shrinkage but
cannot be sintered or glazed.9
In early 1998, IPS ProCAD (Ivoclar
Vivadent) was introduced as a leucite reinforced ceramic, which was

In 2014, the Enamic (VITA) material
was released as a ceramic network
infiltrated with a reinforcing polymer network that has the benefits of
a ceramic and resin in one material,
but no clinical data are available.14

Alumina-based ceramics
Alumina blocks (Vitablocs In-Ceram
Alumina, VITA) are available for milling with the CEREC system (Sirona
Dental) and now compatible with
other milling machines as well. Due
to the opacity of alumina- based ceramic materials, the In-Ceram Spinell (VITA) blocks were developed
as an alternative for anterior aesthetic restorations; it is a mixture of
alumina and magnesia. Its flexural
strength is less than In-Ceram Alumina, but veneering with feldspathic
porcelain for a more esthetic result
could follow it after the milling process.14,15
Nobel Biocare developed Procera
material; for its fabrication high purity aluminum oxide is compacted

During the crystallisation process,
the ceramic is converted from a
lithium metasilicate crystal phase to
lithium disilicate. Some commercial
types of ceramics are Empress CAD
(Ivoclar Vivadent) and IPS E-max.
The first one is a leucite based glass
ceramic with a composition similar to Empress ceramic. IPS E-max
was introduced in 2006 as a material with a flexural strength of 360 to
400 MPa (two to three times stronger than glass ceramics); the blocks are
blue in the partially crystallised state
but it achieves the final shade after it
is submitted to the firing process in a
porcelain oven for 20 to 25 minutes
to complete the crystallisation; the
final result is a glass-ceramic with a
fine grain size of approximately 1.5
µm and 70 percent crystal volume
incorporated in a glass matrix.20
In 2014, Vident released Suprinity;
the first ceramic reinforced with zirconia (10 percent weight); this material is a zirconia reinforced lithium
silicate ceramic (ZLS) available in a
precrystallized or fully crystallized
(Suprinity FC) state indicated for all
kind of single all-ceramic restorations.

Zirconia
Material thickness
Staining technique
Cut-back technique
Layering technique

Anterior
1.2
1.2
0.8

Premolar
1.5
1.5
0.8

Values are expressed in millimetres
Table 1: Recommended dimensions for E-max CAD by Ivoclar Vivadent.

Molar
1.5
1.5
–

Veneers
0.6
0.6
–

Zirconia has been used in dentistry
as a biomaterial for crown and bridge
fabrications since 2004; it has been
useful in the most posterior areas of
the mouth where high occlusal forces are applied and there is limited
interocclusal space.22
Zirconia is a polymorphic material
that can have three different forms

depending on the temperature:
monoclinic at room temperature,
tetragonal above 1,170 °C, and cubic
beyond 2,370°C. According to Piconi
(1999) ‘the phase transitions are reversible and free crystals are associated with volume expansion’. Different authors state that when zirconia
is heated to a temperature between
1,470 °C and 2,010 °C and cooled, a
volume shrinkage of 25 to 35 percent
can occur that could affect marginal
fit or passiveness of the restorations.22 This feature limited the use of
pure zirconia until 1970 when Rieth
and Gupta developed the yttria-tetragonal zirconia polycrystal (Y-TZP)
containing 2 to 3 percent mol-yttria
in order to minimize this effect.10
One of the most interesting properties of zirconia is transformation
toughening; Kelly (2008) describes
it as: ‘A phenomenon that happens
when a fracture takes place by the
extension of an already existing defect in the material structure, with
the tetragonal grain size and stabilizer, the stress concentration at the
tip of the crack constitutes an energy
source able to trigger the transformation of tetragonal lattice into the
monoclinic phase’. This process dissipates part of the elastic energy that
promotes progression of cracks in
the restoration; there is a localized
expansion of around 3.5 percent that
increases the energy that opposes
the crack propagation.4
Zirconia restorations can be fabricated from fully sintered zirconium
oxide or partially sintered zirconium
oxide blanks (green-state). Proponent of milling fully sintered zirconia claim that fitness of restorations
is better because it avoid volumetric
changes during the fabrication process. On the other hand, the partially
sintered zirconia (Fig. 4) is easier and
faster to mill and proponents of milling partially sintered blanks claim
that micro cracks can be induced to
the restoration during the milling
process and it also requires more
time and intensive milling processes; this micro defects or surface flaws
can affect the final strength of the final restoration and could potentially
chip the marginal areas; however
further research is needed about this
topic.10
One of the first systems that used zirconia was In-Ceram Zirconia (Vident),
which is a modification of the In-Ceram Alumina but with the addition
of partially stabilised zirconia oxide
to the composition. Recently many
companies have integrated zirconia
into their CAD/CAM workflow due
to its mechanical properties, which
are attractive for restorative dentistry; some of these properties are:
high mechanical strength, fracture
toughness, radiopacity for marginal
integrity evaluation, and relatively
high esthetics.13,14
Different manufacturers are using
zirconia as one of their main materials such as: Ceramill Zolid (Amann
Girbach), Prettau (Zirkonzahn), Cercon (DENTSPLY), BruxZir (Glidewell
Laboratories), IPS ZirCAD (Ivoclar Vivadent), Zenostar (Ivoclar Vivadent),
inCoris ZI (Sirona Dental), VITA InCeram YZ (Vident), among others.
Companies have introduced materials that are in combination with
zirconia to improve its properties
in different clinical situations. Lava
Plus, for example, is a combination
of zirconia and a nano-ceramic.

CAD/CAM systems
A number of different manufacturers are providing CAD/CAM systems
that generally consist of a scanner,

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◊Page B2
CAD System
3Shape
ARTI / Modelliere
CeraMill
Cercon Eye/Art
CEREC
Delcam
Dental Wings
PlanCAD
Exocad
InLab
Procera

Manufacturer
3Shape
Zirkonzahn
Amann Girrbach
Dentsply
Sirona Dentsply
Delcam
Dental Wings
Planmeca
Exocad
Sirona Dentsply
Nobel Biocare

File output
Propietary/STL
STL
STL
Propietary
Propietary
STL
STL
STL
STL
Propietary
Propietary/STL

Table 2: Most popular dental CAD systems available for 2015.

design computer and a milling machine or 3-D printer. Laboratories
are able to receive digital impression
files from dentists or use a scanner to
create digital models that are used
for restorations designing or CAD.
Dental scanners vary in speed and
accuracy. Milling machines vary in
size, speed, axes, and also in which
restorative materials can be milled;
in this category milling machines
could be classified as wet or dry depending if the materials require irrigation.
The development of dental CAD/
CAM systems occurred around 1980
with the introduction of the Sopha
system developed by Dr. Francois
Duret. A few years after that event,
Dr. Werner Mörmann and the electrical engineer Marco Brandestini developed the CEREC-1 system in 1983,
the first full digital dental system created to allow dentists to design and
fabricate in-office restorations. Since
then, the continuous evolution of
systems dedicated to this field has
continued and has exponentially increased in the last decade.14
CEREC systems has evolved into
CEREC Bluecam scanner;accuracies
as close as 17 microns for a single
tooth have been reported by authors
using this system. Recently CEREC
Omnicam was introduced offering
true colour digital impressions without the need of a contrast medium.
In a recent study by Neves et al. (2013)
on the marginal fit of CAD/CAM
restorations fabricated with CEREC
Bluecam, they compared lithium
disilicate single unit restorations to
heat-pressed restorations and 83.8
percent of the specimens had a vertical gap measurement with less or at
least 75 microns.15
The CEREC InLab CAD software (Sirona Dental) was designed for dental
laboratories for a wide range of dental capabilities that can be combined
with third party systems. With this
software, the dental technician is
able to scan their own models using
Sirona inEos X5 (Sirona Dental) scan-

ner and design the restoration; once
this process is completed, the file can
be sent to a remote milling machine
or a milling centre for fabrication in a
wide range of materials.
The Procera system, introduced in
1994, was the first system to provide
fabrication of a restoration using a
network connection. According to
research data the average ranges of
marginal fit of this restorations are
from 54 to 64 microns.20 A computer
integrated crown reconstruction system (CICERO) introduced by Denison
et al. in 1999 included a rapid custom
fabrication of high-strength alumina
coping and semifinished crowns to
be delivered to dental laboratories
for porcelain layering and finishing.15
Another system that was developed
years ago was the Celay system,
which fabricated feldpathic restorations through a copy-milling
process. The system duplicated an
acrylic resin pattern replica of a restoration. Zirkonzahn developed a
similar system called the Zirkograph
in 2003, which was able to copy-mill
zirconia prosthesis and restorations
out of a replica of the restoration.
Some years after, the Cercon system
(DENTSPLY Ceramco) was able to design and mill zirconia restorations
out of a wax pattern.1
Almost at the same time that these
companies developed the first copy
mill prototypes, Lava (3M ESPE) introduced in 2002 the fabrication of
yttria-tetragonal zirconia polycrystal
(Y-TZP) cores and frameworks for all
ceramic restorations. With the Lava
system, the die is scanned by an
optical process, the CAD software
designs and enlarge the restoration
or framework that is milled from a
pre-sintered blank. Studies on marginal adaptation suggest that Lava
restorations have a marginal fit that
can be as low as 21 microns.27 Some
other systems that were able to mill
zirconia were DCS Zirkon(DCS Dental) and Denzir.16
In the last decade, companies have

CAM System
BruxZir Mill
CeraMill Motion

Manufacturer
Glidewell
Amann Girrbach

Type
Dry
Wet/dry

Datron D5

Datron

Wet/dry

Denzir
PlanMill
InLab MC XL

Ivoclar
Planmeca
Sirona

Dry
Wet
Wet/dry

LAVA
M1/M5

3M ESPE
Zirkonzahn

Dry
Wet/dry

Procera
Zenotec

Nobel Biocare
Ivoclar

Wet
Dry

Table 3: Most popular dental CAM systems available for 2015.

