DT Middle East and Africa No. 2, 2014

Handing over ceremony / CAD/CAM dentistry and the laboratory technician: Partners in success / Leading dental companies form KaVo Kerr Group / Brilliant technology for diagnostics: KaVo DIAGNOcam: A new look at caries / Saliva and Oral Health / Clinical and diagnostic advantages of PreXion 3-D imaging system / Clinical digital photography. Part 1: Equipment and basic documentation / Using Cone Beam (CBCT) in Implantology / Interview: Vanik Kaufmann explains the advantages of KaVo’s new ARCTICA CAD/CAM system / The Inman Aligner: A progressive approach to smile design - Part 2 / Philips Sonicare FlexCare Platinum / Case presentation: OptiBond™ XTR / Two phase treatment of a Class II division 1 patient complicated by traumatic upper incisor intrusion: A Case Report / Invisalign®: clear benefits for your patients / Periodontitis - Diabetes and Smoking / Get to Know the IFDH / Launch of Dental Hygienists Supplement in the Dental Tribune Middle East / Celebrating World Oral Health Day 20th March 2014 / Industry / News

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www.dental-tribune.me

Printed in Dubai

march-april 2014 | No. 2, Vol. 3

WORLD ORAL HEALTH DAY

event

Message from
the Editor

9th CAD/CAM & Digital Dentistry
International Conference
Jumeirah Beach Hotel, Dubai
09-10 May 2014

>Page 29

>Cover Page

dental hygiene tribune

CAD/CAM dentistry
and the laboratory
technician:
Partners in success
Fig. 1

By Lee Culp, USA

he concept of digital
dentistry is one that
started out small and
has progressively increased in momentum until its
boundaries appear to have become endless. New technologies
in dentistry will only be successful if they are combined with a
complete understanding of basic
comprehensive dentistry.

While new technology and
computerization can make procedures more efficient, less laborintensive and more consistent, it will not replace education,
practical experience and clinical/technical judgment.
The most exciting factor surrounding these technologies is
not, however, only in the potential applications of the technology that are being hypothesized
by dental professionals. The excitement truly lies in the fact that

Leading dental
companies form
KaVo Kerr Group
By Dental Tribune International

HICAGO & WASHINGTON, USA: Yesterday, Henk van Duijnhoven, senior vice
president of Danaher Corp., a
U.S. umbrella corporation encompassing brands from various industries, announced the
formation of KaVo Kerr Group.

these “hypothetical” applications are currently being developed today, and some are even
in the final stages.
In a relatively short time period,
distal technology will revolutionize the quality of dental care that
is being delivered in modern
practice. Implants are now well
documented for fulfilling the
functional requirements in prosthetic tooth replacement. These
new technologies, along with
the evolution of sur gical and
prosthetic techniques, allow the

dental team predictable, consistent results in implant rehabilitation. MicroDental is involved as
a beta test area for many of these
emerging technologies.
As dentistry evolves into the digital world, the successful incorporation of computerization and
new technology will continue to
provide more efficient methods
of communication and fabrication, while at the same time retaining the individual creativity
and artistry of the skilled dentist
and dental technician. The utilization of new technology will be

> Page 39

The evolution from hand waxing to “digital waxing” using
the diagnostic wax-up and provisional restorations, as well as
their digital replicas to guide us
in the creation of CAD/CAM restorations, will be presented. The
utilization of these new technologies, along with the evolution
from “hand” design to “digital”

> Page 37

Handing over ceremony
By International College of
Dentists

his was a historic moment for Section X with
the handing over of the
presidency taking place for the
first time outside Lebanon. The
meeting took place in Dubai at
the Fairmont Hotel on February 4th in the presence of fellows from both districts and
guests. The event was sponsored by CARE and Planning

The group strategically unites
leading dental consumable,
equipment, high-tech and specialty brands under one platform.
“The formation of KaVo Kerr
Group enables us to better serve
dental professionals and healthcare providers who purchase

enhanced by a close cooperation
and working relationship of the
dentist/technician team.

Officers at the meeting: from left, Imtiaz Turkistani, Cedric
Haddad, Riad Bacho, President Ali Alehaideb, Ibrahim Nasseh
and Nadim AbouJaoude.

> Page 34

mCME

ORTHO TRIBUNE

ENDO TRIBUNE

CLINICAL

LAB TRIBUNE

Page 6

Page 26

Page 40

Page 17

Page 12

Page 8

By Vicki Vlaskalic BDSc;
MDSc.

Clinical and diagnostic
advantages of PreXion
3-D imaging system

Clinical digital photography. Part 1: Equipment
and basic documentation

Invisalign®: clear benefits for your patients

Biological and conservative root canal instrumentation with BT-Race
file system
By Drs Gilberto Debelian &
Martin Trope

Case presentation: OptiBond™ XTR

Page 18

Two phase treatment of a
Class II division 1 patient
complicated by traumatic upper incisor intrusion: A Case Report

Mr. Kaufmann explains
the advantages of KaVo’s
new ARCTICA CAD/CAM
system

Page 14

The Inman Aligner: A
progressive approach to
smile design - Part 2

[2] =>

2 i n dustry

Dental Tribune Middle East & Africa Edition | March - April 2014

Brilliant technology for diagnostics: KaVo DIAGNOcam:
A new look at caries
plifying monitoring and patient
communication.

By KAVO

ith the introduction of
the caries diagnosis
device DIAGNOdent 15
years ago and more than 60,000
devices sold, KaVo has set a new
standard in caries detection. We
are now combining this great
success with the new DIAGNOcam and is thereby setting new
standards in caries diagnostics.
The new KaVo DIAGNOcam is

the first camera system that uses
the tooth’s structure to verify
caries diagnosis. To do this, the
tooth is transilluminated utilising light of a specific wavelength
and used like a light conductor.
A digital video camera records
the image and displays it live
on a computer screen. Carious
lesions are displayed as dark
shadows. The images recorded
by the KaVo DIAGNOcam can
be stored, thus significantly sim-

With its DIFOTI technology
(Digital Imaging Fiberoptic
Transillumination), DIAGNOcam offers high diagnostic safety which is comparable or superior to X-ray diagnosis in many
cases, in particular with regard
to approximal and occlusal caries. Furthermore, it is possible to
show certain kinds of secondary caries and cracks. The X-ray
free device thereby allows early

and very gentle caries detection.
Compared to other methods, the
clinical significance is not distorted through plaque deposits. DIAGNOcam
Because of its easy handling, the
device can quickly be integrated
in existing routines, thereby resulting in a distinct added value
in terms of patient motivation
and information.
Experience the next generation
of caries detection with the KaVo
DIAGNOcam.

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Tzvetan Deyanov
deyanov@ dental-tribune.me
+971 55 11 28 581

[3] =>

[4] =>

4 oral health

Dental Tribune Middle East & Africa Edition | March - April 2014

Saliva and Oral Health
By Michael Edgar, Colin
Dawes & Denis O’Mullane
and contributed to by C.
Dawes

terioration of oral health but
also has a detrimental impact
on the quality of life for the
sufferer.

Excerpt from Saliva and Oral
Health - An Essential Overview
for the Healthcare Professional,
2012

An understanding of saliva
and its role in oral health
helps to promote awareness
among oral health care professionals of the problems
arising when the quantity or
quality of saliva is decreased;
this awareness and understanding is important to the
prevention, early diagnosis
and treatment of the condition. There is an extensive

T

he presence of saliva
is vital to the maintenance of healthy
hard (teeth) and soft
(mucosa) oral tissues. Severe
reduction of salivary output
not only results in a rapid de-

body of research on saliva as
a diagnostic fluid. It has been
used to indicate an individual’s susceptibility to developing caries; it has also been
used to reflect systemic physiological and pathological
changes which are mirrored
in saliva. One of the major
benefits of saliva as a diagnostic fluid is that it is easily available for non-invasive
collection and analysis. It can
be used to monitor the presence and levels of hormones,
drugs, antibodies, microorganisms and ions.

Factors Influencing Salivary
Flow Rate and Composition
The following article provides an overview of the
differences in flow rate and
composition between unstimulated saliva (secreted
continuously in the absence
of exogenous stimulation)
and stimulated saliva (secreted usually in response
to masticatory or gustatory
stimulation), the factors influencing salivary flow rate
and composition, and their
physiological importance.

Unstimulated saliva
Unstimulated whole saliva
is the mixture of secretions
found in the mouth in the absence of exogenous stimuli
such as tastants or chewing.
It is composed of secretions
from the parotid, submandibular, sublingual, and minor mucous glands but it also
contains gingival crevicular
fluid, desquamated epithelial
cells, bacteria, leucocytes
(mainly from the gingival
crevice), and possibly food
residues, blood, and viruses.
Several large studies of unstimulated
salivary
flow
rates in healthy individuals have found the average
value for whole saliva to be
about 0.3-0.4 ml/minute,
but the normal range is very
large and includes individuals with very low flow rates
who do not complain of a dry
mouth. Such a broad normal
range makes it difficult to say
whether or not a particular
individual has an abnormally
low flow rate. Unless saliva
is almost completely absent,
patients can be said to have a
dry mouth (xerostomia) only
on the basis of their subjective symptoms. However, a
flow rate of <0.1 ml/min is
considered objective evidence of hyposalivation.
Whether the flow rate is high
or low is much less important
than whether it has changed
adversely in a particular
individual. Physicians will
often take a patient’s blood
pressure as a yardstick for
future measurements. Dentists, however, do not routinely measure the salivary
flow rate, so that when a patient complains of having a
dry mouth, it is impossible to
judge whether or not a genuine reduction in flow has
taken place. It would therefore be very advantageous if
dentists included measurement of salivary flow as part
of their regular examination.
Just as there are individuals with very little saliva but
without discomfort, so there
are others with flow rates
within the normal range
who feel that their mouth
is drowning in saliva. This
problem is often due to difficulty in swallowing, rather
than to a genuinely high flow
rate.
Factors affecting the unstimulated salivary flow rate
• Degree of hydration – This
is potentially the most important factor. When body water
content is reduced by 8%, the
salivary flow rate decreases
to virtually zero.
• Body posture – Flow rate
varies with position and a
person when standing or lying will have a higher or
lower flow rate, respectively,
than when seated.

> Page 5

[5] =>

oral health

Dental Tribune Middle East & Africa Edition | March - April 2014

< Page 4
• Biological rhythms – Circadian rhythms are rhythms
with a period of about
24 hours and include the
rhythms in body temperature
and in salivary flow 2. The
body temperature and the
flow rate of saliva peak during the late afternoon but the
flow rate drops to almost zero
during sleep. This circadian
rhythm also has important
clinical implications for the
timing of oral hygiene. The
most important time to clean
the teeth is probably at night
before going to sleep, since
the presence of plaque and
food debris and a greatly
reduced salivary flow during sleep provide optimum
conditions for progression of
dental caries.
• Functional stimulation –
Further studies are needed
to clarify whether regular
stimulation of salivary flow,
as by use of chewing gum,
leads to an increase in the
unstimulated flow rate, although there is evidence that
it increases the stimulated
flow rate

• Age – Many elderly people
receive medication and the
greater the number of drugs
taken, the greater is the tendency for reduction in salivary flow.
Salivary flow rate and oral
health
The unstimulated flow rate
is more important than the
stimulated flow for oral comfort, since only a small fraction of the day (54 minutes in
a group of dental students) is
spent eating4. However, stimulation of the glands through
mastication is beneficial in
terms of promoting clearance of food from the mouth
and may help by causing an
increase in the unstimulated
flow rate, although further

This type of saliva is secreted
in response to masticatory or
gustatory stimulation; Several studies of stimulated
salivary flow rates have been
done in healthy populations
and show a wide variation
among individuals. Many factors influence the stimulated
salivary flow rate which, for
whole saliva, has an average
maximum value of about 7
ml/minute.
Factors affecting the stimulated salivary flow rate
• Chewing gum – Research
shows the flow rate is high
initially but after about ten
minutes, as the flavour and
sweeteners leach out and
only the gum-base remains,
it falls to the rate obtained
by chewing gum-base alone,
namely to two to three times
the unstimulated rate. This
increase in salivary flow
during gum chewing can be
maintained for as long as two
hours and this may be very
beneficial to those with a dry
mouth. Even after two hours
of gum chewing, the salivary
glands do not become ‘exhausted’ and introduction of
a fresh piece of gum causes a
secretory response similar to
that initially.
• Mechanical stimuli – The
action of chewing, in the absence of any taste, will itself
stimulate salivation but to a
lesser degree than maximum
gustatory stimulation with
citric acid.
• Gender, gland size and
unilateral stimulation –
Most studies have found that
females have lower salivary
flow rates than males and a
recent study3 showed that in
females, the sizes of the major
salivary glands are smaller
than in males. Additionally, if
one habitually chews on one
side of the mouth (for instance
with chewing gum), most of
the saliva will be produced by
the glands on that side after
the initial tastants in the gum
have been leached out.

ORTHOPANTOMOGRAPH ® is a registered trademark of Instrumentarium Dental, PaloDEx Group Oy.

Stimulated saliva

studies of this are needed.
A study has shown that two
sugar-free chewing gums,
one containing chlorhexidine, used by a group of ‘frail,
elderly’, dentate subjects over
a one-year period, led to improved oral health and a statistically significant 55-100%
increase in their stimulated
flow rate5. This suggests that
if the glands are stimulated
regularly, their secretory
ability may increase. Unfortunately, unstimulated flow
rates were not measured in
that study.
Carbohydrate clearance from
the oral cavity
One major role of saliva is the
clearance of carbohydrate
from the mouth. The more

rapid the flow, the faster the
carbohydrate is cleared. This
is true whether the saliva is
unstimulated or stimulated,
for example by chewing gum.
If the gum contains sweeteners such as xylitol or sorbitol,
which are minimally metabolised by plaque bacteria,
then the increased salivary
flow will be very effective in
clearance of cariogenic carbohydrates remaining from
previously consumed food.
The composition of saliva
The composition of saliva
is affected by many factors,
such as the type of salivary
gland producing the saliva.
For example, most of the
amylase in saliva is produced
by the parotid glands while

blood-group substances are
derived mainly from the minor mucous glands.
Factors affecting salivary
composition
• Flow rate – The main factor affecting the composition
of saliva is the flow rate. As
the flow rate increases, the
pH and concentrations of
some constituents rise (e.g.
protein, sodium, chloride,
bicarbonate), while those of
others fall (e.g. magnesium
and phosphate).
• Duration of stimulation –
When the salivary flow rate
is held constant, the composition of the saliva depends on
the duration of stimulation6.

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> Page 39

[6] =>

6 mC M E

Dental Tribune Middle East & Africa Edition | March - April 2014

Clinical and diagnostic advantages of PreXion 3-D
imaging system
mCME articles in Dental Tribune have been approved by:
HAAD as having educational content for 2 CME Credit Hours
DHA awarded this program for 2 CPD Credit Points
By Dan McEowen, DDS

or nearly 100 years,
dentists have relied
on 2-D radiographic
imaging for diagnosis and treatment planning.
With the 1999 introduction of
cone-beam computed tomography (CBCT), all dentists
now have tools available for
more accurate diagnosis and
treatment.1

The ability to look at a tooth
in any direction and orientation, as well as in 3-D, eliminates much of the guesswork
commonly experienced with
2-D radiographs.
We have been limited in most
cases to only a buccal-lingual
view provided by periapicals,
bitewings and panoramic radiographs with the occasion-

Fig. 1: Saggital CBCT MPR showing
bone defect at point of dehiscence of the
implant coating.

al axial view of an occlusal
film. Medical CT scans and
images began in the early
1970s and were sometimes
used by dentists, offering our
first multiplaner views. 2
The adoption of 3-D conebeam imaging is appropriate
and has important advantages for all modalities of dentistry. From every specialist
to the general dentist, the
increased amount of radiographic information as well
as increased accuracy will
aid in the most sound diagnosis possible.
CBCT description
CBCT is a single or partial
rotation of an X-ray source
around the head, capturing
X-rays on various flat panel
arrays and sensors. The information is converted to a
series of axial slices by computed tomography and stored
as virtual anatomy in the
computer.
With the use of sophisticated
software, the dentist is able
to view information in several different views, including: axial slices (head-to-toe
orientation), coronal slices
(front-to-back orientation),
saggital slices (side-to-side
orientation) all known as
multiplaner reconstructions
(MPR). The thickness of each
slice can be varied to include
more or less information.
Because the voxels (volumetric pixels 3-D) are isotropic,
other MPR images can be
generated by slices drawn at
any angle, curve or thickness
through the scan to view areas critical to the final diagnosis.3,8
The final view offered by
CBCT is a 3-D view that can
be rotated and viewed in any
direction.

Fig. 2: Periapical does not show the sinus
anatomy or the width of the bone.

Fig. 3: MPR showing post op of sinus
graft and implant placement.

Once again through software
manipulation, 3-D images

can be viewed as conventional radiographs, maximum
intensity projections (MIP),
soft-tissue projections and a
variety other views.
This nearly endless ability
to manipulate the data aids
in the diagnosis and identification of disease, nerve
canals, sinus morphology,
dental caries, bone density,
fractures, endodontic pathology, implant placement criteria, periodontal defects, bone
pathology, fractured teeth,
iatrogenic trauma, TMJ morphology and disease, thirdmolar position and many
more healthy or diseased
conditions.
Early CBCT adoption with
implants
The first and primary use of
CBCT for early adopters was
implant placement. As the
scope and the value of the
information became better
known, dentists of all branches began to see the value of
MPRs and 3-D renderings
including periodontics, endodontics, oral surgery, treatment of TMJ, orthodontics,
implantology
and general
1,7,8
dentistry.
Clinical periapical and panoramic radiographs for the
placement of implants can
be misleading with elongation, foreshortening, superimposition and geometrically
incorrect data.7,8 A look at
the implant in the periapical shows no obvious disease
to an existing integrated
implant. Clinically, a buccal fistula was present with
exudate and slight pain. The
CBCT scan (Fig. 1) reveals a
more accurate view showing
a buccal defect on a saggital
MPR. A surgical flap revealed
a dehiscence of the coating of
the implant. Removal of the
foreign body resulted in an
asymptomatic and healthy
patient.

Fig. 4: The 3-D CBCT showing anatomy
of the maxillary sinuses.

Centre for Advanced Professional Practices (CAPP) is an ADA CERP Recognized Provider.
ADA CERP is a service of the American Dental Association to assist dental professionals
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approve or endorse individual courses or instructors, nor does it imply acceptance of
credit hours by boards of dentistry.

CAPP designates this activity
for 2 CE credits.

The evaluation of the available bone for the initial implant placement can be crucial for the long-term success
of the case. If there is inadequate bone available, grafting may be a necessity. CBCT
studies render the most accurate information available
at a low radiation dose. The
periapical shows an obvious
lack of bone height, but does
not show the buccallingual
dimensions or an accurate
view of the sinus morphology
(Fig. 2).

pain on palpation and pressure and avoids this side of
the mouth.

The MPR view of the CBCT
shows all necessary measurements to perform the
sinus lift and grafting with
the immediate placement of
the implant fixture (Fig. 3).
Three-dimensional
views
show the floor of the sinus
and any soft-tissue pathology (Fig. 4). Having accurate measurements in all dimensions is an advantage of
CBCT scanning.

A CBCT scan reveals a completely different picture. The
coronal MPR reveals a short
fill near the apex of the mesial lingual root and a large
radiolucency (Figs. 7, 8) not
visible on the periapical radiograph (Fig. 6).

CBCT and endodontics
Endodontics is a field that is
rapidly adopting the use of
CBCT and for good reason.
The inherent geometric deficiencies of 2-D radiographs
make the CBCT scan a valuable adjunct to investigate
the root morphology in both
3-D and MPR. The typical
periapical will show superimposed canals in the anteriors, bicuspids and molars as
well as unwanted bone densities both buccal and lingual
to the affected tooth making
the image quality poor.
The ability to view MPR slices in cross-section, long axis
and oblique directions gives
the ability to follow all canals
in any direction and show
their relationship and measurements from other known
structures. This virtual tour
of the root morphology is
a great benefit to the final
treatment outcome (Fig. 5).3,4

Fig. 5: Axial MPR showing mesial buccal roots
in first, second and third molars.

