DT Middle East & Africa No. 4, 2018

Lasers in Dentistry Mastership - Programme Group 6 Registration Opens / 10th anniversary of the Dental Facial Cosmetic Conference & Exhibition / Anterior challenge: obtain high esthetics with two different restoration materials and cements / Industry News / When design and funstion come together...your get FUSION! / Treatment planning: Retention of the natural dentition and the replacement of missing teeth / Bioactive materials support proactive dental care / Gold standard for chairside restorations / SDR® Plus – The Ideal Bulk-Fill Material in High-C Factor Cavities / The Rivelin patch sticks to the mucosal surface for much longer than any other treatment / When art and science meet the digital world / Substitution of two destructive caries with ceramic CAD/CAM crowns in one visit / Capturing the right image / Award winning poster presentations / Why the best dentists never stop learning / Diploma programme that made everyone stronger and ready for the Endodontic world / King’s College London trains a second cohort of master’s students in Dubai, and will continue in 2019 / Top 100 Scientific Reports article for King's College London Dental Institute / Dental Program / Poster Presentation / Distributors / Endo Tribune Middle East & Africa Edition No. 4, 2018 / Lab Tribune Middle East & Africa Edition No. 4, 2018 / Hygiene Tribune Middle East & Africa Edition No. 4, 2018 / Implant Tribune Middle East & Africa Edition No. 4, 2018 / Ortho Tribune Middle East & Africa Edition No. 4, 2018

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www.dental-tribune.me

Published in Dubai

July-August 2018 | No. 4, Vol. 8

ENDO TRIBUNE

LAB TRIBUNE

HYGIENE TRIBUNE

IMPLANT TRIBUNE

ORTHO TRIBUNE

“He brought a world of
enthusiasm and knowledge to
the global endodontic..."

Making a perfect ceramic crown
on a titanium abutment in
the esthetic zone

Interview with Maha Yakob:
“Up to ten times more plaque
removal”

Neoss ScanPeg - simplified
intra-oral scanning

Ormco Unveils SymetriTM Clear
ceramic twin bracket system

ÿA1-8

ÿB1-4

ÿC1-4

ÿD1-4

ÿE1-4

Lasers in Dentistry Mastership
Programme Group 6 Registration Opens

DENTAL TRIBUNE

Aachen Dental Laser Center (AALZ) and RWTH International Academy - RWTH Aachen University announced
new partnership with CAPP
inWorld’s
Dubai, UAE
for Newspaper
the Lasers inMiddle
Dentistry
Mastership
Programme.
The
Dental
East
& Africa Edition
By Dental Tribune MEA / CAPPmea
DUBAI, UAE: The RWTH Aachen
University is one of the leading universities of Germany and Europe,
awarded as University of Excellence. The Aachen Dental Laser Centre – AALZ GmbH - is the worldwide
operating independent leading
dental laser institution under the
umbrella of the university campus.
In cooperation with the Clinic for
Dental Conservation, Periodontology and Preventive Dentistry at
the University of Excellence RWTH
Aachen, the Aachen Center for Laser Dentistry (AALZ) has created the
first dental laser education institute
in Germany. Known for its research
in laser-assisted dentistry, it cooperates nationally and internationally with major research facilities.
CAPP has been recently named
an exclusive partner of AALZ and
RWTH Aachen University in Dubai,
UAE and will be conducting the Lasers in Dentistry Mastership programme in Dubai starting on 21
November 2018 (Group 6)
The use of lasers is associated with
minimal contact, reduced vibration
and pain, as well as a reduction in
bleeding, leading to a more comfortable overall experience for the
patient. Lasers are highly versatile
tools that can be successfully used
in a wide range of applications in
the treatment of mucous membranes, hard tooth structures and
bones.
Additionally, the specific properties of lasers allow the development
of radically new treatments and
surgical techniques, and improvements in treatment success rates
have been observed when lasers are
applied. Modern facilities and increased customer satisfaction help
ensure the long-term financial success of any dental practice and, for
these reasons, dentists take the opportunity to expand and improve
their range of treatments. Lasers
are primarily used in the following
fields: Diagnosis, Cariology, Endodontics, Implantology, Surgery, Periodontology, Cosmetic treatments.
CAPP, Aachen Dental Laser Center
(AALZ) and RWTH International
Academy - RWTH Aachen University have launched Lasers in Den-

tistry Mastership programme in
Dubai, UAE. In the UAE, five groups
have already completed successfully the Mastership programme and a
few dozen groups in over 10 international countries. Group 6 will be
starting on 21 November 2018.
The course is divided into 3 modules requiring 12 days of attendance over a one year period and
upon completion it offers the
participants a chance to obtain a
Mastership Certificate (Certification course), recognising them as
a specialist in laser therapy in dentistry RWTH International Academy - RWTH Aachen University, the
post-graduate education wing of
the University. Module 1 includes
a Laser Safety Ofﬁcer course that
will allow the Participants to obtain
a Laser Safety Officer certification:
Laser construction, function and
handling.
When a delegate successfully completes the 3 Modules of the Lasers in
Dentistry Mastership programme,
she/he can continue to the “Master
of Science in Lasers in Dentistry"
from RWTH Aachen University (optional only). The delegate will be exempt from 2 out of the 10 modules
of the Master in Aachen as these
modules would be completed during the Lasers in Dentistry Mastership programme already.

More information about the programme could be found on the following link: www.cappmea.com/
laser

CAPP EVENTS
Tel: +971 4 347 6747
Mob: +971 52 8423659
E-mail: p.mollov@cappmea.com
Web: www.cappmea.com/laser

[2] =>

IMPRINT

news

Publisher/President/
Chief Executive Officer
Torsten R. Oemus

10 anniversary of the Dental Facial
Cosmetic Conference & Exhibition
th

By Dental Tribune MEA / CAPPmea
DUBAI, UAE: The 2018 Dental Facial
Cosmetic Conference & Exhibition
will be celebrating its 10th Anniversary this year. It has been incredible to experience the growth of this
conference over the past decade, to
review progress and challenges in
cosmetic dentistry.
The term “cosmetic dentistry” was

invented in the 1990s, but it actually dates back to the ancient times.
We all know that the people used
wooden sticks to clean their teeth
for beauty and not for health in early
3000 BC.
Ten years together – one decade,
learning through experience and
exchange, our dental communities
come together to contribute on the
evolution of cosmetic dentistry and

development of the field. Thanks to
the modern technologies and fast
growing evolving of the materials
and techniques; cosmetic treatment
from teeth whitening, laser procedures, composite fillings, dental
bonding to veneers and dental implants, cosmetic dentistry is defining
a new epoch.
And we are very proud to be part of
this progress for the last decade and

to contribute with high-quality education.
Hope to welcome you all at the event.

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

Chief Financial Officer
Dan Wunderlich
DIRECTOR OF CONTENT
Claudia Duschek
SENIOR editor
Yvonne Bachmann
Clinical EditorS
Nathalie Schüller
Magda Wojtkiewicz
Editor & social media manager
Monique MEHLER
EditorS
Brendan Day
Kasper Mussche
Junior EditorS
Franziska Beier
Luke Gribble
Copy Editor
Ann-Katrin Paulick
Sabrina Raaff
Chief technology Officer
Serban Veres
Junior Business Development &
MARKETING Manager
Alyson Buchenau
DIGITAL PRODUCTION MANAGER
Tom Carvalho
Junior DIGITAL PRODUCTION MANAGER
Hannes Kuschick
PROJECT MANAGER ONLINE
Chao Tong
IT & DEVELOPMENT
Serban Veres
GRAPHIC DESIGNER
Maria Macedo
e-learning MANAGER
Lars Hoffmann
PRODUCT MANAGER CME
Sarah Schubert
PRODUCT MANAGER SURGICAL TRIBUNE
& DDS. WORLD
Joachim Tabler
SALES & PRODUCTION SUPPORT
Nicole Andrä
Puja Daya
Madleen Zoch
Accounting
Karen Hamatschek
Manuela Hunger
DATABASE MANAGEMENT & CRM
Annachiara Sorbo
Media Sales Managers
Antje Kahnt (International)
Melissa Brown (International)
Hélène Carpentier (Europe)
Matthias Diessner (Key Accounts)
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
PRINTING HOUSE & DISTRIBUTION
Al Nisr Printing
P. O. Box 6519, Dubai, UAE
800 4585/04-4067170
©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] =>

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] =>

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 4/2018

Anterior challenge: obtain high esthetics with
two different restoration materials and cements
A case study by Dr. Carlos Eduardo Sabrosa, DDS, MSD, DScD featuring 3M™ RelyX™ Veneer Cement and 3M™ RelyX™
Unicem Aplicap™ Self-Adhesive Resin Cement

Fig. 1: Younger male patient with failing composite
fillings on central well as right lateral incisors. Also in
need of a crown on left lateral incisor. Agreement to
make three veneers in addition to the crown to improve his aesthetics and cover the defects.

Fig. 2: Situation after tooth preparation.

Fig. 3: The placement of two retraction cords per
tooth to open up sulcus well for impression taking.

Fig. 4: Application of 3M™ Impregum™ L DuoSoft™
Polyether Light Body Impression material keeping tip
well immersed.

Fig. 5: Making the temporary restoration with 3M™
Protemp™ 4 Temporization Material and a silicone
matrix.

Fig. 6: Finished temporary restoration.

Fig. 7: Temporary in the mouth.

Fig. 8: Fabrication of the final restorations in the laboratory: three Lithium disilicate veneers and a zirconia
crown.

Fig. 9: Try in of the restorations with 3M™ RelyX™ TryIn Paste to determine the optimal cement shade.

Fig. 10: Aspect after try in.

Fig. 11: Pretreatment of the bonding surface of the
zirconia crown with aluminum oxide (maximum 2
bar and a grain-size of 30 or 50 μm).

Fig. 12: After etching with hydrofluoric acid the veneers are silanised with 3M™ Single Bond Universal
Adhesive, rubbing it in for 20 seconds and then air
thinning it gently until no more ripples are observed.

Fig. 13: Prior to cementing the crown the tooth preparation is mechanically cleaned with pumice paste,
rinsed and gently dried to leave the surface slightly
moist and shiny.

Fig. 14: 3M™ RelyX™ Unicem Aplicap™ Self-Adhesive
Resin Cement is directly applied into the previously
sandblasted zirconia crown.

Fig. 15: The crown is firmly seated under finger pressure and the excess removed with a scaler after a 1-2
second tack cure. Final cure for 20 seconds per surface.
Finish and polish as needed.

Fig. 16: The veneer preparations are etched with
phosphoric acid.

Fig. 17: Apply 3M™ Single Bond Universal Adhesive
and rub it in for 20 seconds.

Fig. 18: 3M™ RelyX™ Veneer cement is applied into
each of the pretreated veneers.

Fig. 19: Each veneer is carefully placed under slight
pressure to extrude the excess. A 20 second spot light
cure away from the margin is recommended to ensure a stabilized restoration in place prior to cleaning up the excess. Final cure for 30 seconds from all
surfaces.

Fig. 20: Final restorations in place.

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.

Fig. 21: Lateral view of a happy patient.

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.
3M, Aplicap, DuoSoft, Impregum, Protemp, RelyX and Scotchbond 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.

[5] =>

[6] =>

INDUSTRY

Dental Tribune Middle East & Africa Edition | 4/2018

3Shape releases the newest version
of its CAD/CAM software
By 3shape
COPENHAGEN, Denmark: Well
known for its quality products and
a global leader in 3-D scanners and
dental software solutions, 3Shape
has recently released the newest version of its CAD/CAM software for
dental laboratories, Dental System
2018. The new system now has increased flexibility and functionality,
making scanning, design and production workflows more efficient
and dependable for dental technicians.

The increased flexibility of Dental System 2018 gives technicians
the ability to combine many types
of scans, as well as save and access designs during any step in the
workflow. According to 3Shape, this
makes the design of cases, especially
complicated indications, simpler,
more efficient and more predictable.
During development of the latest
version of its CAD/CAM software,
3Shape worked closely with dental
technicians, and the company said
it has been able to make significant

gains in all the right areas. “Dental
System 2018 is a great leap forward.
It opens new possibilities and brings
us the much-needed freedom to import, export and align scans freely.
The solution’s stability has been
improved and the workflows are
optimised. I love it!” said Przemek
Seweryniak, CEO of Cosmodent laboratory in Sweden.
The Danish company boasts an open
ecosystem, offering a range of treatment workflows, integrated libraries,
design service partnerships and in-

terfaces to virtually all manufacturing equipment and materials. With
over 80 sleeve and implant libraries,
integrated mills, 3-D printers and
materials, laboratories can take advantage of open digital dentistry to
serve the needs of their dentists and
patients.
“This new 3Shape Dental System version received exceptionally positive
feedback from the dental technicians taking part in the beta testing.
Higher reliability and solid improvements have made Dental System

2018 a fantastic release! I really look
forward to our users across the world
benefitting from the new version,”
said Rune Fisker, Vice President of
Dental Lab at 3Shape.

For more information or to request a
demo, please contact your local 3shape
representative.

Beautifil II LS
By SHOFU
Beautifil II LS breaks new ground
in direct resin technology with its
extremely low polymerization
shrinkage and related stress while
exhibiting superior aesthetics, optimal mechanical properties, ease of
handling and polish, lasting natural
lustre and remarkable abrasion resistance for universal application.

A novel low shrinkage “SRS” monomer formulation and unique filler
technology significantly minimizes
polymerization shrinkage stress
while resulting in a more durable,
robust and stable polymer complex
that offers greater predictability to
your restorations. Tooth-like optical
characteristics enable an easy shade
match for a wide spectrum of sim-

ple to complex, challenging cases.
Beautifil II LS exhibits additional
anti-plaque benefits and sustained
fluoride protection to all your restorations. A rational selection of
universal, opaceous dentin, bleach
white and enamel shades allow you
to explore a plethora of possibilities
ranging from simple to complex
polychromatic restorations.

Cara Print 4.0
The new 3D printer from Kulzer.
Quick, precise, economical: The perfect fit.
Accelerated precision for perfect polymer restorations

By Kulzer

Quick & Easy
Thanks to a user-friendly interface,
both beginners and those experienced in CAD/CAM can benefit from
the high average production speed
of cara Print 4.0.
- One hour or less to print most restorations
- Simultaneous printing of multiple
restorations with no time increase
- Digital Light Projection (DLP) generates each layer in a single flash

Precise & accurate
cara Print 4.0 results in smoother,
more homogeneous surfaces than
competing 3D printers. The exceptional precision in the z-axis and the
finely tuned parameters for each
material mean that dental technicians can position restorations in
almost any direction – and always
achieve the perfect fit.

- Long-lasting resin tray, rather than
disposable
- Refill system rather than cartridges
that require care in cleaning

Universal solution for all polymer restorations
Due to the size of the material tray
and exceptional 3D accuracy, cara
Print 4.0 can be used for the production of all polymer-based dental appliances.

Overview of applications
dima Print materials will be available
soon for further indications, including:
- Temporary prosthetic restorations
- Permanent prosthetic restorations
(e.g. crowns & bridges)
- Denture bases

cara Print 4.0
dima Print materials: fine-tuned 3D printing resins
Kulzer combined its longstanding materials expertise with deep knowledge of 3D printing to create dima Print materials.
The materials and 3D printing process are perfectly matched to ensure the best results.
Kulzer has one of the best reputations in the industry for high-quality materials. Technicians and dentists know: if it says
Kulzer, it’s going to work. All Kulzer materials are based on decades of research – including those specifically designed
for the modern digital workflow.
dima Print materials are light-curing monomeric liquids specially optimized for 3D printing and the requirements of
dental applications. When used together with cara Print 4.0 and the HiLite Power 3D post-curing unit, technicians
benefit from a comprehensive 3D-printing system designed for speed, reliability and value for money.

Overview of applications:

Economical
The in-house manufacturing process
with cara Print 4.0 reduces costs and
production time for many applications when compared to analogue
methods, milling and other 3D printers.
- Additive process means minimal
waste compared to milling

Aboubakr Eliwa
Area Manager Middle East
Tel: + 97 (1) 4 294 35 62 (Office)
Fax: + 97 (1) 4 294 35 63
Mob: +97 (1) 56506 89 76
E-mail: aboubakr.eliwa@kulzer-dental.com
Web: www.kulzer.com

A night guard,
made with
dima Print Ortho

An individual impression tray, made with
dima Print Impression

A surgical drill guide,
made with
dima Print Guide

dima Print materials will be available soon for further indications, including:
■ Temporary prosthetic restorations
■ Permanent prosthetic restorations (e.g. crowns & bridges)
■ Denture bases

A dental model,
made with
dima Print Model

A CAD-to-cast structure,
made with
dima Print Cast

[7] =>

MyCrown

[8] =>

INDUSTRY

Dental Tribune Middle East & Africa Edition | 4/2018

When design and function come together...
you get FUSION!
By SWAN

Tight contacts – guaranteed!

Ideal anatomy!

Simplified technique!

Superior tooth separation force
through advanced engineering and
material selection guarantees perfect contacts every time.

Soft-Face™ silicone ring tips with
enhanced marginal ridge anatomy
hug the pre-contoured dead-soft
matrices to the tooth for flash free,
perfectly contoured restorations.

Composi-Tight® 3D Fusion™ is
packed with features like easy ring
stacking, over-thewedge placement
and Ultra- Grip™ anti-ring slip extensions that make system use intuitive
and frustration free.

Only a sectional matrix can
deliver results like this!

Only Composi-Tight® 3D Fusion™
can make the technique this
intuitive and frustration free!

Tofflemire-style System
1 Place the matrix band:

Fails to restore proximal anatomy

Dead-soft three
dimensionally contoured
matrices have placement tabs
for easier occlusal placement
and Garrison’s revolutionary
non-stick coating for hasslefree removal.

Thin contact at the marginal ridge
Large food trap below
Increased likelihood of fracture, occlusal interference,
recurrent caries and periodontal disease

™

All three of Composi-Tight®
3D Fusion’s separator
rings will fit right over the
wedge for easier placement.
With Ultra-Grip™ retention
extensions, they will stay
firmly in place from the distal
of the canine to the widest of
molar preparations.

Operator-friendly retaining system
Naturally contoured bands
Anatomically correct contacts
Contacts at the height of contour
Rings produce optimal tooth separation
for excellent, tight contacts

Composi-Tight®
3D Fusion™
forceps for
precise
control
Composi-Tight 3D Fusion
includes dentistry’s premier
drop-forged ring placement
forceps. Regardless of
your hand size or strength,
Composi-Tight® 3D Fusion™
forceps will give you
incredible control for the
precise placement of superstrong separator rings over
even the widest molars.
®

™

Stack it up – Tru-Stack™
technology allows placement
of the orange ring (tall) over the
blue ring (short) for easier MOD
and multiple tooth restorations

It just keeps going…
Enhanced durability for
extended ring life and
greater tooth separation

Fins with serious function
Soft retentive fins smoothly
fold down during wedge
insertion and then spring
back when clear of the
interproximal space. Wedge
back-out is a thing of the past.

About SWAN
Guided by over 6 years of experience in the medical sales and marketing industry in the MENA region, with a main focus on the GCC region,
SWAN is the partner of the choice for all partners who aim to provide a
novel, high quality and innovative medical solution in the region.

Ergonomic for the masses –
Whether your hands are big
or small, Composi-Tight®
3D Fusion™ forceps give you
the leverage you need for
precise ring placement.

Established in Dubai in 2016, SWAN strives to successfully provide access
to an innovative medical solution and improve health and quality of life
of patients across the region. Our current main focus is Dentistry. We at
SWAN aim to be one of the largest distributors of dental merchandise
and technology leaders for dental practices in the GCC region.
Long-term investment –
Drop-forged stainless steel
prevents leverage-robbing
flexion and makes these
forceps incredibly durable.

A real softie Composi-Tight®
3D Fusion’s Soft-Face™ overmold allows the wedge to
do what no other wedge can
truly do – actually adapt to
interproximal irregularities.

Ultra Adaptive Wedges
Combining Soft-Face™ adaptive
materials, a firm inner core and advanced
mechanical features to produce a
wedge that truly works. Every time.
Dentistry’s first Wide Preparation separator
ring (green) makes Composi-Tight® 3D Fusion™
the most versatile and user-friendly sectional
matrix system available. The Wide Prep ring
greatly simplifies what until now has been one
of the most challenging posterior composite
restorations. Now you can restore these big
preps with confidence knowing that you will
achieve excellent contact and contour without
having to take extra steps.

Hugs the curves –
Soft-Face™ silicone tips
with enhanced marginal
ridge anatomy hug the
matrix band to the tooth
for flash free restorations

3 Place the ring:

Composi-Tight®
Sectional Matrix System

Composi-Tight® 3D Fusion™ Full Curve Non-Stick Matrices
are three dimensionally contoured, ultra-thin and dead-soft
to help you recreate ideal interproximal anatomy.
Easy in – easy out! A Grab-Tab™ centered
on the occlusal edge of the band
simplifies placement while Slick Bands™
non-stick coating reduces composite
adhesion by an impressive 92%!

Get a grip! All Composi-Tight®
3D Fusion™ separator rings
incorporate Ultra-Grip™
retention extensions that
anchor them securely to
virtually any tooth. These rings
stay where you place them!

Composi-Tight 3D Fusion
Ultra-Adaptive wedges glide
in but won’t back out. Their
soft, flexible exterior readily
adapts to interproximal
irregularities for a superior
gingival seal.

Go deep or wide – Improved
subgingival extensions and added wraparound length make for the perfect
matrix band to use with the green Wide
Preparation ring. Now you’re ready to
tackle even the widest preps!

Wider indications,
wider smiles!

More than 20 years of sectional matrix
leadership and an incredible amount of
feedback from users all over the globe were
poured into the design. All this hard work has
resulted in separator rings with significantly
improved performance and ease of use.

2 Wedge firmly:
®

Matrix band perfection

An all-new system designed to handle
even the toughest cases

Contact
Mazaya Business Avenue
Dubai | UAE
Mob: +971 (0) 5 28538713
E-mail: info@swanmedsupply.com
Web: www.swanmedsupply.com

Functionality for all –
As an added bonus,
Composi-Tight® 3D Fusion™
forceps will work with
virtually any ring from any
manufacturer.

Tough on the inside
The firm inner skeleton allows for
easy insertion and tooth separation
just like a traditional wedge.

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

Temporary crown & bridge material
• Less than 5 min. processing time
• Strong functional load
• Perfect long-term aesthetics
• Excellent biocompatibility

Self-curing calcium hydroxide paste
• For indirect pulp capping and linings under dental filling materials
• Sufficient working time in combination with a short
setting time in the mouth
• Bacteriostatic
• Antimicrobic effect due to a high pH-value
• Contains 26% calcium hydroxide
• Preservation of vitality due to pulp recovering
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

[9] =>

[10] =>

mCME

Dental Tribune Middle East & Africa Edition | 4/2018

Treatment planning:
Retention of the natural dentition and
the replacement of missing teeth
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 Scott L. Doyle, DDS
Preservation of the natural dentition
is the primary goal of dentistry. Published surveys indicate that patients
generally value teeth and express a
desire to save their natural dentition
in favor of extraction whenever possible.1,2 Significant technological and
biological improvements have been
made in all disciplines of dentistry,
making long-term retention of natural teeth more attainable. Patients
entrust dental professionals to make
appropriate
recommendations
regarding the maintenance and
restoration of their oral health and
function. It is essential to employ an
evidence-based, interdisciplinary approach that addresses the interests
of the patient when determining the
best possible course of treatment.
In July 2014, the American Association of Endodontists, in collaboration with the American College of
Prosthodontists and the American
Academy of Periodontology, hosted
a two-day Joint Symposium titled
“Teeth for a Lifetime: Interdisciplinary Evidence for Clinical Success.”
Approximately 375 general dentists
and specialists assembled in Chicago
to focus on preserving the natural
dentition.
The educational program included
evidence-based presentations on
advanced regenerative techniques,
improvements in technology, minimally invasive restorative methods
and best practices for interdisciplinary treatment planning. Dr. Alan
Gluskin, chair of the 2014 Joint Symposium Planning Committee, concluded that the current evidence directs clinicians to consider saving the
natural dentition as the first option
when developing treatment plans.
Dental implants are one of the
most significant advancements in
contemporary dentistry. This innovation has had profound effects
on endodontic, periodontic and
prosthodontic treatment planning
for the rehabilitation of edentulous spaces and for teeth with an
unfavorable prognosis.3 Implantsupported restorations minimize
unnecessary preparation of intact
abutment teeth and allow fixed
prosthodontic replacement when
suitable abutments are absent. With
appropriate usage and case selection,
implant dentistry provides a viable
option for the replacement of missing teeth.4,5
There has been an increasing trend
toward replacing diseased teeth with

Fig. 3. A matched-case comparison of
survival rates after treatment with either a restored endodontically treated
tooth (n=196) or a restored singletooth implant (n=196) performed at
the same institution. J Endod 2006;31.

dental implants. Often, an inadequate or inappropriate indication for
tooth extraction has resulted in the
removal of teeth that may have been
salvageable.6 Teeth compromised by
pulpal or periodontal disease have
value and should not be extracted
without thoroughly evaluating restorability and potential retention
therapies.7
A recent systematic review published in the Journal of the American
Dental Association highlights a key
question: “Is the long-term survival
rate of dental implants comparable
to that of periodontally compromised natural teeth that are adequately treated and maintained?”8
Nineteen studies with a follow-up
period of at least 15 years were included in the analysis.
The results show that implant survival rates do not exceed those of
compromised but adequately treated and maintained teeth. These findings support other studies comparing long-term survival of implants
and natural teeth,9,10 providing an
important message: Periodontally
compromised teeth can be retained
with quality treatment and appropriate maintenance. Therefore, it
may be advisable to postpone implant consideration for the periodontitis-susceptible patient to fully
utilize and extend the capacity of the
natural dentition.11

Treatment planning options
A key focus of the Joint Symposium
involved treatment planning decisions regarding endodontic treatment and implant therapy. Should
a tooth with pulpal disease be retained with root canal treatment
and restoration, or be extracted and
replaced with an implant-supported
restoration? This assessment involves a challenging and complex
decision-making process that must
be customized to suit the patient’s
needs and desires.12-14 The topic has
received considerable attention in
the literature, the media and at dental continuing education courses.
Endodontic treatment and implant
therapy should not be viewed as
competing alternatives, rather as
complementary treatment options
for the appropriate patient situation
(Figs. 1a, b). Root canal treatment is indicated for restorable, periodontally
sound teeth with pulpal and/or apical pathosis. Endodontic treatment
on teeth with nonrestorable crowns
or teeth with severe periodontal conditions is contraindicated, and other

Fig. 4a. Pre-op image of tooth
#30 with previous endodontic
treatment and persistent apical
periodontitis. A dentist initially
recommended extraction and replacement of this tooth with an
implant. The patient requested a
second opinion from an endodontist who determined the tooth to
be treatable.

Fig. 1a. Pre-op image of tooth #19
with pulp necrosis and symptomatic apical periodontitis. The patient is interested in rehabilitation
of the edentulous space.
(Photos/Provided by American Association of Endodontists)

CAPP designates this activity for 1 CE Credit

Fig. 1b. Three-year recall image.
The patient has benefited from
both root canal treatment and
implant therapy. Courtesy of Dr.
Tyler Peterson and the University
of Minnesota School of Dentistry.

Fig. 2a. Pre-op image of tooth #29. Fig. 2b. Two-year
Note lateral radiolucency and com- recall image reveals both excelplex canal anatomy.
lent endodontic
and restorative
treatment. Note
healing of lateral radiolucency.
favorable outcomes30
Courtesy of Dr. Joe
and positive patient
Petrino.
31

Table 1_Survival rates following initial nonsurgical root canal treatment.
(Table/Provided by American Association of Endodontists)
options such as implant placement
should be considered.15
When making treatment decisions,
the clinician should consider factors including outcome assessment,
local and systemic case-specific issues, costs, the patient’s desires and
needs, esthetics, potential adverse
outcomes and ethical factors.16

Outcome assessment:
Success and survival
Treatment outcomes play a key role
in the assessment of different treatment options. Patients often ask
whether a procedure is going to be
successful or not. This question can
be challenging for a clinician to answer due to the variety of reported
outcomes in the literature.17 There
are differences in the methodology
and criteria used to evaluate the outcomes for root canal treatment and
implant prosthetics, which makes
comparisons between success rates
difficult, if not impossible.18
Endodontic studies have historically
used “success” and “failure” as outcome measures and have focused on
a strict combination of radiographic
and clinical criteria.19 In contrast,
the implant literature has primarily reported “survival,”20, 21 i.e., the
implant is either present or absent.
Therefore, implant studies that solely evaluate survival as an outcome
measure will likely publish higher
success rates than endodontic studies that rely on biologic healing and
factors related to the entire restored
tooth. To establish more valid and

Fig. 4b. Four-year recall image
demonstrates apical healing following nonsurgical retreatment.
Accurate diagnosis prevented the
unnecessary treatment of tooth
#31. Courtesy of Dr. Martin Rogers.

less biased comparisons, the same
outcome measures should be used.
A more patient-centered measure is
to compare the outcome of survival,
which is considered to be an asymptomatic tooth/implant that is present and functioning in the patient’s
mouth.22,23
Multiple large-scale studies including millions of teeth have used
survival to assess the outcome following root canal treatment. An investigation using an insurance database of more than 1.4 million root
canal-treated teeth demonstrated
that 97 percent were retained within
an eight-year follow-up period.24
Other studies show similarly high
survival rates (Table 1).25,26 An epidemiological approach allows for the
assessment of tooth retention from
a large sample of patients experiencing actual care in private practices.
Systematic reviews27 and controlled
studies from academic settings complement the previous findings. Two
prospective trials each reported 95
percent survival rates at four years28
and four to six years29 for teeth after
initial root canal treatment.

Predictable tooth retention:
Nonsurgical root canal treatment and restoration
The majority of endodontic treatment is performed by general dentists with a high degree of success.26
For complex cases, referral to an endodontist with additional training
and expertise may result in more

Fig. 5a. Pre-op image of tooth #19 with pulp
necrosis and chronic apical abscess.
Fig. 5b. Two-year recall image demonstrates
excellent endodontic treatment and healing
of apical periodontitis. Courtesy of Dr. Deb
Knaup.

experiences.
Interdisciplinary care is important
for the management of endodontically treated teeth. The restorative
dentist plays a significant role in the
outcome by providing an appropriate and timely restoration.32 Root
canal treatment is not complete until the tooth is coronally sealed and
restored to function. Multiple studies have confirmed that a definitive
restoration has a significant impact
on survival.24,25,27,28,33 Therefore, the
likelihood of a favorable outcome increases with both skillful endodontic
care and prompt restorative treatment (Figs. 2a, b).34
Advancements in technology aid in
attaining high levels of tooth retention. The dental operating microscope, nickel-titanium instruments,
apex locators, enhanced irrigation
protocols and dentin preservation
strategies are examples of improvements that allow clinicians to predictably manage a greater range of
treatment options. Additionally,
cone-beam-computed tomography
facilitates more accurate diagnosis
and improved decision-making for
the management of endodontic
problems.35,36

Comparative studies: Endodontically treated teeth and
single-tooth implants
Large-scale systematic reviews have
addressed the relative survival rates
of endodontically treated teeth and
single-tooth implants. The Academy
of Osseointegration conducted a meta-analysis using 13 studies (approximately 23,000 teeth) on restored
endodontically treated teeth and
57 studies (approximately 12,000
implants) on single-tooth implants.
The outcome data demonstrated no
difference between the two groups
during any of the observation periods.37 Another systematic review
supported by the American Dental
Association compared the outcomes
of endodontically treated teeth with
those of a single-tooth implant-restored crown, fixed partial denture
and no treatment after extraction.
At 97 percent, the long-term survival rate was essentially the same
for implant and endodontic treatments. Both options were superior
to extraction and replacement of the
missing tooth with a fixed partial

ÿPage 11

[11] =>

mcme

Dental Tribune Middle East & Africa Edition | 4/2018

◊Page 10

Fig. 6a. Pre-op image. Tooth #14
was determined to have a vertical
root fracture of the MB root. The
patient expressed a strong desire
to retain the natural dentition but
also to rehabilitate the edentulous
space.

Fig. 6b. Two-year recall image.
Tooth #14 had retreatment and
resective surgery on the MB root.
Two dental implants have restored
the edentulous space. Courtesy of
Dr. Brian Barsness and the University of Minnesota School of Dentistry.

denture.38
Retrospective studies also have
compared the outcomes for the two
treatment options. A study conducted at the University of Minnesota
compared the outcomes of 196 restored endodontically treated teeth
with 196 matched single-tooth implants.39 Both groups had 94 percent
survival rates. The survival curves
for these two groups are provided in
Figure 3. Another investigation from
the University of Alabama provided
similar results.40
Based upon similar survival rates,
the decision to treat a compromised
tooth endodontically or replace it
with an implant must be based on
factors other than treatment outcome.37,41 Several factors influence
the decision-making process.42-44 The
following lists provide an overview
of case-specific factors that should be
considered in making this treatment
decision.

Systemic factors
• The list of potential risk factors for
peri-implantitis or implant failure is
extensive. It includes systemic disease, genetic traits, chronic drug or
alcohol consumption, smoking, periodontal disease, radiation therapy,
diabetes, osteoporosis, dental plaque
and poor oral hygiene.45
• There are few medical conditions
that directly affect endodontic treatment outcomes. Risk factors that
may be associated with decreased
survival of root canal-treated teeth
include smoking,46 diabetes,28,46 systemic steroid therapy28 and hypertension.47
• Patients taking antiangiogenic or
antiresorptive (i.e., bisphosphonates)
medications may have an increased
risk for developing medication-related osteonecrosis of the jaw. This may
affect treatment planning for both
implant and endodontic treatment.
• It is generally recommended to
wait for the completion of dental
and skeletal growth prior to implant
placement.48

Local factors
• Accurate diagnosis.
• Restorability assessment: removal
of caries/restorations; adequate ferrule.
• Strategic nature of the tooth as it
fits into the comprehensive restorative plan.
• Caries risk and oral hygiene.
• Periodontal assessment: tissue biotype, adequate biologic width.
• Presence of crack(s), root fracture(s),
resorption.
• Occlusion and parafunction.
• Teeth with less than two proximal
contacts and those serving as fixed
partial denture abutments may have
lower survival.27
• Need for adjunctive treatment
(crown lengthening, orthodontic
extrusion, sinus lift, bone graft, etc.),
which may impact financial cost and
time to function.
• Quantity and quality of bone.
• Proximity to anatomical structures
(maxillary sinus, inferior alveolar
nerve, etc.)
• Implant esthetics in the anterior region may be challenging.49

Fig. 7. Pre-op image.