decided to differentiate
their products by having
a full CAD/CAM platform
or by focusing on specific
areas of expertise like CAD
software and intraoral
scanners; these companies claim to be open
platform because their
systems allow to export
universal files such as STL
or OBJ (Fig. 5) to be used
with the majority of nesting softwares and milling
machines that are able to
import them.
Defenders of closed platforms claim that the integration of different CAD/
CAM systems does not allow for a
good integration between parts and
probably leads to the incorporation
of fabrication errors; at this point
no research about systems integration is available. Table II shows some
of the systems used for dental CAD
with their file output; Table III shows
some of the most used CAM systems
with their material recommendations and capabilities.
Some of the main concerns from clinicians about all-ceramic CAD/CAM
restorations accuracy of fit are: scanning resolution, software designing
limitations, and milling hardware
limitations of accuracy. Clinicians’
and technicians’ experience with the
CAM/CAM system integration is also
a key factor for fabricating good restoration; the computer software per
se will not allow an inexperienced
operator to create an excellent dental restoration from scratch.18

Discussion
Several advantages can be drawn
from including CAD/CAM dental
technology, 3-D scanning and the
use of mill materials for all-ceramic
restorations. Even though clinical
studies have shown that marginal
fit of CAD/CAM restorations is compared to conventional restorations
the fabrication of dental restorations
is still a complex task that requires
experience, knowledge and skills.
The incorporation of new systems
and materials bring a lot of concerns
regarding system implementation,
capabilities and mechanical properties of the different materials. One
of the biggest problems that still remain in CAD/CAM dental systems is
the accuracy of each step in the CAD/
CAM chain, from digital impression
to the milling step. Using computer
aided manufacturing is dependent
on the calibration of hardware with
software in the workflow. Furthermore, the virtual configuration of
the die spacer between the tooth
and the restorations is essential for
the accuracy of the marginal adaptation and has to be calibrated for each
one of the systems. Weittstein et al.

demonstrated that the difference of
fit between CAD/ CAM restorations
is directly related to the gap parameters from the computer design and
also related to the intrinsic properties of the CAD/CAM system.16

Conclusion
This review of current and past literature regarding the evolution,
characteristics, and marginal fit of
milled CAD/CAM all-ceramic restorations materials and systems show
that it is possible to fabricate restorations with the same marginal fit expected from conventional methods
and within the range of clinically accepted restorations. When comparing both methods the advantage of
using CAD/CAM technology is not
to obtain the most precise level of fit,
but rather to obtain a high level of reliability in a large number of restorations; especially when high production levels are expected. However,
there are a limited number of clinical
studies and the diversity of the results between systems and protocols
does not allow us to give a definitive
conclusion.

References
1. Miyazaki T, Hotta Y, Kunii J, Kuriyama S, Tamaki Y. A review of dental
CAD/CAM: current status and future
perspectives from 20 years of experience. Dent Mat Journal 2009. 28:
44–56.
2. Fasbinder DJ. Restorative material
options for CAD/CAM restorations.
Compend Contin Educ Dent. 2002.
3. Pallesen U, van Dijken JW. An
8-year evaluation of sintered ceramic and glass ceramic inlays processed
by the Cerec CAD/ CAM system. Eur J
Oral Sci. 2000.
4. Kelly JR, Denry IL. Stabilized zirconia as a structural ceramic: an overview. Dent Mater 2008. 24:289–98.
5. Kelly, R. Nishimura, I. Campbell,
S. Ceramics in dentistry: Historical
roots and current perspectives. Journal of Prosthetic Dent. 1996.
6. Tinschert J, Zwez D, Marx R,
Anusavice KJ. Structural reliability
of alumina, feldspar, leucite and zirconia based ceramics. J Dent 2000.
28:529–535
7. Luthardt RG, Sandkuhl O, Reitz B.
Zirconia- TZP and alumina advanced
technologies for the manufacturing
of single crowns. Eur J Prosthodont
Restor Dent. 1999.
8. Kurbad A, Reichel K. Multicolored
ceramic blocks as an esthetic solution for anterior restorations. Int J
Comput Dent. 2006.
9. Bindl A, Mormann WH. Survival
rate of mono-ceramic and ceramiccore CAD/ CAM-generated anterior
crowns over 2–5 years. Eur J Oral Sci.
2004.
10. Esquivel-Upshaw JF, Chai J, Sansano S, Shonberg D. Resistance to staining, flexural strength, and chemical
solubility of core porcelains for all-

Milling materials
Zirconia, wax, PMMA
Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate,
Chrome Cobalt, PMMA, wax, titanium
Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate,
Chrome Cobalt, PMMA, wax, titanium
Zirconia
Lithium disilicate, ceramic resin
Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate,
Chrome Cobalt, PMMA, wax, titanium
Zirconia, wax, glass ceramic
Zirconia, Glass ceramic, ceramic resins, Lithium Disilicate,
Chrome Cobalt, PMMA, wax, titanium
Aluminum oxide
Zirconia, wax, PMMA

ceramic crowns. Int J Prosthodont.
2001.
11. Reich SM, Peltz I, Wichmann M, Estafan D. A comparative study of two
CEREC software systems in evaluating manufacturing time and accuracy of restorations. Gen Dent. 2005
12. Anusavice, K. Phillips’ Science of
Dental Materials. 12 edition. In: Saunders. Elsevier; 2014.
13. Kosmac T, Oblak C, Jevnikar P,
Funduk N, Marion L. The effect of
surface grinding and sandblasting
on flexural strength and reliability of
Y-TZP zirconia ceramic. Dent Mater.
1999
14. Raigrodski AJ. Contemporary allceramic fixed partial dentures: a review. Dent Clin North Am. 2004.
15. Neves F, Prado C, Prudente M, Carneiro T, Zancope K, Davi L, Mendonçe
G, Cooper L, Soares C. Marginal fit
evaluation with micro CT of lithium
disilicate crowns fabricated by chairside CAD/CAM systems and the
heat-pressing technique. J Prosthet
Dent. 2014.
16. Hertlein G. Kramer M, Sprengart
T, et al. Milling time vs marginal fit
of CAD/CAM manufactured zirconia
restorations. J. Dent Res 2003. 82:194.
17. Guazzato M, Proos K, Quach L,
Swain MV. Strength reliability and
mode of fracture of bilayered porcelain/zirconia (Y-TZP) dental ceramics.
Biomaterials. 2004.
18. Syrek, A. Reich, G. Ranftl, D., Klein,
C. Cerny, B. Brodesser, J. (2010). Clinical evaluation of all-ceramic crowns
fabricated from intraoral digital impressions based on the principle of
active wavefront sampling. Journal
of Dentistry. 2010.
19. De Vico G, Ottria L, Bollero P, Bonino M, Cialone M, Barlattani A Jr. et al.
Aesthetic and functionality in fixed
prosthodontic: experimental and
clinical analysis of the CAD–CAM
systematic 3Shape. Oral Implantol.
2008; 1:104–115.
20. Gehrt, M. Wolfart, S. Rafai, N.,
Reich, S. Edelhoff, D. (2013). Clinical
results of lithium-disilicate crowns
after up to 9 years of service. Clinical
Oral Investigations. 17(1), 275–84.
21. Gupta TK, Bechtold JH, Kuznickie
RC, Cadoff LH, Rossing BR. Stabilization of tetragonal phase in polycrystalline zirconia. J Mater Sci
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22. Piconi C, Maccauro G. Zirconia as
a ceramic biomaterial. Biomaterials.
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This article was published in CAD/
CAM international magazine of digital dentistry No. 03/2016.

Dr Christian Brenes,
DDS.
Master in Prosthodontics. Clinical Assistant
Professor Dental College of Georgia at
Augusta
University. International speaker for Digital Dentistry Education and BlueSkybio
Academy on guided surgery, clinical digital protocols and dental aesthetics.
He can be contacted at:
christian@blueskybio.academy

Dr Ibrahim Duqum, DDS. MS. Clinical Assistant Professor. Department of Prosthodontics at the University of North Carolina at Chapel Hill.
Dr Gustavo Mendonza, DDS. MS. PhD.
Clinical Associate Professor. Department
of Biologic and Materials Sciences, Division of Prosthodontics, University of
Michigan School of Dentistry.

[52] => DTMEA_No.3. Vol.8_DT.indd

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PUBLISHED IN DUBAI

May-June | No. 3, Vol. 8

M(oral) Education tested in Dubai Youth
Hub: A Creative Way to Tackle Dental Decay
By Dr. Shiamaa Al-Mashhadani
The World Health Organisation
(WHO) considers caries, periodontal diseases, loss of teeth, oral cancers and trauma as major causes of
health burdens. Dental cavities can
be found in 60-90 per cent of children of school-going age. Not only is
there an alarmingly high prevalence
of dental disorders worldwide, but
there is also sufficient evidence to
suggest that the benefits of the current interventions aimed at reducing this burden are not reaching the
populations at risk.
In similarity with the global trend,
surveys in the United Arab Emirates
(UAE) have also revealed a startlingly
high prevalence of various dental
diseases. Surveys have revealed that
83 per cent of children aged five
years are affected by caries, and 52
per cent have four or more decayed,
missing or filled teeth (DMFT). In a
study conducted in Abu Dhabi, an
Emirate within the UAE, the mean
DMFT score was recorded at 8.4, 8.6,
and 5.7 for children aged five years in
various regions of the Emirate. The
latest study focusing on the Emirate
of Dubai shows similar high numbers, with caries prevalent in 65 per
cent of five-year-olds. 10 per cent of
these children have more than five
teeth with untreated caries. Data
from these studies highly suggests
that there is an urgent need for action to counter the widespread dental diseases in the UAE. The WHO has
suggested a number of cost-effective

and holistic interventions to counter
the increasing prevalence of dental
diseases.
Preschools and schools provide an
important base to promote oral
health as they reach large numbers
of students who pass on these messages to their families. Schools can
make substantial contributions to
students’ health and well-being. This
has been increasingly recognised
by many international initiatives
including those from the World
Health Organisation (WHO), UNICEF
and UNESCO. This means that the
oral health messages reinforced in
schools will eventually reach the
whole community. The early years of
a child’s life are the most influential
in reinforcing habits and attitudes,