Post root-canal
infection
can
be difficult to
diagnose with
the
standard
periapical. The
endodontic fills
may
appear
to be normal
even
though
other clinical
findings
and
symptoms are
abnormal. The
patient presents
several months
post root-canal
treatment with

A
periapical
radiogragh
shows minimal pathology
(Fig. 6). The roots appear to
be filled and a small puff of
sealer extends through the
apex of the mesial roots. The
distal root structure and fill
appear normal. There is little
indication of periapical radiolucency only a widening
of the periodontal ligaments
of the mesial roots.

Missed canals are difficult to
see in a buccallingual projection of the periapical radiograph as one canal is superimposed on the other (Fig.
9). Often, as viewed in this
radiograph, we see periapical
pathology with an apparent
normally filled canal. CBCT
scans allow dentists to look
for pathology in MPR planes
to identify the actual problem
before invasive procedures
are performed on the patient. The axial view shows
a lingual canal exists and is
untreated. The coronal view
confirms the diagnosis and
treatment can be completed
(Fig. 10).
Today’s endodontists, as well
as general dentists, are benefiting from the diagnostic
capabilities of the high-resolution CBCT scanners available over conventional 2-D
periapical.5,6
Oral surgery
Oral surgery, with its inherent invasive nature, can be
better served using CBCT
with MPR as well as 3-D images. The ability to perform
virtual surgery is a benefit
to both the doctor and the
patient. Doctors have the advantage of seeing morphology and landmarks in real
time and space with accurate
measurements, and patients
will gain a better understanding of the problems and
the solutions their doctors
are offering them.
Third-molar
extractions
can be risky based on 2-D
and panoramic radiographs.

> Page 7

[7] =>

mc m e

Dental Tribune Middle East & Africa Edition | March - April 2014

7

< Page 6

Fig. 9: Periapical showing a normal fill
with a radiolucency.

Fig. 6: Periapical showing minimal
pathology with no radiolucency.

Fig. 10: Coronal MPR showing the superimposed lingual root unfilled.

These radiographs can often
superimpose nerves and sinuses over root structures.
Dentists using 2-D radiographs must often rely on experience to assess the risks of
iatrogenic trauma. The use
of CBCT with MPRs and 3-D
images reduces any guessing
as well as the chance for any
permanent damage to the
patient. With the adoption of
CBCT, the judgment is based

Fig. 7: Coronal MPR showing a short fill
on the mesial lingual and radiolucency.

Fig. 8: Saggital MPR showing unfilled
canal and radiolucency.

Fig. 11: Coronal MPR showing nerve
between roots of the third molar.

Fig. 12: The 3-D rendering showing supernumary teeth and positions.

on solid evidence and the risk
will decrease.
A panorex of the superimosed
third molars gave no solid evidence the canal lies between
the roots. It is only with the
use of CBCT and the MPRs
that the nerve can accurately
be seen traversing between
the mesial buccal and mesial
lingual root (Fig. 11).4,5

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Other surgical advantages
include the identification and
the position of supernumerary or impacted teeth. The
images show accurate positions and show definitive
morphology that will aid in
removal of the proper teeth
(Fig. 12). Knowing the exact position of many of these
teeth is a benefit to both the
doctor and patient. It will
lead to the most precise surgical path and the least invasive procedure.
Periodontics
The explanation of periodontal problems are often misunderstood by the patient. As
doctors we talk about pockets, point to X-rays and propose treatment only to have
patients refuse treatment
because they do not understand what we are clinically
describing. Using the 3-D
portion of the CBCT scan
can improve the understanding and acceptance of treatment plans. The images are
a picture of the problem that
is owned by that patient and
much easier to understand
by the layperson. Illustrating
periodontal defects and pockets allows the patient to better participate in the process
(Fig. 13).
The MPRs and the 3-D projections aid in surgical
planning for periodontists,
allowing for accurate measurements and bone analysis prior to osseous surgery
that doctors cannot get using
the periapicals or panoramics. Studies have shown that
CBCT images are more accurate than panoramic radiographs. For the periodontist
placing implants, the ability
to measure bone density and
avoid important anatomy is
important.4,5

Fig. 13: The 3-D Rendering with periodontal
defects and calculus bridge.

Orthodontics
Orthodontists are beginning
to adopt large fieldof- view
CBCT. Recent studies show
that linear measurements of
bony structures are more accurate using CBCT and have
less distortion than currently
used methods of measurement: lateral cephalometric,
posteroanterior (PA) and submentovertex (SMVT).5 Accurate measurements of tooth
volume and tooth position
can aid in accelerated treatment times and more precise
treatment.
Along with tooth position,
density of bone and size of
arches, the orthodontist also
has an accurate evaluation of
the temporomandibular joint
and position of the condyles.
Impacted teeth are easily
identified and position either
buccal or lingual can be confirmed prior to movement or
removal. Both MPRs and 3-D
projections give the clinician a complete picture of the
problems and the treatment
course.
With a single CBCT scan, orthodontists can produce all
of the information they need:
panoramic, cephalametric,
PA, SMVT, tooth size and volume, crowding evaluation in
any plane, TMJ evaluation
and airway analysis, all with
both soft-tissue and skeletal
information.5,7
Conclusion
We treat our patients in 3-D,
and now, with conebeam
computed tomography, we
are changing the way we diagnose from 2-D to 3-D. The
addition of this technology
will increase your diagnostic
skills with better and more
complete information at your
disposal. As with any type
of invasive diagnostic tool,

clinicians should weigh the
risk to benefit in using CBCT
scans.
Judicious use of CBCT and
knowledge of patient’s lifetime doses should always be
a consideration as well as
the availability of other diagnostic tests appropriate for
the problems of the patient.
When adopting new technology, training is paramount.
Along with training comes
the responsibility of the doctor to read and diagnose information from CBCT scans.
Do not avoid CBCT from lack
of knowledge; instead, take
this opportunity to become a
better diagnostician and radiologist. As you review radiology and pathology, your use
of CBCT will aid in making
the most accurate diagnosis
and the most complete treatment plans.
Editorial note:
References are available from
the author.

About the author
Dan McEowen, DDS, is a
1982 graduate of Loma Linda
School of Dentistry and has
been in private practice for
26 years. He is a founding
member of the World Clinical Laser Institute, achieving
a mastership level of proficiency.
He has been active in FDA
approval of oral surgery
techniques using Erbium lasers. McEowen has lectured
and trained internationally
in techniques using lasers in
general and specialty dental
fields. He a member of the
ICOI and is active in implantology.
McEowen has been involved
in cone-beam technology
for more than five years and
owns 3D Imaging Center in
Maryland.

[8] =>

8 mC M E

Dental Tribune Middle East & Africa Edition | March - April 2014

Clinical digital photography. Part 1:
Equipment and basic documentation
mCME articles in Dental Tribune have been approved by:
HAAD as having educational content for 2 CME Credit Hours
DHA awarded this program for 2 CPD Credit Points
By Dr. Eduardo Mahn, DDS,
DMD, PhD
Universidad de los Andes
Clinica CIPO Santiago-Chile

A

bstract: The use of
photography is becoming a standard in modern dental practice.
The sharing of pictures is not
only essential for communication between dentist, laboratory technician and patients,
but also for communication
between professionals, undergraduate and postgraduate
students with their teachers

and for documenting of clinical
procedures in cases you want to
show to both patients and work
colleagues at scientific meetings. This article will describe
the necessary equipment for
clinical photography, explain
its uses and deliver the foundation for basic documentation
and structure for clinical cases.
The second part will discuss
the step by step documentation
and show practical examples to
improve your results.

phy was presented to the world
by Louis J. M. Daguerre at the
Paris Academy of Sciences on
January 7, 1839.1 In that same
year, Alexander S. Wolcott, a
manufacturer of dental instruments, designed and patented
the first camera producing images on a silver-coated copper
plate.2 Thanks to the graphic
documentation that this allowed, it created the first dental
journal, the American Journal
of Dental Science.3

Introduction
The first process of photogra-

Due to the advancement in
technology, we now have the
privilege of having digital photography that allows an immediate view of the results and
not having to wait for the processing of films as was the case
of old movies, utilising silver
halide ions in a gelatine emulsion on a strip of celluloid film
to capture latent images. The
advantage of digital images is
that in addition to instantly seeing them through a viewfinder,
there is less cost of developing
film negatives and their storage
is easy and fast. The power of
viewing and saving images in
computers also saves space and
access to a database is almost
immediate. By developing different virtual media files and
almost universal use of email,
information sharing is almost
instantaneous anywhere in the
world.

Figure 1: Clinical photography can be helpful, provided that we
understand the basic principles and have the right equipment.

Figure 2 and 3: Compact and SLR camera (DSLR).

Figure 4 and 5: Macro lateral f lash and ring f lash.

Because many of the procedures performed in dentistry
represent established protocols
that should be read, learned
and then practiced, it becomes
clear that photography aids us
in teaching or explaining to our
patients what we think are common, but to them are complex
and mysterious procedures.
Digital Cameras
There are currently hundreds
of cameras on the market. If we
compare their features and capabilities, we can divide them
into 3 groups:
Compact cameras (point and
shoot), interchangeable lens
cameras (mirrorless system
cameras) and reflex cameras,
SLRs DSLR (Digital Single Lens
Reflex).

Figure 6 and 7: Different types of lenses, Sigma 105mm f/2.8 EX
DG macro and micro Nikkor AF-S 105mm f: 2.8 ED, NC, VR.

Figure 8, 9 and 10: Mirahold, Spandex and OptraGate retractors.

Initially, compact cameras
(Figure 2) may seem appealing, but they have many limitations. They do not have a
consistent image control, the
position of the flash is not suitable for intraoral photography,
distorted images from utilization of an insufficient macro
lens in the wide-angle position,
lack of manual exposure and
focus problems. One of the biggest problems is the inability to
change the lens, which given its

Centre for Advanced Professional Practices (CAPP) is an ADA CERP Recognized Provider.
ADA CERP is a service of the American Dental Association to assist dental professionals
in identifying quality providers of continuing dental education. ADA CERP does not
approve or endorse individual courses or instructors, nor does it imply acceptance of
credit hours by boards of dentistry.

CAPP designates this activity
for 2 CE credits.

Figure 11, 12 and 13: Different types of intraoral mirrors.

Figure 14 and 15: Photo without and with a contrastor. Notice how
other structures distract the viewer from what is to be displayed
effectively.
W hen using a black background, all the attention goes to what the
desired clinician wishes display.

Figure 16 and 17: Examples of a portrait with distracting
factors and a clearer one.

design for a wide angle or middle distance, causes distortion
of perspective, as the clinician
would have to stand close to the
patient. This has another negative effect of poor lighting.4, 5

flash, macro lateral or twin
flash light (Figure 4) or ring
flash (Figure 5), is most suitable
for intraoral photography, and
has been a quite discussed topic
for many years9.

The second group seems promising, but is still in development,
and the third group, DSLR cameras (Figure 3), are those with
greater advantages for clinical
use, thanks to the sensor size
and the many options in manual mode, lenses and flashes.

The ring flash light is the favourite amongst inexperienced
dental photographers and it is
considered the universal flash
system for general macro photography.10, 11 On the one hand,
it is true that the greater the
distance between the ring flash
and the subject, the flatter,
less texturised and refined the
photos are, while a twin flash
generates pictures with more
texture, contrast and that look
more alive12

These cameras use a lens for
both image composition and
image capture6. This design,
which allows direct viewing
and focusing without parallax
error, is ideal for dental photography.6, 7, 8 One of the biggest
advantages is the ability to exchange lenses. For example, you
can take pictures of landscapes,
portraits, and all dental treatments with the same camera,
by just changing the lens. The
same applies with changing the
flash. All professional cameras
more than meet the requirements. Semiprofessional cameras (with a more affordable
price) that meet these requirements are for example Nikon
D7000, D90, D5100, D3200,
Canon EOS 7d, 60d, 550d or other similar brands.
Flash
The discussion with which

The macro lateral flash shows
more variability in light direction, allowing certain details
to be highlighted. The overall
hue of colour, cracks and also
transitions are best captured
with the macro lateral flash.13
Probably the only drawback,
besides its higher cost, is when
photographing posterior regions, where access and space
is limited. In these cases, the
homogeneous light and easy
handling of the ring flash has
an advantage. In the author’s
experience, when a clinician
decides to begin clinical photography, a ring flash is more

> Page 9

[9] =>

mC M E

Dental Tribune Middle East & Africa Edition | March - April 2014
< Page 8

Dr. Eduardo Mahn Hands-On Courses

Figure 18 and 19: Examples of a general anterior photo. Ideally, lips,
corners, mustaches and retractors should not appear in the photo.

Figure 20 and 21: Example of a lateral view. Note the difference
between the two pictures both in lighting and in the presence or
absence of distracting factors.

Figure 22 and 23: Mandibular occlusal view. This kind of picture may
be difficult to achieve with the presence of the tongue.
Examples of a poor and well taken picture.

than adequate; the extra cost
of the macro lateral flash is not
justifiable, since differences in
the early stages of the learning
curve will not be substantial.
Then once they handle certain
techniques, the macro lateral
flash is a great contribution.
Lenses
Basically, macro lenses from 50
to 200mm in focal length are
used for clinical photography. In
the author’s experience, macro
lenses of about 100 mm in focal
length provide the ideal combination of magnification ability
and convenience working distance for dental purposes. Teleconverters or zoom lenses can
be used, but not recommended.
The same goes for lenses with
autofocus mode. If this is the
case, the automatic mode must
be switched off and put on manual. Focusing is done manually
and moving the ring lens near
a sharp image, and with small

Figure 24

movements to and fro, achieves
perfect focus. A high quality
lens is paramount to capturing
crisp and bright photos.14 This
aspect should not be compromised. It is ideal to have a magnification ratio of 1:1. In the
author’s experience a good lens
to start off with at a reasonable
cost is the Sigma 105mm f/2.8
EX DG macro (Figure 6), which
is compatible with different
brands of cameras. On the other hand, for the seasoned and
professional photographer, who
does not want to compromise
quality, a Nikkor micro lens and
the AF-S 105mm f: 2.8 ED, NC,
VR (Fig. 7), would be recommended, though costing more
than doubled compared with
the aforementioned Sigma.
Accessories
Retractors
To gain better access to the buccal cavity, better visualization
of the structures of interest and

Figure 25

that they are sufficiently illuminated, it is essential to have
good lip retractors. They should
neither be very uncomfortable
for patients, should avoid reflections and ideally possess a
certain capacity to stay in place
and avoid having the dental assistant hold them, as is the case
with Mirahold type retractors
(Figure 8). In the case of a Spandex type (Figure 9) or soft latex
retractors from Ivoclar Vivadent
OptraGate (Figure 10), this does
not happen and the picture can
be taken without external help.
Ideally, always choose the largest possible retractor for improved exposure of the structures of interest. The clinician
can make the process less cumbersome by using petroleum
jelly or cream on the patient’s
lips before starting.
Mirrors
When taking pictures in posterior regions, mirrors are invaluable, since the angle of the
buccal area doesn’t allow taking of direct photos. To avoid
double images and to enhance
the sharpness, quality mirrors
are needed, ideally hodium. It is
useful to have mirrors with long
firm handles (Figures 11-13),
in order to position your hands
away from the objects of interest and avoid unwanted shadows. This is of particular importance in documenting steps
when showing the use of materials or objects near to the teeth.
To prevent the mirror misting
up, they must be at a temperature similar to that of the oral
cavity. For this effect you can
use hot water or any type of air
heater. You should also ask the
patient to breathe through their
nose. Another option is that the
dental assistant gives a gentle
stream of air with the triple
syringe. It is noteworthy that
these mirrors are very sensitive
to fractures, bites, abrasions or
scratches, so they must be treated with great care by the staff.
Black background or contrastors
In the previous section, where
the aim is to show the upper and
lower teeth separately, the rest
of the structures in the back-

VENEERS/CROWNS: 12 NOV. 2014
DIRECT VENEERS: 13 NOV. 2014
FACE AND SMILE ANALYSIS: 15 NOV. 2014
JBH, Dubai, UAE
ground can distract from what
you want to highlight. To avoid
this, we recommend the use of
opaque black plates called contrastors, positioned behind the
teeth you want to photograph.
When used correctly, the quality of the picture is improved and
the viewer can focus on the subject (Figures 14 and 15). Besides
commercial products from
brands like Anaxdent, Doctorseyes and Photomed, different
types of black plastic can also be
used as long as they do not generate unwanted reflections. If
you do use material other than
contrastors, it is important to
use your preference consistently when photographing a series
of photos. If you decide to cut
the edges of the picture by using software such as Photoshop,
it not only will not produce the
same results, because cropping
will increase the relative size
of the pixels due to the magnification of the desired area, but
will increase the time invested
by the clinician producing good
quality clinical photos.
Examples
In order to compliment intraoral photography, it is recommended to show pictures of
patients before and after treatment. These types of photos,
although may seem simple and
easy to execute, can present
difficulties. In Figure 16 and
17, you can see a badly taken
picture, distracted by multiple
flaws such as inadequate background, shadowing on the right
side, and an unfavourable facial
expression, etc. In contrast, Figure 16 shows clearer picture,
a neutral background, no unwanted shadows, good lighting
and a positive facial expression.
The second aspect to show in
most of the treatments is a buccal overview of the oral cavity, starting from the anterior
teeth. In the Figure 18 and 19,
you can see two examples of a
photo, the first badly taken and
second well taken. In this case,
interest should focus on the anterior teeth that need treatment.
Therefore, there is no point taking a picture showing lips, facial hair such as moustache’s,
lip retractors and excessively
showing gingiva. These structures only distract from what is
really important.

Figure 26

It is also easy to make errors in
lateral photos, an example of
this is Figure 20, which shows
that, in addition to an underexposed sensor (insufficient light,
the picture is dark, the angle is
not right, you see the lips and
the tip of the mirror). On the
contrary Figure 21 is a better
photo, having the proper exposure, no distracting elements
and the correct angle was taken.
In the occlusal view, both mandibular and maxillary, one
must keep several aspects in
mind. A good mandibular occlusal photo is far more difficult
than the maxilla by several factors: Firstly, the tongue needs
to be retracted, secondly, the
rapid accumulation of saliva of
the patient makes the clinician
act quickly and without hesitation, and thirdly, the angle of
the photo.
In Figure 22 you notice, in addition to being inadequately illuminated, the axis of the arch
is not centered with the photo,
we can see the jaws and teeth as
well as the edges of the mirror.
In contrast, Figure 23 shows an
image best achieved where the
picture is centered, well lit, and
no presence of other distracting
structures.
Case report
One of the main objectives of
the documentation process, is
to explain to our colleagues or
students what steps were performed to reach certain results.
It is also beneficial to graphically present and compare new
and already established techniques. The following is simple
a case of two composite restorations with sectional matrices
and a centripetal layering technique as an example of the detailed documentation and standardization that images should
demonstrate.
Another objective of a systematic and structured documentation is to have graphic material,
either for patients to understand
or to show treatment results
objectively, so they have no obscured treatment expectations.
These types of aesthetically
documented treatments will be
discussed and presented with
documented cases in a step by
step manner in the next chapter
of this series, in addition to discussing common mistakes and
how to solve them.
Editorial note:
References are available from
the author.

Figure 27

Figure 31

Figure 28

Figure 32

Figure 29

Figure 33

Figure 24-34. Example of standardized documented photographs to show a step by step procedure.

Figure 30

Figure 34

About the author
Dr. Mahn is a graduate from the
University of Chile, School of
Dentistry. He received the German
DDS in Munster, Westfalen Lippe
one year later. The New York
University College of Dentistry
certified him as Implantologist
in 2007. In 2008, he published
his doctorate thesis in 2008 titled
“Osseointegration of zirconia
implants, an in vivo study” and got
his doctorate degree in 2010.

[10] =>

10 digital

Dental Tribune Middle East & Africa Edition | March - April 2014

Using Cone Beam (CBCT) in Implantology
By Dr Alexander Luke

A

bstract: Cone beam
computed
tomography (CBCT) is a
diagnostic imaging
technology that has changed
the way in which dental practitioners view the oral and
maxillofacial region, teeth
and the surrounding structures. CBCT is designed in
such a way that 3D images
are seen without distortion
and superimposition which
is similar to CT imaging. The
advantages of CBCT are: sim-

pler image acquisition, lower
capital cost and less radiation
dose to the patient.
Introduction
Radiographic examination is
an important diagnostic tool
in dental implants treatment
planning. Information obtained from a conventional
or a digital radiography is
limited by the fact that the
3D anatomy of the area being
imaged is compressed to a 2D
image. The superimposition
of structures is again a major
limitation of the 2D image1.