In addition to systemic and local
factors, it is critical to include the
patient’s concerns during treatment planning. Common patientcentered factors include costs, treatment duration, satisfaction with
treatment and the potential for adverse outcomes.
Financial considerations can influence a patient’s decision when
weighing treatment options. The
availability of dental insurance may
also impact choices.50 Endodontic
treatment and restoration offer considerable economic advantages to
the patient.51-53 A benefit of root canal treatment is the short time frame
required to completely restore both
dental function and esthetics. In one
study of about 400 patients, the restored single-tooth implant showed
a longer average and median time to
function than similarly restored endodontically treated teeth. Additionally, the implant group had a higher
incidence of post-treatment complications requiring subsequent treatment interventions.39 This increased
post-operative care can impact patients in terms of additional visits,
lost wages and unforeseen costs.
Clinicians should consider the patient’s preferences, which are often
related to function, comfort and esthetics. Tooth loss is associated with
an impaired quality of life,54 and
surveyed patients express a clear
desire to save their natural dentition whenever possible.2 Large-scale
surveys of post-endodontic patients
have demonstrated that endodontic treatment not only preserves
the natural tooth, but also significantly improves patients’ quality
of life.55 More than 97 percent of patients report being satisfied with
their endodontic treatment.31 If an
implant is used to restore an edentulous space, a similarly high percentage of patients have a positive
experience with implant therapy.56
Furthermore, comparative studies
demonstrate that patients report a
high degree of satisfaction with the
overall experience following both
procedures.2,15
Despite high survival rates, both
endodontically treated teeth and
implants are susceptible to complications. Nonrestorable caries, prosthetic failures, periodontal disease,
crown/root fractures and specific
endodontic factors are examples of
complications following root canal
treatment.57 Complications associated with implants and related prostheses include: surgical, implant loss,
bone loss, peri-implant soft-tissue,
mechanical and esthetic/phonetic.58 A retrospective study directly
compared the rates of additional
interventions related to complications. Implant cases had a substantially higher need for subsequent
intervention and maintenance visits
than endodontically treated teeth.40
However, a more recent prospective
study suggests that patients from
both groups have minimal complications at one-year follow-up.15

Endodontic retreatment options
The consequences of failure and
subsequent treatment differ be-

Fig. 8. Root-end filling with MTA.

tween endodontics and implants.
Endodontic failure can usually be
addressed successfully by retreatment, microsurgery or by extraction
and potential implant placement.
Intervention after implant failure
may vary from minimal restorative
repairs to multiple corrective surgeries and/or the use of a different prosthesis.59
Nonsurgical retreatment, or revision,
is often the first choice to address
post-treatment apical periodontitis,60,61 provided that the tooth is
suitable for further restoration and
that the restoration will have a good
long-term prognosis (Figs 4a, b).62
Current best evidence indicates that
the survival of nonsurgical retreatment is similar to that of primary
treatment, and that the two treatments share similar prognostic factors.63 Two studies specifically evaluated survival following retreatment.
An epidemiological study using an
insurance database of 4,744 retreated
teeth reported an 89 percent survival
rate at five years64 and a prospective
trial of 858 retreated teeth reported
a 95 percent survival at four years.28
Modern techniques and rationale
contribute to excellent potential
outcomes for retreatment. An important factor when considering
retreatment is the ability to identify and address the etiology of posttreatment disease.63 Primary sources
of nonhealing are persistent intracanal microorganisms or ingress of
microorganisms following treatment. If the etiology of the problem
is deemed correctable via an orthograde approach, retreatment is often
the first choice. If not, a surgical approach may be the more predictable
option.65
Contemporary endodontic microsurgery has undergone significant
technological and procedural advancements.66,67 Recently performed
studies suggest that microsurgical
techniques using biocompatible
root-end filling materials provide
significant improvements over traditional methods. A meta-analysis
showed contemporary microsurgical techniques to have a significantly
improved outcome (94 percent)
compared to older techniques and
instruments (59 percent).68 A recent
systematic review investigating current microsurgery found survival
rates of 94 percent at two to four
years and 88 percent at four to six
years, indicating that teeth treated
with endodontic microsurgery
tended to be lost at low rates over
the time studied.69 Microsurgery,
with appropriate case selection, is a
predictable procedure for teeth that
may have been considered for extraction in the past.

Ethics and interdisciplinary
consultation
Clinicians are ethically bound to
inform patients of all reasonable
treatment options, explain the risks
and benefits involved with the available treatment options, and obtain
informed consent before initiating
treatment. This information should
be conveyed in an impartial manner.1 Patients value participation in
the decision-making process and
should be encouraged to exercise
autonomy by communicating their
preferences.70 Clinical treatment decisions regarding either endodontic

Fig. 9. Post-op image.

treatment or tooth extraction with
implant therapy must always be
made in the best interest of the patient using the best, most current
evidence.
Should it be necessary, experts from
the dental team may need to be
called upon to assist the clinician
in rendering the highest quality
of care (Figs. 5a, b). The standard of
care must be applied equally to all
clinicians, generalists and specialists
alike. The AAE’s Endodontic Case Difficulty Assessment Form and Guidelines provides valuable information
to aid the clinician in case selection
and determining whether to treat
or refer. Patients are deserving of the
best possible outcome for each case.
Interdisciplinary communication
and collaboration during treatment
planning maximize this likelihood.
Specialists and restorative dentists
should be viewed as partners in the
treatment planning team. Endodontists are uniquely positioned to evaluate the restorability and prognostic
longevity of teeth and recommend
whether to attempt natural tooth
preservation or consider extraction
and replacement with an implant.71
Likewise, the endodontist should be
well-versed in implant treatment
planning to assist patients and referring colleagues in making an informed choice regarding all replacement options.72,73
If a tooth has a questionable prognosis, the endodontic specialist becomes an indispensable part of the
treatment planning team. The endodontist has experience with various
treatment options that have potential to preserve the natural dentition.
Consultation regarding a questionable tooth is often in the patient’s best
interest prior to considering extraction. If the prognosis of a restorable
tooth is categorized as questionable
or unfavorable in multiple areas of
evaluation, extraction should be
considered after appropriate consultation with all relevant specialists.
Only then is the decision to extract
an informed choice. Extraction is an
irreversible treatment, but if necessary, dental implants provide an
excellent option to replace missing
teeth (Figs. 6a, b).

Case report
A case report (Figs. 7-10) demonstrates an alternative treatment option for a patient to save a natural
tooth. A 70-year-old female presented to an endodontist’s office with a
complaint of persistent pain to biting. Tooth #31 had a history of root
canal treatment and coronal restoration. A thorough examination,
including CBCT, led to the diagnosis
of previously treated tooth #31 with
symptomatic apical periodontitis.
A detailed explanation of the risks
and benefits associated with all treatment options was presented. The
patient expressed a strong desire
to save her tooth and consented to
intentional replantation. Tooth #31
was atraumatically extracted and
continuously hydrated with Hanks’
Balanced Salt Solution. No cracks or
fractures were visible. Apical microsurgery was performed extraorally.
The root end was resected, ultrasonically prepared and filled with mineral trioxide aggregate. The tooth
was replanted. The patient remains
asymptomatic and very satisfied

Fig. 10. Seven-month recall image.

with her treatment.
A recent systematic review and meta-analysis revealed a mean survival
rate of 88 percent for intentional replantation.* With careful case selection, intentional replantation may
allow for a reasonable, cost-effective
treatment option for teeth that
do not heal following endodontic
treatment. Clinicians are advised to
explore all options before recommending extraction. Referral to an
endodontist can aid in the retention
of a compromised tooth.

Conclusion
Patients are living longer; therefore,
preservation of the natural dentition
is more important than ever. Helping patients maintain their “Teeth
for a Lifetime” is the fundamental
goal of dentistry and often aligns
with the desires of the patient. A wide
range of endodontic procedures result in a high level of tooth retention
and patient satisfaction. Large-scale
studies provide strong support that
the restored endodontically treated
tooth offers a highly predictable,
long-term approach to preserving
“nature’s implant” — a tooth with an
intact periodontal ligament.
Thus, excellent endodontic treatment followed by an immediate restoration of equal quality promises
to give patients service and function
while maintaining their esthetics for
years. The results of multiple studies
indicate that the high survival rates
for the natural tooth are similar to
those reported for the restored single-tooth implant.
Therefore, clinicians must consider
additional factors when making
treatment planning decisions, all of
which must be in the best interest of
the patient. Endodontic treatment
and implant therapy should not be
viewed as competing alternatives,
rather as complementary treatment
options for the appropriate patient
situation.
This article originally appeared in
ENDODONTICS: Colleagues for Excellence, Spring 2015. Reprinted with permission from the American Association of Endodontists, ©2015. The AAE
clinical newsletter is available at www.
aae.org/colleagues.
A complete list of references is available from the publisher, and also at
www.aae.org/colleagues.
Case report contributed by Dr. Robert
S. Roda.

Scott L. Doyle,
DDS, MS. He currently
practices
with Metropolitan
Endodontics
in
Minneapolis and
serves as an associate clinical professor for the Division
of Endodontics at
the University of Minnesota. Doyle is a
diplomate of the American Board of Endodontics. He is a past president of the
Minnesota Association of Endodontists,
chair of the AAE Continuing Education
Committee and serves as a reviewer for
the Journal of Endodontics. Doyle has
written multiple articles in scientific
journals, as well as a chapter on the “Endodontic Applications of CBCT” in an upcoming textbook.

[12] =>

mCME

Dental Tribune Middle East & Africa Edition | 4/2018

Bioactive materials support
proactive dental care
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 John C. Comisi, DDS, MAGD
Resin bonding of the human dentition has become a “standard” in the
United States and Canada. There are
more than 80 different bonding systems on the market today. We have
seen them evolve through multiple
generations in an attempt to “simplify” the bonding process. Yet, as
these agents have simplified, many
in our profession have seen many
challenges arise.
A significant number of reports in
the literature have been showing
that the “immediate bonding effectiveness of contemporary adhesives
are quite favorable, regardless of
the approach used [however] in the
long term, the bonding effectiveness of some adhesives drops dramatically.”1 The hydrophillicity that
both etch-and-rinse and self-etch
bonding agents offer initially in the
dentin-bonding process becomes a
significant disadvantage in terms of
longterm durability.2
It is this hydrophillicity of simplified
adhesive systems combined with
other operator-induced challenges
that contribute to these failures.
Tay, Carvalho, Pashley, et al. have
reported repeatedly in the literature
of this problem.3,4 They continue to
report that these bonding agents do
not coagulate the plasma proteins
in the dentinal fluid enough to reduce this permeability. The fluid
droplets contribute to the incompatibility of these simplified adhesives
and dual-/auto-cured composites
in direct restorations and the use of

Fig. 4

Fig. 5

Fig. 6

Fig. 8

resin cements for luting of indirect
restorations.
The term “water-tree” formation
has been coined to describe this
process, which originated from the
tree-like deterioration patterns that
were found within polyethylene insulation of underground electrical
cables. It is now being applied to the
water blisters formed by the transfer
of dentinal fluid across the dentinbonding interface. These “water blisters ... act as stress raisers and form
initial flaws that cause subsequent
catastrophic failure along the adhesivecomposite interfaces.”4
The previously mentioned plasma
proteins are released by the dentin
when subjected to acids and cause
hydrolytic and enzymatic breakdown of the dentin and resin bonding agent interface.5 These enzymes
are called matrix metalloproteinases
(MMPs).
Currently, there are only three
methods of reducing these MMPs:
2 percent chlorhexidine solutions
that are used prior to application of
bonding agents; etchants containing
benzalkonium chloride, otherwise
known as BAC (i.e., Bisco’s Uni-etch
products); and polyvinylphosphonic-acid-producing products (glass
ionomer and resin-modified glass
ionomers).
Due to the short efficacy of these
chlorhexidine solutions being used
before bonding, this methodology
has come into question as of late.6
Etchants with BAC have been shown
to be valuable in the reduction of
MMPs and should be considered in

Fig. 7

Fig. 9

Fig. 11

Fig. 10

Fig. 12

CAPP designates this activity for 1 CE Credit

all bonding processes.7 However,
the most intriguing methodology
of reducing MMPs
and remineralizing tooth structure
is with the use of
glass ionomer cements (GIC) and
resin-modified
glass
ionomers
(RMGIC).

Glass ionomers Fig. 1
and resin-modified glass ionomers
Glass ionomer cements have long
been used as a direct restorative material. Their early formulations made
the material difficult to handle, and
the breakdown of the material made
it an undesirable solution in dental
restoration. However, these materials, especially in today’s formulations and pre-encapsulated presentations, have many properties that
make them very important in the
restorative process.
The work at companies such as SDI
North America (Riva product line),
GC America (Fuji product line) and
VOCO (Iono product line) have continued to make great strides in improving these products for easier
and longer-lasting use of GIC and
RMGIC products.
First, these materials are bioactive,
and up until recently, they were the
only materials with this property;
that is they have the capacity to interact with living tissue or systems.
Glass ionomers release and recharge
with ions from the oral cavity.
This transfer of calcium phosphate,
fluoride, strontium and other minerals into the tooth structure helps
the dentition deal with the constant
assault of the acidic nature of day-today ingestion of food and beverages
and encourages remineralization;
and the incorporation of phosphorous into the acid in today’s GICs creates polyvinylphosphonic acid.8
This property of GICs makes them a
major agent in the reduction of MMP
formation, and thereby minimizing
if not eliminating the collagen breakdown commonly found in many
resin-dentin bonding procedures.9
Second, they bond and ultimately
form a union with the dentition by
chemically fusing to the tooth.
The combination of the polyacrylic
acid and the calcium fluoroalumino
silicate glass typically found in GICs
reacts with the tooth surface, which
releases calcium and phosphate ions
that then combine into the surface
layer of the GIC and forms an intermediate layer called the “interdiffusion zone.”10
No resin bonding agents are required due to this chemical fusing to
the tooth structure. This ion release
helps inhibit plaque formation and
provides an acid buffering capability
that helps to create a neutralization
effect intraorally. In addition, these
GICs have very good marginal integrity with better cavity-sealing properties, have better internal adaption
and resistance to microleakage over
extended periods of time, have no

Fig. 2

free monomers, can be bulk filled
and offer excellent biocompatibility.11
Another important consideration is
that GICs are moisture-loving materials, which makes them very sensible for use in the intraoral cavity.
The transfer of dentinal fluid from
the tooth to the GIC essentially creates a “self-toughening mechanism
of glass ionomer based materials…
serves to deflect or blunt any cracks
that attempt to propagate through
the matrix [and] … plays an adjunctive role by obliterating porosities
[which] delay the growth of inherent
cracks in the GIC under loading.”4
The intermediate layer of the GIC
provides flexibility during functional loading and acts as a stress absorber at the interface of the restoration
and the tooth.12
Resin-modified glass ionomers
(RMGIC), which are a hybrid of traditional glass ionomer cements with a
small addition of light-curing resin,
exhibit properties intermediate of
the two materials.13 This material has
been shown to have properties similar to GIC, but with better esthetics
and immediate light cure. RMGICs
have been shown to undergo slight
internal fracturing from polymerization shrinkage, yet have an inherent
ability to renew broken bonds and
reshape to enforce new forms.12
Application of RMGIC to all cut dentin in Class II composite restorations
has been shown to “significantly reduce micro-leakage along (the) axial
wall” of the restoration,14 and helps
prevent bacterial invasion of the
restored tooth. RMGIC biomaterials
are multifunctional molecules that
can adhere to both tooth structure
and composite resin, thus providing an improved sealing ability by
chemical or micromechanical adhesion to enamel, dentin, cementum
and composite resin.
They, like GICs, can be bulk filled to
reduce the amount of composite
necessary to restore the cavity preparation and act as dentin substitutes
in the restoration.15
The use of GIC and RMGIC in the
restoration of posterior Class V restorations and conservative Class I
restorations provides many benefits.
They are easy to place and reasonably forgiving, even in a slightly moist
environment. They should be placed
in a moist but not wet environment,
so familiarity with technique is imperative as it is with all dental restorations.
I will often use Riva SC (SDI) or Fuji 9

Fig. 3

GP Extra (GC America) in posterior
Class I and V restorations (Figs. 1–7).
Polishing and shaping of the materials must be done with water spray
and fine/ultra fine composite finishing burs and polishers so as not to
destroy the surface of the material
(Fig. 8).
The use of RMGIC products, such as
Riva LC or Fuji II LC, is great in bicuspid and anterior Class V restorations,
especially in high caries prone patients (Figs. 9–12).
Class II restorations, however, have
always presented a challenge to the
clinician. If the operator wanted to
use GIC or RMGIC, there was no easy
way to do this that appeared to provide satisfactory results. It is with
this in mind that the “sandwich technique” was developed.
It was thought that using the properties of GIC to bond to the tooth and
then applying resin-bonding agents
and composite to the set GIC could
help reduce sensitivity and bond
failures typically seen in many resinbonded composite (RBC) techniques.
Typically, the GIC is placed in the
preparation, allowed to set, cut back
to ideal form and then bonded to
with an RBC technique. However, the
inability of RBCs to adhere to the set
GIC often creates many failures. The
materials by themselves are incompatible over the long term.
The modified sandwich technique
evolved as a means to overcome this
problem. Placing RMGIC over set GIC
— and then adding a RBC to that —
provided a better solution, but was as
laborious and time consuming to do,
as is the sandwich technique.

The ‘Co-Cure Technique’
In 2006, an article was published16
that, in my opinion, has revolutionized the way I approach direct
posterior restorations and direct
restorations as a whole. The article
presented a radical approach to direct posterior restorations, called the
Co-Cure Technique. This technique is
defined as the simultaneous photopolymerization of two different light
activated materials that involves
“the sequential layering of GIC,
RMGIC and composite resin prior
to photo-polymerization and before the initial set of the GIC [which]
enables an efficient single-visit placement of a [direct] restoration …”16
In the Co-Cure Technique, the composite restoration does not require a

ÿPage 13

[13] =>

mcme

Dental Tribune Middle East & Africa Edition | 4/2018

◊Page 12
bonding agent because the bonding
agent is essentially the RMGIC. The
RMGIC acts as the interface between
the GIC and the com-posite material. It combines the GIC, RMGIC and
composite in a way to form what can
best be described as a “monolithic
biomimetic restoration.”
This restoration is an “open sandwich” type of sandwich technique.
That is, the GIC component is exposed to the oral environment (Fig.
13) at the gingival portion of the restoration. It is quickly and efficiently
accomplished and has significantly
reduced postoperative sensitivity compared with typical direct RBC
techniques. I have been placing these
types of direct posterior restorations
since 2008. They have become the
cornerstone of my practice.
Technique procedure (Fig. 14)
After placement of an appropriate
dental matrix, the technique incorporates the use of 37 percent phosphoric acid to prepare the tooth for
restoration. The acid is essentially
“flooded” into the preparation in
a similar manner to doing a “totaletch” RBC. It is, however, washed off
after five seconds of placement.
The tooth is then dried but not desiccated. The area remains slightly
moist because the GIC that will be
placed next is hydrophilic.
Fill the preparation with the triturated GIC material up to the level of
the DEJ, then immediately place the
triturated RMGIC in a very thin layer
to cover the GIC and walls of the
preparation. Finally, place the composite over the previous materials
to slightly overfill the preparation.
With a large round burnisher dipped
in an unfilled resin material (i.e., Riva
Coat by SDI or G-Coat by GC), wipe
away the excess GIC and composite
restoration material to create your
margins and prevent ditching and
white lines.
The occlusal table of the restoration
can then be compressed gently with
a plastic occlusal matrix by either
having the patient bite or by the
operator pressing gently with his
thumb or forefinger to improve the
coalescence of the three materials.
This can help reduce the time in-

volved in creating the final occlusion
of the restoration by creating a functional occlusal table.
The restoration is then cured for 30
to 40 seconds with an LED curing
light that generates at least 1,500
mw/cm2. Appropriate light output
is critical for all direct cured restorations, and assurance that appropriate output is provided by the curing
light is needed for complete cure of
any direct restoration.
The restoration is evaluated for complete cure and then a layer of an unfilled resin is placed on the exposed
GIC/RMGIC/composite
complex
and cured for an additional 10 seconds. The matrix band is removed
and the restoration is trimmed and
polished as any typical RBC restoration would be.
I have found that an entire threesurface posterior restoration can
be accomplished in less then three
minutes once the matrix has been
placed. Typically, finishing the restoration can also be done in less then
three minutes. This makes the direct
posterior restoration quite efficient
and beneficial to the clinician and
the patient because we are providing
a restoration that will help enhance
healing of the dentition and reduce
recurrent decay and restorative failure.

Nanotechnology in dental
materials
Nanotechnology involves the production of functional materials and
structures in the range of 0.1 o 100
nanometers by various physical or
chemical methods. Today, the development of nanotechnology has
become one of the most highly energized disciplines in science and technology because it can stimulate the
creation of many new materials with
previously unimagined applications
and properties.
Several studies17,18 have shown that
the inclusion of these types of nanofillers and nano-fibers into the dental
materials (dental composites and
bonding agents) can improve the
physical properties by increasing the
strength, polishability, wear resistance, esthetics and bond strengths in
many dental applications.

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Fig. 13

Fig. 14

Fig. 16

Fig. 17

It is also envisioned that the incorporation and utilization of these nanoparticles in the form of nanorods,
nanofibers, nanospheres, nanotubes
and ormocers (organically modified
ceramics) into dental restorative and
bonding agents can create more biomimetic (life-like) restorations. This
will not only enable these materials
to mimic the physical characteristics
of the tooth structure, but will also be
able to facilitate the remineralization
of that structure.
As Saunders states in his conclusion,
“such nanorestorative biomaterials
could very credibly be the next transformative clinical leap” in restorative
dentistry.

Giomers
In that vein, an exciting advancement in bioactive materials is the
development of giomer products
(Shofu Dental, Beautifil II, and Beautifil Flow Plus).
These giomers are resin-based composites that contain pre-reacted glass
ionomer particles (S-PRG).
These particles are made of fluorosilicate glass reacted with polyacrylic
acid (just like a GIC), just before being
incorporated into the resin. This creates a new type of bioactive material.
These giomer products display properties in a manner similar to GICs19:
They release ions and recharge with
ions from the oral cavity, inhibit
plaque formation and neutralize and
buffer the acids of the mouth.20
No other composite material has this
property to date. I use these giomers
instead of traditional nano-hybrid
composites in my restorations
because of these properties. They
complete the entire biomimetic and
bioactive nature of all the co-cure
procedures that I create.
The Beautifil Flow Plus product line
has also expanded the way that I create restorations due to their unique
viscosities. These materials can be
stacked (Fig. 15) and used in a restorative process I call the “modified resin
cone technique” (Fig. 16).
They can also be applied to create
direct composite veneers that can
be easily placed, sculpted and highly
polished (Fig 17). Easy placement,
the ability to stack and maintain
position and shape, plus their bioactive nature, make these materials a
“game changer.”

Resin-modified,
bonding agents

Fig. 15

light-cured

Another advancement that I have
been working with is a product that
is a resin-modified, light-cured bonding agent (SDI, North America: Riva
Bond LC). This product is a specially
formulated liquid RMGIC that can
be used to bond composite restorations in the traditional sense, used in
traditional sandwich and modified
sandwich techniques and, of course,

used in the Co-Cure Technique. This
concept is especially appealing in
light of the research that indicates
RMGICs provide quite good marginal seal when used as a bonding agent
on cut dentin surfaces.14 I especially
like to use it with the Co-Cure Technique and when doing anterior restorations. Using this technique I am
able to get a completely biomimetic,
bioactive restoration in both situations because of the bioactive nature
of the materials used.
The technique for use of this RMGIC
bonding agent with composite is as
follows:
1) Etch with 37 percent phosphoric
acid for five seconds.
2) Wash and dry but do not desiccate.
3) Triturate and apply the RMGIC
bonding agent with a micro-brush
and cure for 20 seconds.
4) Place composite to fill the preparation and cure as appropriate.
When I use this material in the CoCure Technique, I just substitute it
for the traditional RMGIC material
that I would have used otherwise.

Resin-modified calcium silicates
Another recent interesting product
release is from Bisco and is called
TheraCal™ LC. This light-cured bioactive material is used to seal and
protect the dentin-pulp complex. It
is the first of a new class of internal
pulpal protectant materials known
as resinmodified calcium silicates
(RMCS).
It acts as a pulp capping and liner
material. Calcium hydroxide (CH)
has been the “gold” standard for pulp
capping for many years. However, it
has always had difficulties in use as a
liner under RBC adhesives.
In fact, despite their frequent use, the
success of CH based therapies is only
30 to 50 percent.21
It has also been shown that traditional resinbased light-cured liners
have been cytotoxic to cultured odontoblast-like cells, while light-cured
resinbased MTA cements presented
the lowest cytopathic effects.22 Based
on this, the creation of light-cured
RMCS is a logical step in developing a
solution for direct pulpal protection.
Calcium has been shown to be crucial to the formation of apatite, dentin bridge formation and re-apatite
potential of affected dentin. Additionally, alkalinity also seems to be
contributory toward this goal. This
combination in the RMCS material
appears to form good, hard and thick
dentin bridges and stimulates dentin pulp cells to turn into odotoblastic dentin cells.23
This type of material represents a
promising new direction in direct
pulp-capping clinical procedures
with its ability to form apatite and
further contribute to the formation
of new dentin.

Conclusion
It is my belief that using bioactive
materials in the provision of care for
my patients has been paramount to
the success of the care I have been
providing. In this way, I have provided ways to heal the dentition, enhance the restoration and improve
the health of my patients.
I believe we are on the threshold of
further bioactive material advancements and that learning and incorporating these restorative materials
into the day-to-day provision of care
will continue to help our patients,
our practices and our profession.

References
1. J. De Munck, K. Van Landuyt, M.
Peumans, A. Poitevin, P Lambrechts,
M. Braem, and B. Van Meerbeek. A
Critical Review of the Durability of
Adhesion to Tooth Tissue: Methods
and Results. J. Dent Res 84(2):118–132,
2005.
2. C. M. Amaral, DDS, MS, PhD; A. K. B.
Bedran-Russo, DDS, MS, PhD; L. A. F.
Pimenta, DDS, MS, PhD; M. S. Shinohara, DDS, MS; M. C. G. Erhardt, DDS,
MS, PhD. Effect of long-term water
storage on etch-and-rinse and selfetching resin-dentin bond strengths.
General Dentistry, May–June 2008 ,
Volume 56 , Issue 4, pp. 372–377.
3. Tay, Carvalho, & Pashley: Water
movement across bonded dentin —
too much of a good thing? J. Appl.
Oral Sci. vol.12, no. spe Bauru 2004.
The full list of references is availlable
from the publisher.

John C. Comisi,
DDS, MAGD, has
been in private
practice in Ithaca,
N.Y., since 1983.
He is a graduate
of Northwestern
University Dental
School and received his Bachelor of Science in biology at Fordham University.
He is a member of the American Dental
Association and its tripartite organizations, the Academy of General Dentistry,
the American Equilibration Society, the
International and American Association
of Dental Research, a research associate
at New York University Dental School
and an editorial board member of Dental Products Shopper Magazine. Comisi
is a Master of the Academy of General
Dentistry, and holds fellowships in the
Academy of Dentistry International, the
American College of Dentistry, the Pierre
Fauchard Academy and the International
College of Dentistry. He may be contacted
at jcomisi@jcomisi.com.

[14] =>

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 4/2018

Gold standard for chairside restorations
Highly esthetic and high-strength monolithic IPS e.max CAD restorations

By Dr Andreas Kurbad, Germany

suited for chairside manufacturing.
Such materials should be strong
enough to withstand a lifetime of
use. However, very strong materials
are difficult to process in a milling
unit, especially since onsite manufacturing processes are expected to
take only a short time. Furthermore,
the material should also exhibit a
tooth-like appearance in accordance
with a certain esthetic sensibility.
Onsite fabrication methods are not
conceived for elaborate enhancements, such as ceramic veneers. The
term “monolithic restoration” has
become established in this context.
This term describes a material that
meets the requirement for adequate
esthetic integration straight away,
without necessitating any reworking. Furthermore, the materials
should offer good conditions for
adhesive bonding, especially as ever
more tooth-preserving preparation
techniques are preferred (Table 1)

IPS e. max CAD has had a lasting impact on the dental market over the
last decade. The clinical reliability of
hardly any other dental material has
been so well documented. Highly esthetic and high-strength monolithic
IPS e. max CAD restorations have become an alternative to metal ceramics and offer a comparable survival
rate.

Introduction
As dental CAD/CAM systems have
become established in dentistry, the
vision of producing indirect restorations in the dental practice has become reality. An intraoral 3D camera
for digital impression-taking, an intuitive design software and a numerically controlled milling machine are
the technologies that enable restorations to be created onsite in a short
time compared to manufacturing in
the dental lab. In addition to the time
advantage, the digital method has
also the benefit of saving resources,
such as impression materials. Furthermore, the need for temporary
restorations is eliminated.

Fig. 1: IPS e.max CAD has had a lasting impact on the dental market over the last decade.

Note: Adhesive bonding achieves the best values if it
is performed immediately after tooth preparation.

Requirements placed on
materials for chairside
manufacturing

Historical review
The beginnings of CAD/CAM fab-

The technical prerequisites go hand
in glove with materials that are

ÿPage 16

Fig. 4: Defective restorations in the upper posterior region
in urgent need of repair
Fig. 2: Veneered and non-veneered MO restorations were evaluated and
compared with each other in this case. Although IPS e.max CAD MO is
typically a framework material, the differences between the two restorations are not at all that noticeable.

Fig. 3: Monolithic MO crown in situ

Fig. 5: Preparation with the gums in critical conditions

Fig. 6: The CEREC software V3.8 did not yet allow entire quadrants to be
reconstructed in a single step.

Fig. 7: Crowns directly after having been ground from IPS e.maxCAD LT

Fig. 8: Monolithic crowns after having been finalized, crystallized and
characterized.

Fig. 9: Because of the critical conditions of the gums, the crowns (2007)
are seated using a conventional cementation method with glass ionomer cement (Vivaglass CEM).

Fig. 10: Check-up of the crowns in 2012

Fig. 11: Situation after ten years (2017): The crowns are intact and do not
show any visible signs of damage. Abrasion facets can be observed, e.g.
on the bucco-distal cusps of the upper left 6.

Fig. 12: Two insufficient amalgam fillings needing to be replaced

Fig. 13: The cavities were restored with IPS e.max CAD HT restorations
produced at chairside.

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[16] =>

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 4/2018

◊Page 14

Fig. 14: The final result in 2008: beautiful optical integration

Fig. 15: Check-up after 5 years (2013): restorations still look beautiful

Fig. 16: The UR1 and UL1 of this 23-year-old female were damaged in an
accident and restored with composite material.

Fig. 17: As the result was esthetically unsatisfactory, the teeth were prepared using a planned, minimally invasive procedure.

Fig. 18: The exceptional optical properties of IPS e.max CAD Impulse O1
enable a completely natural appearance …

Fig. 19: … and provide a high brightness effect in direct light due to the
high level of opalescence and fluorescence.

e.max CAD MO blocks for creating
monolithic restorations, especially
for crowns, even if originally this was
not the intended use of the material
(Figs 2 to 3).

IPS e.max CAD and its
levels of translucency

Fig. 20: The teeth were restored to the correct proportions and the smile line was optimized. The patient was satisfied with the result.

Basic requirements for chairside materials
- Good resistance to oral conditions
- High strength
- Easy and fast machining in the milling unit
- Tooth-like esthetic characteristics
Table. 1

ricated chairside restorations can
be traced back to a certain feldspar
glass-ceramic. The first attempts of
the CEREC era began with the Vita
Mark I blocks. The material was further developed and for a long time,
Vita Mark II was considered the sole
standard for processing restorations
onsite. The material was relatively
easy to grind and polish and was

capable of fulfilling the esthetic requirements well. With a flexural
strength of 120 MPa, its field of application was, however, limited.
Adhesive cementation was indispensable to ensure a durable stability. By today’s standard, relatively
high minimum thicknesses were
required, resulting in a correspondingly high removal of tooth struc-

Fig. 21: The 3-year check-up did not show signs of ageing.

ture and, at times, unfavourable
geometries in the design of the cavities. The introduction of the ProCAD
blocks (1998) did not bring the decisive breakthrough either. This material was based on leucite-reinforced
glass-ceramic and featured a flexural
strength of 140 MPa. The blocks are
still available in an optimized version as IPS Empress® CAD or as IPS
Empress CAD Multi blocks (185 MPa)
to this very day. Although these materials produced good to very good
longterm clinical results, they always
entailed a risk for failure in the form
of fractures.

Introduction of
IPS e.max CAD
A new category of glass-ceramic materials brought about the decisive
improvement in 2005: lithium disilicate. This material was instrumental

in establishing CAD/CAM systems
for chairside applications. Ivoclar Vivadent launched the IPS e.max® CAD
material on the market. Initially, it
was available in MO blocks (Medium
Opacity) with a relatively high opacity. These blocks were designed for
the veneering technique (Fig. 1). This
meant that this material was, in the
main, inappropriate for chairside applications. However, this is not where
the story ends: Initial experiences
showed that the material was dotted
with excellent optical properties. In
addition, the manufacturing technology made the material attractive
for use in the dental practice even if
it required a crystallization process
of approx. 30 minutes. Above all,
it was the flexural strength of 360
MPa, which was clearly superior to
all materials used in this segment
so far. Soon we began to use the IPS

Driven by the excellent optical properties, users urged the manufacturer
to increase the translucency of the
blocks and to enable the fabrication
of monolithic restorations. Ivoclar
Vivadent responded by introducing
IPS e.max CAD LT in 2007 (Figs 4 to
11). LT stands for Low Translucency.
These blocks ensured results that
met a high esthetic standard, particularly when used in conjunction
with the accompanying IPS e.max
CAD Crystall./Shades and Stains
characterization materials. With its
user-friendly and compact design,
the Programat CS (2007) furnace facilitated the applications at chairside.
On the one hand, the LT blocks were
sufficiently translucent to mimic the
characteristics of the natural tooth
structure and, on the other, they
were sufficiently opaque to mask
“problematic” substrate. Even today, this material may still be called
a universal ceramic. Nonetheless, it
may be regarded as a step forward
that another level of translucency
was launched in 2009: These were
the HT blocks (High Translucency)
(Figs 12 to 15). If used in combination

ÿPage 18

Fig. 22: A patient wearing 10-year-old veneered zirconia crowns wants
her esthetic appearance to be improved. The crowns appear rather dark
and grey. The proportions look unflattering.

Fig. 23: The variation in the shade of the preparations made it necessary
to use a relatively opaque material that nonetheless provided a certain
brightening effect.

Fig. 24: The new restorations were ground from IPS e.max CAD MT.

Fig. 25: The preparations were effectively concealed under the new
crowns (cut-back method) and the brightness of the teeth was considerably increased.

Fig. 26: The final result shows a pleasing esthetic appearance.

Fig. 27: Preparation for a three-unit bridge with an ovate pontic design

[17] =>

[18] =>

RESTORATIVE

Dental Tribune Middle East & Africa Edition | 4/2018

◊Page 16

Fig. 28: Try-in of the ground monolithic bridge whilst still in the pre-crystallized state

Fig. 29: IPS e.max CAD allows the fabrication of restorations for esthetically sensitive areas without the need for veneering them.

Fig. 31: After the extraction and implantation procedure, the site was ready for the new
restoration.

Fig. 32: A monolithic hybrid abutment
crown was created on the basis of a Ti
base connector using CEREC software.
Crystallization and staining were again
carried out in a single step.

Fig. 30: The lower right 6 had been endodontically treated but could not
be saved because of recurring inflammatory processes.

Fig. 33: Beautiful result in 2012

Fig. 34: Check-up after five years: the result is proof of the success of this
therapy concept.