therefore teaching the students at
this age about proper oral health
habits will have a lifelong effect. They
will be healthier and more productive individuals in their community,
having better quality of life with a
potential to long term cost saving.
To eliminate dental problems, one
must follow a tripod approach of education, prevention and availability
of oral health care.
The New York University Abu Dhabi
Public Health Think Tank (PHTT) is a
collaborative, interdisciplinary and
locally engaged initiative, designed
to catalyse public health innovation
in and beyond the United Arab Emirates. This year, the PHTT concentrated on oral health in an immersive, two-day event where delegates

planned an oral health intervention
alongside students from across the
UAE, and received lectures and guidance from leading public health professionals.
The winning team (Team Ras Al
Khaimah) proposed a project with
the aim to decrease the prevalence of
caries in children across the UAE by
increasing oral health awareness and
constant reinforcement through the
incorporation of oral health into the
moral education curriculum within
public schools. To implement this
intervention, a pilot study will be
conducted on schoolchildren from
Grade 1 until they reach Grade 6
(from 2018 to 2024). The group chosen will be educated each year within
the pilot program on multiple lev-

els of dental health awareness, and
the results of their decayed, missing
and filled teeth (DMFT) will be collected after six years. When comparing these results to the DMFT data
of previous sixth graders who were
not exposed to the oral health education program, an improvement is
expected, which will prove the effectiveness of the intervention. The oral
health program will then hopefully
be implemented into the moral education curriculum in schools across
the UAE. The intervention is essential because, at present, there are few
pre-existing long-term curricula on
oral health. It will also provide reinforcement, which is key for children
to break free from unhealthy sociocultural norms, such as tobacco usage. This intervention also capitalises on resources already available by
implementing education through
pre-existing jobs while preventing
the onset of caries, thereby reducing government expenditure in the
long-run.
The intervention was recently presented in the Dubai Youth Hub as a
prototype with the participation of
students from Dubai Modern Education Private School. Feedback collected from students and their parents
who attended has shown promising
results.

For further information on the project, please visit http://2017.phtt.org/

Optimal secondary prophylaxis with CPS perio
simultaneously diagnoses fresh
caries and periodontal disease as
early as possible, remineralises early
changes in the enamel and treats
orthodontic misalignment early on.
Secondary prophylaxis is a part of
daily work in many dental practices.

By DTI
Secondary prophylaxis stabilises
treatment results, for example after
treatment of periodontitis or periimplantitis. Secondary prophylaxis

This is where the CURAPROX brand
comes in. A customised hygiene
programme with the best products,
personal care and instruction to the
patient on using the oral hygiene
products are what ensure successful
treatment. The products and concepts of CURAPROX are the key to
long-term successful prophylaxis.
With the correct and regular use of
soft toothbrushes and interdental
brushes from CURAPROX, patients
can remove newly formed plaque
and older, more established plaque.

Secondary prophylaxis
with CPS perio
As soon as the active treatment
phase has been concluded, the patient follows a specific periodontal
care protocol that takes into account
his or her oral health status, for example if the patient’s papillae are
badly injured or if there are black triangles. Regardless of the treatment,
the work by the practice team constitutes only 30 per cent of the success.
The remaining 70 per cent is up to
the patient him- or herself.
Most interdental brushes do not
completely fill the interdental space
and are much too hard and their use
thus leads to pain. The CPS perio is
especially suited to periodontitis patients. This interdental brush is sufficiently rigid to give a really efficient

clean, but soft enough to avoid pain.
The wire used in the CPS perio is
stronger than that in the CPS prime,
to keep the brush sturdy. The extralong and -fine bristles of the CPS
perio effectively and carefully clean
the large gaps of bridges, crowns or
fillings.
The practice team’s use of a calibrated CURAPROX interdental access
probe to choose interdental brushes
of the right size further supports
the patient in performing optimal
secondary prophylaxis. The probe is
now also available for the CPS perio
range. The chairside box contains
CPS perio and probes for the precise
measurement of interdental spaces.
The holders can be reused if required
and the probes can be autoclaved.
Interdental brushes of all sizes and

probes can be stored hygienically
and neatly ordered right in the treatment unit within easy reach.

Fig 1. IAP

[54] => DTMEA_No.3. Vol.8_DT.indd

HYGIENE TRIBUNE

Dental Tribune Middle East & Africa Edition | 3/2018

Erythritol functional roles
in oral-systemic health
By P. de Cock

Oral health functionality
of Erythritol
Mäkinen et al. 2005 demonstrated
that in comparison to other sugar
alcohols like sorbitol and xylitol,
erythritol can decrease dental plaque
mass and acids associated. Erythritol
has the potential to reduce streptococci mutans in saliva hence minimizing the risk of dental caries.
Falony et al 2016 concluded that the
erythritol group had significantly
fewer tooth surfaces with enamel
or dentin caries in comparison with
sorbitol.
In addition, the time of enamel or
dentin caries lesions to progress and
dentin caries to extend further was
significantly longer in the erythritol group compared with the other
polyol groups.

Runnel et al. 2013 confirmed that
the amount of fresh dental plaque
and counts of S. mutans in saliva and
plaque were lower in the erythritol
group in comparison to the sorbitol
and xylitol groups. Dental plaque
in the erythritol group also showed
lower levels of acetic, propionic, and
lactic acid compared to control.
Honkala et al. 2014 in a study demonstrated that at the end of a 3 year intervention, the erythritol group had
the lowest caries.
Yao et al. 2009 in another study
suggested that compared to xylitol,
erythritol in low concentrations had
a weaker inhibition effect on the bacterial growth and acid production of
S. mutans while having stronger effect at high concentrations.
Hashino et al. 2013 reported that 10%

erythritol had an inhibitory effect
on the microstructure and metabolomic profiles of biofilm composed
of Porphyromonas gingivalis and
Streptococcus gordonii.
Erythritol was the most effective
reagent to reduce P. gingivalis accumulation onto S. gordonii substrata
compared to xylitol and sorbitol

Systemic health effects
Erythritol is noncaloric, noninsulinemic, and nonglycemic besides being well-tolerated. It has a very high
bioavailability, showing potential to
provide cardiovascular benefits due
to its capability to act as an antioxidant systemically.

Effects of Erythritol
on the Gastrointestinal Tract
Munro et al. 1998 reported the fact

that erythritol due to its small molecular size is rapidly absorbed through
passive diffusion. Approximately
90% of the ingested dose is absorbed
from the small intestine and excreted in the urine unchanged. European Food Safety Authority also confirmed that young children tolerate
erythritol equally well as adults on a
body weight basis

Effects of Erythritol
on Cardiovascular Health
Boesten et al. 2013 in a research
confirmed that in endothelial cells,
erythritol could shift a variety of
damage and dysfunction parameters to a safer side, thereby reversing
the damaging effects of hyperglycemic conditions.

proves the endothelial function and
their vascular health status in people
with type 2 diabetes.
- Erythritol provides healthier tooth
protection than sorbitol and xylitol,
in children and teenagers.
- Erythritol is of great importance
not only in oral care or dietary-based
preventive strategy but also to help
maintain oral and cardiovascular
health besides supporting weight
management benefits when replacing sugar.

Erythritol is not just an AIR FLOW
powder, but a complete, efficient
and safe one stop solution for dental
prophylaxis with additional supportive action as an antioxidant.

Conclusion & Sales arguments
- Erythritol as an antioxidant im-

Fluoride varnish in primary dentition
positively affects caries prevention
By DTI
COLOGNE, Germany: Whereas caries
in adults and adolescents in Germany is declining, research has found
that about 14 per cent of 3-year-olds
in the country have cavities in their
primary dentition. According to a report by the Institute for Quality and
Efficiency in Health Care (IQWiG),
fluoride varnish is effective in remineralisation of the tooth surface and
prevents the development and progression of caries.
Permanent teeth may be affected by
caries at an early stage in the case of
caries-affected primary teeth, as the

enamel has not yet fully hardened.
Because oral hygiene and caries prevention can be challenging in young
children, the use of fluoride varnish
can be beneficial.
For this reason, the IQWiG researchers investigated whether the application of fluoride varnish to primary dentition has advantages in
comparison with standard care without fluoride application by comparing the findings of 15 randomised
controlled trials. In these, a total of
5,002 children were treated with
fluoride varnish, and 4,705 children
received no such treatment, being

the control group. Children aged up
to 6 years with or without caries of
their primary teeth were included in
the research.
In several of the studies, further
measures for caries prevention in addition to the application of fluoride
varnish were offered. These included
training on oral hygiene, instruction
on the correct toothbrushing technique, and the provision of toothbrushes and fluoridated toothpaste.
The follow-up observation period
was mostly two years.
The development of caries was in-

vestigated in all 15 studies; side-effects were investigated in nearly all
of the studies. However, owing to a
lack of conclusive data, it is unclear
whether fluoride application also
has advantages regarding further
patient-relevant outcomes, such as
tooth preservation, toothache or
dental abscesses. There was no data
on oral health-related quality of life.
A clear advantage of fluoride varnish
was determined despite the very
heterogeneous study results. After
the application of fluoride varnish,
caries in primary teeth was less frequent. More precisely, the fluoride

treatment could completely prevent
caries in approximately every tenth
child and would at least reduce progression of caries in further children.
Apparently, whether the children
already had caries or whether their
teeth were completely intact made
no difference regarding the benefit
of fluoride varnish application.
The report, titled “Assessment of
the application of fluoride varnish
on milk teeth to prevent the development and progression of initial
caries or new carious lesions”, was
published online by IQWiG on 26
April 2018.