Dr Luke positioning a patient on the CS 9000 3D

Visit us at

CAD/CAM &
Digital
Dentistry Int’l
Conference
09-10 May 2014

The Carestream Dental Training Centre at Ajman
University

Cone Bean Computed Tomography (CBCT / CBVT) is
a 3D x-ray imaging technology that exposes the patient
to an x-ray beam in the form
of a cone which is revolved
around the patient. The benefit that this has over a CT
scan is that a CBCT scan requires significantly reduced
exposure times and so exposes the patient to significantly
less x-ray radiation. However
compared to a 2D x-ray there
is still an increase in dose
and so consideration is still
required when recommending a 3D view. The European
association of osseointegration (EAO) have given guidelines which states that cross
sectional imaging is beneficial in preoperative assessment and treatment planning
of dental implants and that
should not be a regular protocol post operatively unless
needed 2.
A CBCT scan captures multiple images (ranging from
150 to more than 600)1 in a
single scan with fewer artifacts when compared to panoramic radiography 3.
3D Images are ideal for
planning the placement of
implants. As with all x-ray
procedures CBCT carries a
radiation exposure risk to
the patient and so it is necessary to ensure that the dose is
kept to a minimum and will
provided optimum diagnostic
information resulting in improved patient care.

See the New Reality at
CAD/CAM & Digital Dentistry International Conference, 9th Edition,
09-10 May, 2014, Jumeirah Beach Hotel, Dubai

CBCT collimates the x-ray
beam to focus on the area of
interest known as the field of
view (FOV). It is advisable not
to radiate outside of the area
of interest so it is very important that the CBCT system
offers a choice of FOVs ranging from small to medium to
large allowing the user to select the optimum FOV for the
treatment. This function may
not be available in all CBCT
units however it is essential
so that the user can select
the correct FOV for the treatment and more important
has available a small Field of
View (for example 3.5 x 5cm)
which is in fact suitable for

> Page 11

[11] =>

digi ta l 11

Dental Tribune Middle East & Africa Edition | March - April 2014
< Page 10
the majority of dental examinations. At this level the effective dose is small enough
to increases those examinations that can be justified to
have a CBCT scan5.
CBCT images are isotropic
with ranges from as low as
0.076 mm to 0.4 mm. The images in different planes and
the multiplanar reformatted
images had led to achieve
the level of spatial resolution
accurate in measurements
such as in implants site assessment 3.

Indications for CBCT in implants
1. To assess the quantity and
quality of the bone in the
edentulous area.
2. The relationship of the implants to the neighbouring
areas.
3. For the placement of implants in the desired area.
4. In designing a surgical
guidance template.

Conclusion
2D imaging has been serving
the dental fraternity in their
diagnosis and will continue
to do in the future. The recent
availability of 3D imaging using CBCT systems for treatment diagnosis and planning
implant positioning gives the
dentist more accurate information and improved patient
care.

Limitations of CBCT in Implant planning
Crowns or metallic appliances in the mouth can cause
artifacts of the 3D image.

The Carestream CS 9000 3D
has a FOV of 5 x 3.7 cm creating images with a resolution
of 0.076mm. This resolution
is beneficial for accurately
planning implants and overall improved treatment.

The metals causing artifacts
can range from minimum to
the extent that the image interpretation is difficult.

References
Kumar, S. Manoj, Mouli, P.
E. Chandra, Kailasam, S.,
Raghuram, P. H., Sateesh, S.
Applications of Cone-Beam
Computed Tomography in
Dentistry. Journal of Indian
Academy of Oral Medicine &
Radiology. Oct-Dec2012; 23
(4):593-597.
2
CONE BEAM CT FOR DENTAL AND MAXILLOFACIAL
RADIOLOGY
EvidenceBased Guidelines, EUROPEAN COMMISSION RADIATION PROTECTION N° 172,
2012, pg-73
3
William C. Scarfe, Allan G.
Farman. What is Cone-Beam
CT and How Does it Work?
Dent Clin N Am. 2008; 52:
707–730
1

Fig 1. 3D reconstructed view .

Fig 2. Axial cross sections.

Fig 3. Panaromic view.

Fig 4. Sagittal view.

Fig 5. With length and
measurements.

See the New Reality at
CAD/CAM & Digital Dentistry International Conference, 9th Edition,
09-10 May, 2014, Jumeirah Beach Hotel, Dubai
Fig 6. Without length and
measurements.

About the author
Dr Alexander Luke: Senior
Lecturer in oral and maxillofacial Radiology and coordinator of the Carestream Dental Training Centre (for oral
radiology equipment), Ajman
university of science and technology, college of Dentistry,
post box no 346, Ajman, UAE.
(a.luke@ajman.ac.ae).
Carestream Dental has partnered with Ajman University
to combine academia and business through the opening of the
Carestream Dental Training
Centre. CBCT Application and
Awareness Training Courses
are available for dentists and
clinicians. For enquiries please
contact Dr Luke at a.luke@ajman.ac.ae or Montassar Ben
Tili at montassar.bentili@carestream.com.

[12] =>

12 lab tribu n e

Dental Tribune Middle East & Africa Edition | March - April 2014

Interview: Vanik Kaufmann explains the advantages of KaVo’s
new ARCTICA CAD/CAM system
Not only has the proprietor of
the dental laboratory CeraTech in Liestal near Basel
been a CAD/CAM user from
the very beginning but he also
has provided valuable input
into the technology’s development through his active participation in it. Recently he has
become the owner of KaVo’s
new ARCTICA system. We
wanted get his first impressions from working with the
system.

Mr. Kaufmann

By KAVO

hen it comes to state
of the art CAD/CAM
technology in dental
laboratories, then patients are
in best hands at ZTLM Vanik
Kaufmann-Jinoian. His numerous lectures on the subject
are an impressive proof of this.

KaVo: Mr. Kaufmann, you recently started using KaVo’s
ARCTICA CAD/CAM system.
You have extensive experience
with CAD/CAM systems. What
do you consider to be ARCTICA’S particular advantages?
Mr. Vanik Kaufmann: First of
all there is the striped light
scanner. I particularly like
that it is a semi-automatic design. With fully automated
systems I often encounter
problems with cumbersome

IMG 4: Range of materials offered: ARCTICA
Elements of titanium, zirconium, Glassinfused ceramics and plastic; in addition, an
exchangeable holder offers the option of using
third-party materials.

IMG 1 and 2: Completed, milled connecting bar
with screwed locators fabricated in the Arctica
Engine.

IMG 3: Two connecting bar with implant
connectors milled from a titanium block.

re-scans when the first scan
was incomplete. Scans that
require essentially no corrective work can be achieved
with very little experience. In
addition, it works extremely
fast. And even in cases where
the scan shows gaps the model
can be repositioned accordingly, perhaps by tilting, and
the software applies any subsequent corrections automatically.
And what are your experiences
with the grinding unit?
I really appreciate that it is a
compact 5-axis system that
not only uses blanks very economically but also that I am
finally able to process metal,
something that up until now
was not possible with small
systems.
Is zirconium dioxide still important nowadays?
There are still dentists who
request metal frameworks.
When CrCo alloys are required, we have them externally made by selective laser
sintering. When biocompatibility is required, it has to be
titanium. We process a large
number of titanium connecting bar and up until now had
to have them fabricated externally.
Now we are able to do this in
house and the design is simple
and fast by means of the software provided.
How practical is the software?
It is fantastically simple. E.g.
during the design of an anterior bridge, the automatically
proposed crown can be moved

IMG 5: Navigation of the multiCAD
CAD/CAM software is logical and
intuitive.

IMG 6: ARCTICA Engine: a compact 5-axis wet
milling and grinding centre.

and rotated through key combinations which are considerably faster and simpler than
with other solutions that require multiple key clicks. And
its operation is intuitive to
learn: Within half an hour of
receiving it I was able to do a
bar design without a hitch and
without receiving any training. KaVo’s hotline with remote support is equally fantastic and useful especially in the
early stages when one might
have the occasional problem:
These consultants are highly
competent, they can log in remotely and point out mistakes
on your own screen or give
hints on how to do things even
faster.
The multiCAD Software is
equipped with open interfaces,
but not every scanner supplier
offers open interfaces. How
much data transfer can you
utilise?
We are not only able to do this
with manufacturers that provide STL files but also with
others who still believe in the
advantages of proprietary systems. We are using Rhino’s
dental shaper for this purpose;
it can convert all relevant data
sets to compatible STL files.
You also use a printer (Solidscope).
Are you using ARCTICA data in
there as well?
Yes. We have decided to no longer do the wax coating for precious metal castings by hand
as this is very simple and fast
done in the KaVo software. We
design the framework on the
PC and transfer the STL data

directly to the printer. The
printer is very accurate and
saves us a lot of work.
Besides KaVo’s blocks of titanium, Zirconium, glass-infused
ceramics and plastic, there is
the option of using other materials. Do you use them?
We have the open system and
do both. Alongside KaVo’s materials we use blocks by RealLife and Cad-Temp blocks by
Vita. We fabricate our own
plastic and wax blocks that we
can use via the exchangeable
holder.
Could you share your experience with the Implant module?
We fabricate connecting bars
from titanium with bonded
bases. We also use titanium
bonded bases for our zirconium abutments since we
have bad experiences with
whole zirconium abutments
with screw connection - they
losened over time. For lateral
applications we also fabricate
titanium abutments which
we weld to the bonding base.
The design of these abutments
too is amazingly simple: One
draws what one thinks.
Mr. Kaufmann, many thanks
for this interview.

Contact Information
KaVo Dental GmbH
Alexia Valera
9th Floor Rotana Arjaan Tower
Dubai Media City, UAE
Tel. +971 4 4332186
Mob. +971 56 1757141
E-Mail: alexia.valera@kavo.com
www.kavo.com/MEA

[13] =>

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For outstanding cleaning, even deep between the teeth

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This makes the Philips Sonicare FlexCare Platinum ideal

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polished in a further 30 seconds.
• GumCare – combines 2 minutes in the Clean setting
with 1 minute of gentle gum massage for healthy gums.

3 intensity levels
Maximum comfort with the 3 adjustable intensity
levels: low (for sensitive areas), medium and high.
Each of the 3 intensity levels can be combined with
each of the 3 cleaning settings.

Philips Sonicare InterCare brush head
Extra long filaments reach deep into the spaces
between teeth and ensure an excellent plaque
removal there compared to a manual toothbrush.
For better tooth and gum health.

UV-Sanitizer
With the UV light technology from Philips, up to
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are rendered harmless – in only 10 minutes.

Lithium-ion rechargeable battery
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1

E. coli, S. mutans and HSVI, HA

Removes up to 6x more plaque
in the spaces between the teeth in
comparison to a manual toothbrush.

[14] =>

14 lab tribu n e

Dental Tribune Middle East & Africa Edition | March - April 2014

The Inman Aligner: A progressive approach to smile design - Part 2
By Dr Tif Qureshi

T

he following article is Part 2 in a
series
discussing
the use of the Inman Aligner as a tool for
minimally invasive cosmetic
dentistry.1 The first article
(published in DTMEA NovDec 2013) demonstrated that
standalone treatments offer patients an alternative
to both fixed braces, which
are unsightly and have long
treatment times; and to expensive clear aligner treatments in suitable cases. This
article will demonstrate that
patients who desire a more
traditional smile makeover
can achieve beautiful results
in a more progressive manner that allows them to make
their choices along the way.
This often results in virtually no removal of tooth structure and a treatment result
with the responsibility of
decision-making shared between dentist and patient.
Moreover, the subject matter
of this article could potentially start one of the most
controversial debates in cosmetic dentistry for years.
We are not only discussing a

radically different approach
to smile makeovers, but
critically a sharply different
approach to the traditional
methods of planning smile
design.
What would you choose?
Patients entering cosmetic
practices are often assessed
at the initial consultation.
They have digital photographs taken and perhaps
study models are made. Normally, dental imaging software is used to show patients
what can be achieved. These
ingenious
programmes
(see www.snapdental.com/
AUST) can help patients realise what is possible. Naturally, care must always be
taken when promising treatment results that are viewed
digitally.
While computer imaging
can be a very powerful tool
to help the patient see the
potential in his/her smile,
I believe it also can make
a patient focus on a certain
prescribed goal that may not
be the only way of satisfying
his/her wishes. Dentists using imaging would ideally
create a set of five to ten different outcomes of varying

degrees of improvement to
allow the patient to make
a more informed decision.
While ideal, it is not certain that dentists actually
present different levels of
treat- ment to their patients
digitally. Even if they were
able to see various images of
their teeth, it can still be difficult for a patient to really
see and feel the suggested
changes in their mouth. One
can question the ethics of al-

the proposed outline, form
and overall aesthetics.
Despite this, veneers are often used to treat alignment
issues and it is very difficult
for patients to appreciate the
alignment of their own teeth
with wax-up or imaging.
By approaching these cases
with a different protocol in
mind, a dramatically less
inva- sive treatment plan becomes evident.

“We are not only discussing a radically different
approach to smile makeovers.”

lowing patients to commit
to a potentially irreversible
procedure based on 2-D photographs.
Three-dimensional
waxups can also be very useful at this stage. If a patient
is keen on the image, going
to an additive wax-up can
sometimes allow for a direct
preview try-in using a silicone stent taken from set-up.
Temporary material of variable shades can be tried in
directly, without any bonding to allow the patient to see

The first step is to look at the
patient’s tooth alignment.
Mis-aligned
teeth
often
cause issues in gum heights,
line angles, light reflections,
shades and tooth length.
Correcting the misalignment first can create a completely different perception
of the apparent problems.
Next, the teeth should be
bleached. This can be done
either immediately after the
teeth have been aligned or
preferably simultaneously.
After alignment and bleaching, edge bonding (we term
this the ABB concept) should
be offered to improve the incisal edge outline.
This combination of treatments also works well because the Inman Aligner is
a removable appliance and
only needs to be worn 16 to
18 hours a day. This means
simultaneous bleaching is
very possible and straightforward. A recent study from
Sweden indicates a costbenefit advantage of treating patients with removable
appliances in general dental clinics, rather than with
fixed appliances at specialist
orthodontists. 2 The conclusion of this study is significant, since a popular choice
amongst aesthetic dentists
in the UK is removable orthodontics.
The cases outlined here
highlight patients who, either at the start of treatment
or for years, had originally
wanted veneers and had a
specific result in mind that
only veneers could have offered quickly. They were all
concerned about the degree
of preparation required,
so undertook alignment
first. Then, part of the way
through, started bleaching
and very quickly changed
their minds about what they
wanted once they saw their
own teeth improve.
Case 1 (Figures 1-8)
Laura was concerned about
her very prominent central incisors. She wanted to
have them straightened and
had considered veneers. She
had ruled out conventional
orthodontics and invisible
braces because she wanted a
quick treatment and did not
want anything stuck to her

Figure 1. Smile View before treatment.

Figure 2. Occlusal view before.

Figure 3. Close up view before.

Fig 4. Close view after Inman Aligner
and whitening at week 9.

Fig 5. Close view after ABB at week 9.

Fig 6. Smile view after 9 weeks.

Fig 7. Occlusal view after.

Fig 8. Full face view after.

teeth, which is the reason
that she had refrained from
orthodontic treatment. Several years ago, she may well
have had veneers placed.
On viewing her teeth before
the occlusal photograph,
it was quite clear that this
would have involved massive preparation of the upper

> Page 15

[15] =>

Dental Tribune Middle East & Africa Edition | March - April 2014
< Page 14

Fig 9. Before smile view.

Fig 10. Before side smile view.

Fig 11. Before close up view.

Fig 12. After Inman Aligner and
whitening at 10 weeks.

Fig 13. After no-prep edge
bonding at week 12.

Fig 14. Side smile after alignment
and whitening.

Fig 15. Side smile after edge
bonding.

Fig 16. Smile view after ABB.

Fig 17. Full face view after.

central teeth. Preparation
would have been well into
dentine and may have even
involved elective endodontics. Her lateral teeth would
have needed little preparation, but the emergence profiles would have been poor,
creating unrealistic aesthetics and a possible periodontal risk later on. Instead, the
alignment was completed
with an Inman Aligner in
ten weeks. Her treatment sequence is detailed below.
BACD-style digital photographs were taken and the
amount of crowding was calculated using an electronic
crowding calculator, which
can also be done by arch
evaluation of the patient’s
study models. We measured
the ideal curve and subtracted this measurement
from the total mesio-distal
widths of the teeth being
moved. 3 The results showed
that there was only 1.6 mm
crowding. This seemed less
than one would have expected; the reason for this
was that because the laterals
were being pushed out, the
arch was being expanded,
thus creating space.
It was clear from the photographs that despite the obvious crowding, there was
some less obvious irregular
tooth wear. It was important
to indicate this to the patient, as this would become
more evident once the misalignment had been corrected. The patient was quoted
for three incisal composite
tips. She opted for an Inman
Aligner with an incorporated expander. These expanders are a very handy way of
creating extra space either
to treat cases that are more
complex or to use instead of
performing
interproximal
reduction (IPR).
In this case, no IPR was performed. We planned to get
nearly all space by using
the midline expander. The
patient was instructed to
turn the midline screw once
a week after one week of
wear. Each turn is a quarter
of a revolution and equates
to 0.25 mm. At week six,
bleaching was started with

soft rubber sealed trays. After nine weeks, the patient
had expanded 1.8 mm and
her teeth were in alignment
(As a rule, less than 2.5 mm
expansion with an incorporated expander is easily tolerated).
Looking at her post-alignment result, the golden proportion, gingival heights
and axial-inclinations had
improved dramatically, all
without a handpiece being
picked up and in the space
of nine weeks. What was
very clear to the patient at
this point was that she only
needed some simple bonding to improve the incisal
edge outlines. Without the
use of an anaesthetic, the
edge outlines were prepared
with very slight roughening
of the edge, bonding of hybrid composite on the load
bearing edge and a microfill on the facial surface. The
edges were then polished.
The patient was thrilled
with the result we achieved
using an Inman Aligner and
some simple bonding. She
described that when she had
once considered having veneers, she had hoped for a
similar result. There are still
minor imperfections, but, in
my opinion, these contribute
to her natural beauty.
There is a stark contrast between the treatment selected
and the potential treatment
approaches in this case.
Where once a patient, who
refused orthodontics, would
have consented and received
highly
aggressive
tooth
preparations to achieve correct alignment with veneers,
now a removable aligner and
some simple bonding were
able to achieve a similar and
arguably better result in less
than three months with not
a micrometer of tooth reduction needed.
Case 2 (Figures 9-17)
This young lady had been attending my practice for some
time and was aware of porcelain veneers, having seen
our previously advertised
cases. We had spoken about
the aesthetic benefits of ve-

neers years before. However,
on reviewing her case, it was
clear that we could improve
her alignment dramatically
with an Aligner in a short
period.
We took an occlusal image of
her anterior teeth and outlined the amount of tooth
structure that would have
to be removed to produce
veneers that would look
aesthetic. It was immedi-

l a b t r i bu n e 15

ately apparent to the patient
that alignment of her teeth
would offer a possibly better
treatment outcome. Her case
was suitable for an Inman
Aligner and as only 2.5 mm
crowding was present, this
meant it could be treated
quickly and simply.
Her Inman Aligner was fitted and IPR performed progressively over three visits.
At week eight, upper and
lower bleaching trays were
constructed even though her
alignment was not yet complete. Home whitening was
begun with clear and concise instructions. We used
rubber trays with a deep seal
cut into the model to create
a tight dam effect. Over two
weeks, her teeth whitened
nicely and at week ten, she
returned for a review.
Interestingly, the patient’s
perception of her smile had
changed dramatically. Owing to the improved line
angles, whiter teeth and balanced gum heights, her eyes
were now only drawn to the
irregular outline caused by
chipping and differential
wear.
The patient then enquired
about fixing the edges. We
offered to bond the incisal
edge with virtually no prep-

aration. A hybrid composite
(Tetric Flow, Ivoclar Vivadent) was placed palatally
and incisally with a microfill on the facial surface.
This was done in B0 and B1
shades to match the bleaching. The patient was delighted with the result and a wire
retainer was bonded immediately.
Despite some clear deviations from her ideal simulated smile, the patient explained that she felt her smile
after alignment was better
than she had imagined her
veneers would have been.
Had veneers been placed,
we could perhaps have corrected the golden proportion
more fully, balanced the zeniths, improved the canine
outlines, widened the buccal corridors, etc. However,
that was clearly not what the
patient desired. Should she
later decide that she does
need further improvements,
we can proceed with already
straightened teeth. The ABB
smile design is progressive
and not sudden or rushed.
In this manner, the patient
is given the opportunity for
decision-making in his/her
treatment and the responsibility in choice is shared.