Fig. 37: The abutment was ground from an IPS e.max CAD Abutment
MO block and the crown from IPS e.max CAD LT.

with an appropriate luting material,
this blocks allowed the shade of the
substrate to be integrated into the
overall optical effect of the restoration. This meant that partial crowns
and veneers could now be created
with ease directly onsite in a single
visit. The trend towards ever less
invasive procedures led to the introduction of still another variant of IPS
e.maxCAD: the Impulse materials
(2011). Impulse Opal O1 and O2 are
ideal for fabricating monolithic restorations with the aim to reproduce
dental enamel. Outstanding results
can be achieved with comparatively
minimal effort. As many users had
difficulty in classifying the Impulse
blocks appropriately in the product
portfolio, some parts of the assortment were taken over into the recently created category MT (Medium
Translucency, 2015). The IPS e.max
CAD materials of the medium translucency category are mainly used
to improve brightness values. Altogether, five different levels of translucency are available today. With this
“toolkit”, monolithic restorations offering an utmost level of esthetics
can be accomplished in a variety of
clinical situations. The Shade Navigation App assists in selecting the correct translucency. In a few easy steps,
this app provides useful recommendations on the selection of the correct blocks.

Fig. 35: The tooth had already been endodontically treated and restored
with a PFM crown. After a root fracture, it could no longer be preserved.

Fig. 36: Extraction and immediate implantation was followed by a temporization phase, at the end of which a pleasing emergence profile had
developed.

Fig. 38: The completed restoration in 2012: a pleasing result.

Fig. 39: Check-up after 5 years is proof to the long-term stability of this
treatment concept.

able the onsite fabrication of bridges
(up to the second premolar as the
terminal abutment). In this case, the
processing time is longer than for
single-tooth restorations. With the
HT variant, inlays, onlays and partial
crowns can be manufactured to a
high esthetic standard.

Range of indications
for chairside applications

At IDS 2017, Ivoclar Vivadent
launched the IPS e.max CAD 530
MPa initiative. Eleven years of continued quality testing have shown
that IPS e.max CAD provides actually a mean biaxial flexural strength
of 530 MPa. This is also reflected
in the consistently positive results
of many scientific studies on the
survival rate of IPS e.max CAD restorations (literature). In view of the
consistent further development and
favourable longterm clinical results,
the minimum thicknesses recommended for adhesively cemented
IPS e.max CAD crowns have been
reduced to thinner dimensions.
This means that preparing the teeth
is easier and more tooth structure
can be preserved. It also allowed the
range of indications to be extended
to include occlusal veneers, which
have come to play a key part in raising the bite in the posterior region.
Since the introduction of the optically brilliant Impulse blocks (Figs 16
to 21) and the MT materials (Figs 22 to
26), IPS e.max CAD has barely been
rivalled for strength and esthetics in
the fabrication of veneers and partial
anterior crowns.

The range of indications for IPS
e.max CAD evolved in tandem with
the provision of the blocks. The LT
variant is the first choice for crowns
and indications that involve “problematic” substrates. Larger blocks en-

In 2013, abutment blocks made of
IPS e.max CAD were launched. These
blocks are cemented to an adhesive
base (Ti base) (see Figs 31 and 32).
Thus, it has become possible to cre-

ate single-component monolithic
restorations, which are referred to as
hybrid abutment crowns. The chairside production of such crowns is
realistic and has established itself as
a standard among CAD/CAM users
for fabricating implant-supported
single-tooth restorations in the posterior region.

cess. As the material is considerably
easier to process when it is in its precrystallized blue state, corrections
should be implemented directly at
the grinding stage. A try-in can be
performed before the crystallization
process is carried out if the restoration is machined onsite (Figs 27 to
29).

Typical workflow

Crystallization is a mandatory step
in the IPS e.max CAD workflow. The
restoration is secured on a special
firing tray with the help of support
pins and firing auxiliary paste (IPS
Object Fix). Polishing is basically possible. However, it is also possible to
apply a spray glaze or glazing paste.
Individualized shade characterizations can be created with IPS e.max
CAD Crystall./Shade/Stains materials at the same time as the glaze is
applied. The crystallization process
takes 15 minutes in the best case
when using the spray glaze (speed
crystallization), otherwise it takes 25
minutes. Developed specifically for
the chairside method, the Programat
CS furnaces (e.g. the new Programat
CS4 universal furnace) provide optimum results in the shortest possible
time and are therefore a sensible recommendation (Figs 30 to 34).

Preparation is mostly minimally
invasive due to the high strength of
the material. There are no differences with other types of restorations
when it comes to optical impressiontaking and computer-assisted design. The differences only become
noticeable during processing in
the milling and grinding machine.
Lithium disilicate is a material that
cannot withstand unlimited forces.
Gentle processing is essential. The
grinding process for a typical posterior crown takes on average 15 minutes if an MC XL milling unit is used
(Dentsply Sirona). The precision can
be increased by using the extra fine
processing option. The processing
time doubles with this option.
The future lies in the use of new
technologies. The PrograMill One
milling and grinding machine will
deliver significantly better results in
less time as it incorporates innovative new technology. For instance,
the 5-axis turn-milling technology (5 XT) uses a robotic arm, rather
than a milling motor, to move the
workpiece. This enables a consistent milling and grinding procedure
with many degrees of freedom and
increased levels of accuracy. Only
a minimal amount of reworking is
required after the machining pro-

Thanks to the high strength of the
material, several options are available for seating the restorations.
Adhesive bonding should always be
the preferred method. Conventional
cementation is also possible but requires a retentive preparation pattern, which is considered outmoded
by today’s standard.
Monobond® Etch&Prime (etching
and silanating in a single step) can

be used for conditioning the ceramic. Which kind of cementation
is used depends on the clinical situation. Posterior crowns can be seated
quickly and easily using the self-adhesive SpeedCEM® Plus. For higher
esthetic requirements, Variolink Esthetic should be employed. This material is available in a dual-curing and
purely light-curing version. More information and guidance is provided
by the Cementation Navigation System (CNS).

Conclusion
IPS e.max CAD is the gold standard
for chairside restorations (Figs 35 to
39). Together with the Programat
furnaces designed for IPS e.max CAD
and the corresponding cementation
materials, a coherent system that
ensures the necessary robustness
in a wide range of applications has
been developed. IPS e.max CAD sets
benchmarks for efficient, tooth-preserving all-ceramic restorations that
offer a high level of clinical reliability. The new zirconium oxide blocks
(IPS e.max ZirCAD LT) complete the
overarching IPS e.max system, in
line with the motto IPS e.max – all
ceramic, all you need.
Editorial note: Literature is available
on request from the editors

Dr Andreas Kurbad
Dental practice/EC
Excellent Ceramics UG
Viersener Strasse 15
41751 Viersen
Germany
www.kurbad.de

[19] =>

Mastership Programme
Lasers in Dentistry
Certiﬁcation Course

From Aachen Dental Laser Center &
RWTH International Academy - RWTH Aachen University & CAPP

DUBAI
AACHEN

Group 6
Registration Open

Prof. Dr. med. dent.
Norbert Gutknecht
DDS, MS, PhD
Germany

Dr. Dimitris Strakas
DDS, MSc, PhD
Greece

Dr. Miguel Rodrigues Martins
DDS, MSc, PhD
Portugal

Priv.-Doz. Dr. rer. medic.
Rene Franzen
Germany

Pathway to
German Masters
84 CME
& Daily Hands-on

One-year clinical specialisation course for selected wavelengths
Module 1 | 21-24 November 2018 (4 days) | Laser Safety, Laser Devices and Diode Lasers
Laser Safety Officer course | e-learning | Laser technique (Diode lasers) | High power Diode lasers (clinics) |
Scientific background and clinical indications | Skill training every day of every clinical indication | Patient treatments (demonstrations)
Hands on: Pigmentation on soft tissue, gingivectomy and gingivoplasty, frenectomy, fibroma removal, crown lengthening,
depigmentation, endodontic procedure- canal irradiation performed on sheep heads | Patient treatments (demonstrations)
Module 2 | 06-09 March 2019 (4 days) | Module Erbium Lasers
Erbium Lasers (clinics) | Laser technique (Erbium lasers) | Er:YAG and Er,Cr:YSGG | Scientific background and clinical indications |
Skill training every day of every clinical indication | Patient treatments (demonstrations)
Hands on: Preparation in enamel and dentine, generation of a retentive surface, canal decontamination, apicectomy, soft-tissue
cut with short pulses, soft-tissue cut with long pulses, open curettage, crown lengthening and bone preparation performed on
sheep heads. | Patient treatments (demonstrations)
Module 3 | 08-11 December 2019 (4 days) | Combined Wavelengths Therapy Concepts & Mastership Exams
Laser therapy concepts with the use of 2 different wavelengths | Written multiple-choice exam |
Oral Exam (presentation of 5 patient treatments cases with diode or Erbium lasers) |
Graduation Ceremony, after successful completion of an examination at RWTH Aachen University |
600 hours total workload | Over the complete course duration: case documentation & discussions
The programme targets dentists who would like to specialise in certain wavelengths. Over the course of one year, participants are taught fundamental
physical and technical knowledge, and how to recognise primary, secondary, and tertiary indications on 12 attendance days split into 3 modules held
over 3 educational blocks. This programme concludes with an official certificate of RWTH Aachen University, and is offered in collaboration with the
RWTH Aachen International Academy, the post graduate education wing of the University..

+971 528423659 | p.mollov@cappmea.com

www.cappmea.com/laser

[20] =>

restorative

Dental Tribune Middle East & Africa Edition | 4/2018

SDR® Plus – The Ideal Bulk-Fill Material in
High-C Factor Cavities
By Dentsply Sirona
The configuration of post endodontic treatment cavities are typically
deep. If the surrounding tooth structure is still intact, there will be a high
C-factor (cavity configuration factor)
due to the large surface area for the
filling material to bond to.
Polymerisation shrinkage stress
builds up inside a cavity according
to the size of the bonded surface area
that is holding a composite in place.
The larger the bonded surface area
the higher the level of polymerisation stress, resulting in an increased
risk of composite detachment from
the cavity walls or marginal leakage.
Not only does this result in a failed
restoration, it also poses risk to the
integrity of the endodontic procedure underneath¹.
SDR® Plus from Dentsply Sirona is
the ideal material for coronal sealing of endodontic cavities especially
with high C-factors. SDR® Plus can be
bulk-filled in increments of 4mm due

to its patented formulation which
provides the necessary viscoelastic
properties for low-stress, controlled
polymerisation2. As a result, SDR®
Plus has up to 60% lower shrinkage
stress3 than competing conventional
and bulk-fill composites. In addition,
SDR® Plus has unique self-levelling
properties which allow it to automatically adapt to the geometry of
a cavity. This, in combination with
the fact that SDR® Plus has sufficient
mechanical strength for use in the
posterior region, high micro tensile
bond strength and has shown excellent adhesion to the cavity-floor,
makes SDR® Plus the ideal material
for post endo, high C-factor access
cavities.

Case Study
The present case shows the use of
SDR® Plus for coronal sealing and
bulk-filling of endodontic cavities in
one single step.

Conclusion
Given the depth of many access
cavities, the possibility of bulk-filling

Before

After

cavities is also important in post-endodontic treatment. In the present
case SDR® Plus was used to fill Class I
and II cavities in bulk up to 4mm immediately after the root canal treatment. The self-levelling consistency
as well as the reduced polymerisation shrinkage stress of SDR® Plus in
cavities (Van Ende et al. 2016), allows
both optimal adaptation and adhesion to the cavity and thus coronal

sealing of the root canal filling. Another advantage of this bulk-filling
composite is its transparency allowing an easy retrieval of the root canal
filling, e.g. in case of a subsequent
post placement.

ing and the coronal restoration. University of North Carolina, Chapel Hill,
Temple Dental School, USA. Int End J
(1995) 28, 12-18.
2. Data on file
3 Data on file

References
1. Trope, M: Periapical status of endodontically treated teeth in relation to
the technical quality of the root fill-

For more information or to request a
demo, please contact your local Dentsply
Sirona representative.

Fig: 1. Direct restorations Class I and II after endodontic treatment. The access cavities show the root
canals.

Fig: 2. The root canals were obturated with GuttaPercha and AH® Plus sealer.

Fig: 3. Etching procedure with phosphoric acid gel
(DeTrey® Conditioner 36).

Fig: 4. After rinsing and drying of the cavity the universal adhesive Prime&Bond universal™ was applied.
The adhesive was gently air-blowed and light-cured.

Fig: 5. Bulk-filling (one increment, up to 4mm) of the
Class I cavity with SDR® Plus and subsequent lightcuring for 20 secs.

Fig: 6. Occlusal surface was restored with the universal composite ceram.x® SphereTEC™ one.

Fig: 7. In this case study a circumferential matrix band
was placed around the second tooth followed by the
application of Prime&Bond universal™ adhesive. It
would be recommended to use a sectional matrix
system such as Palodent® V3 for more accurate and
contoured contacts.

Fig: 8. After bulk-filling the Class II cavity with SDR®
Plus the occlusal surface was reconstructed with a
2mm layer of ceram.x® SphereTEC™ one.

The Rivelin patch sticks to the mucosal surface
for much longer than any other treatment
By Brendan Day, DTI
Though the oral mucosa’s accessibility and high level of blood supply
make it an ideal site for drug delivery, various other factors can make
drug delivery quite difficult. However, a new polymer plaster, the Rivelin
patch, developed by scientists from
the University of Sheffield’s School
of Clinical Dentistry in collaboration
with Dermtreat from Copenhagen
in Denmark, has the potential to

revolutionise the treatment of oral
conditions. Dental Tribune International spoke with Dr Craig Murdoch, Reader in Oral Bioscience at
the university and lead author of the
research, about how the patch works,
its benefits and upcoming plans for
clinical trials.

What was it that motivated
you and your team to develop
the Rivelin patch? Was it de-

signed to target any specific
conditions?
There are very few ways to deliver
drugs to the oral mucosa. The current methods use mouthwashes,
gels, creams or sprays that are delivered to the entire lining of the
mouth, in which case they affect
both healthy and diseased tissue. In
addition, drugs that are delivered
using these methods have short
contact times with the diseased tissue before they are washed away, so

delivering drugs this way is often ineffective or requires the use of high
drug concentrations to reach a therapeutic dose.
I have worked in the oral medicine
unit at the University of Sheffield’s
School of Clinical Dentistry for over
ten years alongside Prof. Martin
Thornhill, a world-leading expert in
oral medicine. Thornhill, along with
many other oral medicine consultants, has known for some time about

the inadequate treatments for oral
conditions. The issue has been with
the development of a patch that is
able to stick to the moist surface of
the oral cavity, and the willingness
of polymer chemists, drug delivery
specialists and commercial enterprises to identify this unmet clinical
need.

ÿPage 21

[21] =>

interview

Dental Tribune Middle East & Africa Edition | 4/2018

◊Page 20
The project really took off when we
were approached by Jens Hansen
to enter into collaboration. Jens had
worked extensively in the pharmaceutical industry and was involved
in developing patches for skin treatments. The collaboration started in
May 2014, simply as an idea to produce a patch to help people with
chronic inflammatory oral conditions—a large group of patients that
were receiving sub-optimal therapy.
Since then, Jens has established Dermtreat in Copenhagen, and together
with a diverse group of academics,
we have developed the Rivelin patch.
The patch has been specifically designed to treat people suffering from
oral lichen planus—an inflammatory disease—and oral aphthous
ulcers, although the clinical trial will
only be conducted on ulcerative oral
lichen planus.

Dermtreat has been central to the
development of the patch. Without
its funding and industrial knowledge, the development of the patch
would not have occurred. Likewise,
without the experimental knowledge and expertise of researchers at
the University of Sheffield, the patch
would not have been developed.
Both parties acknowledge the crucial
input the other had in the project.
This is a very healthy relationship
that has fully benefited the research
as a whole.

Phase two clinical trials for this
patch are set to take place at
several sites in the US and the
UK. Has it been determined
where and when exactly these

trials will take place, and when
will they begin?
In the UK, the trials will take place in
Sheffield and Leeds and at two hospitals in London. The European arm
of the trials will be coordinated from
Munich whilst the US trials will be
coordinated by Michael Brennan at
the Carolinas Center for Oral Health
in Charlotte in North Carolina. They
will commence in late July, with the
first recruits most likely being in the
US.

The Rivelin patch, a new polymer plaster developed by scientists from the University of
Sheffield’s School of Clinical Dentistry, will soon undergo phase two clinical trials. (Photograph: Craig Murdoch)

How does the patch actually
work?
The patch is made using electrospinning technology. Here, the drug—in
this instance, clobetasol—is incorporated into very fine polymer fibres
that form a mesh-like lattice as the
patch is made. This creates a patch
with a very large surface area, which,
along with specially selected adhesive polymers, allows the patch to
adhere to the moist surfaces of the
oral cavity. It’s a bit like the hairs on
the feet of a gecko—they provide a
large surface area so that they can
stick to walls and then climb them.
Once adhered, the moisture on the
oral mucosal surface interacts with
the polymers, causing the release of
the steroid or drug directly into the
diseased tissue. Because the patch
has a backing layer, the steroid release is unidirectional—into the
tissue only—and none is released
into the oral cavity. This means that
healthy tissue does not come into
contact with the drug.

What benefits does it offer
over conventional treatment
methods for oral lichen planus
and recurrent aphthous stomatitis?
The patch offers targeted release of
drugs directly into the diseased tissue. Our data shows that the patch
will stick to the mucosal surface for
a much longer time than any other
current treatment. This makes the
contact time between the drug and
the oral lesion greater than any other
method currently used, thereby providing greater therapeutic benefit.
The close contact of patch and lesion over a longer period may also
mean that, compared to our current
methods, smaller drug amounts are
required to treat lesions.

Innovative and Digital Solutions in Dentistry
Join us for the inaugural MENA Summit: Innovative and
Digital Solutions in Dentistry to find out more about how
we’re driving innovation and digital dental solutions to
improve oral health in the Middle East and North Africa.

Sharm
El Sheikh,
Egypt

More details to follow...

26th – 29th
September

2018

Does the patch have any potential for treating other oral
conditions?
Yes. It is highly likely that just a
plain patch without a steroid could
be used as a covering for an oral
wound—it would prevent bacteria
entering the wound and so aid healing. Though the clinical trial will
be for oral lichen planus, the patch
could be used to treat several other
inflammatory oral conditions, such
as aphthous ulcers, that affect a large
proportion of the population. We are
also working with Dermtreat to create new patches containing other
drugs that would be useful in an oral
setting. The patches are able to incorporate many drugs, so this flexibility
holds much promise.

What role has Dermtreat
played in the development of
the Rivelin patch?

Save the date...

[22] =>

news

Dental Tribune Middle East & Africa Edition | 4/2018

When art and science meet the digital world
Ivoclar Vivadent hosted the 4th International Expert Symposium
“The Quality of Esthetics” in Rome this year.
By Ivoclar Vivadent AG
Rome provided the attractive backdrop for this year’s International
Expert Symposium organized by
Ivoclar Vivadent. The fourth event of
the series “The Quality of Esthetics”
took place from 15 to 16 June 2018 at
the trendy cultural palace Parco della
Musica in one of Rome’s new architectural highlights. Eighteen worldclass speakers shared and discussed
concepts in dentistry and dental
technology that aim to provide highquality patient care in the modern
age of digital change.
The symposium was held under
the topic “Advanced digital and esthetic dentistry” and attracted 1,000
participants from all continents to
Italy’s capital. In view of the pressing
questions related to the digital developments currently taking place, the
symposium was extended to two
days. In addition, breakout sessions
provided deeper insight into specific
topics. In his welcome address, Robert Ganley, CEO of Ivoclar Vivadent
AG, said: “The international symposium is a platform where research-

Dr. Andreas Kurbad

ers, opinion leaders and users in the
clinical and technical field of dentistry can exchange views and learn
from each other.”

From analogue to digital
How can users who learned the ins
and outs of their trade in the analogue world make smart use of digi-

tal technology in the workplace? This
question was central to many speakers at the symposium. Representing
the views of many of his colleagues,
Dominique Vinci, dental technician
from Switzerland, maintained that
digital technology offers advantages
at many stages in restorative dentistry, starting from optical impression-

taking. Oliver Brix (Germany) stated
that in spite of all the advantages
offered by digital technology, the
knowledge and expertise of the dentist-technician team, a clear vision of
the treatment goal, competent planning, skilful and patient-oriented
finishing and, above all, dedication
and passion would remain decisive
for the success of dental restorations.
To demonstrate his views, he showcased several patient cases in which
a blend of conventional and digital
techniques were skilfully used to
achieve astonishing results. Similarly outstanding results were also
shown by Dr Andreas Kurbad (Germany) and Professor Dr Stefan Koubi
(France) together with Hilal Kuday
(Turkey). A comparison of analogue
and digital protocols in removable
prosthodontics was provided by an
Italian team of four, consisting of Dr
Pietro Venezia and Dr Alessio Casucci and dental technicians Pasquale
Lacasella and Alessandro Ielasi. Their
views were consonant with those of
their colleagues and they were echoed by dental technician Stefan Strigl
(Italy) who stated: “Neither dentists
nor technicians are handing over
the reins to technology; it is only the
tools that change.”

Strategies for daily work
If you want to apply new materials
and strategies, you want to be confident that you can rely on them.
Using the example of an implant
reconstruction in the esthetic anterior zone, Priv. Doz. Dr Arndt Happe
(Germany) and master dental technician Vincent Fehmer (Switzerland)
tested the waters of the latest dental technology. Their findings were
elaborated by Dr Mirela Feraru and
Prof. Dr Nitzan Bichacho (Israel) who
presented the concept of “Cervical
Contouring” to achieve natural soft
tissue integration, drawing from several clinical cases.

Guided by nature
Irrespective of whether conventional
or digital processes are used, the result is what matters in the end. This
was shown particularly clearly in a
case involving bone augmentation
planning, presented by Dr Francesco
Mintrone (Italy). His advice was to
look carefully at new software, hardware and materials before starting
to use them as they vary in performance capabilities. The importance
of an informed decision-making
process was also emphasized by Dr
Victor Clavijo and dental technician
Murilo Calgaro (Brazil): preparation,
shade matching and ingot selection

Dr. Stefen Koubi

need to be considered when choosing a material to be sure that the natural tooth structure can be rebuilt as
closely to nature as possible.
The maxim that nature should be
the guide – rather than a zest for e.g.
maxing out limits – was also central
to the presentation of Dr Gianfranco
Politano (Italy). He advocated using
of a simplified protocol, involving
restorations in only two increments
(Class II) and an efficient cusp buildup to recreate the occlusal morphology in the posterior region.

In dialogue with attendees
The attendees were encouraged to
participate in the presentations.
To facilitate audience participation, Ivoclar Vivadent designed an
event-specific app where questions
could be posted. The questions were
answered by Professor Francesco
Mangani, event moderator, and the
speakers in live Q&A sessions at the
auditorium. The dialogue was continued in a relaxed atmosphere at
the “Ivoclar Vivadent and Friends”
gala dinner on the hill of Monte
Mario. The guests enjoyed resplendent views of Rome and the nearby
Vatican in the sunset.
The dialogue with dentists and
dental technicians will be continued. At the end of the event, Paolo
Castoldi, Managing Director of the
Ivoclar Vivadent subsidiary in Italy,
announced the next edition of the
International Expert Symposium,
which will be held in Paris in two
years.

Ivoclar Vivadent AG
Bendererstrasse 2
9494 Schaan/Liechtenstein
Phone: +423 235 35 35
Fax: +423 235 33 60
E-mail: info@ivoclarvivadent.com
Web: www.ivoclarvivadent.com

[23] =>

[24] =>

DIgITAL DEnTISTRy

Dental Tribune Middle East & Africa Edition | 4/2018

Substitution of two destructive caries
with ceramic CAD/CAM crowns in one visit
By Dr. Pricolo Alfonso, Italy

Introduction
Recently, several new ceramic materials were launched in the market
due to the growing demand of safety
and aesthetically pleasing prosthetic
solutions. CAD/CAM chairside technology has been developed with the
aim of manufacturing prosthetic
structures with characteristics of
constant quality. CAD/CAM technology not only offers the possibility of
directly designing a restoration on a
computer and automatically obtaining the final product, but also offers
many advantages compared to the
conventional techniques in terms of
speed, precision and ease of use. The
following case shows how MyCrown
CAD/CAM chairside can change traditional dentistry by opening new
ways of solving for both aesthetic
and health issues.

Patient first contact
A 52-year-old woman came to my
practice due to acute pain in the

region of the first quadrant. After a
careful, intraoral and radiographic
objective examination, we diagnosed destructive caries of teeth 14
and 15.
In the first instance, we performed
root canal treatment of the teeth and
consequently reconstructed both
of them with Fiberglass Posts and
covered them with ceramics manufactured with FONA MyCrown CAD/
CAM system.

Fig. 1: Teeth preparation

Fig. 2: MyCrown view of the concerned teeth

Fig. 3: Upper jaw scan

Treatment
In order to perform the endodontic
treatment, we used glasses Zeiss 4.3
x 400. The canals were treated with
a protocol, which involves washings
by using NaClO and EDTA, while for
shaping the canals we used instruments Ni-Ti Protaper gold and, in
order to seal them, gutta-percha, associated with the use of pulp canal
sealer.
After the root canal treatment, a
portion of gutta-percha, 8mm deep,

Fig. 4: Contact points

Fig. 5: Margin tracking

was removed from the canal and
the dentin was etched with 37% orthophosphoric acid for 30 seconds
and washed with water for 30 seconds more. Afterwards, we inserted

Fig. 6: Software proposal of crowns

the fiberglass pins inside the canals
and we cemented and reconstructed
them with Relyx Unicem. Subsequently, the teeth were prepared
with gingival chamfer Iuxta.

brand new crowns, in order to make
them look like real teeth.

After the shoulder preparation, we
moved on the treatment with MyCrown. Thus, an OptraGate-type
dam was positioned in the mouth of

After performing the silanization
process inside the crowns, the cementation was done once again using Relyx Unicem. The crowns seem
to be perfectly coinciding and integrating with the surrounding teeth,
totally closing the margins previous-

Fig. 7: Final result from side

Fig. 8: Final result from below

BORA
& PRESTIGE

INNOVATION AND TECHNOLOGY
Fig. 9: Manufactured crowns

the patient and some dry tips were
used in order to control the salivation coming from the Steno Duct.
Later on, HD Spray was applied and
the scan with MyCrown Scan camera started. First, we scanned the
stumps, then the antagonists, and
finally we proceeded with scanning
the vestibular area, with the teeth in
position for maximum contact.

UP TO 3 YEARS WARRANTY
2-year standard warranty and 1-year optional
warranty available through Bien-Air’s PlanCare
extended warranty program.

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After correlating the models with the
software, we started tracing the margins. Moreover, after the definition
of the insertion axes, MyCrown Software gave us its design proposal of
the crowns. Obviously, software proposal of the crown design is based
on the anatomy of the other teeth of
the patient. This does not prevent us
from modifying the tooth anatomy
based on the neighbor and antagonist teeth.
Later on, after checking the contact
points with the neighbor teeth and
the occlusal contacts with the antagonists, we were able to proceed with
the manufacturing phase. Once the
milling process was over, we moved
on to polishing and painting of the

ly prepared. Therefore, no occlusal
retouching was done. The patient
left our clinic satisfied with the precision, the little time spent and the
aesthetic result.

Conclusion
This clinical case demonstrates how
fast, easy and precise it is to work
with FONA MyCrown CAD/CAM
chairside system. The woman needed surgical intervention because of
a severe pain and after only one visit
she went home relieved from this
pain and with a perfect aesthetic result. All this has been done with absolute safety and efficiency, without
loosing time.

Dr. Pricolo Alfonso
He graduated from
the University “Seconda Università degli Studi di Napoli” in
Naples in the 2005,
achieving a degree in
Odontology and Dental Prosthesis.

[25] =>

digital dentistry

Dental Tribune Middle East & Africa Edition | 4/2018

Capturing the right image
By Carestream Dental
Over the past few decades, there
have been advances in all branches
of dentistry, such as the further development and increasing provision of dental implants and the use
of a broader range of orthodontic
treatments. These improvements
have led to the need for diagnostic
tools that are more precise, enabling
more detailed and accurate imaging
within the dental practice.1 For this
reason, many dental professionals
have moved away from the use of
analogue radiography and have incorporated digital imaging systems
into the practice instead.

for a range of tasks, from traditional
panoramic examinations to endodontics, implant planning, oral surgeries and orthodontic applications.
This system includes feature-rich
imaging software that helps with the
analysis of the images and has multiple sharing options (e.g. email and
USB). The option of cephalometric
scanning is also incorporated with
3D technology in the CS 8100 3D SC
system.

Systems that are ideal
for every practice
The range of options in the CS 8100
family means that there is a system

suitable for every practice. As all of
the units have the benefit of being
ultra-compact, they can easily fit
into tight spaces within almost any
practice. In addition, they are accessible to all users and require minimal
training, and can be easily integrated
with the practice’s current processes
for a streamlined workflow.
As the CS 8100 digital imaging family of units from Carestream Dental
combines the most advanced, sophisticated imaging technology in
an easy-to-use system, images can
be captured in just seconds, which
not only allows the dentist to spend

less time waiting for images and
more time caring for patients but
also helps in the provision of a broad
range of treatment options.

CS 8100 3D

1. Shah N, Bansal N, Logani A. Recent
advances in imaging technologies in
dentistry. World J Radiol 2014;6:794807.

For more information, visit www.carestreamdental.com
For the latest news and updates, follow us
on Twitter @CarestreamDentl
and Facebook

Benefits of digital imaging in
dentistry
The use of digital imaging systems
within dental practices has many
benefits. For example, these systems
make the acquisition of images faster and easier, which is better for both
the dentist and the patient. There is
also a lower radiation dose compared
to film-based radiography. In addition, the variety of digital imaging
equipment that is available can help
with the wide range of tasks that are
required within a practice, ranging
from the diagnosis of dental diseases
to the provision of dental implants.

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

The best system for the job
As dental practices can offer a broad
range of treatments, it is necessary
to have a digital imaging system
that has the capability to provide
the appropriate type of image. The
digital imaging systems available
for dentistry include both 2D and 3D
systems, with options for panoramic
imaging and cephalometric imaging.
While 2D digital imaging systems are
suitable for general dental practice,
3D systems are valuable when it is
desirable to have additional detail for
more advanced diagnosis and treatment planning, such as in the case of
traumatic injuries or implantology.
A family of digital imaging systems
The CS 8100 family of digital imaging systems provided by Carestream
Dental encompasses this wide range
of needs. The CS 8100 family was
named The Dental Advisor’s ‘Top
Panoramic Imaging System of 2014’,
with a 99% rating and an Excellent
Five Plus designation and it has been
supplied to well over 10,000 dental
professionals. The family includes
the CS 8100 unit that offers 2D
panoramic imaging, the CS 8100 SC
system that combines both 2D panoramic and cephalometric imaging,
and the CS 8100 3D and CS 8100 3D
SC systems that provide the benefits
of sophisticated 3D technology.
The CS 8100 system minimises spinal column shadows to produce clear
and sharp high-quality images that
are ready for view in just 10 seconds.
Compared to other traditional panoramic units, the CS 8100 features a
wider and thicker focal trough.
The CS 8100 SC system offers one
compact and easy-to-use system,
and it is ideal for everyday orthodontic treatment. It offers very fast
cephalometric scanning in as little as
three seconds.
The CS 8100 3D system provides
the benefits of 3D technology in one
versatile system that covers a broad
range of applications. It is ideal for
daily use and it can capture accurate
3D images in seven seconds. The
CAD/CAM abilities make it useful

WORKFLOW*/5&(3"5*0/ I HUMANIZED5&$)/0-0(: I DIAGNOSTIC&9$&--&/$&

Discover smarter scanning with the CS 3600 family
Thanks to its genius-like features, the CS 3600 family allows you to enjoy intraoral scanning that’s
more intuitive, efficient and powerful. You’ll end up with a smarter acquisition process and the ability
to improve clinical outcomes.
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
t &MJNJOBUFTNBOVBMQPTUTDBOBEKVTUNFOUCZBVUPNBUJDBMMZSFNPWJOHVOXBOUFE
soft tissue
Best of all, the CS 3600 surpasses the competition by delivering the best performance
for overall trueness.*

© Carestream Health, Inc. 2017. 15978 AL CS 3600 PA 0917
*
“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

[26] =>

26

news

Dental Tribune Middle East & Africa Edition | 4/2018

Award winning poster presentations
By Dental Tribune MEA / CAPPmea

ble to win the following awards:

The 10th Dental Facial Cosmetic
Conference in Dubai welcomes submission of abstracts to be presented
during the event that will take place
in InterContinental Hotel, Dubai Festival City on 09-10 November 2018.

All presenters are required to register
for the meeting and pay the appropriate registration fee. The organiser
supports 30% OFF of the registration
fee for the candidates.

Presenters of accepted abstracts are
expected to register for and attend
the event. All accepted abstracts will
be published in a supplement of the
Dental Tribune Middle East and Africa newspaper. Judges will review
all poster and oral abstract presentations and select winners and be eligi-

Abstracts will be presented by poster
format and jury will be asking several
questions about the work presented.
Abstracts can be submitted on the
webiste of the event www.cappmea.
com/aesthetic/poster_presentation.
Deadline for submission is 01 October 2018.

Poster presenters during the last event of CAPPEvents, 13th CAD/CAM & Digital Dentistry Conference

Prof. Dr. Liliana Porojan, Romania

Dr. Dalia Hisham Kokash, Jordan

Dr. Omar Hussein Hallak, Lebanon

Dr. Mai El Najjar, Canada

The 1st place winner Dr. Adrian Mihai
Varvara, Romania with his spouse

[27] =>

THE NEW NiTi FILE GENERATION

HyFlex CM & EDM
™

Stays on track

 High flexibility
 Extreme resistance to fracture
 Centred canal preparation
 Regeneration by thermal treatment

BIOACTIVE SEALING AND FILLING

®

GuttaFlow bioseal
Double safety level
 Cost efficient root filling
 Excellent flow properties even
at room temperature
 Fast working, fast curing, safe
sealing (about 12-16 minutes)

003742

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Step 1 (direct protection)

Step 2 (sleeping protection)

Protection already at filling, e.g. with
bioactivity due to possible residual
moisture in the root canal

Regenerative protection against
possible moisture ingress, e.g.
by cracks

[28] =>

news

Dental Tribune Middle East & Africa Edition | 4/2018

Why the best dentists never
stop learning
By Tipton Training
Just how valuable is education in
dentistry? According to one of the
UK’s leading dental academies, Tipton Training represented by CAPP in
Dubai, it has the power to transform
careers for the better – often giving
dental professionals greater job satisfaction, increased income and flexibility.
For over 25 years Tipton Training has
been helping dentists further their career. During this time over 3,000 delegates have successfully completed the
institution’s courses. On such dentist
is Colin McClure.
“I first considered a career in dentistry
when my older brother of five years
went to study it at Cardiff university,”
explains Colin.
“I’d always liked fixing things, solving
problems and helping people. This
seemed like the ideal career for me. I
graduated from Glasgow University
in 2003 and carried out my vocational
training year in Oban and stayed on as

an associate the year after. Following
this I moved back to Glasgow where I
worked as an associate for six years before setting up my own practice in the
Southside of Glasgow in 2011.”
Since that time, Colin’s practice,
Whitecart Dental Care, has gone from
strength-to-strength – growing to a
team of 11 and servicing 6,000 patients. In 2016, it was named ‘Practice
of the Year’ at the Scottish Dental
Awards.