EFP set to celebrate
European Gum Health Day 2018
By DTI
LEIPZIG, Germany: On 12 May, the
European Federation of Periodontology (EFP) and 29 of its affiliated
national societies will participate in
European Gum Health Day 2018.
With the slogan “Health begins with
healthy gums”, the day seeks to raise
awareness of periodontal disease’s
deleterious effects through a range
of informative and engaging activities.
Co-ordinated by Dr Xavier Struillou, an elected member of the EFP
executive committee, European
Gum Health Day 2018 aims to build
upon the success of last year’s in-

augural event. Through television
and radio interviews, press releases,
press conferences and individually
produced video content, many of
the participating national societies
will be seeking to widely communicate and emphasise the importance
of periodontal health for general
health. Dentists and other dental
professionals are also invited to sign
the EFP Manifesto, a call to action for
the prevention, early detection, and
early treatment of gum disease.
National societies of periodontology
from Austria, Azerbaijan, Belgium,
Croatia, Denmark, Finland, France,
Germany, Greece, Hungary, Italy,

Israel, Ireland, Lithuania, Morocco,
the Netherlands, Norway, Poland,
Portugal, Romania, Russia, Serbia,
Slovenia, Spain, Sweden, Switzerland, Turkey, Ukraine and the United
Kingdom will be actively involved in
the day. All of these societies have
employed the logos, posters, infographics and templates provided by
the EFP to convey a shared message
that transcends borders.

ties of Colombia and Panama, also
taking part in European Gum Health
Day 2018.

In addition, an agreement with the
IberoPanamerican Federation of
Periodontology (FIPP) will see FIPP’s
eight Caribbean and South American member associations, as well as
the national periodontology socie-

“European Gum Health Day 2018
aims to remind people that—even if
still often overlooked—gum health
is a key factor for general health
throughout life, and that gum disease is a relevant public-health

“We are very excited that the Latin
American perio societies are for the
first time joining European Gum
Health Day 2018 and that they are
helping us to convey the awareness
message ‘Health begins with healthy
gums’ ever further,” said Struillou.

concern because it is linked to very
serious conditions, including heart
disease and cerebrovascular disease,”
he added. “Gum health can help us
to save many lives, to detect or prevent many severe conditions, and to
save billions in medical costs.”
Anton Sculean, president of the EFP,
added: “Gum disease’s prevalence
and gravity increase with age and as
a result of contributing factors such
as smoking and obesity, but it can be
prevented and successfully treated,
especially if diagnosed early. That
is why, as our motto says, ‘Health
begins with healthy gums’, and we
have an opportunity to take action.”

[55] => DTMEA_No.3. Vol.8_DT.indd

3

HYGIENE TRIBUNE

Dental Tribune Middle East & Africa Edition | 3/2018

World Oral Health Day 2018
celebrated across Dubai
By Dental Tribune MEA/CAPPmea
Philips Sonicare is an official global
partner of World Oral Health Day
(WOHD), which takes place every
year on March 20th, organized by
FDI World Dental Federation. This
year, the campaign ‘Say Ahh: Think
Mouth, Think Health’ encourages
people to make the connection between oral health and general health
and well-being. World Oral Health
Day is commitment to educating
consumers and dental professionals on the importance of developing good oral healthcare habits at an
early age and increasing education
on the impact oral health can have
on general health conditions.
It’s a day full of activities that make
everyone laugh, sing and smile!
The Dubai Health Authority (DHA)
in cooperation with Philips Sonicare
organised an exciting schedule for
everyone by inviting The Singing
Dentist, Dr Milad Shadrooh, to join
in celebrating WOHD in Dubai. The
schedule of activities for WOHD
was very exciting. It all started on 11
March on the Ch4FM radio, where a
competition for children under the
age of 16 years was held. The competition task was to rap or sing a song
related to oral health. The winner
would receive a chance to make a
recording with The Singing Dentist himself for the following day’s
Breakfast Show, meet and greet The
Singing Dentist in Mirdif City Centre the following week and receive a
Philips Sonicare electric toothbrush
free of charge.

how to maintain good oral hygiene
in line with the WOHD theme “Say
Ahh!”
With the advice to:
- Brush your teeth
- Eat Healthy and
- Visit the dentist
The year 5 group had used one of
the Singing Dentists videos in Moral
Education and the children have
written their own well-being songs
using him as inspiration. The atmosphere was static in the room with the
students dancing and singing along
with the Singing Dentists. A day to
remember of good oral hygiene tips
while having fun!
On 21 March, The Singing Dentist,
the DHA and Philips were present at
the Dubai Modern Education School,
(DMES) where the students were to
form the largest “Human Smile” by
having students wear t-shirts in red,
blue and white (the WOHD logo colours).
On the day, Dr Hamda Sultan al-Mesmar, Director of the Dental Services
Department at the DHA, opened the
ceremony with the following words,
“The Dubai Health Authority’s vision
is to have a happy and healthy community and that of the Dental Services Department is to improve the oral
health of students of the Emirate of
Dubai and to serve the goals of the
2016–2021 DHA strategy to increase
oral health literacy among the population of Dubai and decrease dental
caries among its children.”

Dubai Modern Education School on World Oral Health Day celebration

The DHA extended their thanks and
gratitude to Ms Hamda Lootah, head
of the DMES, Michael Cipriano Principal of DMES, head of the American
section; and respected academic and
medical staff from the school for accommodating this festival of oral
health awareness and the celebration of WOHD that is organised by
the FDI World Dental Federation, as
well as the inauguration of the second edition of the “My Smile” oral
health school programme, of which
Dr Shiamaa Shihab al-Mashhadani
from the DHA is a leader.¬ Additionally, thanks went to the DHA’s strategic partner, Philips Sonicare, for their
continuous support of the Dental
Services Department, and to the
Knowledge and Human Development Authority, as well as the School
and Educational Institutes Unit in
the DHA.
The main attraction of the day
for everyone participating was, of
course, The Singing Dentist. He per-

formed several of his “hit” songs, during which the entire audience sang
along. He also met the students who
had won the competition on oral
health benefits. At the same time,
several stations were placed along
the room with different oral health
activities in which the students participated. The DHA, together with
the Emirates Dental Hygienist Club,

educated the youngest in a fun manner about oral health care.
The DHA hopes that the students
benefited from the programme and
that, in the end, the primary goal was
achieved, which was to have every
student of Dubai be healthy and
happy.

Singing Dentist with “fans” from year 5 Repton School Dubai

The Mirdif City Centre’s audience reserved a warm welcome for The Singing Dentist. A short question and
answer session regarding oral health
was held and answered by children.
Dr. Rafif Tayara demonstrated the
technique of proper toothbrushing.
On 20th March the Singing Dentists
visited Repton School Dubai where
he met 320 exited students from
year 3 and year 5. The Singing Dentists interacted with the children asking and answering questions about
Singing Dentist performing his biggest hit “Save Your Tooth” parody of Ed Sheeran’s “Shape Of You“

Dubai Modern Education School students making the largest “Human Smile”

Year 3 students at Repton School Dubai are listening to the Singing
Dentists oral hygiene advices

DHA Dental Services Department educating students how to properly
brush their teeth

Proud winners of the oral hygiene advice competition in Dubai Modern
Education School

DHA Dental Services Department teaching the students about good
oral hygiene

A common goal to raise awareness and improve students oral hygiene:
Singing Dentist, Michael Cipriani Head Master Dubai modern Education
School, Dr. Hamda Sultan Al-Mesmar Director of DHA Dental Services
Dept, Henny Arstal distributor Philips Sonicare UAE

Oral hygiene education and fun experiments led by Emirates Dental
Hygienist Club

[56] => DTMEA_No.3. Vol.8_DT.indd

Periodontitis?
The solution!
CPS perio interdental brushes

Developed for
periodontitis patients
Effective, yet gentle
Also pleasant for black holes

Easy to use:
in, out, done

CPS 405

Periodontitis patients need quite
sturdy interdental brushes which
can be quite unpleasant to use.
That’s why Curaprox has developed
a new interdental brush: the
CPS perio. It provides an
exceptional clean and is extremely
comfortable for the patient.
Available in four sizes.

chairside box perio

CPS 406

1.3 mm / 5.0 mm

CPS 408

1.7 mm / 6.5 mm

CPS 410

2.2 mm / 8.0 mm

At your fingertips
2.5 mm / 10.0 mm

In the CPS chairside box perio

order here: www.curaprox.com

[57] => DTMEA_No.3. Vol.8_DT.indd

PUBLISHED IN DUBAI

May-June 2018 | No. 3, Vol. 8

www.dental-tribune.me

CAPP’s Clinical Implantology
Programme live surgical treatment
performed in Ajman Universty
By Dental Tribune MEA / CAPPmea
CAPP-Tipton Dental Academy, British Academy of Dental Implantology
(BADI) and the British Academy of
Restorative Dentistry (BARD) have
launched the Clinical Implantology
Dentistry Certificate and Diploma
programme in Dubai, UAE. Group 1
started in January 2018. Group 2 will
be starting on 17 October 2018. The
same programme has been happening in the UK since 1992 and is now
offered in Dubai.
Several weeks ago the delegates con-

cluded Module 2 of the programme
where they performed a live-patient
treatment hands-on training. The
hands-on part of the programme
took place in Ajman University so
the delegates had access to professionally equipped clinic.
The course is ideal for dentists with
little or no experience in placing implants and oral surgery but also for
dentist who are looking to further
enhance their clinical skills by placing implants in real-life situations.
As delegates work towards placing
implants under supervision, they

will be able to practice these skills by
treating patients, not only delivering
results but knowing the reasons why
the results were delivered.
The programme covers the key aspects of dental implantology to provide evidence based, safe and predictable treatment of participants’
own cases. As a live patient course
there is significant focus on patient
selection, identifying suitable implant patients and how to create
an optimum treatment plan using checklists and digital treatment
planning tools. Delegates will grasp

an in-depth knowledge of all the adjunct therapies and diagnostic tools
to ensure that planning stages are
comprehensive and thorough ensuring the patient journey is smooth
and predictable.
This is the third programme that
CAPP-Tipton Dental Academy and
British Academy of Restorative Dentistry (BARD) have started in Dubai,
UAE. There are over 170 delegates
already participating in the Restorative & Aesthetic Dentistry Diploma
and Clinical Endodontics Diploma.
The Certificate consists of 3 modules which take place every 2 to 3
months. Each module is 4 days long.
The course offers the participants
a chance to obtain a Certificate in
Clinical Implantology from the British Academy of Dental Implantology
(BADI) and the British Academy of
Restorative Dentistry (BARD).
After a successful completion of the
Certificate course, the participants
will have the chance to sign up for
the Diploma course which will lead
to Post-Graduate Diploma in Clinical
Implantology from the British Academy of Dental Implantology (BADI)
and the British Academy of Restorative Dentistry (BARD). The Diploma
consists of additional 3 modules