> Page 16

[16] =>

16 lab tribu n e

Dental Tribune Middle East & Africa Edition | March - April 2014

< Page 15
Case 3 (Figures 18-26)
This patient presented with
what she described as a
“wonky smile”. She had previously looked into the possibility of having porcelain veneers placed so understood
some of the aims of smile design. However, on studying
her teeth, it became clear
that there was potential to
pre-align first. Her upper
right central was mesially
rotated by approximately 30°
and her laterals were slightly in-standing and mesially
inclined. Furthermore, she
had fairly stained teeth, with
the canines two shades darker than the centrals.
On examining the occlusal
view, the patient became
aware of the extent of aggressive tooth preparation
that would be required to
place a veneer. She understood that her teeth needed
to be aligned first before we
decided on the next step in
design.
An Inman Aligner was used
over the period of eleven
weeks to de-rotate the front
tooth and to tip out the laterals. At week eight, bleaching was begun using 35- to
45-minute a day H2O2 gels.
Simultaneous
whitening
is a very attractive part of
aligner treatment, as it helps

with patient motivation. After alignment, the case was
re-examined. Once her teeth
had been straightened, it became evident to the patient
that her problem concerned
edge shape, which had actually worsened with alignment owing to dif- ferential
wear. In fact, the left central
was 2.5 mm shorter than the
right. It was very clear to the
patient that only these incisal edges needed building in
order to achieve the smile
she desired.

process was repeated on the
lateral.
The patient was held in retention using her aligner
and an impression was taken
for a wire retainer to be fitted two weeks later. It was
especially nice to retain the
natural aesthetic characterisation of this patient. Ceramic work, as beautiful as it
can be, would certainly have
changed her appearance
more – some may say for the
better, but that was not what
the patient actually wanted.
She wanted her own teeth to
have correct length and look
straighter and whiter.

For placement of the incisal
edges at week twelve, no local anaesthetic was administered. Other than slight
roughening of the worn incisal edges of the upper left 1
and 2, no other preparations
were needed. A tetric hybrid composite (Tetric Flow,
Ivoclar Vivadent) was built
up free-hand on the incisal
edge and palatal surface to
match the outline of the other central. A small amount of
white opaquer was dotted in
to match the facial surface
and was simply filled with a
nano-hybrid composite (Venus Diamond, Heraeus) for
high polish. The composite was polished vertically
using rubber sticks (PoGo,
DENTSPLY DeTrey) to try to
blend in with surface anatomy to mask the join. The

Shared responsibility of
treatment
The ABB concept can truly
be described as minimally
invasive. At the same time,
it actively involves the patient in the treatment, giving
him/her a feeling of being in
control and taking responsibility for his/her treatment.
This has been proven to be
of greatsignificance when
measuring patient satisfaction of treatment results.4
There are many anecdotal
stories about patients who
had technically beautiful veneers placed but found that
these simply did not meet
their desires. The problem is

that even with no-preparation veneers, an irreversible
procedure has been undertaken and this has been done
mainly based upon the treating dentist’s opinion, with
the patient having very little
input.
In my experience, every patient that I have treated according to the ABB concept
has accepted the result happily, even though technically
it might not be perfect from
a smile design point of view.
Nowadays, with rising levels
of litigation, one would have
to question the wisdom of
selecting a treatment path
that could result in conflict
over one in which the patient
participates in key decisions
and sees his/her own teeth
improve.
I believe this approach firmly sits alongside minimally
invasive cosmetic dentistry
core principles, which recommend a more minimally
invasive and patient-led approach.
Conclusion
I understand the controversy
in challenging the traditional approach to smile design,
but the new mantra of progressive smile design is vital
when we are looking to give
our patients what they actually want. Previously, pre-

Fig 18. Smile view before.

Fig 19. Close left side view before.

Fig 20. Occlusal view before.

Fig 21. Close view before.

Fig 22. Close view after alignment
and whitening at week 10.

Fig 23. Close right side view after
Edge bonding.

Fig 24. Occlusal view after.

Fig 25. Smile view after ABB at 12
weeks.

whitening was always a way
of giving our patients an alternative view of their teeth.
Now, and more significantly
with alignment techniques,
patients can make their own
decisions and massively reduce the risks by breaking
down the process of a smile
makeover into stages and reassessing at each point.
With ABB, it is possible to
align, whiten and bond a
case in less than twelve
weeks, which previously
might have required eight to
ten veneers, four times the
cost and significant tooth
preparation. Thus, a dramatic contrast in pathways has
been created. If a patient is
happy after alignment, whitening and minimal bonding,
then this has to be viewed
as a success. This UK technique is now a significant
new treatment discipline in
itself and cosmetic dentistry
will be better for it. After all,
what would you choose to
have?
Editorial note:
References are
from the author.

available

Contact Information
Dr. Tif Qureshi is the Past President of the BACD.
He presents hands on courses
and lectures on the Inman Aligner worldwide.
For information on courses
please go to:
www.inmanalignertraining.com
or contact Caroline Cross on
Tel: +44845 366 5477

Fig 26. Close view after ABB at 12
weeks.

Philips Sonicare FlexCare Platinum
By Philips

hilips Sonicare FlexCare Platinum is the
latest
introduction
from the number one
sonic toothbrush brand recommended by dental professionals worldwide. The new Philips
Sonicare FlexCare Platinum
is uniquely designed to give
patients an even deeper clean
between the teeth, removing
up to six times more plaque
between teeth than a manual
toothbrush.
Sonic technology
The innovative Philips Sonicare FlexCare Platinum power
toothbrush uses Philips Sonicare’s patented sonic technology to deliver an exceptional,
deep clean between the teeth.
Using a unique combination
of high frequency and high
amplitude, the Sonicare FlexCare Platinum produces over

30,000 brushstrokes a minute
to create a dynamic yet gentle cleaning action. Its brush
head moves with a side-to-side
sweeping motion and a high
filament tip velocity to gently
drive fluid deep between the
teeth and along the gum line.
InterCare
the innovative interdental
brush head
The Philips Sonicare FlexCare
Platinum features a new brush
head with innovative anchorfree tufting technology and
extra-long filaments designed
to reach deep between teeth
and remove more interdental
plaque biofilm than a manual
toothbrush.
The Philips FlexCare Platinum’s brush head filaments
are molded directly in the
plastic housing allowing for a
unique filament pattern and
lengths designed to deliver an

optimal and complete clean. As
opposed to other brush heads
that wrap filaments in metal
loops implanted in the brush
head before being cut to size
from above, anchor-free tufting technology pulls filaments
through the brush head until
they are the right length and
are then cut from below. This
ensures that the filament tips
remain uniform in shape and
can be rounded for a gentle yet
effective clean.
Anchor-free tufting technology
also allows for the brush head
to be fitted with more filaments than traditional brush
heads, which can be arranged
in various patterns to perform
specific tasks:
• Reminder filaments – fade to
remind the user to change the
brush head after approximately three months
• Along-the-gum-line
filaments – remove plaque along

the gum line
• Elongated filaments – reach
deep in between teeth
• White filaments – polish and
clean the surface of the teeth
The InterCare brush head is
available in standard and compact sizes.
The InterCare brush head is
available in standard and compact sizes.
Brushing modes – an individual brushing experience
Philips Sonicare FlexCare
Platinum has three individual
brushing modes and three
intensity settings to give patients greater control over their
brushing experience and to
deliver a cleaning action suited to their specific needs. The
toothbrush has three cleaning
settings:
• Clean – standard cleaning
for the whole mouth
• White – removes surface

stains and helps whiten teeth
• Gum Care – gently stimulates and massages the gums
Additionally, three adjustable
intensity levels ensure maximum control and comfort:
• Normal – the standard intensity for normal brushing
• Sensitive – a gentle intensity
for sensitive teeth
• Extra soft – an extra-gentle
intensity for an even softer
brushing experience
Automatic pressure sensor
The new Philips Sonicare FlexCare Platinum also features
an automatic pressure sensor
which provides real time feedback to help ensure an optimal
clean every time.
UV sanitizer
The Philips Sonicare FlexCare
Platinum is also available with
a UV sanitizer to help reduce
the bacteria build up on toothbrush heads.

[17] =>

cli nica l 17

Dental Tribune Middle East & Africa Edition | March - April 2014

Case presentation: OptiBond™ XTR

his 83-year-old patient, who was in good
health, came for a consultation to “improve
his smile”.
This was motivated by jokes
made by his grandchildren
about the condition of his teeth.
Primarily, the 6 anterior maxillary teeth were involved. There
was no particular request to
lighten the smile.
During the first consultation,
the clinical examination revealed the presence of numerous cervical lesions, as well as
fractures of the incisive edges
of 11 and 21.
The above-mentioned fractures of the free edges of the
central incisors, the presence
of a carious lesion on the mesial surface of 11, an old composite on the mesial surface of
21 and the patient’s complaint
about the elongation of the two
centrals led us to opt for two allceramic e.max crowns made of
feldspathic ceramic reinforced
with lithium disilicate. Taking
into account the patient’s age,
this therapeutic choice was not
hindered by the proximity of a
high volume of pulp.
We selected e.max in the hope
of achieving better aesthetic integration, with its translucence
allowing the saturated and
natural appearance of the underlying preparations to show
through.
This type of all-ceramic restoration allows us to take advantage of bonding, which
appeared to us to be the best
solution on the vital teeth. (We
used the bonding agent to seal
the dentinal tubules and improve the sealing of the cervical limits.)
We remedied the cervical wear
on all of the teeth, including
the central incisors (from 14 to
23). For this treatment, we used
OptiBond™ XTR, a two-step,
self-etching adhesive system
(SAM2), and Miris composite in
shade S6.
The central incisors were then
prepared by cutting back the
marginal limits inside the vestibular composite itself, in the
manner described above.
We used the green-ringed tip
(Komet) followed by the red tip
bur for polishing, under heavy
irrigation. The preparations
were carried out with optical
assistance (magnification X
2.5) and the limits were juxtagingival.
An impression of the 2 preparations was made during the
same appointment. One week
later, the two crowns, made by
LNT laboratory in Paris, were
delivered to the practice. They
were tried in and then etched
with 5% hydrofluoric acid for
20 seconds. Once the acid had

been neutralised and the surface carefully dried, a layer of
Optibond XTR universal adhesive (bottle no. 2) was applied to
the restorations’ internal surface shortly before application
of the adhesive.

The advantage of Optibond XTR
is its ability to adhere to all types
of prosthetic substrates without
preparation or initial priming.
This allowed us to perform
our bonding procedures more
efficiently, dealing with both

1. Initial clinical presentation.
2. Creation of two ceramic
AD_kerr_2011
25.8.2011
Pagina 2
The
patient’s concerns
were 15:31 crowns
in e.max.
aesthetic and focused on the
upper dentition.

restorations at the same time
regardless of the prosthetic material. The adhesive treatment
of the preparations was carried
out with the same OptiBond
XTR and, in this case, we applied a first layer of the primer,

3. The crowns were etched with
5% hydrofluoric acid for 20
seconds. Note the white, chalky
appearance on the margins.

Optibond XTR Primer (bottle
no. 1), which was brushed onto
the enamel and the dentine for
20 seconds and then dried for
5 seconds. We were careful to
dip the brush in several times
during the application process,
to ensure fresh acid was being
brought into contact with the
dentinal surfaces each time
and to optimise etching.
Before applying Optibond XTR
Adhesive (bottle no. 2), we
were careful to shake the bottle
lightly to ensure homogeneity

> Page 18

OptiBond XTR
and NX3
The perfect
combination
Indirect Dentin Shear Bond Strength
Total Dark-Cure mode
30

Shear Bond Strength, MPA

By Claude Finelle

25
20
15
10
5
0

OptiBond™ XTR + NX3

Multilink® Primer A&B/Multilink® Automix

XTR and NX3 are so good, you can use both in total dark cure
without any additional self-cure activator. The combination of
OptiBond XTR + NX3 Automix cement demonstrated better indirect
dentin bond strength to the MultiLink Cementation System.

Study performed by State University New York, Buffalo.

OptiBond XTR and NX3 Some things are just meant to be. The powerful
chemistry of Optibond XTR provides high and predictable self-etch bond strengths,
while NX3 resin cement brings unmatched aesthetics, and excellent colour stability.
Put the two together, and you’ve got the perfect match for all your indirect restorations without self-cure activator and additional primers. Try OptiBond XTR and NX3
in your practice. Great on their own – even better together.

kerrdental.eu

00800 41 05 05 05

Your practice is our inspiration.™

[18] =>

18 cli n ical

Dental Tribune Middle East & Africa Edition | March - April 2014

< Page 17

4. Presence of a carious lesion
on the mesial surface of 11, and
an old composite on the mesial
surface of 21.

7. OptiBond XTR Adhesive
(bottle no. 2) was applied on the
internal surafce of the crowns.

8. NX3 adhesive was injected
directly into the crowns.

5. The preparations were carried 6. Preparations on teeth with
out at a magnification of X 2.5.
receded pulp. Green-ringed
The limits were juxta- gingival. and then red tip burs were used
for polishing, under heavy
irrigation.

11. Results achieved the day the two jacket crowns were placed.

9. The crowns in situ.

10. After 1 second of
polymerisation, the excess,
which had a gel-like consistency,
was easily removed.

of the contents, and applied it
by brushing for 15 seconds, followed by 5 seconds of drying
with moderate and then strong
air pressure. We then proceeded in the same way as with the
primer, dipping the brush into
it several times to ensure infiltration and filling of the dentinal surfaces with the adhesive
resin.
Shortly after application of a
layer of universal adhesive –
Optibond XTR (bottle no. 2)
– without polymerisation we
injected the NX3 adhesive directly into the crowns with the
help of an auto-mixing syringe.
Once the crown was in place,
a 1-second polymerisation at a
distance caused the NX3™ adhesive to achieve a gel-like consistency, allowing us to remove
the excess easily. Final polymerisation was achieved in 40
seconds on each surface, aided
by the self-cure material.
Modern adhesive techniques,
combined with the use of appropriate bonding mat erials,
enabled us to place several cer-

vical composites, as well as two
crowns, helping this patient
to smile at his grandchildren
without fear of being teased.

About the author
Claude Finelle
Graduated in 1975 (Paris
University V) Former university attaché to the Faculty of
Dental Surgery Paris V, prosthesis section.
Creation, in 1992, with Prof.
Maurice
Mimoun
(Head
of Plastic and Reconstructive Surgery Service), of the
“Smile Consultation”, currently in place in St Louis
Hospital, Paris.
Member in 1993, then Fellow
of the “American Society for
Dental Aesthetics”.
Author of numerous conferences and articles, in France
and abroad, and presentations of articles and videos
on professional internet sites
Private practice in Paris.

Two phase treatment of a Class II division 1
patient complicated by traumatic upper incisor intrusion: A Case Report
By Dr. Roelien Stapelberg

hase I
A female patient presented at the age of 7
years and 8 months
with the complaint that one of
her upper teeth were absent.
She had a mild thumbsucking
habit with a tongue thrust. She
had a Class II division 1 incisor
relationship on a Class II skeletal base with mildly decreased
vertical facial proportions.
Extra-oral examination
(Figure 1a-c)
Extra-orally the patient presented with a Class II skeletal
pattern convex profile and accentuated labiomental fold. She
had acceptable vertical facial
proportions. The frontal examination revealed acceptable
facial symmetry and balance,
with the upper centerline coincident with the midfacial axis.
Soft tissue examination demonstrated thin upper and lower
lips with mild incompetence, as
well as an acute nasolabial angle. The lower lip was retrusive
to Rickett’s E-line.
Intra-oral examination
(Figure 1d-h)
The patient was in the early
mixed dentition and had good
oral hygiene. There was no
history of dental caries, and
no active dental caries. Mild
generalized extrinsic stain-

ing was present. Furthermore
there were no restorations
present. The maxillary arch
was symmetric and tapered,
whereas the mandibular arch
was square and symmetric.
Both arches had no space deficiency and had well aligned
buccal segments. The upper
right central incisor was missing, and the upper left central
incisor was proclined.
In occlusion, the overjet measured 10mm, with no overbite
present. The molar relationship on the left was full Class II,
and the right side was ¾ Class
II. The lower centerline was
2mm to the left of the upper
centerline, which was coincident with the facial centerline.
There was no crossbites or displacements.
The Dental Health Component (DHC) of the Index of
Orthodontic Treatment Need
(IOTN) was 5i, and the Aesthetic Component (AC) was 9.
Radiographic
(Figure 2a,b)

examination

The DPT demonstrated that all
second molars were present
and developing, as well as the
lower third molars. The upper
right central incisor seemed to
be horizontally impacted.
The cephalometric analysis
confirmed our clinical findings
of a Class II skeletal pattern
with an ANB of 7.0°. The Wits
appraisal affirmed the Class
II skeletal pattern with a mea-

surement of 7.5 mm. The vertical proportions were slightly
decreased, demonstrated by
the
maxillary-mandibular
plane angle of 19.7° and face
height ratio of 52.1%. The upper incisors were severely proclined at 128.5°, as was the lower incisors at 109.6°. The lower
incisors were retruded relative
to the APo line with a measurement of -0.8mm.
Problem list
1. UR1 Horizontally impacted
2. Class II skeletal pattern due
to mandibular retrognathia
3. Convex profile
4. Increased overjet
5. Lower centerline 2 mm to the
left of the upper centerline
Aims and Objectives
1. Facilitate eruption of UR1
2. Correct Class II skeletal pattern by encouraging mandibular growth
3. Improve facial profile
4. Decrease overjet to within
normal range
5. Establish coincident centerlines
6. Maintain result until comprehensive orthodontic therapy
Treatment plan
1. Upper hybrid TPA - tongue
crib appliance to assist in
breaking the thumb sucking
habit and relieve the present
tongue thrust, while reinforcing the anchorage of the UR6 &
UL6.
2. Upper 2x4 pre-adjusted edgewise fixed appliances (0.022” x

0.028” slot) with MBT prescription. Upper utility arch 0.016
SS with an open coil spring to
create and maintain adequate
space for the UR1.
3. Surgical exposure of the
UR1 via the open technique
with bonding of a gold chain
and orthodontic traction to the
archwire to facilitate eruption.
4. Bonded upper fixed retainer
UR1 to UL1 to be maintained
until comprehensive orthodontic treatment phase.
Treatment progression
(Figures 3a,b)
After the manufacture of the
upper hybrid TPA- tongue crib
appliance, it was inserted and
the bonding of the upper with
2x4 fixed appliances with MBT
prescription was placed. An
0.016 SS utility arch archwire
was placed with elastomeric
ties, and the patient was referred for surgical exposure
and placement of a gold chain
for traction of the UR1. After
the surgical exposure, the UL1
& UL2 was ligated together,
and an elastic chain tied to the
gold chain attached to the UR1
using a long ligature to encourage eruption of the UR1. An
NiTi open coilspring was utilized to obtain adequate space
for the UR1. The eruption encouragement was continued
until the UR1 could be bonded
and ligated with an elastic
chain continuing the eruption
process, to the same 0.016 SS.