Why Tipton Training?
So why invest in more education with
Tipton Training? Colin puts it down to
his love of learning and ambition to
the best dentists he can be.
“After the first few years of setting up
my practice and once my children
were a little older, I had some more
time on my hands. I really enjoy dentistry. I enjoy learning and wanted to
provide the best possible care for my
patients,” explains Colin.
“I was also a VT trainer involved in

teaching newly qualified dentists
and wanted to have a more solid
knowledge base. I asked friends and
colleagues where they would recommend for post graduate training. In
Scotland we’re still very fortunate to
actually get paid to take part in CPD.
Unfortunately because of this I feel
that many dentists are reluctant to invest in quality post graduate courses.
My brother who is a dentist in Cardiff
was looking into Paul Tipton’s courses.
He told me that Paul was the best. After researching him myself, I signed
up for The Restorative Course.”

Engaging Course Content
Unlike other dentistry courses, Colin
found Tipton Training’s materials engaging and easy to reference.
“When I first started in dentistry, I
found the reading material very time
consuming. A lot of it was very old,
didn’t seem to be particularly relevant
and quite a heavy read,” explains
Colin.

Creating natural smiles

Since 1995

www.mdentlab.com - info@mdentlab.com
+971 4 3329201 - whatsapp: +971 557590217

“Tipton Training is the opposite. Paul
is very good at bringing everything together and explaining not only what
you do but why you do it. The reading list creates a solid foundation to
base your treatments on. If ever challenged on why I’m doing something
I can confidently refer back to a paper
which backs my treatment up.
“I would absolutely recommend it to
any young dentist. Undergraduate
training is only the beginning. You
learn so much more from doing Paul’s
courses. It makes sense to do this sort
of training at the start of your career as
your time will never be worth so little
and over the course of your career this

investment will pay for itself again
and again.”

Confidence to Tackle
New Treatments
Colin now takes on treatments which
he wouldn’t have in the past. Just recently, Colin has fitted three bridges
which had a combined cost of £5,000.
“The best thing about them though
was that I took my time, planned
them and am confident that they will
be successful. In the past I would have
had to refer these,” adds Colin.
“It’s not just the advanced things
though. Doing the simple things well
is very satisfying. I like having a predictable outcome. In the past when a
restoration would fail I would just do
it again and sometimes again. Now I
know why it has failed and make sure
that it doesn’t happen.”
The Restorative Course.
For more information about the
CAPP-Tipton Dental Academy programmes in Dubai, UAE visit: Restorative & Aesthetic Dentistry Certificate
& Diploma Group 4 starting on 04
October 2018 (www.cappmea.com/
capptipton), Clinical Implantology
Certificate & Diploma Group 2 starting in October 2018 (www.cappmea.
com/implant) and Clinical Endodontics Certificate & Diploma Group 3
starting on 03 March 2019 (www.
cappmea.com/endo).

CAPP EVENTS
Tel: +971 4 347 6747
Mob: +971528423659
E-mail: p.mollov@cappmea.com

[29] =>

[30] =>

news

Dental Tribune Middle East & Africa Edition | 4/2018

Diploma programme that made
everyone stronger and ready for
the Endodontic world
By Dental Tribune MEA / CAPPmea

posites as well as Inlays and Onlays.

DUBAI, UAE: The 8th July 2018

The last and final module 6, “Management of Endodontic Failure -Surgical & Non-surgical Retreatment”
concluded with working with the latest technology on sheep heads performing apicoectomy, a graduation
lunch with goodbye words from the
CAPP team and with heartwarming
words from the Faculty Lead Professor James Prichard.

marked the beginning of a new journey for the first successful graduated Clinical Endodontics Cohort
2017-2018. The delegates have come
a long way starting in 20th April 2017
with Module 1 “Fundamentals of
Endodontics”. Graduation day is the
day we all enter a new world of independence and confidence. And of
course, it is also a day that celebrates
achievements, hard work, and dedication that led the delegates here.
With the endless support from the
entire faculty (Prof. James Prichard,
UK; Dr. Antonis Chaniotis, Greece;
Prof. Paul Tipton, UK and Prof. Göran
Urde, Sweden) who taught the delegates everything from Hand-filing
and Lateral Compaction to Rotary
NiTi and Thermoplastic Obturation,
from Rotary NiTi to Reciproting NiTi.
As a crucial part of Endodontics, the
delegates also learned Implant Prosthodontics with Prof. Göran Urde as
well as Restorations of Endodontically Treated Teeth with Prof. Paul
Tipton who taught Occlusion, Post
and Core Techniques, Posterior Com-

Although everyone will be moving
on and going on their own paths,
they will never forget their experiences at CAPP Training Institute
which has only made them stronger
and ready for the endodontic world.
Delegates group photo during the last Module 6

The next Cohort will be starting on 21
March 2019. Fore more information
visit www.cappmea.com/endo

CAPP EVENTS
Tel: +971 4 347 6747
Mob: +971 528423659
E-mail: p.mollov@cappmea.com

Prof. James Prichard guiding a delegate during the micro surgical retreatent on a sheep
head

Microscope-powered hands-on training.

One of the proud delegates, Dr. Doha with Prof. James Prichard

Graduation trophies

Hands-on training during Module 6

Prof. James Prichard and Dr. Antonis Chaniotis

Dr. Antonis Chaniotis performing demonstration on non-surgical retreatment

Demonstration on special 3D Printed tooth

Prof. Prichard performing a micro surgery on a sheep head

[31] =>

[32] =>

32

nEWS

Dental Tribune Middle East & Africa Edition | 4/2018

King’s College London trains a second
cohort of master’s students in Dubai,
and will continue in 2019
By King’s College London
Ranked 1st in Europe and 2nd globally for dentistry (QS World University rankings 2018), the Dental
Institute at King’s College London
offers high-quality master’s courses,
to bring students to the forefront
of their field, whether undertaking specialist training in London or
enhancing their skills via blended
learning while working in practice
anywhere in the world. The blended
learning model includes online tuition and face-to-face clinical skills
training in intensive blocks.

Dr Hussain is a Clinical Senior Lecturer at King’s College London Dental Institute, where she has been teaching at both
undergraduate and postgraduate level for a number of years.

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

• 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

In response to international demand, King’s chose to offer the
face-to-face training element of its
popular Fixed & Removable Prosthodontics MClinDent in Dubai for
the first time in 2017, in addition
to London. After a successful pilot,
the second Dubai cohort joined this
year, and both the first and second
year groups attended state of-theart 3M Innovation Center, for handson training led by Professor Brian
Millar and Dr. Fariha Hussain, along-

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

Students from around the region
took the opportunity to learn and
practice contemporary clinical techniques at the world-class facility and
will be returning in February 2019.
Dr Fariha Hussain explained ‘In response to the international mix of
our students and growing demand,
we identified Dubai as an important
centre to hold our training, giving
students more convenience and
flexibility.’
Building on the success, applications are now being accepted for
a new cohort for January 2019 entry who will also be able to choose
Dubai as their preferred location for
face-to-face training.

To learn more visit
kcl.ac.uk/fixedremovableprosthodontics
or kcl.ac.uk/distancedentistry

Top 100 Scientiﬁc
Reports article
for King's College
London Dental
Institute
By King’s College London
An article by Professor Paul Sharpe,
head of the Centre for Craniofacial &
Regenerative Biology at King’s College London, ‘Promotion of natural
tooth repair by small molecule GSK3
antagonists’ is one of the top 100 read
papers in Scientific Reports for 2017,
after receiving 17,995 views.
Released in November last year, the
piece chronicles how a new method
of tooth repair – through stimulating the renewal of living stem cells in
tooth pulp – has been discovered by a
team of researchers at King’s College
London.

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

side their team of King’s experts.

The article has ignited a huge amount
of interest worldwide with volunteers eager to take part in trials. The
research is still in early stages and
human trials are not anticipated to
begin until late in 2019 at the earliest.
It is hoped that in the next 5-10 years
the method could be introduced into
dental practices around the world
and be available to the public.
Richard White, Chief Editor of Scientific Reports said:
“Scientific Reports published more

than 24,000 papers in 2017, and so a
position in the top 100 most highly
read articles is an extraordinary
achievement – your science is of real
value to the research community.”
Professor Paul Sharpe said:
“It is very gratifying to see that this
publication has had such a worldwide
impact and been read and reported
by so many.”

The article can be found here:
https://go.nature.com/2kTBrbR

[33] =>

[34] =>

POSTER PRESEnTATIOn

Dental Tribune Middle East & Africa Edition | 4/2018

1st Place Poster Presentation Winner during
the 13th CAD/CAM & Digital Dentistry Conference in Dubai!
Fiber glass reinforced composite for CAD CAM
Authors: Adrian Mihai Varvara1, Elena Bianca Varvara1, Cristina Gasparik1,
Valentin Toma2, Cristina Prejmerean3, Bogdan Culic1
Authors’ afﬁliations:
1
Department of Prosthodotics and Dental Materials, Faculty of Dental Medicine,
University of Medicine and Pharmacy "Iuliu Hațieganu" Cluj Napoca, Romania
2
Research Center for Advanced Medicine MedFUTURE, University of Medicine
and Pharmacy "Iuliu Hațieganu" Cluj Napoca, Romania
3
Institute of Research in Chemistry “Raluca Ripan”, Babes- Bolyai University, Cluj
Napoca, Romania

Introduction
In the last three decades, exciting new developments in dental materials
and computer science have led to the success of contemporary dental
computer-aided design - computer-aided manufacturing (CAD-CAM)
technology. Each year, new materials appear with improved properties and
qualities.
The objective of the work was to develop a new cad cam milling material
using ﬁber glass reinforced composite.
Figure 3. Evolution of the homogeneity

Figure 4. Diﬀerent E type ﬁber glass geometries

Conclusions
Within the limitation of this study, it seems that it is possible to achieve
a ﬁber glass reinforced composite for the use of CAD CAM technology.
Further investigation must be done in order to test all the properties of
the new material.
Figure 1. CAD-CAM restorative materials

Materials and method
A selection of 2 different types of resins (R1 composed from 25%Bis-GMA,
40%UEDMA, 35%DMTEG and R2 composed from 65%Bis-GMA, 35%
DMTEG) with 2 different types of hybrid ﬁller (F1 with 42% quartz, 42%
radiopaque glass and 16% hydroxyapatite and F2 with 90% quartz and 10%
colloidal silica) and 3 different types of E type ﬁber glass geometries (veil
30g/m2, twill 163g/m2 and stratimat 300g/m2) in 4, 6, 8 and 10 layers were
used in this in vitro study. Inside of a silicon cube of 1 cm side, layers of resin
and ﬁber glass were placed one above another. After each layer a light curing
process of 10 seconds was done in 5 different points. 2 mm thick samples
were cut with a precision saw (Isomet 1000, Buehler, USA) and investigated
with SEM and Raman spectroscopy. Data were analyzed with dedicated
software.

x1000

x3000

x5000

x500

x1000

x5000

x300

x1000

x500

Key words: CAD CAM, composite, ﬁber glass
Acknowledgement: This work was supported by the Romanian National
Authority for Scientiﬁc Research and Innovation, UEFISCDI, project
PN-III-P2-2.1-PED-2016-1936

x5000

x1000

x5000

Figure 2. SEM images of ﬁber glass reinforced composite a) FRC1; b) FRC2; c) FRC3; d) FRC4

Type

Resin

FRC1
FRC2
FRC3
FRC4

R1
R2
R2
R2

Hybrid
filling
U1
U2
U2
U2

Fiber glass
geometry
Veil
Veil
Twill
Stratimat

Figure 5. Raman spectra averages measured on the pure polymer, respectively on the 4 classes of FRC materials

Number of layers
6
10
8
4

Results
Raman analysis showed a powerful interaction between the polymer and
the ﬁber glass. SEM data revealed that the different ﬁber glass geometries
were well incorporated inside the resin, resulting an acceptable homogeneity.

References:
1. Petersen R, Liu pr. 3d-woven ﬁber-reinforced composite for cad/cam dental application. Sampe J. 2016 May ;
2. Li RWL, Chow TW, Matinlinna JP. Ceramic Dental Biomaterials and CAD/CAM Technology: State of the Art. Journal of Prosthodontic Research.
2014; 58:208–216.
3. Baroudi K, Ibraheem SN. Assessment of Chair-Side Computer-Aided Design and Computer-Saided Manufacturing Restorations: A Review of
the Literature. Journal of International Oral Health. 2015; 7(4):96–104.
4. Awada A, Nathanson D. Mechanical properties of resin-ceramic CAD/CAM restorative materials. J Prosthet Dent 2015;114:587-593
5. Quinn GD, Giuseppetti AA, Hoffman KH. Chipping fracture resistance of dental CAD/CAM restorative materials: part I-procedures and results.
Dent Mater 2014;30:e99-111.
6. Ryou H, Amin N, Ross A, Eidelman N, Wang DH, Romberg E, et al. Contributions of microstructure and chemical composition to the mechanical
properties of dentin. J Mater Sci Mater Med 2011;22: 1127-35.
7. Nathanson D, Poticny DJ, Klim J. CAD/CAM in-ofﬁce technology: innovations after 25 years for predictable, esthetic outcomes. J Am Dent
Assoc 2010;141: 5S-9S.

Corresponding author: Varvară Adrian Mihai, e-mail: varvara.mihai@umfcluj.ro

[35] =>

Dental Tribune Middle East & Africa Edition | 4/2018

POSTER PRESENTATION

35

2nd Place Poster Presentation Winner during
the 13th CAD/CAM & Digital Dentistry Conference in Dubai!

[36] =>

Dental Tribune Middle East & Africa Edition | 4/2018

POSTER PRESEnTATIOn

3rd Place Poster Presentation Winner during
the 13th CAD/CAM & Digital Dentistry Conference in Dubai!
•

Mai El Najjar 1,2,3, Yara K. Hosein 1,2,3,4, Amin Rizkalla 1,2,3,4

1 Biomedical Engineering Graduate Program, 2 Schulich School of Medicine and Dentistry,
3 Western Bone and Joint Institute, 4 Department of Chemical and Biochemical Engineering
The University of Western Ontario, London, ON

3. Design of CoCr Bar Samples & 3-unit Bridge 5. Mechanical Testing of Bar Samples & 3-unit
Substructures
Bridge Substructures
.

Figure 4: Experimental set-up for bending of the bar samples and 3-unit
bridge substructures. All samples and substructures were loaded at a rate of
1mm/min until failure. Failure was defined as maximum deformation (U-shape)
for bar samples, or fracture for the 3-unit bridge.
Figure 5: Representative loaddisplacement graph obtained
from the bending of CoCr bar
samples.

Similar graphs were also obtained for
bend testing of the 3-unit bridge
substructures.
Statistical analysis of the data was
conducted using one-way ANOVA and
Tukeys multiple comparative test at
95%level of confidences.

6. 3D-printed Bar Samples Exhibited Highest
Flexural Strength & Load, but Similar Modulus

• Cast samples showed higher stresses compared to milled samples.
• Cast Colado exhibited similar maximum load prior failure as milled
samples.

Figure 6: Bar graphs depicting mechanical properties of CoCr alloy bar
samples fabricated using 3D printing, milling and casting. Bars labelled with
similar lowercase letters indicate no significant differences (p>0.05).

Funding Sources:

10. Acknowledgements

1. Azari A, Nikzad S. J. 2009;15(3):216–25.
2. van Noort R. Dent Mater. 2012;28(1):3–12.
3. Gebhardt A, et al., Phys Procedia. 2010;5, Part B:543–9.
4. Jang KS, et al., J Prosthet Dent. 2001;86(1):93–8.
5. ASTM E 0290, 2014;1–10.

9. References

• Quantifying porosity volume and number
• Porcelain coating adherence
• Marginal Fit

• On going research:

• This study will provide important data to critically
assess AM technology for routine fabrication of dental
substructures. Such information will be essential for
future adoption of AM in the Canadian dental
manufacturing sector.

8. Summary and Conclusion

Figure 7: Bar graphs depicting
mechanical properties of CoCr
3-unit bridge substructures
fabricated using 3D printing,
milling and casting.
Bars labelled with similar
lowercase letters indicate no
significant differences (p>0.05).

• 3DP and mill 3-unit bridge substructures showed similar
loads at fracture and similar flexural stiffness (p>0.05).

7. Cast 3-unit Bridges Exhibited Highest
Flexural Load, but Lowest Stiffness

Advanced 3D Metal Additive Manufacturing for Dental Substructures

1. Introduction

CoCr alloys samples were made via AM using selective laser melting
(SLM) technology (Renishaw AM 400; ADEISS):

.
Figure 2: Representative CoCr alloy rectangular bar samples and 3-unit
bridge substructures.

•

Figure 1: Process flow for AM adoption in routine
dental manufacturing.

4. Micro-CT Analysis of 3-unit Bridge
Substructures

Additive Manufacturing (AM) in dentistry has received
much attention as Computer-Aided Design and
Manufacturing (CAD/CAM) is actively being used to
produce dental restorations1.

•

Potential benefits of AM2:
1. Mass production of dental substructures
2. Less waste of material.
3. Less manual procedures for dental technician
4. Allows for intricate design features.

• Sixty rectangular bar samples using ASTM5 standards. (n=15 per group;
3D printing, Mill, Cast Colado & Cast Supreme)
• Thirty 3-unit-bridge substructures designed based on a standardized 3unit die model. (n=10 per group; 3D printing, Mill & Cast Supreme)

•

Figure 3: Micro-CT images obtained to assess internal porosity of
substructures (Nikon Micro-CT Scanner XTH 225 ST model).

Cobalt-chromium (CoCr) is successfully used in Dental
Prostheses3 .

• The advantages of the CoCr over the precious alloys4:
1. Good bonding characteristics with porcelain.
2. Higher of young’s modulus and hardness.
3. Lower density.
4. Good corrosion resistances.

2. Objective and Purpose

• However, little evidence exists to support metal 3D
printing in routine Canadian dental manufacturing.

•

To compare and evaluate CoCr dental substructures
fabricated using AM to those made from conventional
methods of casting and milling for porosity,
mechanical
properties,
porcelain
coating
adherence, and marginal fit.

[37] =>

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[38] =>

THE GBT COMPASS AND
ITS 8 STEPS PROTOCOL
Protocol for Biofilm Management on teeth, implants and soft tissues.

01 ASSESS

PROBE AND SCREEN EVERY CLINICAL CASE
Healthy teeth, caries, gingivitis,
periodontitis Healthy implants, mucositis, peri-implantitis Start by rinsing
with BacterX Pro mouthwash

02 DISCLOSE

MAKE BIOFILM VISIBLE
Show patient disclosed biofilm and
problem zones The color will guide
the biofilm removal Once biofilm is
removed, calculus is easier to detect

03 MOTIVATE

RAISE AWARENESS AND TEACH
Emphasize on prevention
Instruct your patients on
oral hygiene EMS recommends
Sonicare toothbrushes and
interdental brushes or
Airfloss Ultra

04 AIRFLOW®

REMOVE BIOFILM, STAINS AND
EARLY CALCULUS
Use AIRFLOW® for natural teeth,
restorations and implants Remove
biofilm supra- and subgingivally up to
4 mm using AIRFLOW® PLUS 14 μm
Powder Remove remaining stains on
enamel using AIRFLOW® CLASSIC
Comfort Powder Also remove biofilm
from gingiva, tongue and palate

08 RECALL

HEALTHY PATIENT = HAPPY PATIENT
Schedule recall frequency according to
risk assessment Ask your patient if
he or she liked the treatment

07 CHECK

MAKE YOUR PATIENT SMILE
Do a final check for remaining biofilm
Ensure calculus is fully removed
Accurately diagnose caries
Protect with fluoride

ems-dental.com

06 PIEZON®

REMOVE REMAINING CALCULUS
Use the minimally invasive EMS
PIEZON® PS Instrument supra- and
sugingivally up to 10 mm Clean > 10
mm pockets with mini curette Use
EMS PIEZON® PI Instrument around
implants and restorations

05 PERIOFLOW®

REMOVE BIOFILM IN >4 TO 9 MM POCKETS
Use AIRFLOW® PLUS Powder on natural teeth in deep pockets and root furcations and on implants Use depth-marked PERIOFLOW® Nozzle

MAKE ME SMILE.

ems-dental.com - Copyright: 2018 EMS. Electro Medical Systems.

R

[39] =>

[40] =>

[41] =>

www.dental-tribune.me

Published in Dubai

July-August 2018 | No. 4, Vol. 8

“He brought a world of
enthusiasm and knowledge to the
global endodontic community”
dontic meetings together. Fred was a
character, but in the best sense of the
word. He was entertaining, charming
and unpredictable. That was Fred.
But to those of us who knew and
loved him, he was much more than
that. He was a loyal friend who made
a maximum effort to understand
each of us in a personal and supportive way. Really, at the end of the day,
Fred was a mensch. He will be very
much missed.”

Fred Weinstein, DMD, MRCD(C), FICD, FACD, who passed away Oct. 15, 2017, at the age of 78, is pictured in Anaheim, Calif., at the
California Dental Association meeting, CDA Presents the Art and Science of Dentistry, in 2012. A retired endodontist from Vancouver,
British Columbia, Weinstein often traveled to dental meetings to keep his knowledge of the specialty current and to visit with his many
friends. (Photo/Fred Michmershuizen, Managing Editor of DT America)

By Fred Michmershuizen, USA
He will be remembered as a friend, a
teacher and a healer. Fred Weinstein,
DMD, a retired endodontist from
Vancouver, British Columbia, died
Oct. 15, 2017, at the age of 78, after a
brief illness. His fellow specialists
expressed sadness at his passing and
acknowledged how his passion for
the profession rubbed off on them
through many decades of friendship.
Many are also remembering him for
his ability to have fun — especially
when it came time to promote an
international endodontic conference
hosted in his native country.

“Fred has been an inspiration for me
for all these years, ever since we met
over 30 years ago,” said Gerald N.
Glickman, DDS, MS, professor and
chair at Texas A&M College of Dentistry in Dallas, one of many endodontists who shared fond memories
of Weinstein.
“What a remarkably kind and insightful individual he was — always
inquiring about me and others and
never letting on about himself,”
Glickman remembered. “He brought
a world of enthusiasm and knowledge to the global endodontic community. I will miss him dearly.”

“Fred was that special kind of person
who would do anything he could to
help out when needed. He cared for
everyone and was a dear friend,” said
John J. Stropko, DDS, of Prescott, Ariz.
“Fred was a teacher, always encouraging others to use the latest technology to deliver better treatment results
for their patients. During the process,
he went to great lengths to clearly
communicate his beliefs in an easyto-understand manner. Our specialty
has lost one of its great members.”
“I knew Fred for more than 25 years,
and I always found it entertaining to
be in his company,” said Anne Lauren Koch, DMD. “We went to hockey
games, basketball games and endo-

Weinstein was born in 1939 in Winnipeg, Manitoba. He graduated from
the University of Manitoba at the age
of 22 with a degree in general dentistry, and then he went on to study
endodontics at the University of
Pennsylvania School of Dental Medicine in Philadelphia, under the tutelage of Dr. Louis Grossman, known
as the “Father of Endodontics.” After
receiving his Certificate in Endodontics from the University of Pennsylvania in 1969, he moved his family to
Vancouver and established an office
in the Fairmont Medical Building,
where he would go on to practice for
more than 40 years.
“He loved his patients, and he equally enjoyed teaching and lecturing
throughout the world to advance the
learning within dentistry,” his family
wrote in an obituary published in the
Vancouver Sun.
Weinstein’s accomplishments within the profession were notable. He
served as an assistant clinical professor at the University of British Columbia and was a past president of
the Canadian Academy of Endodontics, the British Columbia Society of
Endodontics, the Interspeciality Society of British Columbia and the International Federation of Endodontic
Associations (IFEA). He was a member of the Royal College of Dentists,
and he was a fellow of the American
College of Dentists and the International College of Dentists.

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

issn 2193-4673

roots
international magazine of

endodontics

2017

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

case report
Apexification treatment with MTA REPAIR HP

interview
Understanding sonic-powered irrigation

He served on advisory boards for several leading dental manufacturers,
and he lectured extensively throughout the world. He also served as a
volunteer endodontist at the 2010
Vancouver Winter Olympics, and
performed root canal treatment on
world boxing champion Sugar Ray
Leonard in the 1980s.
He was especially proud to have
served as the general chairman for
the 2007 IFEA World Congress in
Vancouver. To drum up excitement
for that meeting, he dressed as a
Royal Canadian “Mountie” at several
events leading up to it — something
that friends and colleagues remembered for years.
“Fred always had a smile and was
known as ‘the Canadian Mountie’
for his outfit that he wore at every
dental meeting to promote the IFEA
meeting in Vancouver in 2007,” remembered Samuel O. Dorn, DDS.
“He was truly dedicated to the Canadian Academy of Endodontics and its
place in global endodontics. His passion for endodontics and his friendship will never be forgotten.”
“I cherish my photo of us with him
dressed as a Mountie when he was
president of IFEA,” said Dr. William
Ben Johnson. “Fred and I started out
as endodontic colleagues, then became friends. So much so he would
go snow skiing with me even when
he didn’t care for skiing, and I would
drink wine with him when I preferred
scotch. I’ve lost a friend.”
After his retirement from practice,
Weinstein continued to travel to dental meetings to keep his knowledge of
the specialty current and to visit with
his many friends.
For many years, Weinstein was editor in chief of roots magazine, the
international C.E. magazine of endodontics, published by Dental Tribune
America.

Dr. Fred Weinstein with ‘Queen Elizabeth,’ at the IFEA meeting in 2007.
(Photo/Fred Michmershuizen, Managing Editor of DT America)

Dr. Fred Weinstein in Hamburg, Germany, in the summer of 2017.
(Photo/Fred Michmershuizen, Managing Editor of DT America)

“Above all of Fred’s accomplishments and titles, his family remained
his number one priority in his life,
always,” his family wrote in the Sun.
“He had a gentle heart of gold, compassion and sincerity and a smile that
would illuminate a room.”

[42] =>

A2

endo tribune

Dental Tribune Middle East & Africa Edition | 4/2018

MTA placement with
the Produits Dentaires (PD) MAP System

By Dr. Mauro Amato, Switzerland
More than 20 years ago, Torabinejad et al. (1993) first described a
new root-end filling material called
mineral trioxide aggregate (MTA).
MTA showed in vitro better sealing
ability than amalgam or Super EBA
when used as a root-end filling material. Later, several in vivo and in vitro
studies demonstrated more applications for MTA. Pulp capping, apexification, repair of root perforations
and root-end filling are commonly
described clinical procedures to seal
the pathway of communication between the root canal system and the
external surface of the tooth. The application of MTA was first described
as being achieved with aid of plastic
or metal spatulas (Torabinejad and

Chivian 1999). Unfortunately, proper placement was not possible in this
manner.
Therefore, Produits Dentaires introduced a universal carrier system for
clinical and surgical MTA placement.
Its Micro-Apical Placement (MAP)
System offers different application
points for every clinical situation.
The Intro Kit and the Universal Kit
are for orthograde obturation and
the Surgical Kit for retrograde obturation. The NiTi Memory Shape
tips can be manually shaped to any
required curvature. After autoclave
sterilization, the needle returns to
its initial shape. With the use of the
MAP System, proper placement of
MTA has become an easy task for
every dentist.

In combination with the MAP System, Produits Dentaires offers a
white MTA specially developed for
placement with the MAP System.
The optimized practical size means
economical application for each
treatment. There are many indications for the PD MTA White, and with
the MAP System, proper placement
is easy in every situation.

Pulp capping
Vital pulp therapy has become more
popular in recent years. Calcium hydroxide has been the most common
material for pulp capping, but MTA
has shown even better results in biocompatibility and outcome (Aguilar
and Linsuwanont 2011). Cases with
large carious pulp exposure can be
treated successfully with partial pul-

potomy and MTA as a capping agent,
keeping teeth vital (Figs. 1a–e).

MTA may save compromised teeth
(Mente et al. 2014) (Figs. 3a–e).

Apexification

Apical surgery

In order to prevent extrusion of
root canal filling material in immature teeth with open apices, MTA is
used as an apical plug. The results of
many studies have shown that MTA
induced apical hard tissue formation
more often and its use was associated with less inflammation than
with other test materials (Simon et
al. 2007) (Figs. 2a–g).

MTA is the material with the most favorable outcome as a root-end filling
material for apical surgery. MTA has
been associated with significantly
less inflammation, cementum formation over MTA and regeneration
of the periradicular tissue (Torabinejad and Chivian 1999) (Figs. 4a–f).

Repair of root perforations

Dr. Mauro Amato is a lecturer and researcher at the department of periodontics, endodontics and cariology of the University of Basel in Switzerland. Dr. Amato
is a committee member of the Swiss Society for Endodontology. He can be contacted at mauro.amato@unibas.ch

Accidental perforation of the pulp
chamber or of the root canal significantly changes the prognosis of the
tooth. Perforation repair with a biocompatible sealing material such as

Figs. 1a–e: (a) Deep carious lesion. (b) Partial pulpotomy. (c) MTA application with the MAP System and PD MTA White. (d) Filling. (e) Post-op radiograph showing the pulp capping with MTA.

Figs. 2a–g: (a) Endodontically treated tooth with fistula. (b) After retreatment, the tooth showed an open apex. (c) MTA application with the MAP System and PD MTA White. Condensation of the MTA with pluggers (d) or paper
points (e). (f) MTA plug. (g) Post-op radiograph showing the MTA plug and the reconstruction with a fiber post.

Figs. 3a–e: (a) Radiolucency in the cervical part of the canine. (b) Bleeding from the perforation. (c) MTA
application with the MAP System and PD MTA White.(d) Original canal and repair of root perforation. (e)
Post-op radiograph showing the root canal filling.

Figs. 4a–f: (a) Pre-op radiograph with a large periradicular lesion. (b) Periapical surgery. (c) MTA application with the
MAP System and PD MTA White. (d) Condensation of the MTA with pluggers. (e) Mirror view of the root-end cavity
filled with MTA. (f) Post-op radiograph showing the root-end filling.

[43] =>

A3

endo tribune

Dental Tribune Middle East & Africa Edition | 4/2018

Preservation of root cementum:
A comparative evaluation of power-driven
versus hand instruments
By Bozbay E, Dominici F, Gokbuget
AY, Cintan S, Guida L, Aydin MS,
Mariotti A, Pilloni A., Italy

Background

Grzesik et al. suggested that cementum plays an important regulatory
role in periodontal regeneration. One
of the major goals of periodontal
treatment is the removal of pathogenic micro-organisms by scaling
and root planning. In the past the
misconception was to obtain a root
surface with smooth and hard surface characteristics that was free of
endotoxins which resulted in the removal of the subgingival plaque and
calculus deposits, and the removal
of all or most of the cementum.
Recent studies have reported that
endotoxins were not located within
cementum and removal of ‘diseased’
cementum was not necessary for a
successful periodontal treatment.
Saygin et al concluded that preservation of cementum on the root
surface was necessary for new attachment and as a source of growth factor. Hence non-aggressive removal
of cementum is essential for optimal
periodontal health and regeneration.
Ultrasonics with new shaped tips
and subgingival air polishing devices
has been developed for removal of
root accretions with minimal root
damage. Air polishing has been suggested as a treatment modality for
root debridement resulting in probing depth reductions and removal of
subgingival biofilm. No scientific evidence exists today showing the loss
of root substance or surface roughness produced by either ultrasonics
or Air polishing.

Aim

To assess the amount of cementum
remaining following in vivo root instrumentation as well as the surface
characteristics of the retained cementum

Material and Methods

- 48 caries free, single-rooted teeth
in 27 patients diagnosed with severe
chronic periodontitis with periodontal probing depth (PPD) ≥5 mm in at
least two sites per tooth with radiographical bone loss of more than two
thirds of root length and scheduled
for extraction were included in this
study
- Teeth were randomly divided into
four treatment groups: Instrumentations were performed with medium
power settings
1. Piezoelectric ultrasonic scaler - (AirFlow Master Piezon, Instrument Tip
PS; EMS SA)-U
2. Piezoelectric ultrasonic scaler - (AirFlow Master Piezon, Instrument Tip
PS; EMS SA) followed by air polishing
with the glycine powder (Air-Flow
Powder Perio, Perio-Flow Nozzles;
EMS SA) - U + AP
3. Air polishing with the glycine powder (Air-Flow Powder Perio, PerioFlow Nozzles; EMS SA) - AP;
4. Hand instruments (Gracey curettes
5/6, 11/12, 13/14 American Eagle, Missoula, MT, USA)-HC

Treatment

- One approximal root surface of
each tooth was randomly subjected
to debridement, and the other approximal surface was used as control.
- Following instrumentation, the
teeth were immediately extracted

traumatically and analyzed with a
dissecting microscope
- Remaining calculus, root surface
roughness and loss of root substance
were evaluated along with scratches,
gouges, cracks, and any other changes in the cementum that was present
were noted.

Results

Remained cementum:
- Percentage of coronal cementum

remaining following subgingival instrumentation was 84% for U, 80%
for U + AP, 94% for AP and 65% for
HC.
- The amount of retained cementum
with AP was significantly greater
than with HC.
SEM
- Smoothest root surfaces were produced by the HC followed by the AP
- Coronal and apical sections showed
that AP produced the least amount

of cementum loss and therefore the
greatest retention of residual cementum
- Root surfaces instrumented by U
or U + AP presented grooves and
scratches.
Time taken to complete root instrumentation
- Shortest time taken was using AP
and the longest time was with U + AP.
- AP required 31% less time for root
preparation in comparison to HC,

whereas U + AP needed 30% more
time

Conclusions

- Air polishing was significantly more
effective and superior in preserving
cementum.
- Hand instrumentation using curettes was most effective in removing cementum in comparison to ultrasonics or hand instruments

www.ifea2018korea.com

The 11th

International Federation of Endodontic Associations

IFEA 2018 Seoul
October 4lThul -7lSunl, 2018 Coex, Seoul, Korea
Endodontics : The Utmost Values in Dentistry
Overview
Confirmed
Invited
Speakers

W

www.ifea2018korea.com
www.facebook.com/ifea2018seoul
Paul Abbott

Andreas K. Braun

Filippo Cardinali

Australia

The Netherlands

Italy

Is there still a role for medicaments
in endodontics?

Root resorption after dental trauma findings and treatment possibilities

Solutions to simplify shaping and cleaning:
improving the quality of the root canal treatment

Antonis Chaniotis

Gustavo De-Deus

Franck Diemer

Greece

Brazil

France

Management of severe curvatures and
complex anatomy with controlled memory
files: A new approach

The relationship among reciprocation,
glidepath and canal scouting

Samuel O. Dorn

Gianluca Gambarini

USA

Italy

How asymmetric geometry and heattreatment influence the behavior of
rotary root canal instrument

Nick Grande
Gianluca Plotino
Italy
The paradox of minimal invasive
endodontics

Extraction-Replantation: An alternative
surgical technique

3D endodontics: Shaping root canals
in 3 dimensions

Mo K. Kang

Syngcuk Kim

Anil Kishen

USA

USA

Canada

Pulp tissue regeneration: Challenges
and new outlook

Long term prognosis of endodontic
Tx vs. Implant Tx

Nanomaterials in endodontics: A potential
game changer

Sergio Kuttler

Seung Jong Lee

Francesco Maggiore

USA

Korea

Italy

“Past, present and future of endodontic
files”: Where science meets technology

Are the viable cells the only predictor for
delayed replantation?

Tara Mc Mahon

Zvi Metzger

Belgium

Israel

Does heat treated NiTi facilitate
endodontic therapy?