SUBSCRIBE NOW
www.me.dental-tribune.com/e-paper/
Vol. 18 • Issue 4/2017

issn 1868-3207

implants
international magazine of

oral implantology

2017

research
Titanium and its alloys
in dental implantology

case report
Rehabilitation of
edentulous patients

industry
Digital workflow:
From planning to restoration

which take place every 2 to 3 months.
Each module is 4 days long. The entire programme (Certificate and Diploma) is 14 months long; 6 modules
of 4 days, totaling 24 days.
CAPP-Tipton Dental Academy offers
3 Diploma programmes in Dubai
UAE, namely:
1. Restorative & Aesthetic Dentistry
Certificate & Diploma
www.cappmea.com/capptipton
2. Clinical Endodontics Certificate &
Diploma
www.cappmea.com/endo
3. Clinical Implantology Certificate &
Diploma
www.cappmea.com/implant
For more information visit the
above mentioned websites or Call/
Whatsapp +971528423659 or e-mail:
p.mollov@cappmea.com

Live-patient surgical treatment hands-on training

Prof. Göran Urde from Sweden explaining the radiograph to the delegates

[58] => DTMEA_No.3. Vol.8_DT.indd

IMPLANT TRIBUNE

Dental Tribune Middle East & Africa Edition | 3/2018

Considerations for Long Term Success
Implants are Never Forever!
By Dr. Shankar Iyer, USA
This article will emphasize the importance of factors to consider before treatment planning for full
arches with implants. It is not uncommon to make misleading promises to patients when presenting implants as an option with unfounded
claims of 98% success rates. Most of
the survival statistics have evaluated
implants for full mouth reconstructions through profuse citations of
the original Branemark’s work published in 1981. Repeated citations of
this article and the subsequent follow up articles have made claims of a
high percentage of success with implants. While this is partially true, the
circumstances under which these
implants survived has been incorrectly extrapolated to other clinical
situations. The original Branemark
research was done on edentulous
arches with hybrid prosthesis opposing either complete dentures or
prosthesis of similar construction.
Patients are now wondering with
these highly overstated survival
rates, why their implants are ailing and need maintenance within
a short span. The answer lies in the
lack of understanding of biomechanics. The connotation that anything
works has led to confusion in the
field. The diametrically opposite
views of short vs long implants, axial
vs angled implants, graft vs graftless
solutions, regular vs minis, delayed
vs immediate, one piece vs two pieces, guided vs free hand placements
and platform switiching concepts
have only caused anarchy in the
discipline of implant dentistry. Podium concepts have gained popularity through corporate support and
we see opinion leaders vociferously
making unsubstantiated claims
through limited clinical evidence. A
novice finds it very difficult to get involved in implant dentistry because
the education is being blessed by
companies and not through universities or institutions.
After being involved in implants for
over 20 years, I find it to be an humbling experience with cases that I
treatment planned two decades ago
returning to me for maintenance.
Seeing these cases today, I wish I
had this experience at that time so I
could have served my patients better. Today it has taught me a lot in
treatment planning. I am able to
prognosticate the outcome and its
management in the event of an untoward incident. The lessons in biomechanics has complemented the
initial biologic responses that can be
predicted initially so that the survival of implant therapy is prolonged.
I am a firm believer of long term
data and I fear the rapid evolution of
products and techniques that claim
to be faster and easier. If only I could
train my patients osteoblasts to work
harder and faster so their bones can
heal rapidly, all of the problems can
be eliminated and failures can be a
thing of the past. The life cycles of
cells have been a constant over a million years and now we are told that
implants are appoved for immediate load and the cells can adhere to
inanimate objects through unique
surfaces. My understanding of cell

biology may be limited but it is common knowledge that behavior of
cells cannot be hastened because the
mitotic cycle for the DNA takes the
programmed time period for turn
over. Only in disease this rapid uncontrolled proliferation takes place.
If this normal cycle is upset then we
are look at metaplastic or anaplastic
changes according to the turnover
rate. Claims made by certain companies that, bone heals faster with their
implants is presumptuous. Bone
levels are magically maintained with
their unique surface modification is
also far from the truth. I have used
over 16 different implant systems in
my practice over the years and in my
training programs and I have found
that the osteoclasts are notoriously
unbiased. There is bone loss with
every system and modifying the surface or creating morphological shifts
does not predictably deter bone loss.
In the courses I teach, I recommend
waiting for a period of three years
after any new feature or biologic
product is introduced into implant
dentistry. There is no room for latest or newest in clinical practice. If
a company is constantly introducing new product lines and changing
their designs, there is only one conclusion – They are having trouble
and hence they have to change. A
robust system that works seldom
needs modification for getting predictable results. Aspirin can never
be debunked for its efficacy, being so old and dated. The original
Branemark external hex (now made
out of type 4 Titanium but designed
in 1965) is still very functional and
a work horse for hybrid prosthesis.
The surfaces have improved much
but its basic design and biomechanical considerations will be valid for
another 50 years. Premature adoption of technology or materials is
fraught with shortcomings and
unknown consequences. Classical
examples of potential catastrophic
failures include the TPS coatings,
HA surface modifications, sintered
surfaces, flapless surgeries, guided
surgeries, immediate loading, costly
BMPs and the list goes on.
The message is very simple – one
crawls before they walk and you
must learn to walk before you can
run. The same is true for implant
dentistry. The novice today has a
wide choice – you can become a complete arch implant specialist with 4
implants and guided surgery over
a weekend or spend a year learning
the basics and judiciously treatment
plan cases with customized solutions. Half of the participants of our
Maxicourses that we run in the U.S.
and overseas have practitioners who
have placed hundreds of implants
and got their training through corporate education. One does not become a musician by buying a piano
or a musical instrument, nor can you
become a pilot by buying a plane.
Training in implant dentistry has become a fad. Most courses are offered
through companies and the company’s sole interest is to sell their system. There is a whole world of treatment plan that is out there before
the system can be utilized. Lets not
place the cart before the horse. The
void is very apparent the time is now
for implementing judicious treat-

ment plans. Lets serve our patients
with what they need and not what
we want them to have.
Iyer’s Top 10 Guidelines for Predictable Implantolgy
1. Diagnose the problem first and
don’t treat because you have a tool
that you can use.

2. Measure the disease and provide
the therapy, don’t sell concepts.
3. Leave what’s new and latest to the
risk takers, stick with proven and
tried systems.
4. Implants are the last resort in treatment planning – exhaust all conservative, conventional modalities
5. Implants should replace missing

Fig 1

Fig 2

Fig 3

Fig 4

Fig 5

Fig 6

Fig 7

Fig 8

Fig 9

Fig 10

teeth not replace teeth.
6. Expensive implants don’t mean
success rates are better, cheaper does
not mean everything works – you get
what you pay for. There is no substitute for evidence based practice
7. Consider every implant as a failing

ÿPage D4

[59] => DTMEA_No.3. Vol.8_DT.indd

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[60] => DTMEA_No.3. Vol.8_DT.indd

IMPLANT TRIBUNE

Dental Tribune Middle East & Africa Edition | 3/2018

◊Page D2

Fig 11

Fig 15

entity and the trick is to do the best
you can to maintain it as long as you
can.
8. Select the system that does not
change its product line every year.
9. There are no short cuts or faster
way to get success in life and implants are no different.
10. The success rates of implants are
inversely proportional to the number of years you practice implants.

Case Report

Fig 12

Fig 16

A 78 year old Caucasian female presented to my practice for rehabilitation and management of a failing
maxillary implant reconstruction.
She reported having some implants
27 years ago and it has been troubling her with symptoms of sinus
infections and movement of the
entire maxillary prosthesis (Fig
1). Radiograph revealed bone loss
around the unilateral subperiosteal
implants and the blade implants
in the anterior sextant (Fig 2). After
careful examination, it was decided
that none the maxillary implants
was salvageable. Treatment plan
was formulated to stage the case to
permit healing of the inflamed soft
tissue and resorbed bone.
The entire maxillary frame had to be
sectioned and removed piecemeal
(Fig 3, 4). An immediate denture
was fabricated and the tissues were
allowed to heal for a period of two
months. (Fig 5) A sterolithographic
model was created to assess the condition of the remaining bone (Fig 6).
A decision was made to reconstruct
the maxilla with bilateral sinus augmentation. The anterior sextant had
bone loss till the anterior nasal spine.
Six months following the augmentation, nine implants were placed in
the augmented bone (Fig 7). Stage II
surgery was performed after a healing period of 8 months. Impressions
were taken (Fig 8). A Universal modified abutment was utilized to bring
all of the platforms equi-gingival (Fig

Fig 14

Fig 17

9). A verification jig was utilized to
check for passivity and accuracy of
the positions of the abutments (Fig
10). The metal frame was indexed,
cast and tried in (Fig 11, 12). Face bow
transfer record was obtained for orientation relationship. (Fig 13) Porce-

Fig 18

lain overlay for an FP3 prosthesis was
processed and inserted (Fig 14, 15 ) A
mutually protected occlusal scheme
was designed (Fig 16). The patient’s
vertical was maintained. The post
op radiograph reveals a stable outcome. (Fig 17) The anterior cantile-

vered crowns provide for optimal
esthetics in the extremely resorbed
anterior maxilla. The post operative outcome provided an esthetic
and functional rehabilitation of the
failing implant FPD (Fig 18). The
provision of pontics enhanced the

outcome in the esthetic zone and in
this case it favored the design due to
the atrophy that precluded implant
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is not because they fail, but because
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Fig 13

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[61] => DTMEA_No.3. Vol.8_DT.indd

PUBLISHED IN DUBAI

May-June 2018 | No. 3, Vol. 8

www.dental-tribune.me

Digital Orthodontics Symposium
addresses progressive topics

SUBSCRIBE NOW
www.me.dental-tribune.com/e-paper/
issn 1868-3207

Vol. 2 • Issue 2/2017

ortho
international magazine of

orthodontics

2017

By Dental Tribune MEA / CAPPmea
DUBAI, UAE: CAPP (Centre for Advanced Professional Practices) held
its first Digital Orthodontics Symposium. The event evolved around digital orthodontics in present dentistry
and its importance for the future
of orthodontics. From 04-05 May,
around 122 orthodontists attended
the event, which was held at the famous Madinat Jumeirah Conference
Centre, Dubai.