When the position of the UR1
was at an adequate level, it was
engaged on the 0.016 SS with an
elastomeric tie. The time period from surgical exposure of
the UR1 to alignment with the
archwire was 5 months. The
patient was debonded and an
upper fixed retainer from UR1
– UL1 was placed.
Treatment assessment
(Figure 4a-g)
Case one was a 7 years and 8
months old Caucasian female
presenting with a Class II division 1 incisor relationship on a
Class II skeletal base with mildly decreased vertical facial proportions. The mandible was
retrognathic, and the maxilla
normal. The malocclusion was
complicated by a horizontally
impacted UR1. The patient presented with no space deficiency. The upper centerline with
on with the facial midline, and
the lower centerline was 2mm
to the left of the upper. The molar relationship was full unit
Class II on the left and ¼ unit
Class II on the right.
Phase I treatment was deemed
appropriate, and consisted of
a hybrid TPA-tongue crib appliance with 2x4 upper preadjusted edgewise fixed appliances (0.022” x 0.028” slot)
with MBT prescription. Surgi-

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Dental Tribune Middle East & Africa Edition | March - April 2014
< Page 18
cal exposure of the UR1 via the
open technique with bonding
of a gold chain and orthodontic traction to the archwire
was done to facilitate eruption.
Retention via a bonded upper
fixed retainer UR1 to UL1 was
placed until Phase II treatment.
The patient was kept in retention and followed up frequently
to establish the beginning of
the adolescent growth spurt, in
order to initiated phase II.
Phase II
A female patient presented at 9
years 4 months of age for a retention check of her fixed upper retainer, still in place from
her previous orthodontic treatment (Phase I). She had a Class
II division 1 malocclusion, on
Class II skeletal bases, with decreased vertical proportions,
bimaxillary proclination and a
lower lip trap.
Extra-oral examination
Extra-orally the patient had a
severe Class II skeletal pattern
with a convex profile and acceptable vertical proportions of
the face. Frontal examination
revealed no transverse asymmetry, and the upper centerline
was on with the midfacial axis,
with lower centerline being
shifted 2mm to the left. Soft tissue examination demonstrated
a retruded and incompetent
lower lip of normal thickness.
A lower lip trap was also present.
Intra-oral examination
The patient was in the late
mixed dentition and had good
oral hygiene. There were no
restorations, and the patient
was caries free. The maxillary
arch was ovoid and symmetrical with no space discrepancy.
The buccal segments were well
aligned, with mesial buccal rotation on the UR6 and UL6 present. The mandibular arch with
ovoid and symmetrical with no
space discrepancy, with a deep
curve of Spee present. The
buccal segments of the lower
arch was well aligned.
In occlusion the overjet measured 8.5mm, with an overbite
of 3.5mm (50%). The left molar
relationship was ¾ unit Class
II, and the right ½ unit Class
II. The left canine relationship
was full unit Class II, and the
right was ¾ unit Class II. No
crossbites were present.
The dental health component (DHC) of the Index of
Orthodontic Treatment Need
(IOTN) was 4a, and the aesthetic component (AC) was 9.
Radiographic examination
The DPT demonstrated that all
third and second molars were
developing. No other abnormalities were found.
The cephalometric analysis
(Table 1) confirmed a skeletal
Class II antero-posterior discrepancy as demonstrated by
an ANB of 5.8° and a Wits appraisal of 6.3 mm.
Both the upper and the lower
incisors were severely proclined (134.7° upper & 104.5°
lower), with the lower incisor

in a relative normal position in
relation to APo line (0.6 mm).
Problem list
1. Class II skeletal relationship
due to mandibular retrognathia
2. Convex profile with reduced
lower lip protrusion
3. Upper incisor proclination
4. Overjet of 8.5 mm
5. Asymmetric Class II molar
and canine relationship
6. 2 mm lower centerline discrepancy to the left of the upper
dental midline
7. Incompetent lips at rest
Aims and Objectives
1. Utilize favorable mandibular
growth for improvement of the
Class II skeletal discrepancy
2. Improve facial harmony and
increase lower lip protrusion
3. Reduce upper incisor proclination
4. Reduce overjet to normal values
5. Establish optimal buccal segment interdigitation bilaterally
6. Establish coincident centerlines
7. Obtain lip competence at rest
8. Maintain incisor display on
smiling
9. Place teeth in a position conducive to favorable facial and
dental esthetics and long-term
stability
10. Retain corrected result

Figure 1 (a-h) Case 1.
Pre-treatment extra- and
intra-oral photographs

a
Figure 2 (a,b) Case 1. Pre-treatment radiographs

Treatment plan
1. Upper removable appliance
while waiting for eruption of
the upper second premolars
and the growth spurt to occur.
Appliance manufactured with
an expansion screw to establish adequate maxillary dentoalveolar width to accomplish
mandibular forward posturing
without occlusal interferences
from a crossbite tendency, with
a z-spring on the 12 to obtain
initial alignment.
2. Andreason’s Activator appliance for mandibular growth
stimulation with wax bite of
approximately 5mm was given
after the growth spurt was
reached as evaluated by clinical examination. Capping of
lower incisors was done on the
Activator to minimize lower incisor proclination.
3. Full upper and lower preadjusted edgewise fixed appliances (0.022” x 0.028” slot)
with MBT prescription was
placed after Class I canine was
achieved with the Activator.
4. Bonded upper fixed retainer
individually from UR3 to UL3
and upper vacuum formed retainer to be worn at night time
only and a bonded lower fixed
retainer individually from LR3
to LL3.
Treatment progression
(Figure 5 – 8 )
Compliance was excellent with
the upper removable appliance
and expansion attained was
sufficient to prevent crossbite
occurrence when the mandible was postured forward
into a Class I canine relationship. After the growth spurt
was attained, an Activator appliance was manufactured
with forward posturing into

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Dental Tribune Middle East & Africa Edition | March - April 2014

< Page 19

b
Figure 3 (a,b) Case 1. Upper 2x4 MBT pre-adjusted edgewise appliances with hybrid TPA-tongue
crib appliance and eruption UR1 encouragement via elastic chain.

Class I canine relationship bilaterally and a waxbite thickness of 5mm (Figure 5). The
compliance with the Activator was excellent, and after
3 months of wear the patient
was ready for fixed appliances.
A cephalogram after the Ac-

g
Figure 4 (a-g). Case 1.
Post-phase 1 treatment
completion extra- and intraoral photographs

tivator treatment was taken
and analyzed (Figure 6). The
cephalometric analysis (Table
2) revealed a skeletal Class I
antero-posterior relationship
(ANB 3.6°, Wits appraisal 2.8
mm). The SNA reduced during
the use of the Activator, which

was the cause for the reduction
in the ANB angle. The SNB remained almost the same. The
vertical proportions indicated
a mildly anterior growth rotation. The upper incisors retroclined, and the lower incisors
proclined after the Activator
use. The upper incisors were
severely proclined with 120.0°,
and the lower incisors as well
with 111.3°. The lower incisors
protruded in relation to APo
(3.2mm). 0.022 slot preadjusted edgewise fixed appliances
were placed, with the leveling
and aligning phase initiated
with 0.016” heat activated Nickel Titanium archwires in the
upper and lower arches. The
archwires progressed to 0.019 x
0.025” heat activated Nickel Ti-

tanium in the upper and lower
arch, followed by customized
and coordinated 0.019 x 0.025”
stainless steel archwires with
steel ligatures. At this stage the
patient was advised to use Class
II intermaxillary elastics (5/16”
3oz) bilaterally full time to correct our canine relationship after mild relapse occurred during the alignment and leveling
phase of the fixed appliances.
The intermaxillary elastics
were continued for 4 months.
During the torque expression
of the rectangular steel wires,
mild spaces opened in the upper arch, these spaces were
closed with friction mechanics
utilizing a closed elastomeric

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Dental Tribune Middle East & Africa Edition | March - April 2014

< Page 20

b
a
c
Figure 7 (a-c). Case 1. Upper and lower MBT pre-adjusted edgewise appliances with 0.016” heat activated
nickel titanium archwires

a

d

b

b
a
c
Figure 8 (a-c). Case 1. Upper and lower 0.019 x 0.025” stainless steel archwires with closed elastomeric
chain for space closure from UR6 to UL6. Class II intermaxillary elastics bilaterally full time.

Figure 5 (a-d). Case 1.
Activator placed

c

chain from upper right to left
first molars.
A cephalogram was taken after
correction of the anterior-posterior relationship to check the
incisor inclinations and evaluate the patient for the possibility of extractions. The upper
incisors were proclined, as was
the lower incisors, however the
lower incisors did not procline
more than the pre-treatment
value, and the facial appearFigure 6. Case 1.
ance accepted the increased
Cephalogram after Activator
proclination.
no ex-cephalometric analysis.
Table 1 Case Therefore
1. Pre-treatment
Variable
SNA (°)
SNB (°)
ANB (°)
SN to maxillary plane (°)
Wits appraisal (mm)
Upper incisor to maxillary plane
angle (°)
Lower incisor to mandibular plane
angle (°)
Interincisal angle (°)

Pre-phase II
79.3
73.5*
5.8*
12.0*
6.3***

Normal
82 (SD 3)
79 (SD 3)
3 (SD 1)
8 (SD 3)
0 mm

134.7***

108 (SD 5)

104.5*

92 (SD 5)
133
(SD 10)
27 (SD 5)

101.3***

Maxillary mandibular plane angle (°)
19.5*
Upper anterior face height (mm)
59.7
Lower anterior face height (mm)
54.6
Face 2height
ratio
(%)
50.4 %
55
Table
Case 1.
Post-Activator
cephalometric analysis
Lower incisor to APo line (mm)
0.6 mm
0 (SD 2)
Pre-phase
MidVariablelip to Ricketts E Plane (mm)
Lower
-0.3
mm
-2Normal
II
treatment

a

b

e

79.3

77.1*

tractions were done to decrease
the incisor proclination.

108
(SD
82
(SD
3)

*** Denotes values greater than 3 standard deviation from the average Caucasian
values.
*Denotes values greater than 1 standard deviation from the average Caucasian

Table 2 Case 1. Post-Activator cephalometric analysis

values.
Table
3 Case
1. Post-Treatment
cephalometric
analysis
** Denotes
values
greater than 2 standard
deviation
from the average Caucasian
values.
PreMid*** Denotes values
greater than 3 standard deviation
from
the average
Caucasian
Variable
Pre-finish
Normal
phase II treatment
values.
SNA (°)

79.3

77.1*

SNB (°)
73.5*analysis
73.4*
Table
3 Case 1. Post-Treatment cephalometric

77.8*
74.1*
3.7
11.7*
Pre-finish
0.2
77.8*
119.5*
74.1*
3.7
109.9*
11.7*
111.4**
0.2

82 (SD 3)
79 (SD 3)
3 (SD 1)
8 (SD 3)
Normal
0 mm
108
(SD
82
(SD
3)
5) 3)
79 (SD
3 (SD
92
(SD1)
5)
8 (SD
133 3)
0 mm
(SD
10)
108
(SD
27
(SD
5)
5)

ANB (°)
5.8*
3.6
SN to maxillary plane (°)
12.0*
13.6*
PreMidVariable
Wits appraisal (mm)
6.3*** II treatment
2.8**
phase
Upper
SNA (°)incisor to maxillary plane angle
79.3
77.1*
134.7***
120.0*
(°)
SNB (°)
73.5*
73.4*
Lower
ANB (°) incisor to mandibular plane
5.8*
3.6
104.5*
111.3**
angle (°)
SN to maxillary plane (°)
12.0*
13.6*
Interincisal
angle
(°)
101.3***
111.0**
Wits appraisal
(mm)
6.3***
2.8**
Upper incisor
to maxillary
angle
Maxillary
mandibular
plane plane
angle (°)
19.5*
17.8*
19.1*
134.7***
120.0*
119.5*
(°)
Upper
anterior face height (mm)
59.7
64.3
65.0
Lower incisor to mandibular plane
104.5*
111.3**
109.9*
92 (SD 5)
Lower
anterior
face
height
(mm)
54.6
58.0
56.2
angle (°)
Face height ratio (%)
50.4 %
50.6
52.8
55
133
Interincisal angle (°)
101.3***
111.0**
111.4**
Lower incisor to APo line (mm)
0.6 mm
3.2*
3.0*
0(SD
(SD10)
2)
Maxillary
angle
19.5*
17.8*
19.1*
27 (SD
Lower
lip mandibular
to Ricketts Eplane
Plane
(mm)(°)
-0.3
mm
-2.1
-2.1
-2 5)
Upper anterior face height (mm)
59.7
64.3
65.0
Lower
anterior
height
(mm)
54.6 from 58.0
*Denotes
values
greater
than
1 standard
deviation
the
average56.2
Caucasian
Table
3 Case
1.face
Post-Treatment
cephalometric
analysis
values.
Face height ratio (%)
50.4 %
50.6
52.8
55
Lower
incisor
to
APo
line
(mm)
0.6
mm
3.2*
3.0*
0
(SD
2)
*Denotes values greater than 1 standard deviation from the average
Lower lip to Ricketts E Plane (mm)
-0.3 mm
-2.1
-2.1
-2

Caucasian values.
***Denotes
Denotesvalues
values
greater than 2 standard deviation from the average
greater than 1 standard deviation from the average Caucasian
Caucasian
values.
values.
*** Denotes values greater than 3 standard deviation from the average
Caucasian values.

g

i
Figure 9 (a-i) Case 1. Post-treatment extra- and intra-oral photographs

Upper
incisorvalues
to maxillary
planethan
angle 3(°)standard
134.7***
***
Denotes
greater
deviation120.0*
from the 79
average
5) 3) Caucasian
SNB (°)
73.5*
73.4*
(SD
Lower
incisor
to
mandibular
plane
angle
(°)
104.5*
111.3**
92
(SD
5)
values.
Case 1 assessment
ANB (°)
5.8*
3.6
3 (SD 1)
133
SN to maxillary
plane
12.0*
13.6*
8 (SD 3)
Interincisal
angle
(°) (°)
101.3***
111.0**
(SD 10)
Wits appraisal (mm)
6.3***
2.8**
0 mm
Maxillary mandibular plane angle (°)
19.5*
17.8*
27 (SD 5)
108 (SD
Upper anterior
incisor to
maxillary
plane
angle
(°)
134.7***
120.0*
face height (mm)
59.7
64.3
5)
Lower
face
height (mm)
54.6
58.0
Lower anterior
incisor to
mandibular
plane angle (°)
104.5*
111.3**
92 (SD 5)
Face height ratio (%)
50.4 %
50.6
55
133
Interincisal
angle
(°) line (mm)
101.3***
111.0**
Lower
incisor
to APo
0.6 mm
3.2*
0(SD
(SD10)
2)
Maxillary
angle
19.5*
17.8*
27 (SD
Lower
lip mandibular
to Ricketts Eplane
Plane
(mm)(°)
-0.3
mm
-2.1
-2 5)
Upper anterior face height (mm)
59.7
64.3
*Denotes
valuesface
greater
than
1 standard deviation54.6
from the average
Lower anterior
height
(mm)
58.0 Caucasian
values.
Face height ratio (%)
50.4 %
50.6
55
**Lower
Denotes
values
greater
from the average
incisor
to APo
line than
(mm)2 standard deviation
0.6 mm
3.2* Caucasian
0 (SD 2)
values.
Lower lip to Ricketts E Plane (mm)
-0.3 mm
-2.1
-2

f

d

h

Finishing and detailing was
done on a 0.016 stainless steel
wire. The estimated treatment time for Case 1 treatment
was 24-30 months. The actual
SNA (°)
79.3
77.1*
82 (SD 3)
treatment time was 22 months.
Table
1. Pre-treatment
SNB 1(°) Case
73.5* analysis
73.4*
79 (SD 3)Caucasian
*Denotes
values
greater than
1cephalometric
standardanalysis
deviation
from
the average
Table
2 Case
1. Post-Activator
cephalometric
Retention was initiated with an
ANB (°)
5.8*
3.6
3 (SD 1)
values.
to maxillary
planegreater
(°)
12.0*
13.6*
8 (SD 3) Caucasian
upper vacuum formed retainer
Pre-phase
Mid- the average
**SN
Denotes
values
than 2 standard
deviation from
Variable
Normal
Wits appraisal (mm)
6.3***
2.8**
0 mm
II
treatment
and a lower fixed 3-3 retainer.
values.
SNA (°)

c

(Figure 9)

Case 1 presented to the orthodontic clinic at the age of 7
years 8 months, with a Class II
division 1 incisor relationship
on a Class II skeletal base with
mildly decreased vertical facial
proportions. The mandible was
retrognathic, and the maxilla
normal. The malocclusion was
complicated by a horizontally
impacted UR1. The upper centerline was on with the facial
midline, and the lower centerline was 2mm to the left of the
upper. The molar relationship
was full unit Class II on the left
and ¼ unit Class II on the right.
The upper and lower incisors
were severely proclined, with
the lower incisors in normal
position relative to the APo line.
Orthodontic camouflage for
the underlying Class II skeletal discrepancy was carried
out. On initial examination it
was clear that the upper and
lower incisors were proclined.
Lower incisor proclination
would indicate the amount of
correction that can be attained
by orthodontics only. For Case
1, the lower incisors were se-

verely proclined, with no present crowding. Provided we did
not procline the lower incisors
much more, we would be able
to attain an acceptable compromise orthodontic camouflage
result.
Phase I treatment consisted of
a hybrid TPA-tongue crib appliance with 2x4 upper preadjusted edgewise fixed appliances (0.022” x 0.028” slot)
with MBT prescription. Surgical exposure of the UR1 via the
open technique with bonding
of a gold chain and orthodontic traction to the archwire
was done to facilitate eruption.
Retention via a bonded upper
fixed retainer UR1 to UL1 was
placed until Phase II treatment.
Phase II treatment consisted
of growth modification via an
Andreason Activator with full
upper and lower pre-adjusted
edgewise fixed appliances
(0.022” x 0.028” slot) with MBT
prescription. After the use of
the Activator a cephalometric
analysis was done to evaluate
the incisor inclination and position. Although the incisors were
proclined after the functional
appliance phase, her profile
accepted the increased inclinations, and we took advantage of
the increased labial root torque
values of the MBT prescription
to decrease the proclination
closer to pre-treatment values.
As demonstrated by the superimposition (Figure 10), most of
the changes were dento-alveolar in nature. SNA decreased
slightly, but this is likely to be
due to remodeling of A point
following upper incisor move-

Figure 10 Case 1. Mid-treatment
to pre-finish superimposition.

ment, rather than a true change
in skeletal base relationship.
The upper incisors were retroclined form their pre-treatment
position, and with the increase
in lower incisor inclination,
this resulted in reduction of the
Class II div 1 incisor relationship, concomitantly improving
the buccal segment relationship.
During treatment, we maintained the lower archform
and intercanine width, and it
was possible to get good buccal segment interdigitation,
which will aid in maintenance
of the sagittal correction. Furthermore we can expect that
the incisor relationship will be
maintained seeing as we did
not procline the lower incisors
excessively to become influenced by the lower lip. Therefore stability can be expected to
be good.
The patient is aware of the need
for long-term retention.

Contact Information
Dr. Roelien Stapelberg
Specialist Orthodontist
European University College
(previously Nicolas & Asp
University College)
Dubai Healthcare City
Ibn Sina Building, No 27
Block D, 3rd Floor, Office 302
PO Box 53382, Dubai - UAE
drroelienstapelberg@gmail.com
www.dubaipostgraduate.com

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Dental Tribune Middle East & Africa Edition | March - April 2014

Invisalign®: clear benefits for your patients
By Vicki Vlaskalic BDSc;
MDSc.

ince the launch of the
revolutionary Invisalign
orthodontic system in
1999, the removable,
computer activated, aesthetic
Invisalign® aligner has gained
popularity world-wide as an
alternative to traditional fixed
appliances. Invisalign® provides adult and teen patients
an aesthetic, non-invasive and
precisely activated treatment
alternative for improving smile
aesthetics and occlusal requirements, from minor alignment to complex malocclusions. Currently Invisalign® is
available to patients in over 60
countries, with over 85,000 clinicians trained to use the product and over 2.6 million patients
treated or in treatment. (1,2)

Due in part to the digital occlusal data from millions of
treated patients, Align Technology Inc. (the manufacturer
of Invisalign®) has been able
to continuously support rapid
innovation. Some improvements include interactive ClinCheck® software features, new
FDA approved aligner materials, algorithm based features
such as optimized attachments,
specifically engineered to
the tooth’s shape, size and requested movement (Figure 8),
hooks and cut outs for applying
Class II and Class III mechanics, power ridges for assisting
expression of root torque and
eruption pontics for treating
late mixed dentition patients(3,4)
(Figure 1).
In February 2014, the newest series of innovations “Invisalign G5” was launched,
including an integrated mechanical system for treatment
of dental deep bite cases. Invisalign® mechanics are well
suited to dental and mild skeletal open bite cases due to the
occlusal coverage and lack of
detrimental extrusive vertical
side effects. (5,6)

Figure 2: Extra-oral views

Figure 3: Lateral Cephalometric and OPG radiographs.

normal, with no sign of pathological resorption. The lower
anterior segment displays aberrant root angulation (Figure 3).