Early diagnosis and biomechanics of
vertical root fractures

Soft tissue management in endodontic
microsurgery

Yosef Nahmias
Canada
How to prevent instrument breakage
by creating a mechanical reproducible
glide path (don’t rotate, reciprocate)

Cliff Ruddle

Frank Setzer

Hagay Shemesh

USA

USA

The Netherlands

Endodontic Disinfection: 3D Irrigation

Management of iatrogenic errors by
non-surgical and surgical retreatment.

A realistic look at root canal fillings.
Trends, evidence and clinical performance.

Michael Solomonov

Asgeir Sigurdsson

Ibrahim Abu Tahun

Israel

USA

Jordan

Contemporary approaches to
instrumentation of non-round root canals

Is it toothache? non-odontogenic pain
presenting as dental pain

Re-establishing biological order in
reengineering the pulp-dentin complex

Yoshi Terauchi

Martin Trope

Ghassan Yared

Japan

USA

Canada

Predictable and minimally invasive
method to retrieve a separated file

The expanding role of vital pulp therapy

Management of second mesio-buccal,
narrow and curved canals with only one
reciprocating instrument.
Lecture titles are tentative and subject to change.

[44] =>

endo tribune

Dental Tribune Middle East & Africa Edition | 4/2018

Top performance Flexible NiTi file
HyFlex EDM performs well internationally
Full control in
the dental practice
As an established Endo provider,
COLTENE has been working closely
with leading dentists, universities
and endo experts for many years.
The multitude of sophisticated
treatment aids, ranging from specially hardened instruments to bioactive obturation materials, reflects
the self-image of the Swiss innova-

HyFlex EDM File Sequence

By Coltene
In the course of two major international events in the dental industry,
Swiss dental specialist COLTENE
interviewed over 130 dentists and
Endo experts about their experiences with its latest NiTi file system.
The results of the product tests are
more than impressive: 98% of the
participants would continue to use
the HyFlex EDM for the treatment
of their endodontic cases, even after
the tough test.

The necessary cutting edge
Every two years, both the International Dental Show in Cologne (IDS
for short) and the Congress of the European Society for Endodontics (ESE
Congress) serve as an international
platform for professionals with an
interest in endodontics to exchange
experiences between colleagues.
Thus, both events in 2017 provided
the ideal occasion for a large-scale
test campaign for the latest NiTi file
generation from COLTENE. Selected
dentists and joint practices throughout Europe were given the opportunity to put the flexible HyFlex
EDM’s file system through its paces.
76% of the participants particularly
praised the high flexibility that leads
to good adaptation in the canal. The
pre-bendable files work reliably in
all the lengths and sizes currently
available on the market without displacing the centre of the canal. Like
the proven HyFlex™ CM files, the
HyFlex™ EDM files also possess the
so-called “Controlled Memory“ effect and are distinguished by their
high level of flexibility. In contrast
to classic NiTi files, they have almost
no recovery effect and can be prebent. As a result, the files move perfectly through the centre of the canal, which significantly reduces the
risk of ledging, transportation and
perforation. During autoclaving,
they recover their original shape so
that they can be reused safely until
a visible break in their spiral structure clearly indicates the end of their
service life. At the same time, the innovative manufacturing process by
means of spark erosion contributes
to the high breakage resistance of
the HyFlex EDM files, particularly

under heavy-duty use. In fact, HyFlex EDM files are up to 700% more
resistant to cyclic fatigue compared
to traditional NiTi files. A special
combination of material surface
and tapering allows a significant
reduction in the number of files
used without compromising the
preservation of the natural root canal anatomy. These smart features
were also evaluated positively in the
test and the dentists use the robust
high-performance instruments primarily for cases where they want to
produce reliable results quickly with
a reduced number of files.

Additional files sizes allowing more flexible application
Due to limited access endo experts
often want more flexibility from
their instruments. Pre-bendable
tools can extend the horizon into
new dimensions. Particularly in a
limited working space, modular
nickel-titanium systems display
their full strength. With a total of
seven highly flexible file variants,
COLTENE offers a wide-ranging HyFlex NiTi program. In addition to the
usual lengths of 25 mm, all preparation files of the popular EDM series
are also available in 21 mm working
length. The application of the more
agile, shorter models is particularly
recommended in of the posterior
molars and in patients with craniomandibular problems.
The new HyFlex EDM 20/.05 preparation file augments the existing
HyFley EDM line. The additional
file enables fans of the flexible NiTi
range to treat curved channels only
with the efficient EDM files. After
creating a glide path with the Glidepathfile 10/.05, the new file with the
same taper allows minimally invasive, fast preparation of the canal.
Subsequently the actual shaping can
be done in the usual manner with
the universal file HyFlex EDM OneFile, size 25. Depending on the channel anatomy, apical preparation can
be finished with EDM files up to ISO
size 60. Even in these large sizes the
files work safely and without transportation of the canal center.

tion leader. True to the company’s
motto “Upgrade Dentistry”, the
COLTENE service team regularly
asks practice owners and endodontic specialists about their wishes for
even more confident work in virtually all situations. This also formed
the basis for the development of the
production process called “Electrical Discharge Machining” (EDM for
short) by the dental manufacturer’s

renowned R&D department, which
ultimately gave the exceptionally
break-resistant files their name. The
practice-oriented Endo offer is complemented by a large number of application-related workshops, training materials and personal services.

Further product information:
https://hyflex.coltene.com/

[45] =>

[46] =>

endo tribune

Dental Tribune Middle East & Africa Edition | 4/2018

More than just a long-lasting post – VDW’s
Double Taper Shape preserves more dentin
By VDW

the dentist avoids unnecessary dentin removal to fit in the post.

MUNICH, Germany: Improved den-

Tooth protection
and better aesthetics

tin preservation and better aesthetics are two of the convincing advantages of VDW’s DT Posts. These are
resulting from VDW’s Double Taper
Shape de-sign and quartz fiber technology: the key to a long-lasting endo-dontic treatment success.

reactive color pigments of VDW’s
DT ILLUSION® XRO® SL posts enable
their location after the placement.
Being barely visible at body tempera-

ture, they become clearly detectable
after cooling below 29° Celsius.

Read more about VDW’s DT Posts at:
https://www.vdw-den-tal.com/en/products/post-endo/

The DT Posts’ break-resistant quartz
fiber material has advantageous mechanical characteristics. Its low modulus of elasticity distributes chewing
forces correctly and minimizes the
risk for root fractures. Thanks to the
quartz fiber material’s translucency
properties the pa-tient benefits from
better aesthetics.

For endodontically treated teeth
with more than one missing dentin
wall the placement of a post to maintain the coronal structure is strongly
suggested. To place it properly, it is
key to retain as much dentin as possible while preparing the root canal
beforehand. VDW’s DT Posts with
Double Taper Shape preserve more
dentin as the two-stage design corresponds optimally to the morphology of the prepared root canal. Thus,

Safe retention
and easy post location
VDW’s DT Posts offer more convincing features. The Safety Lock® coating ensures maximum bond properties and thus a safe long-standing
retention of the post. The thermal

Fig. 1: DT LIGHT®, DT LIGHT® SL, DT ILLUSIONTM
XRO® SL, each size #1

Fig. 2: With Double Taper Posts (1) less dentine removal is required than with
single tapered posts (2) © Prof. Boudrias / Prof. Sakkal

Success evaluation of N2 treated teeth
with open apical foramen.
A retrospective study
By Dr Anette Joschko, Dr Robert
Teeuwen & Prof. Jerome Rotgans,
Germany

Endodontic failures resulted in ten
cases (13.3%). Statistic significance was
found regarding failure rate of VitA
(7.1%) and root canal treatment of
non-vital teeth (28.6%, p = 0.0157).

Abstract
95 teeth with open foramen were
identified in a general dentist practice
during the years 1985—2006, 75 of
which could be followed-up by X-ray
after an average time of 70 months
(follow-up X-ray). 40 teeth were subject to vital extirpation (VitE), 28 teeth
to vital amputation (VitA), and seven
teeth with necrotic
pulp underwent conservative root
canal treatment (RT). Apexification
success rate amounted to 85.3% (VitE
90%, VitA 85.7%, non-vital RT 57.1%).
Another 12% could be judged as partial success in molars, as a certain
number of the molar roots showed
apexification, however, others not
yet. The percentaged difference of a
successful apexification between vitally extirpated teeth and root canal
treatment of non-vital teeth was significant (p = 0.0243). Apexification result was irrespective of the filling level
of root canal treated teeth as well as of
endodontic success.

Within the observation period 19 out
of the 95 teeth with open foramen
(20%) were extracted. There was a
significant difference regarding extraction frequency between the VitE
group (14.6%) and the non-vital group
(50%, p = 0.0169).

Introduction
Endodontic treatment of teeth with
incomplete root growth poses a special challenge. In young patients, the
necessity for endodontic treatment
results from an accident or profound
caries. Aside from damage control,
this treatment aims at promoting
tooth maturation including narrowing respectively closure of the apical
foramen (apexification) and possibly
root extension (apexogenesis).
According to Zeldow (1967) the following treatment options are commonly used:

100

300

250

months

%
40

100
50

0
50

100

150

200

Various methods favouring maturation of the immature teeth are described. Surgical interventions turned
out to be less promising (Kreter
1959, Khoury 1992). Herforth (1981)
obtained a very high healing rate of
apical periodontitis with Jodoform

150

Krakow et al. (1977) disapprove of a
VitA inevitably following root canal
filling. Joschko (2012) points out that
the often diverging roots of immature teeth exclude a dense root canal
filling, and that open apical foramen
promotes overfilling. Some authors,
like Kvinnsland et al. (2010) and Rafter (2005), state that the dental papilla
may simulate an apical periodontitis
in the area of the open apical foramen.

200

VitE
VitA
non-vital

- For vital teeth: Pulpotomy (VitA)
with subsequent conservative root
canal treatment (RT)
- For non-vital teeth:
– either RT or
– RT in connection with apicoectomy/retrograde root canal filling or
– inducing of bleeding with root canal
filling in the coronal root part only.

250

300

months

Fig. 1: Probability of survival of the 3 therapy groups with the target criterion “No Extraction

10
n = extractions

Fig. 2: Time history of the extractions (N = 19).

deposits, however the success rate
regarding stimulation of hard tissue induction only amounted to 3%
versus 83 % with calcium hydroxide (Ca(OH)2). Hermann (1920, 1930)
introduced calcium hydroxide as
material with osteogenic potential.
Frank (1966) was the first to use it as
medical dressing in teeth with incomplete root growth. These dressings
should be replaced approx. every
three months for a time period of
six through 18 months. Cvek (1972)
and Feiglin (1985), however, do favour a replacement of the dressing
only in case of pathology. The long
treatment duration—and thus loss
of patient compliance—as well as a
decrease of fracture resistance (Cvek
1972, Andreasen, Fabrik and Munksgaard 2002, Andreasen, Munksgaard
and Bakland 2006, Trope 2006) are
regarded as adverse features of the
calcium hydroxide method.
As formaldehyde also features an osteogenic potential (Orban 1935), tests
with formocresol versus calcium hydroxide were made as well. Within
a pulpotomy study, Spedding et al.
(1965) judged formocresol as being
more appropriate for apexification.
Latest literature prefers mineral trioxide aggregate (MTA) over calcium
hydroxide (Andreasen et al. 2006,
Schwartz et al. 2008, Schäfer 2003,
2004). Shabahang et al. (1999) as well
as ElMeligy et al. (2006) made a comparison between mineral trioxide aggregate and calcium hydroxide ending up in favour of MTA.
In a prospective study, Simon et al.
(2007) report on 43 one-stage MTA
treatments, which were followed up
after a control period of at least 12
months (up to 36): 65% of apical le-

sions were completely healed and an
apical barrier could be observed in
11 cases (26%). 78.7% were free from
apical periodontitis, whereas apexification took place in only 64 out of
75 cases (85.3%). The time period for
control of apical development was
clearly longer, though, amounting to
70 months.
Aside from the therapy with various
medicaments, the ‘revascularization’
therapy was established also (Ham et
al. 1972, Hülsmann et al. 2008, Bose
et al. 2009, Cehreli et al. 2012, GarciaGody and Murray 2011) provoking a
light bleeding into the pulp by punction beyond the apex. Dressing is
placed coronary: MTA, calcium hydroxide, formocresol or a triple antibiotic paste. The latter one provided
thicker canal walls than calcium
hydroxide respectively formocresol.
Also the length growth was stronger
versus MTA application (Ebeleseder
2004).
Based on the knowledge that formaldehyde preparations have a similar
(necrotizing, osteogenic) effect to
the pulp like calcium hydroxide, the
secondary author of this study as
long-time owner of a general dental
practice suggested an analysis of his
endodontic treatment cases with
open apical foramen regarding apexification/apexogenesis, which had
been carried out by Joschko (2013) as
then doctoral candidate from which
this article reports.

Material and method
99 endodontic treatments of teeth
with open apical foramen were taken

ÿPage A7

[47] =>

endo tribune

Dental Tribune Middle East & Africa Edition | 4/2018

◊Page A6
Case 1: Male (born 5 June 1987): Tooth 35

Fig. 3a: 18 March 1997 ante pulpotomy.

from the files of the practice examined in this study in the years 1985
through 2006. Treatment method
was the so-called N2 method according to Sargenti and Richter(1954),
which meant: no canal rinsing and
application of the paraformalde
hyde-containing N2. Rubberdam was
not used. The N2 powder contained
7% formaldehyde before admission
by the EU, afterwards the content was
decreased to 5%.

Fig. 3c: 6 May 2005 status

Fig. 3b: 18 March 1997 post pulpotomy

Result
The average age of the patients was
10.7 years (6–25). Most cases (N=54)
were attributed to mandibular molars (72 %), among these mostly the
first lower molars with 48 cases (50.5

% of the cases to be analyzed), followed by nine cases of maxillary
incisors. 75 cases were subject to one
or—in intervals—multiple follow-up
X-rays. 40 teeth (53.3%) were extirpated vitally, 28 teeth (37.3%) were ampu-

tated vitally and seven non-vital teeth
(9.3%) underwent conservative endodontic treatment. Post-endodontic
clinical control averaged at 73 months
(12–271), the follow-up X-rays to be
evaluated at 70 months (10–228). In

Four cases were excluded:
· A non-vital case where the initial
X-ray did not clearly reveal whether
the apical radiolucency of both roots
were a matter of apical periodontitis
or apical papilla.
· A VitA-case was extracted alio loco a
few days up to 18 months after VitA.
· X-ray was insufficient in the third
case, VitE of an upper molar
· In the fourth case, the patient did not
show up again after devitalization of
an upper premolar.
Thus, 95 cases to be judged remained,
of which only two non-vital teeth
were treated in a two-stage therapy.
93 cases were treated in one appointment inclusive definite filling. For
root canal filling, the N2 powder was
mixed with N2 liquid to a creamy texture, a harder consistency was needed
for VitA. N2 application for root canal
filling was done by lentulo, for VitA a
carrier instrument was used to bring
the material into the excavated pulp
cavity up to 1–2mm into the canal accesses.
The 95 anonymous made cases were
clinically followed-up without recall
at an average of 73 months after treatment. 75 cases underwent X-ray control (follow-up X-ray) after an average
of 70 months; 64 cases as single-tooth
X-ray in parallel technique and 11 cases as orthopantomogram.
Judged as endodontic failure were:
pain or fistula at treated tooth, development of apical periodontitis,
lingering or newly developed apical
periodontitis.
Treatment success of the 75 cases was
analysed in two modes considering
the questions:
· Did apexification/apexogenesis occur?
· Did the apex remain unaffected of
apical periodontitis?

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In multi-rooted teeth with different
apical diagnosis, the worst diagnosis
was assumed as being valid for the
tooth. A double magnifier served as
diagnostic aid. Three persons evaluated the X-rays independently from
each other: The doctoral candidate
(author AJ), a dentist with ten years of
professional experience and the practice owner (author RT). The final diagnosis resulted from the consensus of
the three ratings.
Statistic significance was assumed for
an error assumption of p < 0.05 for
comparison of two parameters and
calculated by means of the logrank
test.

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41 cases, X-ray evaluation was done
more than 48 months after endodontic therapy.

ÿPage A8

[48] =>

endo tribune

Dental Tribune Middle East & Africa Edition | 4/2018

◊Page A7
Case 2: Male (born 28 December 1980): Tooth 14

Fig. 4a: 18 August 1989 ante vitalextirpation.

The longer therapy dated back, the
earlier achievement of the treatment
aim apexification or apexogenesis
could be verified. Two cases featured
open apical foramina even 16 respectively 30 months post treatment. In
nine molars, the apical foramina of
various roots were partly still open,
partly already closed after an average
of 28 months. Thus their results could
only be judged as partial success. An
average post-observation time of 71
months was registered in 55 cases
with the diagnosis ‘apex closed without lengthening of the root’. A ‘closed
apex with root growth’ could be stated in nine cases after anaverage of 117
months (see case 1) . The average age
of the nine young patients with root
growth amounted to 9.5 years, those
without root growth had an average
age of 11.2 years.
Overall, an apexification success
was found in 64 cases (85.3 %, confidence interval 77.3–93.3 %). In nine
other multi-rooted teeth (12 %), the
maturation process of the roots was
differently distinct: The same tooth
featured a root with closed apical
foramen, whereas another root still
showed an open foramen. Maturation progress of the immature teeth
was ob served on the basis of the 49
cases with multiple follow-up X-rays
in different intervals. A first follow-up
X-ray was available after an average of
34.6 months (4–130). 18 cases (36.7 %)
featured advancement, whereas the
status of the other cases remained
unchanged.
Not considering the nine partial successes as mentioned above, an apexification success rate with/ithout root
lengthening of 90 % (confidence interval 80.7–99.3%) was determined
in the VitE group, the success rate of
the VitA group was 85.7% (confidence
interval 72.7–98.7%), the non-vital
group showed a success rate of 57.1 %
(confidence interval 20.5–93.8 %). The
percentaged difference of apexification success VitE versus VitA with a
probability of error of p = 0.5893 and
VitA versus non-vital group with p =
0.0910 was not significant statistically. A statistic significance could be
determined when comparing VitE
with the non-vital group (p = 0.0243).
Apexification success in root-filled
teeth proved not to be depending on
the filling level (p = 0.2441).
Ten endodontic failures (13.3%), nine
of which radiographically and one
clinically due to fistula formation (see
case 2), were observed: six following
VitE (15%), two following VitA (7,1%)
and two following conservative root
canal treatment of the seven non-vital teeth (28,6%). Regarding endodontic success/failure of VitE versus nonvital group, a statistic significance
revealed (p = 0.0587). A statistic significance could be stated when comparing VitA with the non-vital group
(p = 0.0157). Apexification occurred in
nine of the ten failures. Patient classification in age groups of younger
than 125 months and older than 125
months was not relevant regarding

Fig. 4c: 16 January 2004 status.

Fig. 4b: 18 August 1989 post vitalextirpation

avoidance of endodontic failure (p =
0.448).

Case 3: Female (born 8 August 1988): Tooth 11

19 teeth (20 % of the 95 treated teeth)
were extracted during the observation period. Seven of these teeth
belonged to the VitE group, eight to
the VitA group and four to the nonvital group. A statistic significance of
extraction frequency existed when
comparing the VitE with the non-vital
cases (p = 0.0169). Figure 1 shows the
three groups’ probability of survival
with the aim of no extraction.
Nine teeth (47%) were extracted within the first 50 months after treatment.
The time history of all extractions is
featured in Figure 2. Main reason for
extraction was damage/fracture of
the natural tooth crown (42%) or an
endodontic failure (31%). 33 of the 48
endodontic treatments of first lower
molars had been done prior to the age
of ten years. 14 first lower molars (73.7
% of all extractions) were extracted, 12
of which prior to the age of 20 years.

Discussion
The present study is a retrospective
one with data collected out of a regular dental practice, where endodontic treatments were done according
to the Sargenti N2 technique (1954)
exclusively, a method not accepted
in the established dental doctrine,
primarily due to the formaldehyde
content in the N2 powder, but also
because of elimination of root canal
rinsing. 95 cases could be evaluated.
Whereas apexification literature is
generally based on front teeth with
necrotic pulp, only 10 % of the 95
evaluated teeth were non-vital (see
case 3). 38% were treated by VitA, 52%
by VitE. The first mandibular molars
were represented most with 48 cases.
Patient recall did not take place. In
contrast to clinics, patient loyalty nevertheless allowed a clinical control of
all 95 cases, which was done after an
average of 73 months. 75 cases were
subject to X-ray control. The actually
evaluated X-ray had been taken after
an average of 70 months. 49 of the 75
cases had more than one follow-up Xray taken so that X-ray interpretations
could have been done for various
time intervals thus allowing control
of the further apical development. A
first control X-ray was generally available after 34.6 months. 18 cases of
the more than one follow-up X-rays
documented a continuous maturation. For lack of previous X-rays, the
result of 31 cases of final apical condition after 34.6 months does not mean
that apexification or apexogenesis
could not have been occurred prior
to this time, which could have been
clarified in a prospective study only.
However, the radiographic observation period of 70 months is long compared to other publications. The longest is indicated by Herforth (1981) with
3.9 years after treatment of 541 front
teeth, condition after accident, with
calcium hydroxide and Jodoform and
with four years by Cvek (1972), who
evaluated the data of 328 immature
luxated/subluxated maxillary front

Fig. 5a: 4 September 1995 ante RCF
(non-vital).

Fig. 5b: 4 September 1995 post RCF.

Fig. 5c: 22 April 2002 status.

teeth treated with calcium hydroxide by 58 practitioners. 12 months after MTA treatment of 30 single-root,
non-vital teeth with open apical foramen Annamalai and Mungara (2010)
obtained the following results: apical
healing 100%, apexification 86.6 %,
root extension 30%. After an observation time of 12–44 months, Holden et
al. (2008) determined a success rate of
85 % (N=17) for their 20 teeth treated
by MTA in several appointments. The
healing and apexification process was
not subject to recall interval. However, advanced growth of the apices
after N2 application over a period of
several years could have been well observed in the present study (average:
without extension 71 months, with
extension 117 months), possibly due
to the different characteristics of MTA
versus N2.

containing N2: 90 % following VitE,
85.7 % following VitA, 57.1 % following
conservative root canal treatment of
non-vital teeth. The success rate of
57.1 % for non-vital teeth should not
be taken too seriously because of the
20.5–93.8 % wide confidence interval
due to the small number of cases.
The percentaged success referred to
the respective teeth as a whole. Another 12% referred to some molar
roots with partly open, partly closed
apices. Sheehy and Roberts (1997)
comparatively report on the formation of a hard substance barrier after
calcium hydroxide application after
5–20 months in 7–100 % of the cases.
In contrast, the authors Roberts and
Brilliant (1975) considered the interpretation of an X-ray as being unrealistic for determination of a possible
apical closure matching the Liang et
al. proof of insufficient diagnostics
of the periapical X-ray versus digital
volume tomography (DVT). 23 teeth
were reexamined according to both
techniques two years after endodontic treatment. 74 % of periapical radiolucencies could not have been visualized with conservative X-ray and 61 %
with DVT. Despite of the diagnostic
deficits to be assumed, X-ray in combination with a clinical examination
remains the only practical method.
An inter pretation bias in this study
can be largely eliminated due to the
consensus finding of the three X-ray
evaluators.

Garcia-Godoy and Murray (2012)
made up a survey with hints to deficits in apexification literature. According to this survey, 200 case studies on calcium hydroxide had been
published. Reports on unfavourable
and long-term effects would be missing. One problem of long-term calcium hydroxide dressings would be an
alteration of the mechanical dentine
characteristics, which could lead to
fractures. Long-term studies regarding MTA would be missing. However,
for achieving apexification, mineraltrioxide aggregate would be more effective than calcium hydroxide.

The authors Simon et al. (2007) observed 43 single- rooted teeth with
open apical foramen that had been
one-stage treated with MTA for a time
of 12 up to 36 months. They stated a
complete healing in 65%, an incomplete healing in 30 % and an ‘apical
closure’ in 26 % of these cases (N =
11). The radiographic diagnosis of the
present study is: 78.8 % positively
without apical periodontitis, 9.3 %
apical periodontitis questionable,
12 % apical periodontitis with 85.3
% featuring ‘apical closure’ and 36.7
% root extension. However, a direct
comparison between the Simon and
the present study is not admissible
due to the low number of cases, the
different observation periods and the
non-coordinated interpretations of
the evaluation modalities.
El Meligy et al. (2006) examined 30
pulpotomy cases (15 Ca(OH)2, 15 MTA),
24 of which were first molars, which
suggests a comparison with our
study. The following assumptions
were applied: no clinical problems,
radiographically no apical periodontitis, apexification occurred. 13 calcium
hydroxide cases (87 %), but all MTA
cases came up to this.
The three above mentioned therapy
groups of this study achieved an
apexification success of totally 85.3
% by means of the formaldehyde-

While in short-term studies with low
case numbers extractions are not
mentioned, this study counted 19
extractions, 14 of which were allotted
to the first mandibular molars. Thus
the mandibular molars represented
73.7% of all extractions with a 50.5 %
share in treatments. This relatively
high extraction frequency may be
due to the fact that these teeth erupt
early as the first permanent molars
thus having been exposed to toothdamaging influences for the longest
time. Extraction is avoided less in the
posterior area versus the anterior areas, as in young patients the gap normally closes the natural way without
orthodontic or prosthodontic treatment.

Also regarding regenerative procedures, only case studies and case
series would exist. The ‘blood clot’
generated during this therapy should
however have no contact to the inserted sealer, as sealers were not biocompatible and featured a cell-toxic
effect.
In the present study, pulp tissue, possibly blood as well, had contact to the
cell-toxic N2. As the long-term observation showed, this contact had no
disadvantageous effect to the respective teeth. Regarding apexification
and apexogenesis, a perennial study
rather proved that the success rate
was at least equal to MTA and calcium
hydroxide. Root fracture, as suspected in calcium hydroxide cases, could
not have been noticed in any of the
cases. One-stage treatment has to be
considered as special advantage of N2
application aiming at apexification,
which at the same time is a time- and
cost-saving method.
Editorial note: A list of references is
available from the publisher.

Dr Anette Joschko
General Dentist, Cologne, Germany
Dr Robert Teeuwen
General Dentist, Geilenkirchen,Germany
Prof. Jerome Rotgans
RWTH Aachen University, Medical Faculty,
Aachen, Germany

[49] =>

Published in Dubai

July-August 2018 | No. 4, Vol. 8

www.dental-tribune.me

Making a perfect ceramic crown
on a titanium abutment in
the esthetic zone

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Vol. 8 • Issue 4/2017

issn 1616-7390

CAD/CAM
international magazine of

digital dentistry

2017

Overcoming a challenging situation step by step

interview
“Dentistry has finally arrived in the digital age”

case report
Screw-retained implant-supported restoration
in the edentulous maxilla

By MDT Patrick Rutten, Belgium
For reasons of strength, a titanium
abutment may be required in the
esthetic zone. However, masking the
dark metal to achieve a natural-looking outcome will present a challenge.
A ceramic crown with a zirconia coping should be used to mask the metal
abutment. A layering protocol is used
to create natural light and color and
avoid a greyish-looking gingival tissue in the cervical area. In the following clinical report, MDT Patrick Rutten (Tessenderlo, Belgium) presents
how to handle such a challenging situation and obtain predictable white
and pink esthetics.

Clinical situation
More than 40 years after a sports in-

jury, extensive caries was detected radiographically under a post crown on
a maxillary right central incisor (Fig. 1
and 2). The tooth was determined to
be nonrestorable and was extracted.
After a healing period of eight weeks,
an implant was placed (Fig. 3) together with allogenic bone augmentation
and soft tissue regeneration with a
free connective tissue graft harvested
from the palate. A healing abutment
was screwed onto the implant and a
removable provisional denture provided. For strength reasons, a custom
CAD/CAM-fabricated titanium abutment was chosen (Fig. 4). “I do not
prefer using titanium in the front if
possible, but in this case, function is
more important than esthetics,” Rutten explains.
The challenge was now to veneer a

Fig. 1 and 2: Initial situation, clinically and radiographically, before extraction of right maxillary central incisor.

zirconia coping with the fine-structure feldspar ceramic VITA VM 9 to
reproduce the natural appearance
of the adjacent teeth and to support
and sculpt the soft tissue for optimal
gingival management. “Working
with a titanium abutment is very difficult. The gingiva can look greyish.
We have to mask the greyish cervical
part,” Rutten warns. Precise shade determination was the first essential for
success.
To guarantee a perfect shade match,
the VITA Linearguide 3D-MASTER
was used (Fig. 5) to cover the whole
three-dimensional tooth shade spectrum and to allow shade determination in three defined steps. In the first
step, the shade value was verified, followed systematically by chroma and
hue. The basic shade of the adjacent

Fig. 3: Radiograph
after implant
placement.

teeth was measured digitally with the
VITA Easyshade V spectrophotometer. Independently of one another,
the expert and the digital device both
determined the tooth shade to be
3M2. For Rutten to achieve a shade
match between the natural teeth
and the restorations, the correct basic
shade is highly important.

Layering procedure
The zirconia coping was virtually designed, milled, sintered, and fitted.
An initial wash firing with VITA VM 9
EFFECT LINER was a crucial step in
adding a fluorescent layer to the nonfluorescent zirconia coping. The liner
also provided reliable bonding to the
framework. The firing temperature
should be 50 degrees higher than
that of normal dentine firing.

Fig. 4: Titanium abutment screwed onto implant.

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

VITA VM 9 BASE DENTINE 3M3 with a
higher chroma was used in the cervical area to mask this critical area and
to mask the lifeless and greyish appearance of the titanium abutment.
Yellow EFFECT CHROMA 4 (EC4) was
then applied with a deeper orange in
the interdental areas with a mixture
of EFFECT CHROMA 5 (golden rod)
and 6 (sunflower) to enhance the
masking effect. For the incisal third
area, a higher value was selected with
3M2. To create the ridges, the bluish

ÿPage B2

Fig. 5: Determination of basic shade with VITA
Linearguide 3D-MASTER.

Fig. 6a: MDT Patrick Rutten at work.

Fig. 6b: Layering dentine core.

Fig. 6c: Creation of mamelons.

Fig. 6d: Layering of enamel.

Fig. 6e: Characterization with INTERNO.

Fig. 6f: Result after first dentine firing.

[50] =>

lab tribune

Dental Tribune Middle East & Africa Edition | 4/2018

◊Page B1

Fig. 7: Shade assessment after first dentine firing.

Fig. 8: Final layering and contouring.

Fig. 9: Clinical evaluation.

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CAD/CAM
international magazine of

digital dentistry

2017

Fig. 11 and 12: Cemented maxillary right central incisor crown
intraorally and periapical radiograph.

Fig. 10: Evaluation before glaze firing.

EFFECT ENAMEL 9 (EE9) mixed with
ENAMEL LIGHT (ENL) was chosen
(Fig. 6 a-f). The synergy of these three
basic components is essential for the
incisal edge:
- Color
- Enamel
- Translucency
VITA VM 9 ENAMEL LIGHT and EFFECT ENAMEL 9 (EE9) were layered

to create a bluish accentuation and
replicate natural esthetics. In addition, VITA INTERNO 2 (sand) and
4 (orange) were added to replicate
the characteristics found in the
contralateral tooth. VITA INTERNO
ceramics played an important role
in increasing fluorescence and natural warm color effects with internal
characterization. These characterizations should always be arranged
irregularly for a natural appearance.

Fig. 13: Natural and esthetic smile.

interview

To achieve a contrast, BASE DENTINE
was layered onto the palatal side of
the incisal edge. During contouring
the ceramic mixture must remain
creamy and stable to achieve an efficient and successful layering procedure. This layer was increased slightly
to allow for intraoral adjustment. An
implant crown should be adjusted so
that functional loading is minimized.

“Dentistry has finally arrived in the digital age”

case report
Screw-retained implant-supported restoration
in the edentulous maxilla

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

Fig. 14: Close-up lateral view of maxillary incisors

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Be careful with translucency!
If the crown contour needs to be increased, translucent porcelain should
never be added since the addition
will always reduce value and chroma.
Using too much translucent enamel
is a common mistake, which will automatically lead to a greyish-looking
tooth. BASE DENTINE should be used
again to correct the deficient contour
(Fig. 7 and 8). If the value has to be
changed, the technician should go
back two steps and correct the basic
value. “The basic value is the most
important thing for me. You should
play around with it,” is Rutten’s strategy. The palatal side was layered with
EFFECT CHROMA 4 (lemon drop) and
BASE DENTINE to mask the transition
between coping and layering in these
areas. This is Rutten’s general advice
for finding the correct ceramic shade
combination: “Getting the right mixture will sometimes take more time
than the layering itself. Don’t start
mixing thousands of powders.”

Finishing the restoration
Maintaining adequate healthy pinkcolored gingiva is challenging for the
dentist, especially around implant
restorations. To accomplish optimal
gingival architecture, the shape of
the neighboring lateral incisor was
replicated and the gingival papilla
supported to avoid creating black
triangles. The distal and mesial marginal ridges were created with a fine
diamond instrument to produce a
fluent curvature toward the apex. After the fine-structure feldspathic ceramic was fired, the subgingival areas
were contoured and polished with
a rubber wheel to create a smooth
and compatible environment for the
surrounding soft tissue. The chipped
adjacent tooth was matched in the
restoration, although in a different
location for a more natural outcome.
A vertical crack line was accom-

plished with a fine tungsten carbide
bur. As Rutten says: “You can place
your cracks two or three millimeters
away from the position on the corresponding neighboring tooth. We
need an irregular crack line.” Final
characterization was achieved with
VITA AKZENT Plus EFFECT STAINS
and then fired. “I try to create something soft without overdoing it,” says
Rutten in describing this final step.

“Make the best,
but keep it simple!”
The goal should be to keep the technique straightforward and to know
when a restoration is finished so that
time is not wasted and economic
goals are met. Consequently, every
veneering procedure should be consistently ended at some point. The
crown was clinically evaluated before
the final glaze firing (Fig. 9 - 10). After
evaluating the esthetics, function
and occlusion, the restoration was
finalized in the dental laboratory and
definitively cemented (Fig. 11 - 14).
The restoration looked exceptionally natural and integrated harmoniously in the esthetic zone. Texture
and ceramic layering created a highly
esthetic combination of contour and
color. The crown supported the gingival architecture and was thereby able
to accomplish pink esthetics. The
patient was delighted with his new
restoration and appreciated the outcome. Thanks to know-how, technical skills, interdisciplinary teamwork,
and outstanding ceramics, a challenging clinical case was solved in a
highly esthetic manner.

Source
This case has been previously published in dental dialogue 5/16, teamwork media GmbH, Germany

[51] =>

[52] =>

LAB TRIBUNE

Dental Tribune Middle East & Africa Edition | 4/2018

Celtra® Press – All Ceramic Power
By Dentsply Sirona
Life’s getting easier! In today’s dental laboratory, selecting the right
material has become a complex issue. Dental technicians are continually confronted with new materials
whose development often paves

the way for more advanced forms
of dental rehabilitations. Celtra®
Press Zirconia-Reinforced Lithium
Silicate, is a new material on the market that makes life for dental technicians easier. Its excellent optical
properties open up new and better
options in the area of high-strength

glass ceramic restorations. Master
dental technician Hans-Jürgen Joit
discusses the ideal optical properties
required from a material and illustrates how Celtra® Press meets the
high aesthetic demands from both
dentists and technicians today.