Delegates during the scientific programme of the Digital Orthodontics Symposium

The event gathered Top Key opinion
Leaders from the dental field with
a focus on the latest trends and de-

velopments in digital orthodontics.
Digital dentistry can assist us in
many ways, by assessing space and
measuring the amount of crowding in cases, predicting treatment
outcomes, assisting patients’ communication but also storing models
digitally and treatment planning.
With the introduction of 3D Printing in dentistry, the opportunities in
orthodontics have expanded from
digital impression taking, to developing virtual treatment plans and
3D printing of dental models. The
Digital Orthodontics Symposium illustrated the necessity for orthodontists to look-into and highly consider
digitalizing their working ways to
save time, money and provide more
efficient and effective treatments for
the patients.
Kicking off the symposium’s scientific program, Dr Naif Almosa,
Assistant Professor at the Division
of Orthodontics, and Consultant in

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case report
Use of diode laser in the treatment of gingival
enlargement during orthodontic treatment

industry report
Sensorimotor training with RehaBite
during orthodontic treatment

Orthodontics welcomed warmly all
present orthodontists at the event
with his opening speech.
The symposium provided as exclusive opportunity to learn more
about relevant topics from the experts in orthodontics.
Keynote speaker, Dr Francesco
Garino from Italy focused on the
digital revolution with intraoral

ÿPage E2

OUR SPEAKERS

DR. SONIA PALLECK

DR. MATIAS ANGHILERI

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A new paradigm
in orthodontic
bracket bonding
By King’s College London

brackets at the end of the treatment.

Orthodontic treatment is widelyused in preventing and correcting
irregularities of the teeth and jaws,
by the use of braces. A novel method
in orthodontic bracket bonding, developed by the Deb group from the
Tissue Engineering & Biophotonics
Division at King’s College London,
could eliminate enamel damage.
This is a frequent occurrence on
debonding including white spot
lesion formation and chipping or
cracking of enamel during bracket
removal after orthodontic treatment.

An international patent has been
published on this know-how, which
is expected to provide a revolutionary leap in orthodontic bracket
bonding. The study was conducted
in the Deb laboratories by Ali Ibrahim, an orthodontist and a PhD student at the Dental Institute at King’s
with support from Professor Van
Thompson. Professor Sanjukta Deb
explained “Orthodontists will embrace the technique since there are
less clinical steps, no specialist training involved and in fact, due to no adhesive remnants left on enamel, this
will eliminate the need for enamel
polishing after bracket removal.”

Introducing the PER system in orthodontics, which embodies the basic
principles of the widely-used acidetch technique which is designed to
enable orthodontists to use metal
brackets, and which now addresses
the need to meet growing preference
for ceramic brackets that are clear
and provide an invisible appearance, which usually results in more
enamel damage on removal of the

King’s College London
London, United Kingdom
Tel.: +44 (0)20 7836 5454
W: www.kcl.ac.uk

[62] => DTMEA_No.3. Vol.8_DT.indd

ORTHO TRIBUNE

Dental Tribune Middle East & Africa Edition | 3/2018

◊Page E1
scanner and clinical applications of
intraoral scanners in orthodontics.
Another speaker Dr. Amar Benaddi
from France spoke about a New 3D
Concept in Vestibular Orthodontic
Treatment, Prof. Ross Hobson from
UK spoke about improving planning and predictability using digi-

tal workflows in ortho-restorative
cases. After the break the stage took
Dr Khaled Hazem Attia from Egypt
and his lecture “The Role of CBCT in
Evaluating Carriere® Motion Appliance”. The event was concluded by
Dr Jaswinder Gill from UK explaining how to increase case acceptance

with the digital workflow.
During the second day there were
four various tables where the handson trainings took place. The tables
operated simultaneously with a
rotation of several groups for each
table. The trainings were held in

Opening speech by Dr Naif Almosa during the scientific programme of the Digital Orthodontics Symposium

small groups (10 seats available per
session) in order to have the highest
impact. Outstanding orthodontists
presented various topics of a great
interest. The participants had an opportunity to interact immediately
and ask their personal questions.
The practical demonstrations, at the

same time, provided inspiration and
offer means of trouble shooting.
The next Digital Orthodontics Symposium will take place from 12-13
April 2019 in Madinat Jumeirah Conference Centre, Dubai.

Delegates during the scientific programme of the Digital Orthodontics Symposium

Dr. Francesco Garino from Italy during his lecture during the Digital
Orthodontics Symposium

Dr. Amar Benaddi from France during his lecture during the Digital
Orthodontics Symposium

Prof. Ross Hobson from UK during his lecture during the Digital Orthodontics Symposium

Dr Amar Benaddi from France representing Sinterex during his handson training the Digital Orthodontics Symposium

Dr. Khaled Hazem Attia from Egypt during his lecture during the Digital
Orthodontics Symposium

Dr. Jaswinder Gill from UK during his lecture during the Digital Orthodontics Symposium

Turgay Guelal from UAE representing invisalign during his hands-on
training the Digital Orthodontics Symposium

Dr. Jaswinder Gi from UK representing Carestream during his hands-on
training the Digital Orthodontics Symposium

Delegates practicing during his hands-on training the Digital Orthodontics Symposium

Dr. Khaled Hazem Attia from Egypt representing Henry Schein during
his hands-on training the Digital Orthodontics Symposium

Delegates during the scientific programme of the Digital Orthodontics
Symposium

Panel discussion during the scientific programme of the Digital Orthodontics Symposium

[63] => DTMEA_No.3. Vol.8_DT.indd

Dental Tribune Middle East & Africa Edition | 3/2018

ORTHO TRIBUNE

A retrospective study to evaluate the intra-arch dimensional changes in moderate crowding cases treated
non extraction with a passive self-ligation appliance
By Vishal Bharadwaj, Gurkeerat Singh, Sridhar Kannan, Raj Kumar Singh,
Ashish Gupta,5 Gaurav Gupta, and
Abhishek Goyal

Background
Irregularly placed front teeth is one
of the most frequently encountered
chief complaint in day to day orthodontic practice. The etiology for
which may be tooth size-arch length
deficiency (1-4). This condition can
be treated, either by reducing tooth
size and/or by increasing arch width
and/or arch depth (5-7). In other
words, Orthodontists can gain space
by expanding the arch anteroposteriorly or transversely along with
other conventional means, depending on the treatment plan.
Non-extraction treatment protocols
are better accepted by patients as
well as clinicians. Among the techniques and mechanics with the potential to facilitate nonextraction
treatment includes headgears, fixed
sagittal correctors, transverse expansion screws and selfligating systems.
Although each of these approaches
necessitates an increase in arch
length to facilitate alignment without extraction, it has been purported
that passive self-ligating brackets can
induce specific, uniquely stable arch
dimensional changes when used
with thermalloy archwires (8).

Self-ligating brackets (SLB) are not
new in orthodontics. They were introduced to the specialty nearly a
century ago, with the Russell Lock
(9) edgewise attachment being described in 1935. The Damon SL bracket (10) were introduced in 1996 and
have been modified over the years.
In the past two decades, there has
been an increase in the manufacturing and release of self-ligating brackets with active or passive ligation
modes. The basic advantage of these
brackets involves the elimination
of certain utilities or materials such
as elastomeric modules along with
the process or tools associated with
their application. This is supposed
to bring about several favorable features to the treatment including, the
elimination of potential crosscontamination with elastic ligatures,
consistently full engagement without the undesirable force relaxation
of elastomeric modules, reduced
risk for enamel decalcification from
the elimination of the retentive site
for plaque accumulation, reduced
friction in sliding mechanics, and
assumedlow-magnitude forces resulting in fewer side effects (11).

Objectives
The Objective was to retrospectively
evaluate the intraarch dimensional
changes in moderate crowding cases,
treated non-extraction with a passive self-ligating (Damon 3MX) appli-

Fig 1. Scanned Digital Image of Pretreatment and Post Treatment Archwidth of Maxillary Arch

Fig 2. Scanned Digital Image of Pretreatment and Post Treatment Arch Depth of Maxillary Arch

Fig 3. Scanned Digital Image of Pretreatment and Post Treatment Arch Width of
Mandibular Arch

Fig 3. Scanned Digital Image of Pretreatment and Post Treatment Arch Depth of
Mandibular Arch

ance by assessing the pre treatment
and post treatment digitized models
and lateral cephalograms.
The study was formulated as a double blind study.

Methods
A total of 20 patients between the
age group of 15 - 18 years who had undergone non extraction orthodontic
treatment with the Damon 3MX
(Ormco, San Diego, Calif) appliance
were selected. Patients with a full
complement of teeth up to erupted
second permanent molars with
moderate crowding in the maxillary
and/or mandibular arch, with skeletal Class I jaw base relation treated
with non-extraction treatment plan
were included in the study. Orthodontically retreated cases, congenital
absence of teeth, aberration in tooth
size/shape were excluded.
Only those pretreatment and post
treatment models and lateral cephalograms were selected for scanning
which met all the inclusion and

exclusion criteria as well whowere
treated according to the passive self
ligation philosophy as well with the
standard wire sequencing. The following arch wire sequencing were
used:
0.013” / 0.014” Copper Nickel-Titanium (Cu Ni-Ti) was in place for 2 - 4
months.
Followed by 0.016” x 0.016” Cu Ni-Ti
for a minimum period of 2 months
or a 0.014” x 0.025” Cu Ni-Ti for a
minimumperiod of 2 months
0.016” x 0.025” Cu Ni-Ti for minimum of 2 months
0.017” x 0.025” SS, 0.019” x 0.025”
Titanium Molybdenum alloy (TMA)
finishing wire for minimum period
of 2 months.
All the pre-treatment and post-treatment dental stone models of maxillary and mandibular arches were
scanned using 3D digital scanner
(Maestro 3D, Great lakes, USA) and
converted into digital models which
could be examined in all the 3 planes
of space.