Figure 1: Class II/1, late mixed
dentition patient treated with
aligner features such as eruption
pontics, precision hooks and
button cut outs for Class II
elastics and power ridges for
palatal root torque

Below is a case report depicting
a Class II skeletal, dental Class
I, mildly crowded dental open
bite case complicated by gingival recession, typically difficult
to treat with conventional appliances.
Case Report
The patient is a healthy 28 year
old female with no history of
previous orthodontic treatment. Her presenting complaint is “my upper 2 front teeth
are crossed and the lower right
tooth is twisted” (Figure 2).
Cephalometrically, the patient
has a dolichofacial, skeletal
Class II relationship with proclined upper incisors. The OPG
radiograph shows the third
molars are missing, previously
extracted. Root length appears

Intra-orally, the patient displays a Class I molar and ¼
unit Class II canine relationship with mild upper and lower
crowding and open bite extending from right second premolar
to left first premolar region. Her
overbite is deficient (-2mm) and
overjet excessive (6mm). Her
arch forms are non-coincident
in shape, with a narrow upper
arch form due in part to palatal
inclination of the upper dentition. There is generalized gingival recession with significant
recession and active inflammation involving the lower left lateral incisor (Figure 4).
The treatment plan was to align
and coordinate the arch forms,
increase buccal crown inclination and to reduce the overjet
and close the anterior open
bite using relative incisor extrusion (tipping back), leaving
a partial curve of Spee in the
lower arch due to an already
“gummy smile”. Space acquisition for resolution of crowding and relative incisor extrusion would be via conservative
arch expansion (buccal crown
inclination rather than bodily
expansion) and
computer calculated
interproximal reduction of anterior
segments. Initial periodontal

Figure 4: Pre-treatment Smile and Intra-oral view.

Figure 5: ClinCheck Plan of initial occusion and lower arch
superimposition initial and final stages.

Figure 6: Final ClinCheck Plan
stage U L 25.

treatment of the lower left incisor segment and continual periodontal maintenance through
treatment was prescribed. Mechanics selected was the Invisalign® system due to the desire
of the patient for a high degree
of aesthetics (she was married
half way through treatment),
excellent vertical control, accurate measurement and planning of movements prior to initiating mechanics and ability to
maintain a high degree of oral
hygiene through treatment. A
3D ClinCheck® Plan was developed, based on PVS impressions
and the Invisalign prescription
form (Figures 5 & 6).
Treatment progessed well,
with excellent complaince with
prescribed 20-22 hour daily
aligner wear. Each aligner was
worn for a period of 2 weeks.
Monitoring visits were sceheduled every 6 weeks, every
3 aligners. This ensured that
no more than 0.75mm of movement occured between visits so
that close monitoring of dental and periodontal response
could be performed. The initial
aligner series was 25 upper and
lower aligners (U L 25), representing 12.5 months of treatment. At aligner 24, attachments were removed and the
patient assessed for refinement
(Invisalign® finishing). Most
of the treatment goals were fufilled, except the complete rotation of the lower right canine.
(Figures 7 & 8)
A new lower PVS was taken to
capture the clinical result and
4 upper and 6 lower refinement
aligners were manufactured
to fulfil the occlusal goals. A
new generation of custom engineered attachments was now
available to complete the canine rotation. (figure 8)
Final Treatment time was 16
months, with 24 of the initial
25 aligners and 4 upper and
5 lower refinement aligners
worn. The occlusal goals were
satisfied as well as the patient’s
chief concerns. Comparison
of figures 9 and 10 show that
periodontal health was not
only maintained but improved
throughout treatment and gingival inflammation reduced,
especially in the lower left lateral incisor region (figure 10).

For this patient, the benefits of
Invisalign® ClinCheck® software planning (Table 1) with
the ability to superimpose and
view degree of movement and
to have the ability to program
small, precise activation in the
aligners made treatment predictable in terms of vertical
control and preserving periodontal health(7,8). In this case,
the patient would not consider
a surgical option and there was
no obvious functional aetiology
for the open bite. Post treatment
stability, even of open bite patients and incidence of root resorption have been found to be
favorable with the Invisalign
system®.
Table 1 : Advantages of ClinCheck ™Software
3D visualization of each planned
stage of treatment, including
treatment duration for clinicians
and patients.
Accurate crown and generic root
programming and assessment
of magnitude and direction of
movement.
Interactive tools to design mechanics such as attachment
choice, Class II and Class III correction features.
Clinical tool for treatment monitoring and motivation enhancement.
Tooth movement animation
may be used by colleagues in
multi-disiplinary planning
Summary
The Invisalign® system has
many unique benefits to offer
both patients and clinicians. Its
distinct 3D ClinCheck® software not only provides a valuable planning tool but it directly
programs the activation of the
aligners, offering for the first
time, aligners designed with
multiple small and precise
tooth activations engineered to
cummulatively correct malcocclusions. The scope of related
research conducted by the
manufacturer as well as by the
private dental and academic
communites is unique to Invisalign®, and offers significant
scientific value to users, with
over 300 publications and case
reports around the globe. As a
result, the Invisalign® system
has continually evolved to become a predictable orthodontic appliance applicable to all
categories of malocclusion,
including extraction and surgical treatments (9), depending
largely on the treating doctor’s
level of experience using Invisalign®.

> Page 26

[26] =>

26 ortho tribu n e

Dental Tribune Middle East & Africa Edition | March - April 2014

< Page 25

Figure 7: Initial and predicted Final Clincheck stage

Figure 9: Initial clinical and ClinCheck stages.

Figure 10: Final Clinical & Refinment ClinCheck stages.

Figure 8: initial refinement stage with optimized canine
rotation attachment.

Science in Every Smile

References
1. Align Technology Inc.
http://www.aligntech.com/Pages/Home.aspx
2. Miller KB, McGorray SP,
Womack R, Quintero JC,
Perelmuter M, Gibson J, Dolan
TA, Wheeler TT
A comparison of treatment impacts between Invisalign aligner and fixed appliance therapy.
AJODO Vol. 131 no. 3
3. Schott TC, Göz G. Color fading of the blue compliance indicator encapsulated in removable clear Invisalign Teen®
aligners. Angle Orthod. 2011
Mar;81(2):185-91.
4. Castroflorio T, Garino F, Lazzaro A, Debernardi C. Upperincisor root control with Invisalign appliances.
J Clin Orthod. 2013 Jun;47(6):
346-51.
5. Maria Paola Guarneri, Teresa Oliverio, Ivana Silvestre,
Luca Lombardo, Giuseppe Siciliani. Open bite treatment using clear aligners. Angle Orthodontist 2013 Sep; Vol. 83 (5), pp.
913-9
6. Schupp W, Haubrich J, Neumann I. Treatment of anterior
open bite with the Invisalign
system. J Clin Orthod. 2010
Aug;44(8): 501-7.
7. Kuo E, Miller RJ. Automated
custom-manufacturing technology in orthodontics.
AJODO2003; 123:578-581.
8. Miller R, Kuo E, Choi W.
Validation of Align Technology’s Treat IIITM digital model
superimposition tool and its
case application. Orthodontics & Craniofacial Research
2003;6:143-149.
9. Womack WR. Four-premolar
extraction treatment with Invisalign.
J Clin Orthod. 2006 Aug;40(8):
493-500.

About the author
Dr. Vicki Vlaskalic is a
practicing orthodontist in
Melbourne, Australia and
Clinical Instructor at the
University of Melbourne,
Department of Orthodontics. She has worked with
the Invisalign System since
the initial feasability study
in 1997 at the University of
the Pacific, San Francisco,
working as Assistant Professor in the Department of Orthodontics under Professor
Robery Boyd.

[27] =>

aca de mi a t r i bu n e 27

Dental Tribune Middle East & Africa Edition | March - April 2014

Periodontitis, Diabetes and Smoking
By Drs Khawla Al Matroushi,
Dr. Shatha Al Khatri and
Professor Crawford Bain,
Dubai School of Dental Medicine

eriodontal
diseases
have, for a half of a
century, been known
to be initiated by the
accumulation of bacterial
plaque (R). It has however
been increasingly apparent
in recent years that other intrinsic and extrinsic risk factors influence the progression
of periodontitis. Of these the
most important are Diabetes
and Smoking. Since both of
these factors are common in
the UAE this is of particular
importance to UAE dentists.
It is the purpose of this paper to review the current association between these risk
factors and periodontitis, and
to discuss the likely bi-directional relationship between
management of periodontitis
and diabetes control.
Periodontitis and Diabetes
Diabetes mellitus occurs
when the level of sugar (glucose) in the blood becomes
higher than normal. There
are two main types of diabetes. In type 1 diabetes the
body stops making insulin
and the blood sugar (glucose)
level becomes very high (R).
Type 2 diabetes, also called
adult-onset diabetes and
noninsulin-dependent diabetes, is a chronic condition
caused by high levels of glucose (sugar) in the blood.
Although some people can
overcome the symptoms by
losing weight and following
a healthy diet and exercise
plan, most people with type
2 diabetes will have it for life
(R).
Both diabetes and periodontitis are chronic diseases.
Diabetes has many adverse
effects on the periodontium,
and conversely periodontitis may have deleterious effects further aggravating the
condition in diabetics. The
potential common pathophysiologic pathways include
those associated with inflammation, altered host responses, altered tissue homeostasis, and insulin resistance. A
recent study also showed that
scaling, polishing and root
planning of the pre-diabetic
can lower blood sugar levels
potentially offering a practical means of reducing the
numbers who develop full
type 2 diabetes ®
Diabetes has many adverse
effects on the periodontium,
including decreased collagen turnover, impaired
neutrophil function, and increased periodontal destruction. Neutrophil chemotaxis
and phagocytic activities
are compromised in diabetic patients, which can lead
to reduced bacterial killing
and enhanced periodontal
destruction.
Inflammation
is exaggerated in the pres-

ence of diabetes, insulin resistance, and hyperglycemia
(R).
Neelima et al (R) examined
1500 diabetic patients; the
prevalence of periodontal
disease in these patients was
86.8%, significantly higher
than the general population.
By the early 1990s periodontitis was referred to as the
‘sixth complication of diabetes’, and in 2003 the ADA
formally acknowledged that
periodontal disease is more
often found in diabetics.(R).
Epstein (R) demonstrated
that essentially all the aspects
of bone growth and mineralization are diminished in the
absence of insulin i.e. hyperglycemia. Vascular changes
also increase with increase
in blood glucose levels (Oliver and Tervonen) (R).
Periodontitis and Smoking
Second to bacterial plaque,
smoking is the strongest of
the modifiable risk factors for
periodontal disease. Smokers
harbor a higher prevalence of
potential periodontal pathogens, and smoking impairs
various aspects of immune
responses, including neutrophil function, antibody production, fibroblast activities,
vascular factors and inflammatory mediator production.

no differences between smokers,
former smokers,
and nonsmokers
in pockets ≥ 4mm
(R). This colonization,
along
with low gingival blood flow
may lead to an
increased prevalence of periodontal breakdown.

Fig1. A significant inf lammatory
response, with bone loss in a poorly
controlled diabetic

Smoking exerts a major effect
on the protective elements of
the immune response, resulting in an increase in the extent and severity of periodontal destruction. Neutrophils
obtained from peripheral
blood or saliva of smokers,
have been shown to demonstrate functional alterations
in chemotaxis, phagocytosis, and the oxidative burst.
Smoking has been shown to
impair the chemotaxis and
phagocytosis of neutrophils
obtained from the oral cavity, and in vitro studies of the
effects of tobacco products
on neutrophils have shown
detrimental effects on cell
movement and the oxidative
burst (R).

Fig2. Advanced periodontitis and
imminent tooth loss in a heavy smoker.

Discussion
Both diabetes and smoking
are increasing in the UAE
particularly in younger individuals.
Since
scaling,
polishing and root planning
have been shown to lower
blood sugar levels, and since
smoking cessation improves
the periodontal condition in
many of these patients, it is
the responsibility of all dental professionals to provide
comprehensive
periodontal care for all diabetics and
pre-diabetics, and to provide
accurate smoking cessation
advice with appropriate referrals as indicated. The situation can be compounded
when a diabetic also has a
smoking habit.

The relationships between
Periodontitis, Diabetes and
Smoking are major areas of
research interest at Dubai
School of Dental Medicine.
Editorial note:
(R) References are available
from the authors.

About the author
Drs. Khawla Al Matroushi and
Shatha Al Khartri are first year
residents at the Dubai School of
Dental Medicine (DSDM) Periodontics MSc programme located in Dubai Healthcare City
(DHCC).
Dr. Crawford Bain is Professor
of Periodontology, and Director of the MSc in Periodontics
at Dubai School of Dental Medicine (DSDM) located in Dubai
Healthcare City (DHCC).

In smokers inflammation in
response to plaque accumulation is reduced compared
with nonsmokers and smokers have a decreased expression of gingival inflammation
and bleeding on probing in
the presence of plaque accumulation when compared
with nonsmokers ®.
Smoking has been associated
with a two- to eight-fold increased risk for periodontal
attachment and/or bone loss,
depending on the definition
of disease severity and smoking dose.
One of the largest epidemiological studies reporting an
association between smoking
and periodontitis included
12,329 U.S. adults 20 years
and older. In this study, current smokers were four times
as likely to have periodontitis compared to nonsmokers
after adjusting for age, race
ethnicity, income, and educational level. Heavy smokers (≥ 31 cigarettes per day)
using a stricter definition of
periodontitis (mean whole
mouth attachment loss of ≥
4mm), the adjusted odds ratio was increased to 25.64
among smokers aged 50 years
or more (R). Longitudinal
studies have demonstrated
that young individuals smoking more than 15 cigarettes
per day showed the highest
risk for tooth loss (R).
Smokers have a greater extent of colonization by periodontal pathogens than nonsmokers or former smokers
particularly at shallow sites
(pocket depth ≥ 4mm) with

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[28] =>

28 de n tal hygie n e tribu n e

Dental Tribune Middle East & Africa Edition | March - April 2014
Hands On course

Get to Know the IFDH
By JoAnn R. Gurenlian, RDH,
PhD

The purposes of the IFDH include the following:
he International Fed- • Safeguard and defend the ineration of Dental Hy- terests of the profession of dengienists (IFDH) is an tal hygiene, and represent and
organization designed advance the profession of dental
to represent the interests of den- hygiene.
tal hygienists worldwide. Origi- • Promote professional alliancnally founded in 1973 by the In- es with its association members
ternational Liaison Committee as well as with other associaon Dental Hygiene, the organi- tions, federations and organizazation was formalized in 1986 in tions whose objectives are simiOslo, Norway. Since that time, lar.
the IFDH has functioned as an • Promote and coordinate the
international, non-governmen- exchange of knowledge and intal, non-profit organization that formation about the profession,
unites dental hygiene associa- its education, and its practice.
tions from around the world in • Promote access to quality prethe common
causeListerine
of promoting
ventive oral
health services.
(U) J00273
A4 Advertorial.pdf
1
3/10/14
9:52 AM
oral health.
• Increase public awareness
that oral disease can be prevent-

ed through proven regimens.
• Provide a forum for the understanding and discussion of
issues pertaining to dental hygiene.
Currently, the IFDH consists of
26 member countries. These
include:
Australia, Austria,
Canada, Denmark, Fiji, Finland, Germany, Ireland, Israel,
Italy, Japan, Korea, Latvia,
Nepal, Netherlands, New Zealand, Norway, Portugal, Russia,
Slovak Republic, South Africa,
Spain, Sweden, Switzerland,
United Kingdom, and United
States of America. Individual
dental hygienists, students enrolled in accredited dental hygiene education programs, and

Periodontal Instrumentation
Prof. Mary Rose Pincelli Boglione
10 May 2014 Jumeirah Beach Hotel, Dubai
other professional organizations and health care providers
may join the IFDH.
The IFDH endeavors to provide
online resources for dental hygiene colleagues. Our website,
www.ifdh.org, provides information about the process of
seeking employment in member countries, research and
education, national and international meetings of interest,
becoming a member, and projects and partnerships designed
to improve the oral health of the
public.
One of our exciting new partnerships is with the Global
Child Dental Fund. We are

Dr. Dina Debaybo
D.D.S, MSc
Associate Clinical Professor,
European University College
Diplomate American Board of
Pediatric Dentistry

EVERYDAY RINSING

AN ESSENTIAL ROUTINE FOR COMPLETE ORAL HEALTH
Oral hygiene is an integral component of one’s health and well being. It aids in the prevention of dental problems such as
cavities and gum disease. Tooth loss can also be prevented or delayed with proper oral care. But good oral hygiene can do
more than just keeping teeth and gums healthy; it can act as a mirror of one’s overall health.
Over the past decades, there has been a mounting interest in the possible interplay between poor oral hygiene and various
diseases. In recent studies, periodontal disease has been reported to increase risk for atherosclerotic vascular disease (ASVD),1
as well as for premature labor and low-birth-weight (PLBW) babies.2 Decreased lung function, increased severity of chronic
obstructive pulmonary disease (COPD),3 and type 2 diabetes4 have also been linked to the gum disease. Experts say that poor
oral hygiene, although modiﬁable, is an independent risk factor for oral human papillomavirus (HPV) infection.5
Recent studies have also put forth evidence that poor oral hygiene is associated with higher levels of risk of cardiovascular
diseases (i.e., heart attack and stroke) and low grade inﬂammation, although further research is needed to conﬁrm the
underlying nature of such association.6

ORAL HYGIENE ROUTINES
The American Dental Association recommends the cornerstones of proper oral care – brushing and ﬂossing.7

Brushing: Brushing the teeth twice a day with a soft-bristled brush is the key to healthy gums and teeth. The size and shape
of the brush should ﬁt the mouth to reach all areas easily. Toothbrush should be replaced every three or four months or when
the bristles are frayed. A pea-size of ﬂuoride-rich toothpaste may also come in handy.7

Flossing: Flossing once a day can help remove plaque from between teeth. It is an important part of the routine as plaque
that stays in the mouth can eventually harden into calculus or tartar. Once tartar has formed, professional cleaning may be
required for its removal. 7

HOWEVER, BRUSHING AND FLOSSING MAY NOT BE ENOUGH
A strong body of evidence has shown that brushing and ﬂossing are not effective enough to prevent dental caries and
periodontal diseases. The teeth represent only around 24% of the surface area of the mouth, and thus, such basic routine may
miss 75% of the oral cavity,8 which serves as a reservoir of pathogenic bacteria that can cause plaque and gingivitis.1

RINSING CAN HELP REACH WHAT THE BASIC ROUTINE CANNOT
Adding rinsing to the brushing-ﬂossing routine can help reach nearly 100% of the mouth and get rid of bacteria that cause
cavities and periodontal diseases. A trusted mouth rinse brand is Listerine®, the ﬁrst over-the-counter mouth rinse that has
been awarded the American Dental Association Council on Scientiﬁc Acceptance.9 It offers different variants that are
especially formulated to achieve ultimate cavity prevention. It contains a ﬁxed combination of 4 different oils (i.e., thymol,
menthol, methyl salicylate, and eucalyptol), individually enhancing its antimicrobial properties and ﬂavors, and killing up to
97% of bacteria left behind after brushing and ﬂossing.9 These oils have been clinically proven to offer superior anti-plaque
and anti-gingivitis efﬁcacy to other medicated mouthrinses.10
Special variants of Listerine are available, with Rapid Fusion Technology, which dramatically boosts ﬂuoride uptake and
remineralization, and consequently provide extra enamel protection. Another variant, despite having no alcohol content,
maintains its efﬁcacy at eliminating plaque-causing bacteria.9 The latest addition to the oral hygiene arsenal is Listerine® Total
Care Zero, which in addition to Rapid Fusion Technology, is fortiﬁed with zinc chloride ions that can reduce calculus build-up
and keep teeth whiter.9 There are many options available but make sure to pick the rinse that best meets the patient’s personal
care needs to guarantee a healthier mouth, a happier smile.
Information on Listerine contributed by JnJ Professional

References: 1. Lockhart B. Peter, et al. Periodontal Disease and Atherosclerotic Vascular Disease: Does the Evidence Support an Independent Association?: A Scientiﬁc Statement From the American
Heart Association. Circulation. 2012;125:2520-2544. 2. Rajiv Saini, et al. Periodontitis: A Risk for Delivery of Premature Labor and Low Birth Weight Infants. Journal of Natural Science, Biology, and
Medicine. 2011; 2(1):50-52. 3. Deo vikas et al. Periodontitis as a Potential Risk Factor for Chronic Obstructive Pulmonary Disease: A Retrospective Study. Indian Journal of Dental Research.
2009;20:466-470. 4. Southerland H. Janet, et al. Diabetes and Periodontal Infection: Making the Connection. Clinical Diabetes. 2005;23:171-178. 5. American Dental Association. https://www.ada.org
/news/8952.aspx. Accessed February 23, 2014. 6. Cesar de Oliveira, et al. Toothbrushing, Inﬂammation, and Risk of Cardiovascular Disease: Results from Scottish Health Survey. British Medical
Journal. 2010;340:c2451. 7. American Dental Association. http://www.mouthhealthy.org/en/adults-under-40/healthy-habits. Accessed February 23, 2014. 8. Kerr WJ, Kelly J, Geddes DA. The areas of
various surfaces in the human mouth from nine years to adulthood. J Dent Res. 1991 Dec;70(12):1528-30. 9. Data on ﬁle. Johnson and Johnson. 10. Sharma NC, et al. Superiority of an Eessential Oil
Mouthrinse When Compared with a 0.05% Cetylpyridinium Chloride Containing Mouthrinse: A Six-Month Study. International Dental Journal. 2010;60(3):175-180.