Conclusion
The material properties of Celtra®
Press allow the dental technician to
concentrate more on the morphology. The opalescent effect looks just
great in the mouth, and the crown
becomes simply – a tooth.

For more information please contact your
local Dentsply Sirona representative.
www.dentsplysirona.com

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CAD/CAM
international magazine of

digital dentistry

2017

interview
“Dentistry has finally arrived in the digital age”

case report
Screw-retained implant-supported restoration

Fig. 1: This image shows two rows of samples of polished opals for use in
jewellery. The top row has been photographed with a ﬂash from above;
the opals appear as radiantly blue in the incident light. The lower row
has been photographed with a ﬂash from below; the samples appear
to be made of a completely different material. This interaction is a basic
prerequisite for the optical intraoral acceptability of a dental material.

Fig. 2: Ultimately, our goal as dental technicians is to produce copies of
natural teeth with exactly the same characteristics. One of the main aspects of the optical effect is the opalescence of the material. With Celtra®
Press, in transillumination the teeth appear more orange, while in direct
incident light they appear bluish.

in the edentulous
Fig. 3: This image shows six Celtra®
Press maxilla
veneers, about 0.6 to 0.8mm
cone
beam
supplement
thick, placed on the window sill in
the
laboratory
and transilluminated
Dynamic navigation for reliable
and predictable flapless implant placement
by sunlight. The special microstructure, with its particularly fine crystalline structure and high glass-content, provides the material with outstanding light-optical properties. Thanks to this combination of high
translucency and opalescence Celtra® Press exhibits an amazingly natural chameleon effect to surrounding teeth in the mouth. Restorations
fabricated with it blend into the natural dentition extremely well and
assure users maximum aesthetics for mimicking natural teeth.

Fig. 4: The same jewellery opaque as previously photographed in transillumination and in incident light, now in cross-polarised light. An orangeblue ﬂicker and a lively, playfully changing colour can be seen.

Fig. 5: Shows previously transilluminated Celtra® Press veneers in polarised light. Celtra® Press possesses the same characteristics as the polished
opals, meaning it has an optimised balance of translucency and natural opalescence resulting in a game-changing chameleon effect (in-vivo
blending) that makes the restoration indistinguishable from the natural
tooth.

Fig. 6: This image shows an extracted natural tooth with a Celtra® Press
MT coping in A2. The coping was merely fitted on the tooth and manually polished. Note the conspicuous transition from the unprepared root
to the Celtra® Press crown. The crown practically becomes a part of the
tooth.

[53] =>

www.dental-tribune.me

Published in Dubai

July-August | No. 4, Vol. 8

“Up to ten times more plaque removal”

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ISSN 2567-286X

An interview with Maha Yakob, PhD, RDH, Global Director, Professional
Relations and Scientific Affairs, Philips Oral Healthcare
By Dental Tribune MEA/CAPPmea
Maha is a scientific guru for Philips
Sonicare. She started as a dental hygienist many years ago in Sweden
while also lecturing at the Karolinska
Institute. Karolinska is well known in
the industry of dentistry since it has
housed many Nobel Laureates, both
in physiology and medicine. Dental
Tribune MEA had a chance to hear
from Maha on her evidance based
approach on Sonicare, the electronic
toothbrush.
I was completely on the academic
side when Philips approached me,
and I joined them three years ago.
What I implemented in the company
was this whole evidence-based ap-

proach. Before I joined Philips, they
had all these great studies that they
had done, but they didn’t really focus
as much on getting the publications
to the professionals. We just assumed
that once people tried Sonicare, they
would love it. But then my focus
shifted and I thought, let’s publish
these papers and show our peers and
colleagues why they should recommend Sonicare based on evidence.
In that case, they are not just recommending Sonicare because they like
the product. Often, we would hear
dentists or dental hygienists say, I
know it is working because when my
patients come back they have fewer
splitting gingivae. They could all see
the clinical results, but our approach
needed to be evidence-based. Patients

loved the product, it was just that the
scientific part was missing, which is
what we see now with the Journal of
Clinical Dentistry, launched at the
International Dental Show, with five
studies that were published in this
peer-reviewed journal.

In the first study, we saw that the
Philips Sonicare Diamond Clean
power toothbrush was statistically
significantly more effective than a
manual toothbrush in reducing supragingival plaque, gingival inflammation and gingival bleeding

In this special issue, you will find five
papers. The first two are randomised
control trials looking at Sonicare
versus manual toothbrushes. Two
randomly assigned groups are compared after one group receives a
manual toothbrush and the other, a
Diamond Clean. Not surprisingly, of
course, Sonicare performed significantly better in the areas of plaque
removal and gingival health.

The second study showed that the
Philips Sonicare FlexCare Platinum
with the Premium Plaque Control
brush head significantly reduced gingival inflammation, gingival bleeding and plaque following two and six
weeks of home use, compared with
manual toothbrushing alone. This is
how we substantiated the claim, “Up
to ten times more plaque removal.”
The Sonicare toothbrush has flexible
sides, allowing it more coverage of a
larger surface area.
The objective of the third study was
to evaluate the short-term clinical
efficacy of high-frequency, high-amplitude sonic-powered toothbrushes
compared with manual toothbrushes on plaque removal and gingivitis
reduction in everyday use, through
a meta-analysis of randomised controlled trials. The combined results
of 18 studies with a total of 1,870
subjects showed that sonic-powered
toothbrushes had significantly greater plaque removal. In conclusion,
high-frequency, high-amplitude sonic-powered toothbrushes decreased
plaque and gingivitis more effectively than manual toothbrushes in
everyday use, in studies lasting up to
three months.
Of course, studies one, two and three
confirm that Sonic technology is superior to the manual toothbrush.
Study four is a head-to-head study
done by an independent research
organisation to compare the effect of
the Philips Sonicare DiamondClean
used with the Premium Plaque Control brush head to the Oral-B7000
used with the CrossAction brush
head on gingivitis and supragingival
plaque reduction. In the results, we
can see that the numbers were significantly better than with the other
technology .
The fifth study is moving away from
simply brushing your teeth to using
AirFloss in-between your teeth as
well. The addition of interproximal
cleaning to manual toothbrushing
is statistically proven to significantly
reduce gingivitis and plaque compared with manual toothbrushing
alone. Among the adjunct interproximal cleaning regimens, AirflossPro
provides a similar reduction in gingivitis and plaque to string floss.
The question now is: shall I change
to AirFloss when I floss every day? If
you floss every day and you do it the
right way, regular floss is acceptable.
But, as a dental hygienist, I can tell
you that very few of my patients floss
every day and even fewer of them
floss the right way. AirFloss was really
developed for the majority of people
who don’t floss every day, i.e. inconsistent flossers. There is a solution

1
2017

Opinion:
A vision and
a need for prevention

Advertorial:
Dentists reveal ways
to proﬁt from
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Special:
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for them now that can help, is easy
to use, is user-friendly and disrupts
the biofilm. We wanted to make sure
that it was backed by science, which
is why we did the study. We saw that
manual toothbrush users still had
significant amounts of plaque, but
as soon as we added the string floss
or AirFloss, there was a reduction in
plaque. In fact, we found eight times
more plaque removal if something
was used in addition to the manual
toothbrush. Again, the scientific
evidence suggests that AirFloss is as
good as floss when you use it with a
manual toothbrush and strands.
This is something we have shared
with the community. We do trade
shows, events and different kinds of
summaries of the studies. In the US,
we aired a TV commercial that talks
about the studies and, of course, the
different conclusions.
Together with the FDI World Dental
Federation, we are trying to educate
and raise awareness. Partnership
with the FDI’s World Oral Health Day
is something of which we are very
proud and it is our way of spreading
the message.
For me, working for a company like
Philips feels like the perfect fit. It is
not just a technology company, but
also a health tech. Forget the lights
and everything else that people associate with Philips, it is a health tech
company that has everything from
diagnosis to home treatment to prevention, and we are really focusing
on the holistic approach so that the
FDI’s World Oral Health Day is about
increasing awareness of the oral systemic link. That’s why a partnership
with the FDI is perfect - it increases
public awareness and helps you
make the smart decision about what
you are using in daily care. Many
people are still unaware of good oral
health care, especially in this region.
They still use manual toothbrushes,
which means we still have plenty of
work, but I think we have more to do
in education.

Maha Yakob, PhD, RDH
Dr Maha is a scientific guru for Philips
Sonicare. She started as a dental hygienist many years ago in Sweden while also
lecturing at the Karolinska Institute.
Karolinska is well known in the industry
of dentistry since it has housed many
Nobel Laureates, both in physiology and
medicine.

[54] =>

hygiene tribune

Dental Tribune Middle East & Africa Edition | 4/2018

Pregnant women are hardly informed
about the importance of oral health

By DTI
A new mother herself, pregnancy
gingivitis has become a subject close
to Dr Anja Carina Borer’s heart. She
set up a joint campaign between
Oral-B and the European Federation
of Periodontology (EFP), which promotes oral health during pregnancy
and educates health professionals
and the wider public on the issue.
Originally trained as a dentist in
Mainz in Germany, Anja now serves
as Professional and Scientific Relations Manager Europe at Procter &
Gamble in Geneva in Switzerland,
where we met with her for some
questions and answers on the subject. Fittingly, she brought along her
4-monthold daughter, who cooed
quietly in her pram throughout the
interview.

Oral-B and the EFP have
touched upon a very important and personal topic, in
that periodontal disease could
affect the developing baby.
Dr Anja Carina Borer: Yes. Gingivitis is a well-known side-effect
during pregnancy and the latest
data shows that practically every
pregnant woman suffers from it. The
number of bleeding sites is about
three times higher in pregnant women than in the average adult. Even I,
a dentist equipped with more than
enough scientifically soun Oral-B
products, experienced some gingival
bleeding for the first time in my life!
As we know, untreated gingivitis can
lead to periodontitis, the inflammatory burden of which can negatively
impact pregnancy. Although more
consistent in-depth studies are necessary, periodontitis during pregnancy has already been linked with
premature birth, low birthweight
and pre-eclampsia. This topic is im-

portant as most pregnant women
are not aware of this problem and
therefore often do not recognize the
warning signs of gum problems such
as bleeding or sensitive gums. With
our campaign, we want to inform
women and make sure they take
good care of their oral health and see
a dental professional in order to prevent possible oral health problems
and pregnancy complications.

How can periodontitis lead to
these complications?
Clinical studies suggest that bacteria
from the oral cavity —specific microorganisms associated with periodontitis—colonise the foetus and
the placenta, with blood as the most
likely vehicle of transmission. As a
consequence, the presence of periodontal bacteria in the feto-placental
unit may activate a local immune or
inflammatory response that might
negatively affect the pregnancy

Biologically, that makes
perfect sense, but how widely
accepted is this point of view?
Although clinical research on the
matter has existed for years, it is
still a fairly neglected topic. Not only
does it not receive enough attention from dental professionals, it is
also largely overseen by healthcare
professionals such as gynaecologists
and midwives. When I was pregnant, I was warned about many potential risks, ranging from flying to
eating sushi or dying my hair! I did
enough research on the aforementioned “risks” to conclude that there
is no scientific data to support these.
However, no one—my gynaecologist included—told me to go and see
a dental professional or take care of
my oral health.
To me, this really is a very personal
matter, as I fell pregnant while es-

tablishing the cooperation concerning pregnancy gingivitis with the
EFP. I find it worrying that pregnant
women are hardly ever informed
about the importance of good oral
health during pregnancy. Therefore,
I was passionate about establishing
the Oral-B/EFP cooperation and lead
the joint campaign. Our aim is to better educate dental professionals and
medical professionals in general, as
well as the wider public, on the importance of good oral health during
pregnancy.

Could you explain the changes in the bodies of pregnant
women that cause pregnancy
gingivitis?
The biggest hormonal changes in a
woman’s life take place during pregnancy. It is a period of great change
and obviously the mouth is one
of the main areas affected by such
changes, which in itself can lead to
gingivitis.
It is not for nothing that people used
to say that women gain a child and
lose a tooth. During pregnancy, there
is a 150 times increase in oestrogen
compared with the amount during
a normal menstrual cycle. This and
the increase of progesterone and
other hormones lead to an increased
vascular permeability of gingival
tissues, which promotes gingival
inflammation in the presence of
dental plaque. For women who have
already developed periodontitis, the
situation usually gets worse because
of the changed hormonal situation.

Apart from cardiovascular
disease, periodontal disease is
known complication of diabetes. What is the risk of pregnant women with diabetes

developing periodontitis?
For women who already have diabetes, the biggest challenge is to
keep their blood sugar under control. Independent from this, a small
percentage of women develop diabetes during pregnancy. Although
this type of diabetes disappears after pregnancy, these women need
treatment in order to avoid serious
complications. Both groups, however, have a higher risk of developing
periodontal disease. It is important
to note that treatment is more likely
to succeed if a person’s blood sugar
levels are under control. Vice versa,
periodontal disease also negatively
impacts diabetes. Overall, it is important that women with diabetes take
care of their oral health before and
during pregnancy.

How do you integrate all of
your findings in your Oral-B
seminars?
Oral-B’s mission is to promote oral
health and work closely with dental professionals to ensure optimal
home care. Our collaboration with
the EFP serves as a way to raise
awareness about all matters concerning oral health during pregnancy. Our educational activities
such as the Up-to-Date events are a
way to communicate this and support dental professionals in their
objective to improve oral health. We
believe a healthy mouth is part of a
healthy body and promoting good
oral health during pregnancy is one
way to help to achieve this.

How can general dental practitioners, periodontists and
dental hygienists integrate
this last thought into their
daily practice?
It is important that they under-

stand the connection between oral
and general health, be it the link between periodontitis and diabetes,
as well as cardiovascular disease, or
complications during pregnancy.
Gynaecologists, cardiologists and endocrinologists too should be aware
of this connection. That being said,
many women avoid professional
dental care during pregnancy and,
conversely, many dental professionals are insecure about treating
pregnant patients. However, female
patients of childbearing age should
be informed about the importance
of oral health during pregnancy.
This is especially important for patients who suffer from periodontitis.
These patients should be encouraged
by dental professionals to undergo
treatment before pregnancy. During
pregnancy, non-surgical periodontal
therapy has been considered safe in
the second trimester.

Finally, what would your tips
be for pregnant women?
Women who have periodontitis
must seek treatment before pregnancy, whereas women who enjoy
good oral health should go and see
a dentist or a dental hygienist in the
second trimester for a dental cleaning. Of course, they should brush
their teeth twice a day with a fluoride-containing toothpaste—even
better is an antibacterial toothpaste
containing stannous fluoride—and
clean their teeth interdentally. It is
scientifically proven that electric
brushes such as our Genius toothbrush are particularly good for reducing plaque and gingival bleeding.
Moreover, they are a practical solution for women who have less time
to brush their teeth. There is no question that all mothers with a baby
will know exactly what I am talking
about.

[55] =>

hygiene tribune

Dental Tribune Middle East & Africa Edition | 4/2018

Preservation of root cementum:
A comparative evaluation of power-driven
versus hand instruments
By Bozbay E, Dominici F, Gokbuget
AY, Cintan S, Guida L, Aydin MS,
Mariotti A, Pilloni A., Italy

Background

Grzesik et al. suggested that cementum plays an important regulatory
role in periodontal regeneration. One
of the major goals of periodontal
treatment is the removal of pathogenic micro-organisms by scaling
and root planning. In the past the
misconception was to obtain a root
surface with smooth and hard surface characteristics that was free of
endotoxins which resulted in the removal of the subgingival plaque and
calculus deposits, and the removal
of all or most of the cementum.
Recent studies have reported that
endotoxins were not located within
cementum and removal of ‘diseased’
cementum was not necessary for a
successful periodontal treatment.
Saygin et al concluded that preservation of cementum on the root
surface was necessary for new attachment and as a source of growth factor. Hence non-aggressive removal
of cementum is essential for optimal
periodontal health and regeneration.
Ultrasonics with new shaped tips
and subgingival air polishing devices
has been developed for removal of
root accretions with minimal root
damage. Air polishing has been suggested as a treatment modality for
root debridement resulting in probing depth reductions and removal of
subgingival biofilm. No scientific evidence exists today showing the loss
of root substance or surface roughness produced by either ultrasonics
or Air polishing.

traumatically and analyzed with a
dissecting microscope
- Remaining calculus, root surface
roughness and loss of root substance
were evaluated along with scratches,
gouges, cracks, and any other changes in the cementum that was present
were noted.

Results

Remained cementum:
- Percentage of coronal cementum
remaining following subgingival in-

strumentation was 84% for U, 80%
for U + AP, 94% for AP and 65% for
HC.
- The amount of retained cementum
with AP was significantly greater
than with HC. SEM
- Smoothest root surfaces were produced by the HC followed by the AP
- Coronal and apical sections showed
that AP produced the least amount
of cementum loss and therefore the
greatest retention of residual cementum

- Root surfaces instrumented by U
or U + AP presented grooves and
scratches.
Time taken to complete root instrumentation
- Shortest time taken was using AP
and the longest time was with U + AP.
- AP required 31% less time for root
preparation in comparison to HC,
whereas U + AP needed 30% more
time

Conclusions

- Air polishing was significantly more
effective and superior in preserving
cementum.
- Hand instrumentation using curettes was most effective in removing cementum in comparison to ultrasonics or hand instruments
Editorial Note: The article was originally published in International Journal of Dental Hygiene.
08 September 2016, page 1-8

The Dental Tribune
International Subscriptions
www.dental-tribune.com

Aim

To assess the amount of cementum
remaining following in vivo root instrumentation as well as the surface
characteristics of the retained cementum

Material and Methods

- 48 caries free, single-rooted teeth
in 27 patients diagnosed with severe
chronic periodontitis with periodontal probing depth (PPD) ≥5 mm in at
least two sites per tooth with radiographical bone loss of more than two
thirds of root length and scheduled
for extraction were included in this
study
- Teeth were randomly divided into
four treatment groups: Instrumentations were performed with medium
power settings
1. Piezoelectric ultrasonic scaler - (AirFlow Master Piezon, Instrument Tip
PS; EMS SA)-U
2. Piezoelectric ultrasonic scaler - (AirFlow Master Piezon, Instrument Tip
PS; EMS SA) followed by air polishing
with the glycine powder (Air-Flow
Powder Perio, Perio-Flow Nozzles;
EMS SA) - U + AP
3. Air polishing with the glycine powder (Air-Flow Powder Perio, PerioFlow Nozzles; EMS SA) - AP;
4. Hand instruments (Gracey curettes
5/6, 11/12, 13/14 American Eagle, Missoula, MT, USA)-HC

Treatment

- One approximal root surface of
each tooth was randomly subjected
to debridement, and the other approximal surface was used as control.
- Following instrumentation, the
teeth were immediately extracted

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[56] =>

hygiene tribune

Dental Tribune Middle East & Africa Edition | 4/2018

CS 5460:
Dental care reinvented
By Curaden
For effective oral care, it is very important to use a toothbrush with soft
bristles. The reason for this is that
hard bristles can often damage teeth
and gums. This is a negative sideeffect which also occurs if too much
pressure is used while brushing.
Curaden’s CS toothbrushes have one
special feature in particular: they are
incredibly soft. The 5,460 CUREN®
filaments of the CS 5460 ultra soft
form an extraordinarily dense and
efficient cleaning surface. The bristles are stiffer than Nylon and remain just as stable in the mouth as
they are when dry. These properties
make it possible to manufacture
toothbrushes with many very fine
bristles. Soft on the gums and teeth,

the CUREN® filaments are extremely
tough on plaque. Anyone who has
tested the cleaning power of a CS
toothbrush will never want any other brushing experience.
An ideal toothbrush head is small
and slightly angled to make it easy
to reach those crucial areas. The bristles should be fine enough to clean
the teeth and gums softly and thoroughly. The handle should make
it possible to properly position the
toothbrush at about a 45-degree angle, always half on the gums and half
on the teeth. The gumline is just as
important as the teeth.
The CS 5460 ultra soft combines
these exact standards of design and
function. The small but efficient head
at the proper angle ensures that your

patients reach those crucial areas. An
eight-sided handle facilitates the perfect angle on the teeth and gums for
optimal cleaning. The large cleaning
surface with incredibly fine, rounded
filaments ensures soft and efficient
brushing of the teeth and gums.
The cleaning efficiency of the bristles
is tightly packed into 39 holes. Combined with the lively colours of the
CS 5460 ultra soft, it makes for one of
the most popular CURAPROX products. The toothbrush is also available with the CPS Prime interdental
brush. The CURAPROX Superduo offers the perfect choice for everyone.

Visit the website to learn more about our
products: www.curaprox.com/ch-en

Periodontal disease may be
key initiator of rheumatoid arthritis
By DTI
AMSTERDAM, Netherlands: In recent years, increasing attention has
been given to aspects of oral health
in patients with rheumatoid arthritis (RA), especially related to associations with periodontal disease. The
results of a study conducted at the
University of Leeds in the UK, and
recently presented at the Annual European Congress of Rheumatology
(EULAR 2018) in Amsterdam, demonstrated increased levels of periodontal disease and disease-causing
bacteria in individuals at risk of RA.

The study found that the prevalence
of periodontal disease was increased
in patients with RA and could be a
key initiator of RA-related autoimmunity. This is because autoimmunity in RA is characterised by an
antibody response to citrullinated
proteins in which the amino acid
arginine has been converted into
the amino acid citrulline, altering
the proteins’ structure. The oral bacterium Porphyromonas gingivalis is
the only human pathogen known to
express an enzyme that can generate
citrullinated proteins.

The study included 48 at-risk individuals (positive test for anti-citrullinated protein antibodies), 26 patients
with RA and 32 healthy controls. The
three groups were balanced regarding age, sex and smoking.
“It has been shown that RA-associated antibodies, such as anti-citrullinated protein antibodies, are present
well before any evidence of joint
disease. This suggests they originate
from a site outside of the joints,” said
study author Dr Kulveer Mankia,
clinical research fellow at the university’s Institute of Rheumatic and

Musculoskeletal Medicine. “Our
study is the first to describe clinical
periodontal disease and the relative
abundance of periodontal bacteria in
these at-risk individuals. Our results
support the hypothesis that local
inflammation at mucosal surfaces,
such as the gums in this case, may
provide the primary trigger for the
systemic autoimmunity seen in RA.”
“We welcome these data in presenting concepts that may enhance
clinical understanding of the key
initiators of rheumatoid arthritis,”
said Prof. Robert Landewé, Chair-

person of the EULAR 2018 Scientific
Programme Committee. “This is an
essential step towards the ultimate
goal of disease prevention.”
The study abstract is titled “An increased prevalence of periodontal
disease, Porphyromonas gingivalis
and Aggregatibacter actinomycetemcomitans in anti-CCP positive
individuals at-risk of inflammatory
arthritis”.

Patient motivation techniques
By DTI
When it comes to motivating patients to maintain good oral hygiene
practices, a clear plan is essential given the time constraints of most dental appointments. What this plan entails, however, depends on what the
most pressing issues to the patient
are. prevention magazine spoke with
Sandy Basheda, a dental hygienist at
the M & N Dental Practice in Bedford
in the UK, about how she structures
her oral hygiene appointments and
the importance of building relationships with patients.

Ms Basheda, how did you
first get started as a dental
hygienist at M & N Dental
Practice?

Sandy Basheda: I’ve been working at
M & N Dental Practice for three years
now. I started basically straight after
I graduated from the University of
Liverpool with a degree in dental hygiene and therapy. Prior to that, I had

a background in dental nursing, but I
wanted more of an instrumental role
with dental patients, which led me to
hygiene and therapy.

What does your average day
at work involve, and what
is the structure of your oral
hygiene appointments?
I see many patients with periodontal
problems and so conduct a lot more
hygiene right now than therapy. I
also deal with a lot of children that,
unfortunately, have dental caries
due to a poor diet, lack of oral hygiene and likely a lack of education
on how to prevent it. It’s not a good
start for children if they have to have
fillings put in or even have their
teeth pulled if it’s particularly bad—
it doesn’t give them a good first impression of the dentist.
Each oral hygiene appointment is
scheduled for half an hour and begins with a discussion about the
patient’s existing problems and

current oral hygiene routine. I then
explain to the patient what the purpose of the appointment is and what
it will entail and conduct an assessment of his or her oral health. Every
patient is very different, and it really
depends on what he or she needs addressed as to how the appointment
will proceed from there.

How can you get patients
to continue with good oral
hygiene practices after an
appointment?
I think one has to build a relationship
with them. They have to trust one
and understand what the benefits of
oral hygiene are, as they might not
be aware that they have any problems in the first place. For example,
if smokers aren’t experiencing any
bleeding in their mouths, they might
not think that there’s anything to
worry about. One needs to be able
to explain to them in a clear and understandable way why taking care
of their teeth is important not just

for their oral health but their overall
health too.

But is it possible to achieve
this all within half an hour?
Well, it’s not a lot of time, but we
can always schedule an hour-long
appointment if it is necessary. I see
many anxious patients, patients who
might not have been to the dentist in
ten to 15 years. With these patients, a
shorter appointment is often good
in the beginning, because it means
that they’re not overwhelmed and
that one can build up from there
over the ensuing sessions. By the second or third appointment, they’re a
bit more relaxed and eager for treatment.

How do you motivate your
patients to take charge of
their own oral hygiene?
I think it’s mostly about re-educating
patients on what the correct and
most effective cleaning methods are,
what products are best for them. It’s

about finding something that works
for the patient, something that will
get him or her excited about taking
care of his or her teeth and seeing
the benefits. In dentistry, it can be
difficult to engage in a cooperative
relationship with one’s patients—often, it’s a one-way conversation with
the professional giving the patient
instructions or advice on how to take
care of himor herself. I like to leave
that sort of instructional conversation to the beginning or the end of
the appointment, as this allows the
patient to think, while in the chair,
whether he or she has any questions
about anything I’ve said or what our
future appointments will entail. Being able to answer these questions in
a clear and understandable way is essential to motivating patients.
Thank you very much for the interview.

[57] =>

A soft
approach
for tough areas.
Enamel is hard. Harder than steel, even.
And it should stay that way. Enamelfriendly brushing means: pampering
your teeth and gums with tender loving
care. Like with the gentle CS 5460 ultra
soft. Mmmm, let’s do that again.

curaprox.com

[58] =>

hygiene tribune

Dental Tribune Middle East & Africa Edition | 4/2018

Oral hygiene instructions and patient
motivation with and without dental hygienists
An interview with Dr Eric Thevissen, periodontist and pioneer of Belgian prophylaxis

By DTI

Dr Thevissen, I wanted to
talk to a dental hygienist in
Belgium. Why is that not yet
possible?
Dr Eric Thevissen: Well, the good
news is that, from June 2019 on, it
will be possible to visit and talk to a
dental hygienist in Flanders. Why
Flanders has waited such a long time
to start the education and training of
dental hygienists is politically motivated and due, in large part, to the
representative dental associations.
Belgium has a long tradition of onedentist clinics, often working without dental assistants. Since the introduction of a quite difficult admission
exam for dentistry in 1997, the discipline has attracted fewer students.
As a consequence, the number of
graduating students has dramatically decreased, while the demand for
dental care is continually increasing.
Slowly, but surely, more and more
group practices have emerged, hiring dental assistants. Back in 2006,
the first meetings were organised between universities and dental societies about the qualifications needed
to become a dental hygienist and
the tasks that could be delegated to
them. As always, there were proponents and opponents, and it took a
very long time before all stakehold-

ers agreed on the conditions and criteria needed to start dental hygienist
training in Leuven and Ghent.

Let’s talk about your study
“The provision of oral hygiene
instructions and patient motivation in a dental care system
without dental hygienists”.
Please tell us more about it.
Thirty years ago, I started working as
a periodontist in Hasselt with another colleague. Since we were the first
periodontists in this province, we
had a flying start. After a few years, I
noticed that dentists were always referring patients to our clinic with the
same complaints, such as bleeding
gingivae or bad oral hygiene. In my
opinion, treating bleeding gingivae
or giving oral hygiene instructions is
the duty of every dentist and belongs
in the sphere of primary dental care
rather than in secondary or specialist
care. Although we organised courses
where a general dental practitioner
(GDP) could learn about patient instruction and guidance, I realised
that we were considered by a large
number of GDPs to be dental hygienists rather than periodontists. The
truth was that we were both, periodontists and dental hygienists. This
annoyed me because I knew that in
neighbouring countries periodontists could spend their precious time

on the work they were trained for.
In 2004, I took the initiative to set
up a pilot study in Limburg with
65 referring dentists. We used the
Dutch Periodontal Screening Index,
a screening test for periodontal status that had been introduced in the
Netherlands a few years earlier. We
collected data from 814 patients.
The results clearly showed that the
screened age groups had, on the
whole, periodontal problems and
that there was a high need for treatment.
Around the same time, Prof. Hugo
De Bruyn joined the teaching staff
of Ghent University’s Department
of Dental Sciences. Probably thanks
to my publication, he asked me to
become one of his staff members.
Working with Prof. De Bruyn, one is
quickly involved in clinical research
and so I had the opportunity to investigate, in depth, the questions
that had bothered me ever since I
started my career. One of these questions was the kind of oral hygiene
instructions GDPs provide to their
patients.
Using questionnaire responses of
776 dental professionals gathered
for various postgraduate courses in
Flanders, we were able to determine
that, given the absence of dental
hygienists in Belgium, oral health
instructions and patient motivation
appeared to be non-compliant with
international guidelines. Though
dental professionals were concerned
with prevention, there were several
mitigating factors working against
them delivering this adequately.

The study mentioned lack
of time, remuneration and
patient interest as complicating factors for the provision of
preventative care. However,
qualification, work experience
and time are crucial for providing oral hygiene instructions
and patient motivation. Can
dental hygienists be seen as a
solution to these problems?

Dr Eric Thevissen

It is my conviction that dental hygienists are the solution to these
complicating factors. Prophylactic
care will be the main target of their
work, since dentists are primarily
trained for restorative care. Owing to
factors such as the decreasing number of graduating dental students,
the increasing number of retiring
dentists in the next ten years, an ageing population and a higher demand
for preventative care, the stress of
work increases and forces dentists
to manage their work time more
strictly. Of course, GDPs prefer restorative and other more rewarding
treatments. We all know how timeconsuming patient motivation techniques for behaviour change can be.
There is no dentist prepared to spend
that time on preventative care. Generally speaking, dentists are used to
giving a basic package of information on oral hygiene to every patient
and, depending on compliance, they
may want to spend more time on
patient guidance. Here, dental hy-

gienists can make the difference.
They will be trained to insist on the
importance of behavioural change
and will take the time to explain and
show how to perform proper home
oral care.
You have also published studies on
implants, such as on implant design.
What made you publish your study
titled “Attitude of dental hygienists,
general practitioners and periodontists towards preventive oral care: An
exploratory study”? You could have
just continued with your research on
implant systems.
Indeed, the team around Prof. De
Bruyn is very driven by and focused
on the outcome of implant therapy.
To my knowledge, the Department
of Dental Sciences at Ghent University published around 40 scientific articles in 2016, the majority of which
are related to implant therapy. The
subject of my PhD is not implantrelated, but deals with different relationships in dentistry: between the
patient and the dental professional,
and between primary and secondary dental care, that is between GDPs
and specialists.

What were the objectives and
results of this study?
This second study was a step further
than the first one. In the first study,
we looked for an explanation for the
differences in patient motivation
techniques between Flemish GDPs
and periodontists. In this second one,
we compared our rather unique Belgian system with the Dutch system,
a completely differently structured
healthcare system including dental
hygienists. We wanted to know if the
Dutch system represented the gold
standard and how we were situated
in Flanders.
The results showed that periodontists and dental hygienists shared
more common viewpoints than
GDPs and hygienists did. What was
remarkable was the fact that more
than 80 per cent of periodontists
and dental hygienists were satisfied with their efforts in informing
and motivating patients, compared
with 38 per cent of GDPs. Secondly,
whereas GDPs indicated nurture
as the factor most contributing to
the oral hygiene level of the patient,
periodontists and dental hygienists
focused on the influence of the dental practitioner and a patient-centred
approach. In our multivariate analysis, the presence of chairside assistants seemed to be of major importance.
But, as always in questionnairebased studies, the results can be biased by socially desirable answers
and by the inevitable structural differences between Belgium and the
Netherlands. One of these differences, for example, is the fact that
providing oral hygiene instructions
is not reimbursed in the Belgian dental care system, as it is not considered
an autonomous activity.

What should the role of the
dental practitioner in the
successful treatment of

periodontal disease be? What
does the patient need to do?
The role of the dental practitioner,
in particular the GDP, undoubtedly
remains to keep a panoramic oversight over everything that has to do
with the dental and oral health of the
patient. Especially considering the
introduction of dental hygienists in
the near future in Belgium, the dentist’s role as a supervising manager is
important. It is my experience that
progressive problems often remain
untreated until complications or
even complaints surface. A trigger
seems to be needed to make the idea
of treatment approachable or acceptable. Unfortunately, waiting for
this trigger often leads to the loss of
the tooth instead of its repair.
From the patients’ point of view, I am
convinced that some of them insist
on not being treated for things they
do not complain about, as they see
these treatments as unnecessary.
If I personally have to undergo an
annual medical check-up, I would
hope that all the exams needed are
performed, as this will set me at ease.
Why then does this appreciation not
apply to oral health?

What are some of the oral
hygiene instructions and
patient motivational actions
that you would recommend?
Thanks to research and clinical findings, lifestyle habits, genetics, stress,
hygiene, medication, age, nutrition
and different systemic factors have
been shown to accelerate the development of periodontal disease in
the presence of biofilm, activated
by a hyperreactive or even a hyporeactive immune system response. It
is a fact that this sort of risk analysis
has become part of the graduate curriculum, including counselling on
healthy food habits or how to quit
smoking, detecting periodontal risk
through assessment, using caries detectors, and so on.
Firstly, the patient should demonstrate his or her home care habits
using his or her own toothbrush.
We distinguish four levels of patient
information needs: the lowest level
is the patient who is almost totally
ignorant about proper home care;
the second level is the patient who
brushes his or her teeth on autopilot without paying attention to any
technique, time duration or interdental cleaning; the third level is the
patient who regularly cleans even
the interdental spaces, but unfortunately not frequently enough or
not with adequate instruments; and
finally, the fourth level is the patient
who performs extremely well and
needs none or only minor adjustments, for example tongue brushing.
In accordance with the technique
of motivational interviewing, we
build up a conversation with the
patient while giving instructions,
waiting for approval, repeating and

ÿPage C7

[59] =>

Dental Tribune Middle East & Africa Edition | 4/2018

hygiene tribune

◊Page C6
counselling. One needs two or three
control sessions to check his or her
dexterity and oral cleaning performance. Plaque disclosure remains a
confronting but very effective tool
to show the results of the patient’s
cleaning habits.
Finally, the dental professional
should show enthusiasm and keep
on repeating until there are visible
improvements.

From your point of view, does
the dentist spend enough time
on the diagnosis of a disease?
Of course, dentists are dutiful people
who are concerned with their jobs.
Spending time to ensure correct diagnosis is their core business. Examining patients means exploring and
looking for mostly hidden troubles
or discomforts.
The next question is the most important one: is this problem acute
enough that it should be treated immediately, in the very near future, or
can we wait and see how it develops?
This is risk management and it is dependent on multiple factors.