Parameters undertaken for study
were measured digitally on the computer in millimeters which included
Intercanine width (C) of maxilla and
mandible, Inter-1st premolar width
(PM1) of maxilla and mandible,
Inter-2nd premolar width (PM2) of
maxilla and mandible, Inter-molar
width (M1) of maxilla and mandible,
Arch depth of maxilla and mandible,
Maxillary incisor inclination and
Mandibular incisor inclination (Figures 1 - 4).
Inter-canine width: Measurements
were made from the cusp tips of the
right and left canine.
Inter-first premolar width: Measurements were made between the
buccal cusp tips of right and left first
premolars.
Inter second premolar width: Measurements were made between the

ÿPage E4

[64] => DTMEA_No.3. Vol.8_DT.indd

ORTHO TRIBUNE

Dental Tribune Middle East & Africa Edition | 3/2018

Bharadwaj V et al.

◊Page E3
Table 1. Descriptive Statistics of Pre-Treatment and Post Treatment Arch Width and Arch Depth Values Are Shown (mm)a
Variable

Mean

Std. Deviation

Std. Error Mean

Mean Difference

T-Test Value

P Value

Pre treatment

32.97

1.27

0.29

-1.27

-4.194

0.001b

Post treatment

34.24

1.08

0.25

Pre treatment

24.10

2.25

0.52

-2.57

-4.404

< 0.001b

Post treatment

26.67

1.30

0.30

Pre treatment

39.29

1.73

0.40

-1.88

-3.980

0.001b

Post treatment

41.17

1.76

0.40

Pre treatment

31.87

1.12

0.26

-2.48

-6.705

< 0.001b

Post treatment

34.35

1.26

0.29

Pre treatment

43.88

2.03

0.47

-2.15

-3.645

0.002c

Post treatment

46.03

1.53

0.35

Pre treatment

37.11

2.48

0.57

-2.77

-3.687

0.002c

Post treatment

39.88

1.57

0.36

Pre treatment

48.29

2.90

0.67

-1.39

-2.599

0.018d

Post treatment

49.68

2.02

0.46

Pre treatment

42.86

1.60

0.37

-0.29

-0.804

0.432

Post treatment

43.15

1.54

0.35

1.25

4.029

0.001

-0.59

-1.268

0.221

ductions to attain good teeth alignment (14). In the absence of distalization, the changes in arch dimensions
involve transverse expansion and
increased proclination of teeth.

Maxillary Inter-canine width

Mandibular Intercanine width

Passive self-ligation treatment philosophy (10) is based on providing
optimum force levels for orthodontic tooth movement which should
be just high enough to stimulate cellular activity without completely occluding the blood vessels in the PDL.
Light continuous forces will produce
continuous, frontal resorption and
will not overpower the periodontal
and orofacial muscltature, and will
prevent proclination of anteriors
and causes more expansion in the
transverse direction. Photoelastic
modelshowed lower stress in periodontal tissue with self-ligating appliance as compared to conventional
bracket system (15).

Maxillary Inter 1st PM width

Mandibular Inter 1st PM width

Maxillary Inter 2nd PM width

Mandibular Inter 2nd PM width

Maxillary Inter molar width

Mandibular Inter molar width

Intra arch dimensional changes in
both maxillary and mandibular
arches in moderate crowding cases
treated non-extraction with a passive self ligation appliance (Damon
3MX) were analyzed using digitized
models and digital cephalograms.

Maxillary arch depth
Pre treatment

33.23

2.67

0.61

Post treatment

31.97

1.47

0.34

Pre treatment

30.43

3.06

0.70

Post treatment

31.03

1.82

0.42

Mandibular arch depth

P-value ≥ 0.05 Non-significant difference.
P-value < 0.001 - Very Highly Significant difference.
c
P-value < 0.01 - Highly Significant difference.
d
P-value < 0.05 Significant difference.
b

Bharadwaj V et al.

Table 1. Descriptive Statistics of Pre-Treatment and Post Treatment Arch Width and Arch Depth Values Are Shown (mm)a

(Table 1) similar to maxillary arch. Study also showed an
5.1. Conclusion
increase
in
the
mandibular
arch
depth
(Table
1).
Change
a
Study
showed
increase
inter-canine
width, inter 1st
Table 2. Descriptive Statistics of Pre-Treatment and Post Treatment Upper Incisor and Lower Incisor
Inclination
Values
Are Shown in
(Degrees)
nd
in inclination of lower incisors was evaluated using L1 to
premolar width, inter 2 premolar width and inter moN-B
(Angular) values, L1 to mandibular
and L1 Std.lar
Variables
Mean plane
Std.angle
Deviation
Error
Mean in both
Mean
Differenceand mandibular
T-Test Value
P Value
width
maxillary
arches,
with
U1
to
N-A
Angular
to occlusal plane angle (Table 2). Results showed increase
more expansion in premolar area. Arch depth was found
in proclination
Pre treatmentwhich was statistically
24.56 significant.
6.62 Insuffi1.52 decreased in upper
-2.79 arch it was found
-5.524 to be increased
< 0.001***
to be
Post treatment
5.58cause of
cient interproximal
reduction can27.35
be one of the
in 1.28
lower arch however the passive self-ligation appliance
U1
to
Palatal
plane
angle
increased proclination of lower anteriors and increase in
can be used as a valuable tool because it minimizes the
Pre treatment
6.99
1.60
-3.74
-6.853
< 0.001***
arch depth
in mandibular arch. 112.16
proclination
which could
have been produced
during
unPost treatment

115.89

5.12

U1 to SN plane angle

Results of the study also showed more increase in the
Pre treatment
113.74
6.82
mandibular intercanine and interpremolar widths as comPost treatment
116.74
5.03
pared
to the inter molar width with increase in arch depth
L1 to N-B (Angular)
and increase in proclination. Previous studies showed
Pre treatment
24.27
2.71
transverse
expansion and incisor 28.85
proclination, 1.63
and more
Post treatment
expansion
in the
inter
molar region (11, 18).
L1 to Mandibular
plane
angle

1.17

raveling of crowding in both the arches without the space
which have been gained with passive self ligation appli1.56
-3.00
-5.266
< 0.001***
ance by posterior expansion.
1.15

5.2. Limitations of Study
0.64

-4.58

-9.320

< 0.001***

-4.28

-6.898

< 0.001***

Present study had the limitations of small sample size
0.38
of twenty patients and retrospective in nature. As ret-

Pre treatment

96.13

3.43

0.81

Post treatment

100.42

1.69

0.40

Pre treatment

8.05

3.41

0.80

Post treatment

12.72

1.42

0.34

Iran J Ortho. 2018; 13(1):e8324.

L1 to Occlusal plane angle

-4.67

-6.477

< 0.001***

P-value ≥ 0.05 Non-significant difference, P-value < 0.05 Significant* difference, P-value < 0.01 - Highly Significant** difference, P-value < 0.001 - Very Highly Significant*** difference.

conventional brackets in the permanent dentition: a mulrospective
studies
are always
subject to various
of Upperand
Table
2. Descriptive
Statistics
of Pre-Treatment
and Posttypes
Treatment
Incisor
and Lower Incisor Inclination Values Are Shown
ticenter, randomized controlled trial. Am J Orthod Dentofacial Ora
bias
because
of
the
lack
of
randomization.
Hence,
the
re(Degrees)
thop. 2013;144(2):185–93. doi: 10.1016/j.ajodo.2013.03.012. [PubMed:

sults obtained from the current study should be further
strengthened using a larger sample size and preferably using a prospective study model.