JoAnn R. Gurenlian

working together to support a
social responsibility award focused on improving the oral
health of disadvantaged children. This volunteer project is
designed to recognize, on an
annual basis, dental hygienists
and student dental hygienists
who participate in a volunteering project which benefits disadvantaged children, mainly,
but not exclusively, in low- and
middle-income countries. Any
dental hygienist who is either an
Individual or Student member
of the IFDH, or an IFDH Country Member is eligible to apply
for the award. Applications are
available through www.gcdfund.org. Project proposals are
due by June 1, 2014 and awards
will be announced on September 30, 2014. One winner will
receive a cash prize of $3000 to
implement their project. Two
runner-ups will receive cash
prizes of $1000 for their project.
In addition, the IFDH is investigating a partnership with
“Text2Floss”. This program is
an innovative way to promote
improved oral home care by
texting reminder messages to
brush and floss daily. Additional educational information
is offered concerning oral care
including saliva and the pH of
the mouth, heart disease and
oral health, stress, and diabetes.
There is an app for Ipads, Ipad
minis, and Iphone 5s as well as
through ITunes at http://itunes.
apple.com/us/app/text2floss/
id797806327?mt=8.
Every three years, the IFDH
hosts an International Symposium on Dental Hygiene, providing an opportunity to network
and learn the latest research
and technologies supporting the
growth of the profession. The
next scientific symposium will
be held from June 23 to 25, 2016
in Basel, Switzerland. For more
information about this meeting,
visit http://isdh2016.dentalhygienists.ch.
We hope you will join us as we
work together to improve the
oral health of the public and
support our profession around
the globe!

Contact Information
JoAnn R. Gurenlian, RDH,
PhD, is President of the International Federation of Dental
Hygienists and Professor and
Graduate Program Director
of the Department of Dental
Hygiene, Division of Health
Sciences, of Idaho State University. jargphd@verizon.net

[29] =>

Dental Tribune Middle East & Africa Edition | March - April 2014

de n tal hygie n e tribu n e 29

Launch of Dental Hygienists Supplement
in the Dental Tribune Middle East
qualifications. Dental professionals are increasingly becoming aware of our key role
within the dental practice, both
as a valued team member in
the delivery of complete dental
care, and in the promotion and
restoration of our patients’ oral
health.

Victoria Wilson,
Dental Hygiene Therapist

By Victoria Wilson

UBAI, UAE: It is
my pleasure to announce the launch of
a new Supplement in
the Dental Tribune Middle East
targeted completely to Dental
Hygienists.
It is an extremely exciting time
for Hygienists in this region,
as we continue to gain more
recognition for our skills and

In 1906, Alfred Fones, an American dentist from Bridgeport,
Connecticut who is also the
founder of the Dental Hygienist profession, had an important
vision. He wanted to create a
new paradigm for dentistry that
focused on prevention and promotion of oral healt h instead of
simply tooth loss and disease.
Alfred’s cousin, Irene Newman, became the first known
Dental Hygienist and in 1913
they opened the first dental Hygiene School.
After qualifying as a Dental Hygienist & Dental Therapist from
the Eastman Dental Hospital
in the UK over 10 years ago, I
became acutely aware of the
public’s lack of knowledge as
to what we do within the dental clinic. At that time, a good
deal of further education was

periodontal disease.
• Provide preventive oral care
to patients and liaise with dentists and patients on the treatment of caries, periodontal
disease and tooth wear, as well
as replacement of existing deficient restorative treatment.
• Undertake supragingival and
subgingival scaling and root
debridement using manual
and powered instruments and
The question still remains in administer appropriate antithe Middle East - does every microbial therapy to manage
member of the dental team plaque related diseases.
completely understand what • Apply topical treatments and
the Hygienist can bring to the fissure sealants.
• Offer patients advice on how
clinic?
to quit smoking.
The following list can help pro- • Take, process and interpret
vide an insight into our skills various film views used in general dental practice.
and valuable contributions.
• Take impressions.
The Dental Hygienist will:
• Provide dental hygiene care • Identify anatomical features,
recognise abnormalities and
to patients.
• Plan the delivery of care for interpret common pathology
patients to improve and main- as well as carry out oral cancer
screening.
tain their periodontal health.
• Obtain and evaluate a de- • Refer patients to other dental
tailed dental and medical his- professionals and discuss options for further dental treattory from patients.
• Complete periodontal exam- ment.
• Perform Tooth
Whitening
inations and
charting
use
U-Listerine
WOHDand
QP Ad
(14.5x20.6cm).pdf
1
3/9/14
5:55 PM
procedures
to
the
prescription.
indices to screen and monitor
also required to educate people
on our role within the community. Ten years has passed and
it would now be difficult to find
a clinic in the UK without a Hygienist. I can also see that this
is the direction that clinics are
taking in the UAE. The prevention and education that Hygienists provide is fundamental to
all dental treatments.

• Act as overall Team Builder.
The Dental Hygienist is ultimately a great communicator
within the team. He/she motivates patients and helps them
to make the right decisions for
long term dental health and acts
to build the practice. Successful periodontal therapy, and
the maintenance of a healthy
periodontium is the basis of all
good restorative dentistry.
The number of Dental Hygienists in the region is steadily
growing, and thanks to the
Dental Tribune Middle East,
we now have a platform to
reach out and connect further
with the dental profession.

Contact Information
Victoria Wilson
Dental Hygienist
Dr. Roze & Associates
Dental Clinic
victoria@dradubai.com

Celebrating World
Oral Health Day
20th March 2014

By Dr. Maimona A. Rahim,
DDS

UBAI, UAE: The
GCC Oral Health
week is the annual
celebration of all
the efforts during the year
to improve Oral Health. This
year the celebrations will
take place on 20th March
2014 at the Arabian Center –
Al Khawanij Road in Dubai
starting from 16:30 – 10:00
with the slogan being “Teeth,
Health & Beauty”. The day
will highlight on bad oral
health habits, maintaining
good oral hygiene and the
importance of dental visits.
The targeted audience are all
age groups, children, adults,
men and women.
The event will be held under
the patronage of Mr. Nasser
Al Budor, Director of Dubai
Medical District and Dr. Aisha Sultan, Director of Dental Services at the Ministry of
Health. This wonderful celebration is made possible in

collaboration with Dubai
School for Dental Medicine
(DSDM) and sponsored by
Philips, Jordan, Beverly Hills
tooth paste and First Gulf
Bank. Several dentists from
DSDM, Al Baraha Hospital
Dental Department and various different clinics from
UAE will be carrying out oral
examinations, education, experiments, competitions and
photo shooting throughout
the day. Giveaways will be
distributed by Jordan and
Beverly Hills with 10 electric
tooth brushes being sponsored b Philips for a competition. Balloons will be distributed by DSDM. The success
of this event will be brought
together by a team work of all
including the Mall administration, Sponsors, Dentists
and Audience.

What Brushing starts, Listerine ﬁnishes

In Partnership with

All are invited and welcome
to celebrate with us World
Oral Health Day.

[30] =>

30 i n dustry

Dental Tribune Middle East & Africa Edition | March - April 2014

An interview with Tuomas Lokki

Tuomas Lokki

By Inside Dental Technology

nside Dental Technology
(IDT): Do you believe that
CAD/CAM technology is
here to stay in the dental
profession?
Tuomas Lokki (TL): Absolutely. However, we are at the
very beginning of this transformation. There are many
new applications on the horizon. CAD/CAM technology is
the entry point for many dental offices converting to digital processes and will be one
of the primary technologies
in the dental arena in the future. Dental laboratories are,
in many cases, leaps ahead of
the dental office. I see huge
growth opportunities for laboratories in terms of complex
and specialty cases because
they are perfectly poised to offer dentists expert guidance.

How do you see the relationship between the dentist and
laboratory evolving?
New digital impression technologies will improve the relationship between the laboratory and the dentist. The
proliferation of this technology, as well as advancements
in dental materials and equipment, will continue to make
open and consistent communication between the dentist
and dental technician absolutely crucial. New software,
such as Planmeca’s Romexis,
will facilitate this communication through better data
management and open architecture, allowing for the easy
import and export of digital
files to and from any system,
and acting as the conduit that
brings all the case data together. Additionally, digital
impressioning will open new
avenues for laboratories to
perform more complicated
and demanding restorations
in less time.
What are some of the critical
factors that laboratories need
to consider when working with
their dentist partners?
Communication is critical to
achieving the best results.
Today’s technology opens the
door to online communication and I would encourage
laboratories to use those tools
to design restorative solutions
in cooperation with their dentists. As these technologies

continue to evolve and become
more commonplace, the working relationship between dentists and dental technicians
will allow for increased production capacity for both sides.
Are there scanning systems on
the market today that smaller
laboratories can afford?
Yes. Scanning systems continue to become more affordable.
This allows everyone equal
access to digital technologies
and will help laboratories develop new product lines and
services for their dentist partners. Modular systems, such
as the Planmeca Planscan digital restorative system, allow
that flexibility for growth. You
can start with the scan-only
module and then move into
the scan and design system,
or go all in to full production
milling.
There has been much debate on
open versus closed CAD/CAM
systems and whether conversion to a digital workflow requires multiple systems. What
are your thoughts on this and
how can Planmeca address
these concerns?
Planmeca has always been a
great believer in open platforms. Our imaging software
operates on any operating system platform that imports and
exports DICOM and Twain
images and data. We will continue this same philosophy
within our CAD/CAM strat-

egy. We encourage the market
to have open solutions and develop technologies that communicate with each other.

they work with dental laboratories that can attest to having quality systems and good
manufacturing practices in
place to produce such restorations.

What is your position on the expanding role of the laboratory
as it relates to partnering with
dental practices in the implant
planning process?
Digital impressions as they
relate to dental implants, although a small piece of the
restorative market, are growing 15% to 17% annually. We
expect this trend to increase
even more as the population
base continues to age. The
complexity of implants and the
communication bridge that
digital impressions provide
requires an enhanced service
level interface between dentists and dental technicians.
Our Planmeca Romexis software platform provides tools
that enable the dental team
to visualize and share threedimensional files, such as
CBCT scan data and implant
treatment plans, on one platform. This technology helps
laboratories create implantbased restorations faster and
better with guidance from
oral surgeons. Also, due to
increasing regulatory controls, dental laboratories that
offer implants and implant
abutments are likely to face
increased regulatory review.
This new level of compliance
will require dentists do their
due diligence in ensuring that

What is your vision on how the
dental industry will look in 5
years?
CAD/CAM will play an increasingly important role in
the dental industry. Digital
impressions in combination
with 3D imaging will become
the standard of care in most
practices. The use of combined
datasets has opened new avenues that pave the way to new
applications and has created
new opportunities for dental
laboratories. We have only begun to experience the impact
of the digital impression and
CAD/CAM revolution. I would
like to invite you all to challenge the manufacturing community with your future needs
to make the dental profession
even more exciting.
Published with the permission
of Aegis Publications, LLC – Inside Dental Technology.

Contact Information
Tuomas Lokki is the President
of E4D Technologies in Richardson, TX., and Vice President
Marketing and Sales Planmeca
Oy, Finland.

www.idem-singapore.com

THE BUSINESS OF DENTISTRY
REGISTER ONLINE NOW!
Enjoy free entry to the Trade Fair & Conference Early Bird rates

APRIL 4 - 6, 2014
Pre-Congress Day: April 3, 2014
IDEM Singapore offers an unrivalled opportunity to reach out to the dental fraternity in the Asia-Pacific region. With a powerful combination of an extensive
international trade exhibition and a world-class scientific conference, IDEM Singapore has been a cornerstone event in the dental community calendar since
2000. It is a “must-attend” for dental practitioners and professionals in the Asia-Pacific looking for the latest cutting edge technology and innovations in dental
solutions and services.

ONE-STOP SHOPPING AND BUSINESS NETWORKING
With more than 450 exhibitors from over 36 countries in one location - See, learn and shop for the latest and best deals in dental technology at IDEM Singapore
2014. For the traders and distribution houses, IDEM Singapore 2014 will also feature many new exhibitors globally, using this exhibition as a platform to seek
distributors in Asia. Meet dental professionals from all over the Asia-Pacific region. Establish contacts, exchange ideas and socialise with colleagues both familiar
and new from the regional dental fraternity. For a full list of exhibitors, please visit our website. Register online to visit the trade exhibition for free.

A CONTINUAL EDUCATION PROGRAM THAT IS TAILORED TO YOUR NEEDS
In four power-packed days of lectures and workshops, IDEM Singapore 2014 caters to Dentists and the rest of the dental team, including Dental Technicians,
Dental Hygienists and Dental Therapists. A diverse range of topics and educational sessions will be presented, so you can tailor a valuable program that is
relevant to your needs.

Planned Topics Include:
Regenerative Endodontics • Making “Real World” Practice Productive and Enjoyable • Future of Dental Implants • Developing your Ideal Practice •
Multidisciplinary Approach to Periodontal Therapy • Adult Orthodontics Today

Featured Speakers:

Gordon J. Christensen

Ken Hargreaves

Derrick Setchell

Founder and Director of Practical
Clinical Courses (PCC) and
Chief Executive Officer of
Clinicians Report Foundation (CR)

Professor and Chair of Endodontics,
University of Texas Health
Science Center,
USA

Hon. Professor of UCL and
Hon. Consultant,
Eastman Dental Hospital,
UK

For list of speakers and their topics, visit www.idem-singapore.com

#NewDentist Forum
Aside from the main scientific conference, dentists within 7 years of graduating with a dental degree and final year dental
students will enjoy two unique and exclusive sessions to provide them with the foundation for success in the early stages of
their career.

Dental Technician Forum
This 2-day dedicated program includes groundbreaking lectures from the industry’s key opinion leaders, focused entirely
on the latest advances in the dental laboratory.

Dental Hygienist and Dental Therapist Forum
Dental Therapists & Dental Hygienists from the region will have the opportunity to learn about new developments in
their field, to meet and network with fellow colleagues.
Endorsed By

Supported By

Held In

In Co-operation With

Co-organizer

Singapore Dental Association

Koelnmesse Pte Ltd
Andrea Berghoff
Tel: +65 6500 6706
a.berghoff@koelnmesse.com.sg

[31] =>

[32] =>

32 i n dustry

Dental Tribune Middle East & Africa Edition | March - April 2014

Sirona’s international success: Russian clinic buys the
40,000th C8+ treatment center
By Sirona

ALZBURG,
Austria:
Products “Made in Germany” have long been
sought after around the
world. This is also reflected in
the international sales figures
for the Sirona C8+. The treatment center combines high
quality with timeless design.
The 40,000th C8+ dental center
recently rolled off the production line at Sirona in Bensheim,
the world’s largest production
site in the dental industry –
making this unit, which was
designed for the global market,

even more successful than the
classic M1. The milestone unit
and three other C8+ centers
were purchased by the Kremlyovskaya Stomatologia dental
clinic in Ryazan, Russia. “We
have had very good experience
with Sirona equipment. The
company’s treatment centers
are of a very high quality and
are known for their reliability,
long functional life, and support
features for ergonomic patient
positioning that prevent back
strain while working,” said clinic director Andrey Archipenko,
explaining his decision. “Made
in Germany” is always a key
quality factor around the world

– especially in Eastern European, Latin American, Asian, and
Arabian markets. The 30,000th
C8+ treatment center was sold
to a buyer in China in 2011.
Easy operation and timeless
design
Because of the wide range of
possible applications, the C8+
units can be found in practices,
clinics, and universities in over
100 countries. The sturdy construction and intuitive operation make them ideally suited
for ongoing use in clinical practice routine as well as for teaching.

Fig 1: Still popular around the world: Sirona has produced its
40,000th C8+ treatment center. Along with the milestone unit from
left to right: Dominik Fabry, Susanne Schmidinger, Klaus Jöckel,
Michael Geil, Marc Bonaduce, Burkhard Blomberg, Claudia
Ruland-Bosch, Thomas Nack

In addition to its top quality, the
timeless design of the C8+ gives
it the high-end look. Users can
choose between various finishes and three color schemes

FDI 2014 · New Delhi · India
Greater Noida (UP)

Annual World Dental Congress

11-14 September 2014
Deadline for
early bird registration
31 May 2014

Fig 2: Andrey Archipenko, Director
of the Kremlyovskaya Stomatologia
dental clinic in Ryazan, Russia, was
given a certificate by Sirona when
his milestone unit was delivered.

for the upholstery – elegant,
natural, and active. Director Archipenko chose a premium decor in trendy orchid that blends
seamlessly into his newly refurbished clinic. You can use the
online C+ configurator to determine which color scheme best
matches your facilities before
purchasing. Dentists can design
their treatment rooms virtually
to get some initial assistance in
selecting colors.
Optional features
Dentists can configure the C8+
individually depending on their
personal preferences and local
conditions. The range of optional features has been continually
adapted in response to technical developments and sets new
trends. For example, optional
features include a brushless motor (BL ISO C), LEDview treatment lamp, and an intraoral
camera system. Dentists who
want to provide their patients
with an especially comfortable
atmosphere can also have their
C8+ treatment center equipped
with the new lounge upholstery,
which has a premium cushion
design, a soft, elegant feel, and
an attractive double-seam look.

A billion smiles welcome the world of dentistry
www.fdi2014.org.in
www.fdiworldental.org

Exemplary ergonomics
With its serial ErgoMotion system, Sirona also ensures patients’ comfort and gives the
treatment team optimal access to the mouth. At the same
time, the individual operating
elements are arranged to allow
the dentist to work without back
strain. The many options, the
outstanding workmanship, and
the timeless design make the
C8+ a treatment center that is
still very popular today – 40,000
units sold – with dentists all
around the world.