Often, prevention is neglected
in dental practices in favour of
diagnosis and restorative treatment. How can dental professionals implement prophylaxis
in their daily practice, especially
primary prophylaxis?
I would say, rather, that prevention
is not neglected. Sixty-five per cent
of GDPs provide information about
oral hygiene as a standard procedure. Depending on compliance, the
GDP may decide to spend more time
on patient guidance. This requires
delicacy, as one cannot tell from a patient’s face how motivated he or she
is, nor what he or she is interested in.
This is not often asked of the patient,
so one could rather say there is not
enough time spent on communication.
I invite practitioners to do an experiment in their waiting rooms. While
the patient is waiting for his or her
appointment, he or she can be given
a short questionnaire asking him
or her to write down in a few words
his or her understanding of proper
home care and his or her personal
ritual. The patient can then be asked
if he or she would be interested to
know more about it. We use this
method in our clinic. In the waiting
room, patients have time to reflect
and one might be surprised at how
interested patients really are if one
gives them the opportunity to communicate and to prepare their questions in advance.
To be honest, I think that primary
prophylaxis is impossible to achieve

because we do not control all the
influencing factors, of which some
can be health- or patient-related. It
means that we need to try to prevent people from developing caries
or periodontal disease. This is somewhat futile, since caries and periodontal disease are the most widespread infectious diseases present
in almost every patient. Twenty-five
per cent of 5-year-old children have
bleeding gingivae, and this figure
rises to 55 per cent for 15-year-olds.
Primary prevention is like placing speed cameras on highways: it
works all the time and for everyone,
it is highly effective and inexorably
justified. Today, I heard in the news
that, thanks to these speed cameras
and other regulations, the number of
persons killed by traffic every year is
diminishing. This is primary prevention. However, I strongly believe in
secondary prevention; it is the dentist’s duty to examine and to intervene, preferably before detrimental
clinical signs occur.

How important are home care
and high-quality oral hygiene
products such as those of
CURAPROX?
It is a fact that oral hygiene devices
are not considered as pharmaceuticals and they therefore don’t have to
be thoroughly tested. If a company
designs a nice, good-looking toothbrush, it is allowed to produce it
and sell it, even if the brush does not
meet the criteria desired in an effective toothbrush.
Comparing the oral hygiene products from different companies, we
see a variety of designs and features.
This is interesting because there is no
such thing as the perfect interdental
brush. There are always compromises to make and what some patients
like, may be rejected or disapproved
of by others. We as dentists have only
an advisory, consultative role.
Nevertheless, CURAPROX makes
Swiss-quality products designed by
dental professionals, and the company is willing to listen to advice on
how to improve its products.

What is the status of dental
hygiene in Belgium? In other
words, how does the Belgian
mouth look?
When I go abroad to congresses and
meet with peers, I feel their displeasure when they hear that I come from
Belgium. The first thing I am asked is,
how can you treat periodontal disease without a dental hygienist? For
them, it is like having bars and pubs,
but no beer.
I have read some articles in which
the decayed, missing and filled teeth
and decayed, missing and filled sur-

faces scores of children were compared between different European
countries. Though Belgium was not
top of the class, it wasn’t at the bottom either. In articles from the US, it
is reported that, at 30 years of age, 25
per cent of the American population
have mild periodontitis, 60 per cent
have chronic periodontitis and 15 per
cent have aggressive periodontitis.
This is exactly the same breakdown
as in Europe. The question is not
about whether dental hygienists are
necessary; the question is, what percentage of the population do dentists reach and can afford to go to a
dental hygienist on a regular basis?
Despite all this, we seem to be able to
manage the periodontal situation in
Belgium and this was one of the reasons for the second study.

Does the addition of dental
hygienists make financial
sense or does prophylaxis
make financial sense for the
dental practice if the practice
already makes good money
with implants?
I understand your point of view that,
in the perfect world of prophylaxis,
dental implants have no place because everything should be done to
prevent implant treatment.
I remember Prof. Jan Lindhe saying
that, nowadays, too many treatable
teeth are extracted to be replaced by
dental implants. As a periodontist I
agree with Prof. Lindhe; a dental implant is an effective instrument to rehabilitate edentulous areas, but only
after all other options have been considered. But often life decides differently, and at Ghent University, I see
a lot of young people seeking dental
care because of, for example, fracture of one or more of the front teeth
owing to biking and other kinds of
accidents, sometimes under the influence of alcohol or drugs. These
students don’t want to wear removable dentures for life.
With respect to the first part of the
question, of course the addition of
dental hygienists makes financial
sense. The purpose is to relieve dentists of those tasks that can be delegated to auxiliary staff. Secondly,
dental hygienists will be trained to
communicate with patients about
their problems and questions. Delegating prophylactic care to the dental hygienist implies that more patients can be treated and followed up
on. We also must not forget patients
who live in nursing homes. Since
nurses are not allowed to provide
dental treatment, we are glad that,
in the near future, dental hygienists
will be available to give these people
the necessary preventative care.

What kind of prophylaxis does
the Belgian dentist perform in
the office? How much time do
you devote to prophylaxis?
Supposing that patients go to their
GDP on a yearly basis, supragingival
scaling and scaling of shallow pockets is standard procedure. The Dutch
Periodontal Screening Index is a perfect tool to screen patients for periodontal disease and treatment needs,
but this index is unfortunately not
yet applied widely enough, even
though it is reimbursed. If a GDP
remarks that the gingivae bleed easily or if the patient complains about
periodontal infection, then the periodontal probe is used and the patient will eventually be referred to a
periodontist.

UC Leuven-Limburg and
Artevelde University College
(in Ghent) are offering a new

professional bachelor’s degree
programme in dental hygiene.
Is that a breakthrough?
It certainly is. It is a pity that this
programme is not yet offered in the
French-speaking part of Belgium.
Let’s hope they will follow with us
as soon as possible to ensure the
levelling of our nation’s dental care.
Since Leuven and Ghent are the
only Flemish universities where the
dental graduate curriculum can be
followed, it is logical that dental hygienists will be trained at those same
universities, and that both professional groups will start to work together at chairside from trainee level
onwards.

When looking at your Dutch
neighbours, what do you
think should be replicated in
Belgium?
In the Netherlands, they have more
than 50 years of experience with
dental hygienists. This profession is
well represented and has a strong,
hardworking and lobbying society.
We in Belgium have always respected and admired the pioneering way
of organising dental care in the Netherlands. Although tough discussions
have had to be conducted, they have
always reached a consensus. Today
in the Netherlands, up to ten different levels of dental professionals
are distinguished, from specialists
to dental assistants. I don’t think we
will ever see this development in Belgium.

of our diploma as a specialist in periodontology and oral implantology.
This dream was only fulfilled in
2003. My second dream was that
dental hygienists would be legalised
to work in Belgium, and as you know,
this will also become true from 2019
onwards. So, the future is bright. I
fortunately did not mention how
long it would take before my dreams
would be fulfilled!
Looking back to ten years ago, taking digital impressions with oral
scanners was still a utopia; there
were no navigation systems available for implant therapy, and we did
not yet have these composites with
hydroxyapatite nanoparticles. Dentistry has evolved in such a rapid way
that the future is today.
However, in my opinion, the evolving trend towards cosmetic dentistry
is almost alarming. There is nothing wrong with the high demand
for aesthetic dental treatments because it has been proven that these
patients show more compliance
in cleaning their teeth, but there is
a tendency towards the belief that
appearance is more important than
function. Many patients prefer whitening their front teeth to periodontal treatment to save natural teeth.
While they argue about periodontal
therapy not being reimbursed by
the healthcare system, this point is
not raised when they seek aesthetic
dental care.

Finally, where do you see the
future of Belgian dentistry?

Another rather regrettable observation is the fact that stock-marketlisted companies invest in dental
clinics and hire dentists as employees. Of course, this is a sign of the
times. Being the manager of a group
clinic today has turned into a fulltime job that has almost nothing to
do with dentistry. Let’s hope that the
financial management of these clinics is not more important than the
patients and that the dentists working in the system still feel the same
responsibility towards their patients.

When I graduated in 1986 as a periodontist I had two dreams, the first
of which was the official recognition

Thank you very much for the interview.

The advantage of us being behind is
that we can copy the best things that
have proven to be solid and to work,
and delay the more complex or risky
things until we see how it works out
there.
I hope that dental hygienists will integrate easily into the dental workplace and that their future will be as
bright as it is in the Netherlands.

[60] =>

[61] =>

Published in Dubai

July-August 2018 | No. 4, Vol. 8

www.dental-tribune.me

Neoss ScanPeg
- Simplified intra-oral scanning

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

implants
international magazine of

4
By Dr. Jakob Zwaan, Italy

Patient
60 year old woman. Non-smoker in
good general health.

Clinical situation
Missing lower first molar. Part of a
complex case with multiple reconstructions in both jaws.

Treatment plan
Placement of Aesthetic Healing Abutment at time of implant
placement. Digital impression using the Neoss ScanPeg. CAD/CAM
CoCr single crown with angulated
screw hole.
A 4.0 x 11 mm Neoss ProActive®
Tapered implant was placed in the
lower first molar position follow-

ing 3D radiological examination. A
minimal flap was raised to split the
small amount of keratinized soft
tissue. Excellent primary stability
was obtained, insertion torque >50
Ncm and 76 ISQ.
An Aesthetic Healing Abutment
Pre-molar was placed and the soft
tissue closed with single sutures
(Fig. 1). Note the buccal orientation

Vol. 18 • Issue 4/2017

oral implantology

2017

of the groove, which functions as a
direction feature, to ensure proper
anatomical transgingival shape.
The screw channel was filled with
PTFE material (Fig. 2).
At time of scanning, the PTFE material was removed, the push-in
ScanPeg was seated inside the Healing Abutment (Figs. 3 & 4), and an
intra-oral scan was taken. The as-

research
Titanium and its alloys
in dental implantology

case report
Rehabilitation of
edentulous patients

industry
Digital workflow:
From planning to restoration

sembly allows the digital impression of the implant
position and soft tissue (Fig. 5) to be taken without unscrewing the abutment, thereby leaving the healing of

ÿPage D2

Fig. 1

Fig. 2

Fig. 3

Fig. 4

[62] =>

implant tribune

Dental Tribune Middle East & Africa Edition | 4/2018

◊Page D3
the soft tissue completely undisturbed.
Since there was no need for a temporary crown for esthetic
reasons, and the soft tissue was conditioned by the healing
abutment, it was decided to immediately produce the definitive restoration. A CAD crown was designed by the laboratory with a minor correction of axis (12°). A library of preset
transgingival shapes in the CAD library that matched the
shape of the healing abutment simplified the design work.
A Cobalt Chromium restoration was milled (Arc Solutions,
Helsingborg, Sweden). The milled abutment was mounted in
the stone model and occlusion was tested before layering the
framework with porcelain (Fig. 6).
At time of placement of the final restoration, the Esthetic
Healing Abutment was removed, revealing a mucosa around
the implant anatomically shaped by the Healing Abutment
(Fig. 7).

Fig. 6

Final restoration with matching transgingival shape in place
(Fig. 8)

Dr. Jakob Zwaan, The Netherlands
Born in 1962 in the Netherlands. Graduated in dentistry in 1987 at the
University of Utrecht, NL and emigrated to Italy in the same year. Operating in a private dental office at Calusco d’Adda(BG, Italy) since 1990 as
a general practitioner. First approach to periodontal and implant surgery
and implant supported prosthodontics in 1993, continuously updating professional knowledge and skills following lectures and attending
courses.

Fig. 5

Professor and Director, Department of Orthodontics, Dental School, University of Brescia, Brescia, Italy.

Fig. 7

Fig. 8

When to avoid implants
By DTI

as the patient’s oral care mindset
cannot be changed easily.

Located in the Salamanca district of
Madrid, Spain’s capital, Clínica Vilaboa was founded more than 30 years
ago by Drs Beatriz and Débora Vilaboa. With polished hardwood floors
and a stylishly minimalist in terior,
the practice’s aesthetic emphasis is
immediately evident. A pioneer in
aesthetic dentistry when first established, the multilingual clinic has
since expanded its focus to two disciplines, implantology and prophylaxis—which may at first seem contradictory. prevention spoke with
practice dentists Drs Amparo Llorente and José Manuel Reuss about
the clinic’s approach to prevention
in implantology.

Llorente: Prophylaxis is the main
way that conditions like peri-implantitis can be prevented. We know
that implant treatment requires
follow-up; implants need to be taken
care of continuously, so it is very important to instruct and motivate patients to have regular check-ups that
are complemented by a good home
oral hygiene routine.

As a periodontist and implantologist, how do you work together?

Reuss: In cases of severe periodontal disease, such as aggressive periodontitis, we try to delay the implant
placement as far as possible. I am
not talking about weeks or months,
but even years. If we need ten years
for a patient with periodontitis to
have the necessary oral health for
implant placement, then we wait.
Sometimes, it depends on the patient; sometimes, it is the wrong approach to oral hygiene; sometimes,
it is genetics. At the same time, we
have seen implant failure without
any clear reason.

Why did you choose
implantology?

Dr José Manuel Reuss: I was always
very interested in prosthetics and replacing what was missing. I am very
motivated by the fact of giving back
what patients have lost. The combination of prosthetics and surgery
makes implantology perfect for me.
Dr Amparo Llorente: I am a trained
periodontist and I am wholly dedicated to it. I look more at periodontal
disease and prevention of implants
[laughs]. However, I think I also have
a good understanding of implants,
so we make a good team.
Reuss: You definitely have a very
good understanding!

What is your approach to
implantology and prevention?

Reuss: It is very difficult to be able to
tell a patient that something should
last for a lifetime, but this is our
goal, our wish and our belief. Placing an implant should naturally be
our last solution once we have done
everything to save the natural tooth.
When we do the treatment, we do
not want to have the implant last
for only ten years. That is not really

Drs Amparo Llorente and José Manuel Reuss in talks with Dental Tribune.

a success. We want to provide a treatment that lasts for a lifetime.
Llorente: The great thing about Dr
Reuss is that, as an implantologist, he
is devoted to restoration and replacing. However, whenever he sees a
tooth that still has the potential to be
maintained, he does everything to
maintain it. That is very important.
Nowadays, implantology is so fashionable. Everybody wants to place
implants. Some dentists see the implants only, but we should look at
oral health first. The patient needs to
have an implant for a lifetime. This
involves good initial oral health and
a wellplanned treatment.

So, you argue that implants
should be avoided as much as
possible?

Reuss: Well, implants are a great
treatment modality and we are very
thankful for this invention. However, implants should be delayed as
far as possible. If we can preserve the
tooth for ten more years and then
place the implant, that is the way
forward. Patients should not have
their teeth removed and replaced
with implants instead. After implant
treatment, patients need to be twice
as careful with their mouths. There
is no way to go back to another solution. The dentist needs to communicate this as far as possible.

Llorente: An implant is the best solution for a missing tooth, but it is not
an alternative for a tooth that can
still be saved. An implant is more expensive than maintaining the natural tooth, so we try to preserve the
tooth if we still can.

Llorente: The major risk factors include bacterial contamination, a history of periodontitis and habits such
as smoking. This means that we need
to look at the patient’s habits and
anatomy and the surgical protocol.
These factors are more related to
early loss. Another factor is the prosthetic design.

Do you think that implantology and prevention of implants
can work side by side?

What role does poor oral hygiene play in terms of implant
success?

Reuss: Prevention is the best thing
one can do for one’s patient in the
long run. If we can get our patients to
believe in prevention and therefore
come to the dentist more regularly,
it will be beneficial for all of us. However, this is a long and bumpy road,

Reuss: When we see a patient with
very poor oral hygiene, we do not
place the implants. We are that radical. We tell our patients that the peri-

ÿPage D3

[63] =>

IMPLANT TRIBUNE

Dental Tribune Middle East & Africa Edition | 4/2018

◊Page D2
odontal tissue needs to be strong.
In the case of poor oral hygiene, the
implant will fall out eventually. We
need to make sure that the patient
has good oral health habits. Edentulous patients with a lack of good
oral hygiene are not good candidates
for implants. We have to do several
hygiene appointments first before
continuing with implant placement.

mindset that patients only come
when they are in pain. Now, we are
moving in this direction of coming
at least every year. From a periodontal perspective, I would like to see my
patients every three to six months,
especially during maintenance therapy. During the dental appointment,
they already look forward to the next
appointment.

How can we motivate the patient to use oral care products
more effectively and regularly?

Reuss: We understand now that we
have to work with patients as a team.
We can no longer simply provide
treatment. We have to spend extra
time educating them, motivating
them on how they can maintain and
preserve their oral health, which is
ultimately their responsibility.

Reuss: First of all, we have a growing
awareness of oral health among our
patients. That helps a lot in the general predisposition of patients. When
they come to our practice, they have
changed their dietary attitude and
work out more. They are starting to
believe more in prevention. They
also come in every six months, while
we only saw them every two years in
the past.
Llorente: In Spain, we still have this

Do you also instruct your patients on how to use toothbrushes, interdental cleaning
tools and toothpaste?
Reuss: Our dental hygienists focus
more on oral care instructions. Their
role in prevention is crucial. They es-

tablish a close relationship with the
patient and make sure that every patient gets the individual tools he or
she needs, be it toothbrushes, interdental brushes or floss. Everything in
our office is teamwork.
Llorente: Every patient is different, no doubt, but everyone needs
interdental brushes, for example.
I brush interdentally every day. As
dentists, we need to make sure that
we reinforce oral hygiene measures
every time the patient visits. With
improving oral health habits comes
greater satisfaction for the patient.
The best thing in dentistry is that we
can see the change. We can see how
the bleeding stops. And the patient
feels it.

What do you think about
CURAPROX products?

Reuss: Products that are easy to
use help us progress in our treatments quicker and provide patients
with the tools to easily establish a

positive home care dental regimen.
CURAPROX’s products are often
gentler than other products, and this
meant that it went against the general trend of the market for the past
few years. However, this softness is
extremely beneficial, as it helps to
prevent damage to tissue and teeth.

What role does the implant
design play for oral hygiene?

Reuss: Implant prostheses are not
easy to clean. The implant has a very
thin cylinder compared with the
anatomy of the tooth. The design of
the implant needs to accommodate
the structure of the overall anatomy,
as well as the neighbouring teeth.
In the case of missing periodontal
tissue or of full-arch restorations,
we need to have a different implant
design.
In any case, we use the design most
suitable for oral hygiene measures,
especially in non-aesthetic areas. For
example, for lower arch rehabilita-

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tions, we try to have no contact with
the soft tissue. That is not possible
in the upper arch. But we want to
have implant surfaces that can be
polished easily. Interdental brushes
and dental floss also need to be used
regularly. We work very closely with
the laboratory and have clear instructions. Tissue contact continues
to be crucial.

Finally, optimal prevention and
oral health require an interdisciplinary partnership. How
do you work with other medical doctors towards achieving
overall health for your patients?

Reuss: As healthcare professionals, we see patients every day who
are sent to us by heart specialists,
endocrinologists, and so on. This is
because there is an intrinsic relationship, proved by many studies, between oral health and overall health.
For example, we have patients who
have been referred by cardiologists
who have detected some form of cardiovascular disease and want their
patients to be orally healthy as soon
as possible. We also have diabetics
referred to us by endocrinologists,
often straight out of the hospital.
This is because, if they have anything
wrong with their mouths, an infection or anything that needs to be
addressed, it is essential that this issue is resolved so that the diabetesrelated issues may also be resolved.
Patients need to know about these
relationships.
Llorente: We always have to contact
doctors if the patient has a special
need. Interestingly, medical doctors
send us their patients with immunosuppression and other conditions
to get rid of the dental problems. In
comparison with other medical disciplines, we can quickly manage to
control the inflammation and regain
the microbial balance in the mouth,
thereby helping the overall immune
system. The dental knowledge of
general medical doctors is growing,
as they understand the need for a
healthy mouth for general health.

The interview was originally published in Prevention International
Magazine for Oral Health 1/18.

[64] =>

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[65] =>

Published in Dubai

July-August 2018 | No. 4, Vol. 8

www.dental-tribune.me

Ormco Unveils Symetri™
Clear ceramic twin bracket system

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

Vol. 2 • Issue 2/2017

ortho
international magazine of

orthodontics

2

2017

New Bracket Incorporates Advanced Manufacturing Technologies in
Polycrystalline-Alumina to Forge Next-Generation of Ceramic Brackets

technique

By Ormco
ORANGE, Calif.: Ormco Corporation,
a leading manufacturer and provider of advanced orthodontic technology and services, today announced
the next generation of aesthetically-pleasing ceramic twin brackets:
Symetri™ Clear. Adding to Ormco’s
expansive product portfolio of both
lingual and self-ligating bracket systems, Symetri Clear is a refined, aesthetic bracket system incorporating
design features that apply expert
clinical advice and analysis, end-user
feedback and technological advancements and achievements of the
Company.

“Over the past 30 years, ceramic materials have evolved to bring more
sophistication to manufacturing
capabilities, and to deliver an appearance that meets the aesthetic
interests of patients. Ormco has been
keen on developing proprietary
technologies and manufacturing
products that leverage the advancements in materials, and also serve
clinical demands,” said Matt Turner,
president of Ormco. “Backed by over
seven years of research and development, we’re pleased to bring our latest innovation, Symetri Clear, to the
conventional twin market.”
Boasting a low profile and ample

torque and tie-wing strength, Symetri Clear addresses and minimizes
the challenges that may come with
leveraging a ceramic system—bracket breakage, wire notching and difficulties while debonding. Symetri
Clear is designed to debond in one
piece without fracturing requiring
minimal forces. Initially offered in
the McLaughlin, Bennett, Trevisi+
prescription, Symetri Clear was designed with upwards of seven years
of dedicated research and development, focusing on clinical analysis,
end-user feedback and Ormco’s
proprietary development of technological advancements in ceramics. Serving the needs of doctors and

patients, the twin bracket is designed
with round surfaces and edges, creating enhanced patient comfort and
greater radii on sliding surfaces.
Combining state-of-the-art manufacturing technology and the latest
in ceramic materials, Symetri Clear
provides the benefit of aesthetics
and offers easy, non-destructive, single-piece debonding. Its noteworthy
clinical features include:
- Torque and Tie-Wing Strength: To
better manage treatment flexibility
and prevent bracket breakage, Symetri Clear is made of polycrystallinealumina using a small particle size
and is designed to withstand clinically applied forces. The material,
combined with advanced processing, promises tie-wing and torque
fracture resistance allowing clinicians to confidently treat effectively
and efficiently, especially when steel
ligatures are needed.
- Low Profile: Up until now, a lower
profile bracket may have been associated with limited bracket strength
or compromised performance; Symetri Clear changes that. With optimized in/out dimensions and a

Tongue star 2 (TS2) –
System for rapid open bite closure

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

industry report
Sensorimotor training with RehaBite
during orthodontic treatment

design that angles tie-wings inward
on the lower incisors, Symetri Clear
is less likely to interfere with opposing occlusion.
- Advanced Aesthetics: Symetri
Clear has been designed with more
rounded surfaces that diffuse light
better than a flat surface. This enhances the bracket’s ability to blend
with tooth enamel, adding to its aesthetic appeal for patients.
- Ease of Debonding: Ormco’s patented laser-etched pad technology
allows for a precise, controlled surface that results in reliable bonding
and safe, easy, non-destructive single-piece removal.

To learn more about Symetri Clear, please
visit www.ormco.com/products/symetri/
or connect with your Ormco sales representative directly.

Digital Orthodontics
Symposium 2019
Save the date: 12 April 2019, Dubai, UAE
By Dental Tribune MEA / CAPPmea

AVAILABLE SOON

Just scan the QR code and to get further details.

ormco.eu

DUBAI, UAE: The event is open to
all orthodontists and general practitioners interested in the latest orthodontic progressions in the digital era.
The event will attract delegates from
across Middle East, Africa and Asia
coming April.
The event will gather top key opinion leaders with a focus on the latest
trends and developments 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 will illustrate 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.
Delegates will have a sneak peek at
the latest technologies at the exhibition area where the dental industry
will present its latest research, development, equipment and solutions to
serve better the dental professionals.

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

[66] =>

ORTHO TRIBUNE

Dental Tribune Middle East & Africa Edition | 4/2018

Incisal apical root resorption evaluation
after low-friction orthodontic treatment
using two-dimensional radiographic
imaging and trigonometric correction
By Fabio Savoldi, Stefano Bonetti,
Domenico Dalessandri, Gualtiero
Mandelli, Corrado Paganelli, Italy

Abstract

Background: Root resorption shall
be taken into consideration during
every orthodontic treatment, and it
can be effected by the use of different techniques, such as the application of low friction mechanics. However, its routinely assessment on
rthopantomography has limitations
related to distortions and changes in
dental inclination.
Aim: The aim of this investigation
was to evaluate the severity of apical root resorption of maxillary and
mandibular incisors after low-friction orthodontic treatment, using
the combination of panoramic and
lateral radiographs, and applying a
trigonometric correction.

Fig. 1-3: Pre-treatment intra oral pictures, latero-lateral cephalogram, and orthopantomography

Ethics
The procedures followed were in accordance with the ethical standards
of the responsible institutional committee on human experimentation
and with the Helsinki Declaration of
1975 that was revised in 2000.
Fig. 4-6: Post-treatment intra oral pictures, latero-lateral cephalogram, and orthopantomography

Settings and Design: A hospital
based Retrospective study at the
orthodontic Department (Dental
School, University of Brescia, Spedali
Civili di Brescia, Brescia, Italy).
Materials and Methods: Ninetythree subjects (53 females and 40
males; mean age, 14 years) with mild
teeth crowding were treated without
extractions by the same operator
using a low-friction fixed appliance
following an integrated straight
wire (ISW) protocol. The pre- and
post-treatment tooth lengths of the
maxillary and mandibular incisors
were measured on panoramic radiographs. A trigonometric factor
of correction for the pre-treatment
length was calculated based on the
difference between the pre and posttreatment incisal inclination on lateral cephalograms.
Statistical Analysis: The changes
in lengths were investigated using
the Student’s t-test for paired values
(p<0.05).
Results: Maxillary central incisors
showed no changes (0.3%, 0.6%),
maxillary lateral incisors showed a
small increase (1.4%, 1.8%) that was
attributed to the completion of root
development in younger patients,
mandibular central and lateral incisors underwent slight resorption
(-3.1%, -3.4%). A statistically significant difference was found for the
mandibular incisors but not for the
maxillary ones.
Conclusion: In patients with mild
crowding and consequent low
amount of root movement, a lowfriction orthodontic treatment can
lead to slight apical root resorption,
mainly involving lower incisors. The
use of a trigonometric correction in
the panoramic radiograph analysis
may reduce the limitations of this
2D evaluation.

Introduction
With the exception of cases that involve deciduous teeth1, root resorp-

ing stage II: 0.019 x 0.025 SS during
stage III: and 0.019 X 0.025 SS, 0.019
X 0.025 TMA, 0.016 X 0.025 SS, 0.016
SS or 0.018 SS during stage IV: the
protocol finished with 0.019 X 0.025
SS or 0.019 X 0.025 TMA.
The mean treatment duration was
2.1 years, with patients showing mild
crowding (between 0 and 4 mm) at
the beginning of treatment (Fig. 1-6).

Fig. 7: Representative screenshot of the panoramic radiography measurements uploaded digitally
Fig. 8: Sample representation of the angle between the pre and post-treatment inclination of the maxillary central incisors (∆δ), superimposed on the ANS-PNS of the cephalometric X-ray, and differential length in the frontal plane (∆L)

tion is an undesirable and unpredictable occasional consequence of
orthodontic treatment, which leads
to shortened root lengths. It tends
to occur when pressure on the cementum overcomes the reparative
capacity of the innermost cellular
structures. Root resorption starts
adjacent to hyalinised tissues and is
associated with the removal of this
zone of sterile necrosis. As orthodontic forces are usually concentrated at
the apex of the tooth, the resulting
resorption typically travels from the
root tip to the coronal surface2.
Multiple patient-specific factors
are associated with apical root resorption during orthodontic treatment, including morphological
features such as root shapes3, or oral
habits4, biological and genetic factors5,6, endodontic treatment7, sex8,
age9, and anomalies in dentition
such as malocclusions10. Moreover,
treatment-specific variables include
treatment with extractions11, mechanical factors12, treatment duration11,13, amount and direction of the
orthodontic force applied14,15, and the
amount and type of tooth movement16,17. For example, it appears that
the intrusion of teeth causes approximately four times more root resorption than extrusion18, however, it has
also been demonstrated that extrusive movement is not without risk18.
Consequently, root resorption may
depends on the orthodontic technique used12,13,16, since different or-

thodontic technique can generate
different forces and teeth movements.
Low-friction: mechanics are now
commonly used, and previous clinical investigations have analysed
their biomechanical properties19-22.
However, differences may exist
among different lowfriction clinical protocols. The purpose of the
current study was to evaluate the
amount of root resorption using a
specific low-friction treatment protocol, Integrated Straight-Wire (ISW).
The amount of root resorption was
investigated in a retrospective study
involving patients treated by the
same orthodontist. Furthermore,
because of the limitation existing in
the evaluation of the root resorption
using panoramic radiographs23, we
combined the analysis with lateral
cephalograms and application of a
trigonometric correction.

nonextraction cases were included,
with no criteria given relatively to
the skeletal class. Their mean age was
14.2 years (SD=2.6), with a median
value of 13 years.

Materials and Methods

An a priori sample size (n) calculation, with the apical root resorption
as the main outcome, was performed
fixing a power (β) of 90% (zβ = 1.28)
and an a of 5% (zβ/2=1.96). The difference considered as clinically significant was 5% between the mean (µ)
pre and post-treatment root length,
with a standard deviation (s) of 10%,
estimated from a preliminary study
(n=10). The calculation was carried
using the following formula [24]:
n = {( zα/2 + zβ)2 x 2σ2}{(µ2 – µ1 )2} = 10.5
x 200/25 = 83
Consequently, because of the retrospective nature of our study, we
chose a representative sample size
of 93, including 10 more patients
because of possible variations in the
standard deviation of the data of the
final sample.

Our retrospective study investigated
the orthodontic records of 93 patients (53 females and 40 males), who
were selected from the orthodontic
department of the Dental School
of the University of Brescia in 2013,
with the following inclusion criteria:
there was no history of trauma or
bruxism, endodontic or prosthetic
treatments, or previous root reshaping involving the maxillary and
mandibular incisors, and were only
successfully completed cases. Only

All patients were consecutively treated by the same orthodontist with
the same low-friction ISW protocol
using a fixed multi-brackets appliance with passive self-ligating (Damon©, Ormco Co., USA) pre-adjusted
(0.022X0.028 slot) braces. The archwires used in the basic set-up were
all Damon©Q form as follows: maxillary and mandibular 0.014 NiTi or
0.014 CuNiTi during stage I: 0.014 X
0.025 NiTi, 0.018 x 0.025 CuNiTi dur-

Measurement techniques
In order to analyse the degree of
root resorption, panoramic and
lateral cephalometric radiographs
were examined before and after orthodontic treatment. Each subject
had his/her pre and posttreatment
panoramic and cephalometric film
taken by the same radiology technician using a standardized procedure.
Each film was uploaded digitally as
a .jpeg file and cephalometric analysis of pre and post-treatment lateral
radiographs was performed using
the Nemoceph NX© software. The
change of inclination of maxillary
and mandibular central incisors was
then measured (with reference to
the long axis of the tooth, from the
incisal edge to the root apex).
Pre and post-treatment panoramic
radiographs were evaluated using
Adobe Photoshop CS6® (Fig. 7). Initial
and final tooth lengths of maxillary
and mandibular incisors (with reference to the long axis of the tooth,
from the incisal edge to the root
apex, through the midpoint of the
CEJ) were measured in pixel using
the tool “ruler”. For each film, the
length of the mesio-distal diameter
of the crown of the mandibular right
first molar was measured in pixels,
and then all the measurements were
converted using this value as the
specific unit for each patient. This
procedure ensured the normalization of the data for the intra-patient
comparison, assuming no changes
in the coronal diameter, despite the
changes in the root length. Two different clinicians performed each
measurement.
In order to ensure that the shortening of the length (∆L) that showed in
the frontal plane was not a result of
the change of inclination of the teeth
in the sagittal plane (∆δ) (Fig. 8), the
values of the pre-treatment teeth
lengths were adjusted using the following formula:
Lpre(OPTpost) = Lpre(OPTpre)(1 ± Cos∆δ)
Once this trigonometric correction
was adopted, it was possible to compare the values for pre- and posttreatment teeth lengths. The same
amount of correction was adopted

ÿPage E3

[67] =>

length that was comparable to the post-treatment length without
an inclination bias [Table/Fig-9]. [Table/Fig-10,11] summarizes the
outcomes of our measurements. The values of the pre- and posttreatment inter-rater absolute agreement in the measurement of
the parameters are showed in [Table/Fig-12].

in the orthodontic treatment planning, especially when multiple
evaluations are needed.
Studies that use panoramic radiographs to measure changes in
root lengths between pre and post-treatment values that do not
take modification of the incisal inclination into account should
consider this potential bias.

in both the Kolmogorov-Smirnov and Shapiro-Wilk tests (p > 0.05;
[Table/Fig-13]).