23910199].
9. Stolzenberg J. The Russell attachment and its improved advantages.
Int J Orthod Dent Dent Child. 1935;21(9):837–40. doi: 10.1016/s00970522(35)90368-9.
10.intersection
Damon DH. Theof
Damon
low-friction
bracket:
a biologically
compatbuccal cusp tips of right and left sec- angle formed by the
tained
from
a same
group or
a pair
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ible straight-wire system. J Clin Orthod. 1998;32(11):670–80. [PubMed:
ond premolars.
the long axis of the upper
central in- of values obtained from the same
10388398].
1. Brunelle JA, Bhat M, Lipton JA. Prevalence and distribution
of selected
cisors and
the line joining
the
nasion
sample.A, Eliades T. Self-ligating vs con11. Pandis N,
Polychronopoulou
occlusal characteristics in the US population, 1988-1991. J Dent Res.
ventional
brackets
in
the treatment of mandibular crowding:
Inter1996;75
firstSpec
molar
width: Measure- to point A.
No:706–13. doi: 10.1177/002203459607502S10. [PubMed:
a
prospective
clinical
trial P-value
of treatment
dental
ments
were made between the meThe
wasduration
taken and
significant
8594094].
effects. Am J Orthod Dentofacial Orthop. 2007;132(2):208–15. doi:
2. Infante cusp
PF. Antips
epidemiologic
study
molar resio-buccal
of right and
leftof deciduous
L1 to Mandibular
plane
angle: It is when less than 0.05 (P < 0.05) and
10.1016/j.ajodo.2006.01.030. [PubMed: 17693371].
lations
in
preschool
children.
J
Dent
Res.
1975;54(4):723–7.
doi:
first molars.
the angle formed by12.theFleming
intersection
interval
of 95%
was takPS, DiBiase AT,Confidence
Lee RT. Self-ligating
appliances:
evolution
or
10.1177/00220345750540040501. [PubMed: 1057556].
revolution?.
J Clin Orthod.
2008;42(11):641–51. [PubMed: 19075378].
of
the
long
axis
of
the
lower
incisor
en.
3. Kerosuo H. Occlusion in the primary and early mixed dentitions
13. Rinchuse DJ, Miles PG. Self-ligating brackets: present and fuwith
mandibular
plane. It indiin a group
of Tanzanian and Finnish children.
ASDCthe
J Dent
Child.
3.1. Arch
Depth
ture. Am J Orthod Dentofacial Orthop. 2007;132(2):216–22. doi:
1990;57(4):293–8. [PubMed: 2373787].
cates
the
inclination
of the lower The [PubMed:
following
results were obtained
10.1016/j.ajodo.2006.06.018.
17693372].
First
line
is
drawn
connecting
the
4. Gabris K, Marton S, Madlena M. Prevalence of malocclusions
incisors.
after
the
statistical
analysis:
14. Weinberg M, Sadowsky C. Resolution of mandibular
arch crowding in
central
fossa ofadolescents.
first molars
the 2006;28(5):467–70. doi:
in Hungarian
Eur on
J Orthod.
growing patients with Class I malocclusions treated nonextraction.
[PubMed:
16923783].line
right10.1093/ejo/cjl027.
and left sides.
A second
Am J Orthod Dentofacial Orthop. 1996;110(4):359–64. doi: 10.1016/S0889L1 to orthodontics.
Occlusal plane angle:
It is the
5. Damon
Treatment of the to
facethe
with
biocompatible
was
drawnD.perpendicular
first,
5406(96)70035-5. [PubMed: 8876484].
In: Graber TM, Vanarsdall Jr RL, Vig KWL, editors.inferior
Orthodontics:
current
inside angle15.formed
byVedovello
the Filho M, Degan VV, Santamaria MJ. PhotoelasSobral GC,
bisecting
the contact point between
Self ligation appliances regained
principles and techniques. 4th ed. Philadelphia: Elsevier; 2005. p. 753–
intersection
of
the
long
axis
of
the
tic
analysis
of
stress generated by wires when conventional and
the central
incisors.
831.
popularity
the Press
early
nineself-ligating
brackets are
used: a pilotsince
study. Dental
J Orthod.
lower incisor
with the occlusal
plane.
6. Yu YL, Tang GH, Gong FF, Chen LL, Qian YF. [A comparison
of rapid
ties
because
of
the
certain
advan2014;19(5):74–8. doi: 10.1590/2176-9451.19.5.074-078.oar. [PubMed:
This angle correcis read as a positive
or negpalatal expansion
and Damon
appliance
Cephalometric
tracings
were
per-on non-extraction
25715719].
tages which were claimed such as:
tion of dental crowding]. Shanghai Kou Qiang Yi Xue.
2008;17(3):237–42.
ative
deviation
from
the
right
angle.
16. Maltagliati
LA, Myiahira YI, Fattori L, Filho LC, Cardoso M. Transverformed
using digital cephalometrics
increased patient comfort, better
[PubMed: 18661061].
L1 to N-B (Angular): Itsalischanges
the angle
in dental arches from non-extraction treatment with
(Nemo
Ceph,
6.0, WP.
Spain).
Pre- controlled
7. McNally
MR,version
Spary DJ, Rock
A randomized
trial comhygiene,
increased
patientdoi:coself ligating brackets.oral
Dental
Press J Orthod.
2013;18(3):39–45.
formed
by the
paring the
quadhelix
and the expansion
the correction
of intersection of the
treatment
and
post-treatment
read-arch for
operation,[PubMed:
less chair
time, shorter
10.1590/S2176-94512013000300008.
24094010].
long axis of the lower
central inci2005;32(1):29–35.
doi: 10.1179/146531205225020769.
ingscrossbite.
of eachJ Orthod.
patient
were evaluated
17. Lineberger MB, Franchitreatment
L, Cevidanes LH,
Huanca
Ghislanzoni
LT, Mctime,
greater
patient
ac[PubMed: 15784941].
sorsandthe line joiningNamara
the nasion
to
JJ. Three-dimensional
digital cast analysis of the effects profrom
the software
and
pre treatment
8. Fleming
PS, Lee RT,
Marinho
V, Johal A. Comparison of maxil-

Discussion

point
arch
dimensional
changes with passive and
activeB.
self-ligation
andlary
post
treatment
superimposition
was also carried out.
6

Results

3.2. Upper Incisor Inclination
U1 to SN plane angle: It is the inferior inside angle formed between
the long axis of the upper incisor
and Sella-nasion plane. U1 to Palatal
plane angle: It is the inferior inside
angle formed between the long axis
of the upper incisors and palatal
plane (formed by line joining the anterior nasal spine and posterior nasal
spine) U1 to N-A (Angular):- It is the

All the pretreatment and post treatment measurement of scanned digital models and the measurement
obtained from the scanned cephalograms were subjected to statistical
analysis using software SPSS (statistical package for social sciences) version 21.0 and Epi-info version 3.0 and
Paired t-test was applied to see the
statistical significance - It was used
for comparison of 2 mean values ob-

ceptance, expansion, and less dental
extractions (10, 12, 13). Self ligation
appliances achieved significant
J Ortho. 2018;
13(1):e8324.
amountIran
of expansion
with
no apical
root resorption and with increase in
buccal bone thickness. Self ligation
appliance also offer precise control
of tooth during translation, reduce
overall anchorage demands, rapid
alignment and more certain space
closure.
Alleviating dental crowding without
extractions requires an increase in
arch perimeter or interproximal re-

This study showed an increase in
maxillary intercanine width, inter 1st
premolar width, inter 2nd premolar
width and inter molar arch width
(Table 1). More transverse expansion
was observed in the region of 1st and
2nd premolars as compared to the
inter-canine and inter molar region.
More expansion in the premolars
region can be because of lip bumper
effect which minimizes the proclination of anterior teeth and allow more
expansion in posterior region. Previous study also showed majority of
transverse changes in the premolar
areas in both upper and lower arches, with less expansion in the canine
and molar region (16, 17).
While assessing maxillary arch
depth, the study showed (Table 1) a
decrease in arch depth which can
be because of more of transverse
expansion, which created space and
helped in unraveling of crowding in
upper anteriors and less proclination. Overlapping because of crowding in anteriors was reduced with
minimal proclination.
Because of lateral expansion and
derotation in posterior segment,
some amount of mesial movement
of molars could also have occurred,
to improve molar relation.
The inclination of upper incisors was
evaluated using U1 to N-A (Angular),
U1 to palatal plane angle and U1 to SN
plane angle (Table 2). Results showed
an increase in proclination which
was statistically significant. Similar
studies done in past also showed significant amount of arch expansion
in the maxillary arch (8).
In the mandibular arch also an increase in mandibular intercanine
width, inter 1st premolar width, inter
2nd premolar width and inter molar arch width was observed (Table
1) similar to maxillary arch. Study
also showed an increase in the mandibular arch depth (Table 1). Change
in inclination of lower incisors was
evaluated using L1 to N-B (Angular)
values, L1 to mandibular plane angle
and L1 to occlusal plane angle (Table
2). Results showed increase in proclination which was statistically significant. Insufficient interproximal
reduction can be one of the cause of
increased proclination of lower anteriors and increase in arch depth in
mandibular arch.
Results of the study also showed
more increase in the mandibular
intercanineandinterpremolar
widths as compared to the inter
molar width with increase in arch

depth and increase in proclination.
Previous studies showed transverse
expansion and incisor proclination,
and more expansion in the inter molar region (11, 18).
5.1. Conclusion
Study showed increase in intercanine width, inter 1st premolar
width, inter 2nd premolar width and
inter molar width in both maxillary
and mandibular arches, with more
expansion in premolar area. Arch
depth was found to be decreased
in upper arch it was found to be increased in lower arch however the
passive self-ligation appliance can
be used as a valuable tool because it
minimizes the proclination which
could have been produced during
unraveling of crowding in both the
arches without the space which have
been gained with passive self ligation
appliance by posterior expansion.
5.2. Limitations of Study
Present study had the limitations of
small sample size of twenty patients
and retrospective in nature. As retrospective studies are always subject to
various types of bias because of the
lack of randomization. Hence, the
results obtained from the current
study should be further strengthened using a larger sample size and
preferably using a prospective study
model.

References
1. Brunelle JA, Bhat M, Lipton JA.
Prevalence and distribution of selected occlusal characteristics in the
US population, 1988-1991. J Dent
Res. 1996;75 Spec No:706–13. doi:
10.1177/002203459607502S10. [PubMed: 8594094].
2. Infante PF. An epidemiologic
study of deciduous molar relations in preschool children. J
Dent Res. 1975;54(4):723–7. doi:
10.1177/00220345750540040501.
[PubMed: 1057556].
3. Kerosuo H. Occlusion in the primary and early mixed dentitions
in a group of Tanzanian and Finnish children. ASDC J Dent Child.
1990;57(4):293–8. [PubMed: 2373787].
4. Gabris K, Marton S, Madlena M.
Prevalence of malocclusions in Hungarian adolescents. Eur J Orthod.
2006;28(5):467–70. doi: 10.1093/ejo/
cjl027. [PubMed: 16923783].
5. Damon D. Treatment of the face
with biocompatible orthodontics. In:
Graber TM, Vanarsdall Jr RL, Vig KWL,
editors. Orthodontics: current principles and techniques. 4th ed. Philadelphia: Elsevier; 2005. p. 753– 831.
6. Yu YL, Tang GH, Gong FF, Chen LL,
Qian YF. [A comparison of rapid palatal expansion and Damon appliance
on non-extraction correction of dental crowding]. Shanghai Kou Qiang
Yi Xue. 2008;17(3):237–42. [PubMed:
18661061].
7. McNally MR, Spary DJ, Rock WP. A
randomized controlled trial comparing the quadhelix and the expansion arch for the correction of crossbite. J Orthod. 2005;32(1):29–35. doi:
10.1179/146531205225020769. [PubMed: 15784941].
8. Fleming PS, Lee RT, Marinho V,
Johal A. Comparison of maxillary
arch dimensional changes with
passive and active self-ligation and
conventional brackets in the permanent dentition: a multicenter, randomized controlled trial. Am J Orthod
Dentofacial Orthop. 2013;144(2):185–
93. doi: 10.1016/j.ajodo.2013.03.012.
[PubMed: 23910199].
9. Stolzenberg J. The Russell attachment and its improved advantages. Int J Orthod Dent Dent Child.
1935;21(9):837–40. doi: 10.1016/
s0097-0522(35)90368-9.
Editorial note: The full references list is
available from the publisher.

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