◊Using
Page E2
Student’s t-tests, we found no statistically significant
difference in the lengths of the maxillary incisors between the
pre-treatment length

post-treatment length

(units)
av
maxillary

central

lateral

mandibular

SD

Our group of patients was selected with a mild grade of crowding,
because our aim was to evaluate the most representative sample
concerning a non-extractive orthodontic protocol by means of a
specific straight-wire, low-friction technique. In order to allow a
differential inclination
(∆δ)

(units)
ci

av

SD

trigonometric correction
(∆l)

(°)
ci

E3

ORTHO TRIBUNE

The dataTribune
sets for the Middle
tooth measurements
were normally
distributed
Dental
East & Africa
Edition
| 4/2018

av

SD

(units)
ci

av

SD

dontists at the initiation and end of
treatment, patients did not need to
undergo further radiography.

pre-treatment length #
(units)

ci

av

SD

ci

right

2.18

0.21

2.14-2.22

2.18

0.21

2.14-2.23

1.43

6.68

0.07-2.79

0.01

0.03

0.00-0.02

2.19

0.21

2.15-2.23

left

2.15

0.20

2.11-2.19

2.16

0.21

2.12-2.21

1.43

6.68

0.07-2.79

0.01

0.03

0.00-0.02

2.16

0.20

2.12-2.20

right

1.99

0.22

1.95-2.03

2.02

0.22

1.97-2.06

1.43

6.68

0.07-2.79

0.01

0.03

0.00-0.02

2.00

0.22

1.94-2.04

left

2.00

0.21

1.94-2.04

2.03

0.22

1.99-2.08

1.43

6.68

0.07-2.79

0.01

0.03

0.00-0.02

2.01

0.21

1.96-2.05

central

right

1.63

0.18

1.59-1.67

1.58

0.21

1.54-1.62

2.19

5.40

1.09-3.29

0.01

0.03

0.01-0.01

1.64

0.19

1.60-1.68

left

1.64

0.21

1.60-1.64

1.58

0.22

1.54-1.63

2.19

5.40

1.09-3.29

0.01

0.03

0.01-0.01

1.65

0.21

1.60-1.69

lateral

right

1.73

0.19

1.69-1.77

1.67

0.22

1.63-1.72

2.19

5.40

1.09-3.29

0.01

0.03

0.01-0.01

1.73

0.19

1.69-1.77

left

1.72

0.20

1.68-1.76

1.66

0.23

1.61-1.71

2.19

5.40

1.09-3.29

0.01

0.03

0.01-0.01

1.73

0.20

1.68-1.77

Table.
1: Average
values
respective
standard
deviations
andintervals
conﬁdence
intervals of
thelengths,
pre-treatment
lengths,
post-treat[table/Fig-9]:
Average
valuesand
and respective
standard
deviations
and confidence
of the pre-treatment
tooth
post-treatmenttooth
tooth lengths,
angle
between
the pre
and post-treatment
inclination,
trigonometric
correction
and adjusted pre-treatment
tooth lengths
after the trigonometric
correction
applied. pre-treatment
All of the length
ment
tooth
lengths, angle
between
the pre
and post-treatment
inclination,
trigonometric
correction
andwas
adjusted
measurements use the mesiodistal diameter of the crown of the mandibular right first molar as the standard unit
tooth
lengths
after deviation,
the trigonometric
correction
was
applied.
All
the length
measurements
use the
diameter of the
AV= average
SD= standard
CI= confidence interval,
#= trigonometric
correction
applied,
unitof
= mesiodistal
diameter
of the crown of the mandibular
right mesiodistal
first molar
crown of the mandibular right ﬁrst molar as the standard unit AV= average SD= standard deviation, CI= conﬁdence interval, #= trigo72nometric correction applied, unit = mesiodistal diameter of the crown of the
Journal
of Clinical and
Diagnostic
Research. 2015 Nov, Vol-9(11): ZC70-ZC74
mandibular
right
ﬁal.,
rst
molar
www.jcdr.net
www.jcdr.net
Fabio
FabioSavoldi
Savoldietetal.,
Root
RootResorption
Resorptionafter
afterLow-friction
Low-frictionTreatment
Treatment

www.jcdr.net

www.jcdr.net

[table/Fig-10]:
[table/Fig-10]:
Mean
Mean
pre
preand
andpost-treatment
post-treatment
length
lengthvalues
values
ofofthe
the
maxillary
maxillaryincisors
Table.
2: Mean
pre
and
post-treatment
length
values
ofincisors
the
and
andtheir
theirrespective
respectiveconfidence
confidenceintervals.
intervals.The
Themeasurements
measurementsuse
usethe
themesiodistal
mesiodistal
maxillary
incisors
and
their
respective
conﬁ
dence
intervals.
The
diameter
diameterofofthe
thecrown
crownofofthe
themandibular
mandibularright
rightfirst
firstmolar
molarasasunit.
unit.[table/Fig-11]:
[table/Fig-11]:
Mean
Meanpre-treatment
pre-treatment
and
andthe
post-treatment
post-treatment
length
length
values
valuesofofthe
the
mandibular
mandibular
incisors
incisors
and
measurements
use
mesiodistal
diameter
of
the crown
ofand
the
the
therespective
respectiveconfidence
confidenceintervals.
intervals.The
Themeasurements
measurementsuse
usethe
themesiodistal
mesiodistaldiameter
diameter
mandibular
right
ﬁrst molar
as
unit.
ofofthe
thecrown
crownofof
the
themandibular
mandibular
right
rightfirst
firstmolar
molarasasunit
unit
Table. 3: Mean pre-treatment and post-treatment length values
[table/Fig-10]: Mean pre and post-treatment length values of the maxillary incisors
icc
icc
ofandthe
incisors
and the
respective conﬁ
dence
intertheirmandibular
respective confidence
intervals.
The measurements
use the
mesiodistal
diameter
of measurements
the crown of the mandibular
right
first molar as diameter
unit. [table/Fig-11]:
vals.
The
use
the
mesiodistal
of
pre-treatment
pre-treatment
maxillary
maxillary
right
right
central
central
0.981
0.981the
Mean pre-treatment and post-treatment length values of the mandibular incisors and
[table/Fig-10]:
Mean
pre
and
post-treatment
length
values
of
the
maxillary
incisors
crown
of theconfidence
mandibular
right
ﬁrst molar use
aslateral
unit
the respective
intervals.
The measurements
the mesiodistal0.975
diameter
lateral
0.975
and their respective confidence intervals. The measurements use the mesiodistal
of the crown of the mandibular right first molar as unit
diameter of the crown of the mandibular right
as unit. [table/Fig-11]:
left
leftfirst molar
central
central
0.985
0.985
Mean pre-treatment and post-treatment length values of the mandibular incisors and
lateral
lateral
0.950
0.950
the respective confidence intervals. The measurements use the mesiodistal icc
diameter
of the crown of the mandibular
right first molar
as unit
mandibular
mandibular
right
right
central
central
0.980
0.980
pre-treatment
maxillary
right
central
0.981
lateral
lateral
0.989
0.989
lateral
0.975
icc
left
left
central
central
0.972
0.972
left
central
0.985
pre-treatment
maxillary
right
central
0.981
lateral
lateral
0.987
0.987
lateral
0.950
lateral
0.975
post-treatment
post-treatment
maxillary
maxillary
right
right
central
central
0.992
0.992
mandibular
right
central
0.980
left
central
0.985
lateral
lateral
0.995
0.995
lateral
0.989
lateral
0.950
left
left
central
central
0.991
0.991
left
central
0.972
mandibular
right
central
0.980
lateral
lateral
0.985
0.985
lateral
0.987
lateral
0.989
mandibular
mandibular
right
right
central
central
0.992
0.992
post-treatment
maxillary
right
central
0.992
left
central
0.972
lateral
lateral
0.992
0.992
lateral
0.995
lateral
0.987
left
left
central
central
0.988
0.988
left
central
0.991
post-treatment
maxillary
right
central
0.992
lateral
lateral
0.993
0.993
lateral
0.985
lateral
0.995
[table/Fig-12]:
[table/Fig-12]:Intraclass
Intraclasscorrelation
correlationcoefficient
coefficient(ICC)
(ICC)values
valuesofofthe
theprepre-and
andpostpostmandibular
right
central
0.992
left
central
treatment
treatmentmeasurements,
measurements,representing
representingthe
theinter-rater
inter-raterabsolute
absolute
agreement
agreement0.991
lateral
0.992
lateral
0.985

maxillary
maxillary

av
av

SD
SD

cici

(%)
(%)

(%)
(%)

(%)
(%)

sign
sign

central
central right
right
0.3
0.3
9.3
9.3
(-1.6)-(2.2)
(-1.6)-(2.2)
0.90
0.90
Fabio Savoldi et al., Root Resorption after Low-friction Treatment
left
left
0.6
0.6
9.3
9.3
(-1.3)-(2.5)
(-1.3)-(2.5)
0.81
0.81

lateral
lateral
right
right
1.4
1.4
10.1
10.1
(-0.7)-(3.5)
(-0.7)-(3.5)
0.36
0.36
av
SD
ci
sign
Fabio Savoldi et al., Root Resorption after Low-friction Treatment
left
left
1.8
1.8
10.9
10.9
(-0.4)-(4.0)
(-0.4)-(4.0)
0.27
0.27
(%)
(%)
(%)
mandibular
mandibular central
central right
right
-3.1
-3.1
12.7
12.7
(-5.7)-(-0.5)
(-5.7)-(-0.5)
****
maxillary
central
right
0.3
9.3
(-1.6)-(2.2)
0.90
av
SD
ci
sign
left
left
-3.1
-3.1
13.0
13.0
(-5.7)-(-0.5)
(-5.7)-(-0.5)
****
left
0.6
9.3
(-1.3)-(2.5)
0.81
(%)
(%)
(%)
lateral
lateral
right
right
-3.1
-3.1
10.9
10.9
(-5.3)-(-0.9)
(-5.3)-(-0.9)
****
lateral
right
1.4
10.1
(-0.7)-(3.5)
0.36
maxillary
central
right
0.3
9.3
(-1.6)-(2.2)
0.90
left
-3.4
12.5
(-5.9)-(-0.9)
left
-3.4
12.5
(-5.9)-(-0.9)
****
left
1.8
10.9
(-0.4)-(4.0)
0.27
left
0.6
9.3
(-1.3)-(2.5)
0.81
[table/Fig-14]:
[table/Fig-14]:
Analysis
Analysis
ofof
the
thedifferences
differencesbetween
between
pre
preand
and
post-treatment
post-treatment
tooth
tooth
Table.
6:
Analysis
of
the
differences
between
pre
and
post-treatmandibular
central
right
-3.1
12.7
(-5.7)-(-0.5)
**
lengths
lengths
lateral
right
1.4
10.1
(-0.7)-(3.5)
0.36
ment
tooth
lengths
AV=
average;
DS=
standard
deviation;
CI=
AV=
AV=average;
average;
DS=
DS=
standard
standard
deviation;
deviation;
CI=
CI=confidence
confidence
interval;
interval;*=*=<0.05;
<0.05;**=
**=<0.01;
<0.01;
left
-3.1
13.0
(-5.7)-(-0.5)
**
left
1.8
10.9
(-0.4)-(4.0)
0.27
***=
***=<0.001
<0.001

conﬁdence interval; *= <0.05; **= <0.01; ***= <0.001

mandibular

lateral
central

right
right

-3.1
-3.1

10.9
12.7

(-5.3)-(-0.9)
(-5.7)-(-0.5)

**
**

ofofroot
rootresorption
resorptionofof7.8%
7.8%SD
SD==6.9%
6.9%[28],
[28],milder
milderdegrees
degreesofofroot
root
left
-3.4
12.5
(-5.9)-(-0.9)
**
left
-3.1
13.0
(-5.7)-(-0.5)
**
resorption
resorption
could
could
be
be
the
the
result
result
of
of
many
many
variables,
variables,
including
including
lower
lower
[table/Fig-14]: Analysis of the differences between pre and post-treatment tooth
lateral
right
-3.1
10.9
(-5.3)-(-0.9)
**
amounts
amountsofofroot
rootmovement
movement
[11,29,30].
[11,29,30].
For
Forthis
this
reason,
reason,our
ourfindings
findings
lengths
AV=
average;
DS=
standard
deviation;
CI=
confidence
interval;
*=
<0.05;
**=
<0.01;
could
couldbe
beless
lessevident
evident
than
thanthe
the
results
results12.5
reported
reported
by
bythe
theliterature.
literature.
left
-3.4
(-5.9)-(-0.9)
**
***= <0.001

As a result of difficulties in discriminating the crown from the root on
panoramic X-rays, our measurements involved the whole tooth,
assuming the absence of changes in
the tooth crown and ascribing any
possible shortening only to the root.
As panoramic radiographs are not
suitable for the qualitative evaluation of the root shape23,25, and periapical radiographs were not available for all patients, we limited our
evaluation of resorption on length
measurements. X-rays were in digital format and direct measurements
were not possible, therefore, we carried a pixel unit measurement on
the digital format.
As panoramic radiographs are based
on a para-frontal plane, different
inclinations of the incisors between
the pre and the posttreatment may
result in length changes. In order to
reduce the above-mentioned error,
the difference between pre and posttreatment incisal inclination was
measured on the respective lateral
cephalogram, and each patient had
his/her initial tooth length modified using a mathematical correction. This trigonometric correction
can set the root length that the pretreatment tooth would exhibit in
the post-treatment panoramic radiograph to normalize the intra-tooth
comparison. However, this method
is based on a theoretical trigonometric formula, and further studies

would be useful to evaluate its accuracy and biological cost-effectiveness. Additionally, as showed in our
previous investigations26, a comparison between 2D and 3D methods is
worth of interest in the orthodontic
treatment planning, especially when
multiple evaluations are needed.
Studies that use panoramic radiographs to measure changes in root
lengths between pre and post-treatment values that do not take modification of the incisal inclination into
account should consider this potential bias.
Our group of patients was selected
with a mild grade of crowding, because our aim was to evaluate the
most representative sample concerning a non-extractive orthodontic protocol by means of a specific
straight-wire, low-friction technique.
In order to allow a qualitative comparison, if our results were transferred onto the scale of Malmgren
(grade 0 to 4)27, the maxillary incisors
would be represented by grade 0 or
1 and the mandibular incisors by no
more than grade 2, none of our patients had grade 3 resorption or more.
Although Previous studies found an
overall percentage of root resorption
of 7.8% SD = 6.9%28, milder degrees
of root resorption could be the result
of many variables, including lower
amounts of root movement11,29,30. For
this reason, our findings could be less

[table/Fig-14]: Analysis of the differences between pre and post-treatment tooth
As
Asreported
reportedby
byother
otherauthors
authors[19],
[19],aaslight
slightincrease
increaseininroot
rootlengths
lengths
lengths
the
inter-rater
of
root
resorption
of
7.8%
SD
=
6.9%
[28],
milder
degrees
of
root
was
was
shown
shown
in
in
the
the
maxillary
maxillary
lateral
lateral
incisors
incisors
(1.4-1.8%),
(1.4-1.8%),
although
although
this
this
AV= average; DS= standard deviation; CI= confidence interval; *= <0.05; **= <0.01;
absolute
agreeresorption
could
be the
result clinical
of
variables,
including
***=
<0.001
This
retrospective
investigawas
was
not
notstatistically
statistically
significant
significant
ininmany
our
ourstudy
study
pp>>0.05.
0.05.This
Thislower
could
could
amounts
ofthrough
root
movement
[11,29,30].
Fordevelopment
this
reason,
our
findings
ment
be
beattributed
attributed
toto
the
thecompletion
completion
ofofroot
root
development
ininyounger
younger
tion
resorption
after
of root resorption of 7.8%
SD analysed
= 6.9% [28],root
milder
degrees of root
could
be less
evident
than
the
results reported
by
the
literature.
patients,
patients,
which
which
would
would
be
be
in
in
accordance
accordance
with
with
the
the
median
median
age
age
ofof
intraclass
corlow-friction
orthodontic
treatresorption could be the aresult
of many variables,
including lower
our
our
sample
sample
(13
(13
years)
years)
and
and
with
with
the
the
root
root
completion
completion
sequence.
sequence.
As
reported
by
other
authors
[19],
a
slight
increase
in
root
lengths
relationof rootcoefamounts
movement
[11,29,30].
this reason,
our findings
ment.
ToothForlength
measurements
was
shown
in the
maxillary
lateral
incisors
(1.4-1.8%),
although
this
could
be less
evident
than
the
results
reported
by
the
literature.
ficient
(ICC),
were performed on panoramic rawas
not statistically significant in our study p > 0.05. This could
lIMItAtIOns
lIMItAtIOns
using
two-way
As
reported
by other authors
[19], a slight
increase
root lengths
diographs
thatdevelopment
are
theinstandard
rabe
attributed
the
completion
of root
in
younger
Even
Even
though
thoughto
we
we
followed
followed
aa standardized
standardized
protocol
protocol
during
during
the
the
was
shown in the
maxillary
lateral
incisors
(1.4-1.8%),
although
this
ANOVA
with
diographic
exams
orthopatients,
whichawould
be
in
accordance
withrequired
the
age
of
X-ray
X-rayexams,
exams,
adifferent
different
level
level
ofofdistortion
distortion
may
maymedian
exist
existby
between
between
was
not statistically significant in our study p > 0.05. This could
mixed-effects
our
(13 years) andradiographs.
with the rootThis
completion
sequence.
pre
presample
and
andpost-treatment
post-treatment
radiographs.
Thisbias
biaswas
was
reduced
reducedby
by
be attributed to the completion of root development in younger
average
measmeasuring
measuringthe
the
mesiodistal
mesiodistaldiameter
diameterofofthe
thecrown
crownofofthe
themandibular
mandibular
patients, which would be in accordance with the median age of
right
rightfirst
firstmolar
molarand
andusing
usingit itasasaabaseline
baselineunit
unitfor
forallallthe
theother
other
lIMItAtIOns
ures
(ranging
our sample (13 years) and with the root completion sequence.
measurements
measurements
on
on
the
the
same
same
X-ray,
X-ray,
in
in
order
order
to
to
normalize
normalize
the
the
intraintraEven
though
we
followed
a
standardized
protocol
during
the
from 0 to 1, with
patient
patient
comparison.
comparison.
However,
However,
acertain
certain
degree
degree
ofofexist
distortion
distortion
may
may
X-ray
exams,
a different
level aof
distortion
may
between
0 indicating no
lIMItAtIOns
still
stillbe
bepresent.
present.
pre
and
post-treatment radiographs. This bias was reduced by
consistency
and
Even
though we
followed a standardized protocol during the
measuring
the mesiodistal
diameter
ofright
the
crown
of incisors
the
mandibular
ToTodistinguish
distinguish
between
betweenthe
the
left
leftand
and
right
central
central
incisors
on
onthe
the
X-ray
exams,
a
different
of distortion may exist between
1cephalometric
indicating
a usinglevel
right
first molarradiograph
and
a baseline
unit for selected
allselected
the other
cephalometric
radiograph
isitisas
difficult,
difficult,
we
wetherefore
therefore
the
the
DUBAI | UAE
pre
and post-treatment
radiographs. This bias was reduced by
perfect
consistmeasurements
on
the
same
X-ray,
in
order
to
normalize
the
intramost
most
inclined
inclined
tooth
tooth
in
in
the
the
maxillary
maxillary
and
and
mandibular
mandibular
arch
arch
and
and
then
then
KolmogorovKolmogorovShapiro-Wilk
Shapiro-Wilk
6-8 DECEMBER
left
central
0.988
measuring the mesiodistal diameter of the crown of the mandibular
mandibular
right
central
0.992
Smirnov
Smirnov
patient
comparison.
However,
a certain
degree
of distortion
may
ency
among
applied
applied
the
the
obtained
obtained
correction
correction
to
to
both
both
the
the
central
central
and
and
lateral
lateral
lateral
0.993
right first molar and using it as a baseline unit for all the other
0.992
still
be present.
coeff.
coeff. lateral
sign
sign coeff.
coeff.
sign
sign
incisors.
incisors.
Even
Eventhough
thoughour
ourestimate
estimatewas
wasspecific
specificfor
forthe
thecentral
central
raters).
measurements
on the same X-ray, in order to normalize the intra[table/Fig-12]:
Intraclass
correlation
coefficient
(ICC)
values
of
the
preand
posttest
test
test
Table. 4: Intraclass correlation coefﬁ
(ICC)
valuestest
of 0.988
the pre- To
leftcient
central
incisors,
incisors,
it
it
was
was
useful
useful
for
for
the
the
laterals
laterals
but
but
less
less
effective.
effective.
Therefore,
Therefore,
distinguish
between
the
left
and
right
central
incisors
on
the
treatment measurements, representing the inter-rater absolute agreement
patient comparison. However, a certain degree of distortion may
and
posttreatment
measurements,
inter-rater
maxillary
maxillary
central
central right
right
pre-treatment
pre-treatment representing
0.08
0.08 lateral
0.20
0.20the
0.99
0.99
0.38
0.38
0.993
the
thelateral
lateralincisors
incisors
values
valuesisreported
reported
inwe
inour
our
results
resultsmay
maybe
beless
less
cephalometric
radiograph
difficult,
therefore
selected
the
still be present.
absolute
agreement
post-treatment
post-treatment
0.05
0.05
0.20
0.20
0.99
0.99and 0.40
0.40
realistic
realistic
than
thanthe
thevalues
values
related
related
totothe
thecentral
central
incisors.
incisors.
most
inclined
tooth
in the
maxillary
and
mandibular
arch and then
Kolmogorov[table/Fig-12]:
Intraclass correlation
coefficient (ICC)
values
of the Shapiro-Wilk
prepostTo
distinguish
between
the left and right central incisors on the
treatment measurements, representing the inter-raterSmirnov
absolute agreement
Each
pre
and including
applied
obtained
correction
to both
the central
and lateral
left
left
pre-treatment
pre-treatment
0.06
0.06 0.20
0.20 0.98
0.98 0.16
0.16
Further
Furtherthe
researches
researches
including
different
different
amount
amount
ofofcrowding
crowding
and
and
cephalometric
radiograph
is difficult, we therefore selected the
coeff.
sign
coeff.
sign
post-treatment
incisors.
Evenwith
though
our
estimate
was specific
theaccuracy
central
comparisons
comparisons
withother
other
X-ray
X-ray
examinations,
examinations,
e.g.
e.g.for
high
high
accuracy
post-treatment
post-treatment 0.06
0.06 0.20
0.20 0.99
0.99 0.52
0.52
most inclined tooth in the maxillary and mandibular arch and then
KolmogorovShapiro-Wilk
test
test
incisors,
it was
useful for the[31],
laterals
but
less effective.
Therefore,
average
tooth
CBCT
CBCTlinear
linear
measurements
measurements
[31],shall
shall
assess
assess
the
thereliability
reliability
ofofthe
the
Smirnov
lateral
lateral right
right pre-treatment
pre-treatment
0.06
0.06
0.20
0.20 0.98
0.98 0.31
0.31
applied the obtained correction to both the central and lateral
maxillary
central right
pre-treatment
0.08
0.20
0.99
0.38
the
lateralused
incisors
values
reported
in our results may be less
methods
methods
used
in
in
this
this
preliminary
preliminary
study.
study.
length
was
calincisors. Even though our estimate was specific for the central
post-treatment
post-treatment coeff.
0.05
0.05 sign
0.20
0.20 coeff.
0.99
0.99 sign
0.96
0.96
post-treatment
0.05
0.20
0.99
0.40
realistic than the values related to the central incisors.
test
test
culated.it wasThen,
incisors,
useful for the laterals but less effective. Therefore,
left
left
pre-treatment
pre-treatment
0.07
0.07 0.20
0.20 0.98
0.98 0.07
0.07
pre-treatment
0.06
0.20
0.98
0.16
Further
researches
including
differentin amount
of crowding
and
cOnclusIOn
cOnclusIOn
maxillary
central left
right
pre-treatment
0.08
0.20
0.99
0.38
the
lateral
incisors
reported
our results
may be less
depending
onvalues
post-treatment
post-treatment 0.05
0.05 0.20
0.20 0.99
0.99 0.51
0.51
comparisons
with
other
X-ray
examinations,
e.g.
high
accuracy
In
In
patients
patients
with
with
mild
mild
crowding
crowding
and
and
consequent
consequent
low
low
amount
amount
of
of
root
root
post-treatment
0.06
0.20
0.99
0.52
post-treatment
0.05
0.20
0.99
0.40
realistic
than the values related to the central incisors.
DR. SONIA PALLECK
DR. MATIAS ANGHILERI
DR. BILL DISCHINGER
the
differential
mandibular
mandibular central
central right
right pre-treatment
pre-treatment
0.05
0.05 0.20
0.20 0.99
0.99 0.59
0.59
CBCT
linear
measurements
[31],
shall
assess
the
reliability
of
the
movement,
movement,
a
a
straight
straight
wire
wire
low-friction
low-friction
orthodontic
orthodontic
treatment
treatment
can
can
lateral right
pre-treatment
0.06
0.20
0.98
0.31
left
pre-treatment
0.06
0.20
0.98
0.16
Further
researches
including different amount of crowding and
inclination,
methods
used
inthe
this preliminary
study.
lead
leadtotoaapost-treatment
post-treatment
decrease
decrease
ofofmandibular
mandibularcentral
centraland
andlateral
lateral
post-treatment
post-treatment 0.05
0.05 0.20
0.20 0.99
0.99 0.58
0.58
post-treatment
0.05
0.20
0.99
0.96
comparisons
with other X-ray examinations, e.g. high accuracy
post-treatment
0.06
0.20
0.99
0.52
respective
trigoincisor
incisorroot
rootlengths
lengthson
onboth
boththe
theright
rightand
andleft
leftside
sideapproximately
approximately
left
left
pre-treatment
pre-treatment
0.06
0.06 0.20
0.20 0.99
0.99 0.96
0.96
CBCT linear measurements [31], shall assess the reliability of the
pre-treatment
0.07
0.20
0.98
0.07
lateral left
right
pre-treatment
0.06
0.20
0.98
0.31
ofnometric
of3%.
3%.However,
However,
our
ouranalysis
analysison
onpanoramic
panoramicradiographs
radiographsfound
found
corcOnclusIOn
post-treatment
post-treatment 0.06
0.06 0.20
0.20 0.99
0.99 0.46
0.46
methods used in this preliminary study.
post-treatment
0.05
0.20
0.99
0.51
no
no
evidence
evidence
that
that
resorption
resorption
involved
the
themaxillary
maxillary
incisors.
incisors.
The
The
post-treatment
0.05
0.20
0.99
0.96
In
patients
with
mild
crowding involved
and
consequent
low amount
of root
rection
was
aplateral
lateral right
right pre-treatment
pre-treatment
0.05
0.05 0.20
0.20 0.99
0.99 0.50
0.50
mandibular central right
pre-treatment
0.05
0.20
0.99
0.59
use
use
of
of
a
a
trigonometric
trigonometric
correction
correction
may
may
reduce
reduce
the
the
limitation
limitation
ofof
movement,
a
straight
wire
low-friction
orthodontic
treatment
can
left
pre-treatment
0.07
0.20
0.98
0.07
plied to obtain
cOnclusIOn
post-treatment
post-treatment 0.04
0.04 0.20
0.20 0.99
0.99 0.90
0.90
the
the
2D
2D
radiographs,
radiographs,
but
but
further
further
studies
studies
are
are
needed
needed
to
to
assess
assess
its
its
lead
to
a
post-treatment
decrease
of
mandibular
central
and
lateral
post-treatment
0.05
0.20
0.99
0.58
post-treatment
0.05
0.20
0.99
0.51
apatients
pre-treatment
In
with mild crowding and consequent low amount of root
left
left
pre-treatment
pre-treatment
0.06
0.06 0.20
0.20 0.99
0.99 0.50
0.50
accuracy.
accuracy.
incisor root lengths on both the right and left side approximately
pre-treatment
0.06
0.20
0.99
0.96
mandibular central left
right
pre-treatment
0.05
0.20
0.99
0.59
length that
was wire low-friction orthodontic treatment can
movement,
a straight
of 3%. However, our analysis on panoramic radiographs found
post-treatment
post-treatment 0.04
0.04 0.20
0.20 0.99
0.99 0.92
0.92
post-treatment
0.06
0.20
0.99
0.46
lead
to
a
post-treatment
decrease of mandibular
and lateral
post-treatment
0.05
0.20
0.99
0.58
comparable
DR. central
SKANDER
DR. ANMOL KALHA
DR. BADER BORGAN
no
evidence that to
resorption involved the maxillary
incisors. ELLOUZE
The
AcknOwledgeMents
AcknOwledgeMents
[table/Fig-13]:
[table/Fig-13]:Analysis
Analysisofofthe
thenormal
normaldistribution
distributionofofthe
thetooth
toothlength
lengthdata
data
incisor
root
lengths
on
both
the
right
and
left
side
approximately
lateral right
pre-treatment
0.05
0.20
0.99
0.50
left
pre-treatment
0.06
0.20
0.99
0.96
the
use
apost-treattrigonometric
correction
reduce
the limitation
of
Any
Anyof
paid
paid
support
support received
received
from
frommay
JCDR
JCDR
inin preparation
preparation
ofof the
the
of 3%. However, our analysis on panoramic radiographs found
0.04
0.20
0.99
0.90
qualitative
qualitativecomparison,
comparison,post-treatment
if ifour
ourresults
resultswere
weretransferred
transferred
onto
the
the the
post-treatment
0.06
0.20
0.99 onto
0.46
2D radiographs,
but
further
studies
needed
to
assess
its
manuscript.
manuscript.
We
Wewould
would
like
like
thank
thankDr
DrLinda
Lindaare
Sangalli
Sangalli
for
forher
herexemplary
exemplary
ment
length
no evidence that resorption involved the maxillary incisors. The
scale
scaleofofMalmgren
Malmgren
(grade
(grade
0
0
to
to
4)
4)
[27],
[27],
the
the
maxillary
maxillary
incisors
incisors
would
would
left
pre-treatment
0.06
0.20
0.99
0.50
accuracy.
dedication
dedication
and
and
precious
precious
contribution
contribution
to
to
this
this
article,
article,
and
and
Dr
Dr
Maria
Maria
lateral right
pre-treatment
0.05
0.20
0.99
0.50
without
an incliof a trigonometric
correction may reduce the limitation of
be
berepresented
representedby
bygrade
grade
00oror11and
andthe
the
mandibular
mandibular
incisors
incisors
by
byno
no use
Clara
ClaraPiccinelli
Piccinelli
for
forher
hercontribution
contributiontotothe
thetaking
takingofofmeasurements.
measurements.
post-treatment
0.04
0.20
0.99
0.92
post-treatment
0.04
0.20
0.99
0.90
nation
bias
(Tathe
2D
radiographs,
but
further studies are needed to assess its
more
more
than
than
grade
grade
2,
2,
none
none
of
of
our
our
patients
patients
had
had
grade
grade
3
3
resorption
resorption
We
We
also
also
acknowledge
acknowledge
the
the
service
service
of
of
Oxford
Oxford
Science
Science
Editing
EditingLtd.
Ltd.inin
AcknOwledgeMents
[table/Fig-13]: Analysis of the normal distribution of the tooth length data
left
pre-treatment
0.06
0.99
0.50
ble.
1). (Table. 2,
3)thismanuscript.
accuracy.
orormore.
more.Although
Although
Previous
Previous
studies
studiesfound
found
an
an0.20
overall
overall
percentage
percentage
the
thepreparation
preparation
ofofthis
manuscript.
Any
paid
support
received
from JCDR in preparation of the
0.04 transferred
0.20
0.99 onto
0.92
summarizes
the like thank Dr Linda Sangalli for her exemplary
qualitative comparison, post-treatment
if our results were
the
manuscript.
We would
73
73
Journal
JournalofofClinical
Clinical
and
andDiagnostic
Diagnostic
Research.
Research.
2015
2015Nov,
Nov,
Vol-9(11):
Vol-9(11):
ZC70-ZC74
ZC70-ZC74
AcknOwledgeMents
[table/Fig-13]:
Analysis
of
the
normal
distribution
of
the
tooth
length
data
Table.
5:
Analysis
of
the
normal
distribution
of
the
tooth
length
outcomes
ofprecious
our
scale of Malmgren (grade 0 to 4) [27], the maxillary incisors would
dedication
and
contribution to this article, and Dr Maria
Any
paid support received from JCDR in preparation of the
be represented by grade 0 or 1 and the mandibular incisors by no
data
measurements.
Clara
Piccinelli for her contribution to the taking of measurements.
qualitative comparison, if our results were transferred onto the
DR. KIRILL ZERNOV
manuscript. We would like thank Dr Linda Sangalli for her exemplaryDR. FIRAS HAMZEH
more than grade 2, none of our patients had grade 3 resorption
We
alsovalues
acknowledge
the service of Oxford Science Editing Ltd. in
The
of
scale of Malmgren (grade 0 to 4) [27], the maxillary incisors would
dedication and precious contribution to this article, and Dr Maria
or more. Although Previous studies found an overall percentage
the
of this manuscript.
thepreparation
pre- for
and
be represented by grade 0 or 1 and the mandibular incisors by no
Clara
Piccinelli
her contribution to the taking of measurements.
more than
grade
2, none Research.
of our patients
grade
3 resorption
Journal
of Clinical
and Diagnostic
2015 Nov, had
Vol-9(11):
ZC70-ZC74
posttreatment
We
also acknowledge the service of Oxford Science Editing Ltd. in 73
or more.
Previous
overall percentage
for
both Although
the central
and studies
lateral found
inci- an inter-rater
the agreement
preparation of in
this manuscript.
absolute

Discussion

PALAZZO VERSACE

Results

ÿPage E4

OUR SPEAKERS

Featuring Six Hands-On Workshops

sors,
even though lateral incisors theZC70-ZC74
measurement of the parameters
Journal of Clinical and Diagnostic Research. 2015 Nov, Vol-9(11):
could have slightly different inclina- are showed in (Table. 4).
tion changes compared to the centrals.
The data sets for the tooth measurements were normally distributed in
both the Kolmogorov - Smirnov and
Statistical analysis
All the data were uploaded in a Ex- Shapiro-Wilk tests (p>0.05; (Table. 5).
cel© (Microsoft, USA) worksheet and Using Student’s t-tests, we found no
analysed using SPSS Statistics© v.22 statistically significant difference in
software (SPSS, USA). We evaluated the lengths of the maxillary incisors
the normality of the data distribu- between the pre and post-orthodontion by the asymmetry and kurtosis tic treatment values for the central,
values and with the Kolmogorov- lateral or both sides p>0.05. On the
Smirnov and Shapiro-Wilk tests contrary, there was a statistically sigp<0.05 taken as significant. Then, a nificant difference in the shortening
twotailed Student’s t-test was used of the mandibular incisors between
for paired values to evaluate the dif- the pre- and post-orthodontic treatferences between the pre- and post- ment values for the centrals and lattreatment measurements p<0.05 erals, and on both the left and right
taken as significant. We estimated side p<0.01 (Table. 6).

73

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◊Page E3
evident than the results reported by
the literature.
As reported by other authors19, a
slight increase in root lengths was
shown in the maxillary lateral incisors (1.4-1.8%), although this was not
statistically significant in our study
p>0.05. This could be attributed to
the completion of root development
in younger patients, which would be
in accordance with the median age
of our sample (13 years) and with the
root completion sequence.

Limitations
Even though we followed a standardized protocol during the X-ray
exams, a different level of distortion may exist between pre and
post-treatment radiographs. This
bias was reduced by measuring the
mesiodistal diameter of the crown of
the mandibular right first molar and
using it as a baseline unit for all the
other measurements on the same
X-ray, in order to normalize the intrapatient comparison. However, a
certain degree of distortion may still
be present.
To distinguish between the left and
right central incisors on the cephalometric radiograph is difficult, we
therefore selected the most inclined
tooth in the maxillary and mandibular arch and then applied the obtained correction to both the central
and lateral incisors. Even though our
estimate was specific for the central
incisors, it was useful for the laterals
but less effective. Therefore, the lateral incisors values reported in our
results may be less realistic than the
values related to the central incisors.
Further researches including different amount of crowding and comparisons with other X-ray examinations, e.g. high accuracy CBCT linear
measurements31, shall assess the reliability of the methods used in this
preliminary study.

Conclusion
In patients with mild crowding and
consequent low amount of root
movement, a straight wire lowfriction orthodontic treatment can
lead to a post-treatment decrease of
mandibular central and lateral incisor root lengths on both the right
and left side approximately of 3%.
However, our analysis on panoramic
radiographs found no evidence that
resorption involved the maxillary
incisors. The use of a trigonometric
correction may reduce the limitation of the 2D radiographs, but further studies are needed to assess its
accuracy.

Acknowledgements
Any paid support received from
JCDR in preparation of the manuscript. We would like thank Dr Linda
Sangalli for her exemplary dedication and precious contribution to
this article, and Dr Maria Clara Piccinelli for her contribution to the
taking of measurements.
We also acknowledge the service of
Oxford Science Editing Ltd. in the
preparation of this manuscript.

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Fabio Savoldi, Italy
Postgraduate Student, Department of
Orthodontics, Dental School, University of
Brescia, Brescia, Italy.
Stefano Bonetti, Italy
Assistant Professor, Department of Orthodontics, Dental School, University of
Brescia, Brescia, Italy.
Domenico Dalessandri, Italy
Adjunct Assistant Professor, Department
of Orthodontics, Dental School, University
of Brescia, Brescia, Italy.
Gualtiero Mandelli, Italy
Adjunct Assistant Professor, Department
of Orthodontics, Dental School, University
of Brescia, Brescia, Italy.
Corrado Paganelli, Italy
Professor and Director, Department of
Orthodontics, Dental School, University of
Brescia, Brescia, Italy.

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[cover] => DT Middle East & Africa No. 4, 2018

Table of contents

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