[33] =>

n ews 33

Dental Tribune Middle East & Africa Edition | March - April 2014

Visit us at
www.promedica.de

high quality glass ionomer cements
first class composites

Glass ionomer luting cement
• highly biocompatible, low acidity
• micro-fine film thickness
• excellent adhesion
• no temperature rise during setting

innovative compomers
modern bonding systems
materials for long-term prophylaxis
temporary solutions
bleaching products …

Light-curing nano-ceram composite
• highly esthetic and biocompatible
• universal for all cavity classes
• comfortable handling, easy modellation
• also available as flowable version

All our products convince by
excellent physical properties
perfect aesthetical results

Dental desensitising varnish
• treatment of hypersensitive dentine
• fast desensitisation
• fluoride release
• easy and fast application

PROMEDICA Dental Material GmbH

phone: +49 43 21/5 41 73 · fax +49 43 21/5 19 08 · Internet: www.promedica.de · eMail: info@promedica.de

AAID president-elect named vice dean at
Harvard School of Dental Medicine

AAID President-Elect Dr. John Da Silva. (Photo: AAID)

By Dental Tribune America

EW YORK, USA:
After an extensive
nationwide search,
AAID
PresidentElect John Da Silva, DMD,
MPH, ScM, AFAAID, has been
named vice dean at Harvard
School of Dental Medicine.
Dean Bruce Donoff stated that
Da Silva’s “extensive institutional knowledge and experience in [HSDM’s] three focal
areas — research, education
and patient care — will be of
great value as HSDM continues its strategic planning process.”
Da Silva serves on the board
of trustees of the American
Academy of Implant Dentistry
and is currently the president
elect. He is also chair of the
Bylaws Committee and serves
on the Education Oversight
and Nominating committees.
He has received widespread
recognition during his academic career, including being
named an honored fellow of
the American Academy of Im-

plant Dentistry and receiving
the HSDM Distinguished Junior Faculty Award.
He has published numerous
journal articles and lectured
nationwide.
Da Silva has made major contributions in research and the
area of color science. He has
also been involved in curricular changes to improve
content on substance-abuse
screening and brief interventions.
Da Silva was born in New York
City and attended Williams
College as an undergraduate.
He received his dental degree from the Harvard School
of Dental Medicine and his
MPH degree from the Harvard
School of Public Health. He
later returned to the School of
Public Health and received an
ScM in health policy and management.
Da Silva completed specialty
training in implant dentistry
and prosthodontics at HSDM
in 1992. He has been a faculty
member there since 1993.

[34] =>

34 n ews

Dental Tribune Middle East & Africa Edition | March - April 2014

< Page 1
for Hospitals Ltd who were represented by the chairman Mr
Elie AbouChedid. CARE are the
agents of Planmeca in the Kingdom of Saudi Arabia. Also present at the event, was the President of Planmeca Mr Heikki
Kyostila and Mrs Kyostila from
Finland.

Planmeca makes
CAD/CAM easier
than ever

President Riad Bacho gave a
brief word and then handed
over the presidency medal to
President Ali Alehaideb.

Fellows at the ceremony: from left Abdallah Al Kradees, Jihad
Abdallah, Hani Ounsi, Mounir Silwadi, guest Dr Youssef Al
Khodair, Abdulghani Mira, Youssef Talic and Ziad Salameh.

President Alehaideb thanked
all those present as well as the
event sponsors and praised the
work of fellow Youssef Talic, the
section’s past vice president,
who had done the groundwork
for the organization of District
2.
Councilor Cedric Haddad also
gave an update of the activities
of the International Council
and of the changes that were
taking place in the College.
Mr Elie AbouChedid then introduced his company (CARE)
and gave a presentation of the
technically advanced services
that it provided.

From left, President Alehaideb, Youssef Talic, Riad Bacho, Cedric
Haddad, Ibrahim Nasseh, Mrs Kyostila, Mr Heikki Kyostila Mr
Elie AbouChedid, and with her back turned, Imtiaz Turkistani.
IDEM14 210x275mm DTI Inc2.ai

4/3/14

cording and the dental surface identification algorithm
make the device extremely
flexible to use. Thanks to
these features, you can pause
the scanning at any time and
continue later on at any point
from where data is already
available.”

A banquet followed the meeting and gave all those present
the chance to socialize, renew
acquaintance and exchange
ideas.

Petri Kajander

By Petri Kajander

lanmeca’s open-interface-based CAD/CAM
solutions
introduce,
above all, quality, cost-efficiency and precision to the
daily workflow at dental clinics or laboratories. Petri Kajander, Product Manager for
Planmeca’s CAD/CAM solutions, explains the revolutionary features of these new
products.

11:01 AM

State-of-the-art
for dentists

DENTAL
TECHNICIAN
FORUM

Part of

APRIL 5 - 6
2014

Planmeca PlanScan® – super-fast intraoral scanner

www.idem-singapore.com

The new Planmeca PlanScan® is a digital and powderfree intraoral scanner that
scans the patient’s dentition
quickly and accurately. The
scanner produces real-time
digital impressions from
one-tooth to full-arch scans.
Thanks to the open STL
data, the scanned files can
be sent to any dental laboratory for design work. This is
the world’s first dental unit
integrated intraoral scanner
that can also be connected to
a laptop.

SUNTEC SINGAPORE INTERNATIONAL CONVENTION AND EXHIBITION CENTRE

FEATURED SPEAKERS

Minimal invasive
restorations (0.3mm)
is it possible with
CAD/CAM?

Management of simple and
complex cases in light of the
New Technologies:
The Digital Intrascanner

DENTSCAPE™:
Anterior Esthetics
with All-Ceramic
Restorations

Vanik
Kaufmann-Jinoian,
Switzerland

Dr. Andrea Mastrorosa Agnini,
Dr. Alessandro Agnini,
Italy

Naoki Aiba, CDT,
Oral Design,
USA

3D printing of
biocompatible
materials for
dental technical
applications

Presentation “The
Bridge” - Connect
dental handcraft
with the digital
future

Rik Jacobs,
The Netherlands

Ralf Oppacher,
MDT, Germany

inLab – The
Digital Solution
for Your Lab
John Philipp,
Germany

For the full abstracts, please visit www.idem-singapore.com and refer to the Dental Technicians Forum page.

CMY

TABLE CLINIC SESSIONS
Outs
Outstanding
dental technicians will present various topics of great interest in table clinic demonstrations.
Dele
Delegates will have the opportunity to interact with the demonstrator/speaker to ask on their questions of
interest. The practical demonstrations will, at the same time, provide inspiration and offer a means of troublee
inter
shoo
shooting the method of application. See demo abstracts on the dental technicians forum webpage of IDEM
Singapore.
Sing

Th first Dental Technician Forum will take place on April 5 - 6 at IDEM Singapore 2014, with sessions
The
specially tailored for Dental Technicians, who are imperative to the success of almost all dental treatments –
sp
from small prosthetic cases to the complicated implantology clinical cases.
fro
Th
ion
This two-day dedicated scientific program will include groundbreaking lectures from the industry key opinion
lea
ry
leaders, table clinic demonstrations and an accompanying trade exhibition focused on the dental laboratory
pro
profession.
Gold Sponsor
Go

Official Sponsors

Co-organizer
Tzvetan Deyanov
CAPP | Dental Tribune Middle East & Africa
Tel: +97 1551 128 581
Email: deyanov@cappmea.com

Andrea Berghoff
Koelnmesse Pte Ltd
Tel: +65 6500 6706
Email: a.berghoff@koelnmesse.com.sg

solutions

“The scanner has only one
cable, so it is extremely easy
to move from one place to another, for example between
different treatment rooms or
clinics”, says Product Manager Petri Kajander. “In addition, the scanner is delivered
with a laptop, so the device
can be flexibly shared between different users. In other words, Planmeca PlanScan
offers value for your investment: it is not a device for just
one dentist but can be used
by the entire clinic.”
The scanner utilises blue
laser technique. It projects
a pattern on the surface of
the teeth and then analyses
it from different directions
while calculating distances.
In this way, the device is able
to calculate a model that is
extremely accurate. “You can
view the result as a real-time
video image. The video re-

The scanner includes a range
of exchangeable tips in various sizes, the smallest of
these facilitating access to
the posterior parts, particularly with small children and
trauma patients. The tips can
be autoclaved for efficient infection control. In addition,
the scanner is extremely
durable since it has no other
moving parts inside except
for a fan that removes warm
air. “Thus, the device stays
calibrated and is not subject
to mechanical wear”, explains Kajander.
Planmeca PlanCAD® Easy
– efficient design tool for
prosthetics
Planmeca also offers dentists a new kind of open software solution for 3D design.
Planmeca PlanCAD® Easy
is seamlessly integrated in
Planmeca Romexis® software and it is a user-friendly
design tool for the design
of inlays, onlays, veneers,
crowns and bridges.
“The software runs on the socalled floating licence basis.
This means that it is not tied
to just one computer or workstation, but the work is saved
on the Planmeca Romexis
server. In this way, the scanning station can be used only
for scanning, while another
workstation is used for the
actual design work. This is a
truly unique feature, which
allows work to be continued
straight away on another
computer, while the scanner
is freed for more productive
operation”, says Kajander.
Every dentist designing his
or her own prosthetic works
will also face cases that require assistance from a
dental laboratory. For this
reason, Planmeca’s system
utilises an open STL file format that allows the work to be
sent immediately to a partner
via the Planmeca Romexis®
Cloud service.
Since Planmeca PlanCAD
Easy is integrated in Planmeca Romexis software,
soft tissue scans can also
be conveniently paired with
the patient’s CBCT image.
This combined data provides
valuable information for im-

> Page 35

[35] =>

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Dental Tribune Middle East & Africa Edition | March - April 2014
< Page 34

Planmeca PlanCAD Easy

Planmeca PlanMill 50

Planmeca PlanScan

plant planning, for example,
because in addition to the
soft tissues, it visualises the
crown that is designed for
the occlusion. This facilitates
the planning of the implant
screw’s location.
The Planmeca PlanCAD Easy
workflow from preparation to
the finished result includes
just five easy stages: work description, scanning, marking
of the margin line, automatic
design, and sending the work
to the mill. “Once the work
has been sent to the mill, it
is transferred there in its entirety and the mill’s computer finishes the work. In this
way, the software and scanner are immediately freed for
a new assignment.”

Planmeca PlanScan Lab

force the material, it may
break prematurely. Even the
smallest hairline crack in
the material can lead to a cemented piece breaking when
Planmeca Premium

> Page 38

Planmeca PlanMill 40

VITA VMK Master
Innovation in the third generation!
®

The new VITA metal ceramic with the familiar layering you’re accustomed to.

The software is very userfriendly. All design phases
are saved automatically, and
if further impressions are
needed, previous phases can
be returned to flexibly. The
automatic design software
automatically takes into account the adjacent teeth’s
cusps and marginal ridge in
addition to the
contact strengths defined by
the user. This creates a design that always fits its surroundings.

Av
ail
an able
d V in
ITA VI
cla TA S
ss YS
ica TE
lA M
1 – 3D
D4 -M
sh AST
ad E
es R ®
!

Planmeca PlanMill® 40 –
fast and precise milling unit
for dental clinics

Since the mill handles the
milled pieces completely
independently, as many as
several dozen pieces can be
sent to the mill at a time.
In addition, the device tells
which block size, colour and
material should be used, so
any member of the staff can
place the block in the mill.
“This saves everyone’s working time. The dentist does not
need add the block himself,
but anyone can do it”, says
Kajander.
The mill has a six-tool exchange mechanism, and it
changes tools independently
according to different job requirements. In addition, the
device mills different materials according to their properties. For example, it knows
how to gently handle delicate
ceramics in work phases that
require precision. “If you

3399E

Planmeca PlanMill® 40 is an
extremely precise four-axis
milling unit operating under
the control of its own computer. The device is suitable
for all the indications of a single tooth, in other words for
the milling of crowns, inlays,
onlays and veneers. The mill
can manage bridges of up to
five units to the posterior and
three units to the anterior
area.

VITA shade, VITA made.
Over 50 years. 3 letters. 1 original. For generations VMK has

VITA VMK Master is best suited for the veneering of

been the synonym for metal ceramics. With the power

non-precious metal alloy frameworks. Furthermore,

of the original, VITA VMK is the benchmark for easy,

the standard layering continues to provide the most

safe and cost-efficient handling. With VITA VMK Master

simple handling. VITA VMK Master stands above all

this is more true than ever. Thanks to its firing tempera-

for one thing: quality without compromise.

ture

www.vita-zahnfabrik.com

and

3399E_210x297neu V14.indd 1

chemical

and

physical

characteristics,

facebook.com/vita.zahnfabrik

05.02.14 13:21

[36] =>

36 n ews

Dental Tribune Middle East & Africa Edition | March - April 2014

Interview: “Kennedy’s wound was clearly incompatible with life”
When I looked up later, the room was filled
with the senior chiefs
of all surgical departments at Parkland.
There were also some
people I did not know.

Dr. Don T Curtis speaking at a recent event on the occasion of the 50th
anniversary of the Kennedy assassination. (DTI/Photo Stephanie Price/
Panhandle-Plains Historical Museum, USA)

By Dental Tribune International

ew people are granted the opportunity to
become an active part
of historical events.
Seventy-six-year-old Dr. Don
T. Curtis, a former dentist
from Amarillo in Texas, is
one of them. As a resident in
oral and maxillofacial surgery at Parkland Memorial
Hospital in Dallas, he was
one of the first doctors to
have performed emergency
treatment on U.S. President
John F. Kennedy after he was
shot on 22 November 1963.
Dental Tribune ONLINE had
the opportunity to speak with
him about that day and the
reason he thinks that there
was more to the assassination than a lone gunman.
DTI: A feature film about the
events at Parkland Memorial Hospital, produced by
Tom Hanks and starring Billy
Bob Thornton, has just been
released on the 50th anniversary of the Kennedy assassination. Have you seen it, and
does it stay true to the events,
in your opinion?
Dr. Don T. Curtis: I have not
seen it but I have heard criticism that it paints rather a
sensationalised picture of
the events. I guess I would go
see it if it were shown here in
Amarillo.
You began working at Parkland Memorial Hospital in
1963. What was your position
back then?
At that time, I was half way
through my first year of residency in oral and maxillofacial surgery. Before I took a
residency there, I also completed an internship. I became interested in the field
while working as a surgical
technician in a general hospital during my time in dental school at the Baylor College of Dentistry in Waco.

Were you aware of the president being in Dallas on 22 November 1963?
I was not aware of that and
was surprised when they
brought him to the hospital.
I had a surgery scheduled
for later that day and was on
my way to have lunch. The
way to the lunch-room however required me to leave the
building and walk across the
receiving area of the emergency room, where I noticed
police cars and the presidential limousine, which had
blood on it and roses that
were given to the first lady,
Jacqueline Kennedy, when
she arrived at the airport.
When a policeman asked
me whether I was a doctor, I
said yes. He then replied that
the president was hurt and
escorted me to the trauma
room where President Kennedy was.
In what condition was Kennedy when you arrived?
When I got there, it was obvious that the president was in
extremis. He tried to breathe
but was unable to do so. Dr.
Charles James Carrico, a
Parkland resident surgeon,
had placed an endotracheal
tube in an attempt at ventilation. However, that did not
work because there
was a blockage of the
president’s airway, so
he decided to do a tracheostomy.
I helped the nurse to
undo the president’s tie
and remove his shirt
to prepare him for the
procedure. Then Dr.
Malcolm Perry, a senior
surgeon, came into the
room and it was decided that he should do the
tracheostomy. Dr. Carrico assisted Dr. Perry,
and I performed a cutdown on the left leg to
provide for intravenous
replacement of blood.

Where you aware that
the president had been
the subject of an assassination attempt?
I was unaware of the
nature of the injury to
the president because
his head was on a pillow and I could not see
a wound. I remember
the chief of neurosurgery, Dr. William Kemp
Clark, rotating Kennedy’s head to the left,
revealing that the posterior part of his skull
had been radically
fractured. He then said,
“Stop; this injury is incompatible with life.”
What was the atmosphere in
the room?
It became very quiet. Nobody
said anything.
In your opinion, was there any
chance that the president’s life
could have been saved?
Nothing that we did made a
difference. Kennedy’s wound
was clearly incompatible with
life.
According to eyewitnesses,
discussions broke out about
who was authorized to do the
autopsy. Did you notice any of
that?
I did not because I left the
trauma room soon after
the president had been pronounced dead and went back
to the clinic to see my patient
in the operating room. However, I found that all scheduled
surgeries for that day had been
cancelled and all patients had
been sent back to the ward.
Only a few surgeries were underway at that time, including
that of Governor John Bowden
Connally, who had also been
injured during the shooting.

“My personal belief is that there were of course
multiple shooters and that Oswald did not do it
alone.”
I told my patient that her surgery had been postponed. She
understood that. Since there
was nothing else for me to do,
I then cleared my business
in the clinic and went home.
There, we spent the weekend watching television and
listening to the news on the
radio. We were relieved that
President Lyndon B. Johnson had made it safely back to
Washington and that the government was uninterrupted.
Finally on Sunday, we learned
that the suspect, Lee Harvey
Oswald, had been shot, which
indicated that there was something going on in addition to
just alone shooter.
The majority of Americans do
not believe that Oswald acted
alone by hitting Kennedy with
three shoots in the back, as concluded by the report of the Warren Commission appointed by
the government to investigate
the circumstances of the assassination. Did you observe any
irregularities between this official version and the events you
witnessed?
The Warren Commission’s report reflected what the people
wanted to hear, which was that
Oswald acted alone and that
there was no conspiracy. The
doctors of Parkland however
when wiping the blood from
Kennedy’s neck for the tracheostomy found a single bullet
hole that was apparently an
entrance wound, which meant
that must have been a projectile that entered the president
from the front. Because of its
nature, another wound on the
back of Kennedy’s head was
an exit wound, so there must
have been at least two bullets
that came through the front.
While all the doctors’ testi-

“We learned that the suspect, Lee Harvey Oswald,
had been shot, which indicated that there
was something going on in addition
to just alone shooter.”

monies, including mine, were
included in the report, their
knowledge of the wounds
did not have much influence
on the Commission’s overall
conclusion. Why it was interpreted that way has remained
a mystery for the past 50 years.
What do you believe actually
happened that day?
My personal belief is that there
were of course multiple shooters and that Oswald did not do
it alone. This would indicate
however that there was in fact
a conspiracy.
After the events, you stayed at
Parkland Memorial Hospital
for another two years. Were
the events still discussed by the
staff in the aftermath?
We actually never talked about
it. This was something we just
did not want to discuss. However, I left Parkland in 1965 for
an exchange residency in London and Zurich, where I often
discussed the events with my
colleagues abroad. Particularly in England, there was much
interest in U.S. politics and the
assassination.
You recently went public with
your knowledge after 50 years.
What were your reasons for doing so?
Everything that I would say is
already in the literature about
the assassination but I think
there needs to be general
knowledge of what people who
were actually involved knew.
More than six million pages of
classified evidence on the Kennedy assassination are going
to be released by 2017. Are you
interested in this knowledge, or
do you consider that chapter of
your life closed?
There is a great deal of speculation of what information
these documents actually contain. I do not look forward to
it but would be interested to
know what could be learned
from them.
Thank you very much for the
interview.

Left: Dr Don T. Curtis as a dental student in 1962. (DTI/Photo courtesy of Baylor College of Dentistry,USA)— Right:
US Secret Service agents and local police examine the presidential limousine outside of Parkland Memorial Hospital
in Dallas, Texas, as President John F. Kennedy is treated inside the hospital after being shot. (DTI/Photo courtesy of
John F. Kennedy Presidential Library and Museum, USA)

[37] =>

ca d/ca m 37

Dental Tribune Middle East & Africa Edition | March - April 2014
< Page 1
production to become vertical
rather than linear.
The current laboratory fabrication process follows a very linear
progression: model fabrication,
day one; waxing, day two; finishing, day three; ceramics, day
four, etc. Average production
time for an all-ceramic or porcelain-fused-to-metal restoration
is approximately five to seven
working days based on this fabrication method.
Fig. 2

toration files electronically has
provided the catalyst for a significant change in the way we
view and structure the dentist/
laboratory relationship.

Fig. 3

design—with the addition of the
latest developments in intra-oral
laser scanning, materials and
computer milling/printing technology—will only enhance the
close cooperation and working
relationship of the dentist/dental
laboratory team (Fig. 1).
The dental laboratory’s primary
role in restorative dentistry is
to perfectly copy all of the functional and aesthetic parameters
that have been defined by the
dentist into a restorative solution. Throughout the entire restorative process, from the initial
patient consultation, diagnosis
and treatment planning to final
restoration placement, the communication routes between the
dentist and the laboratory technician require a complete transfer of information.
Functional components, occlusal parameters, pho netics and
aesthetic requirements are just
some of the essential types of information that are necessary for
the technician to complete the
fabrication of successful, functional and aesthetic restorations.
Today, as in the past, the communication tools between the
dentist and the technician are
photography, written documentation and impressions of
the patient’s existing dentition.
The clinical models from these
impressions are created and
mounted on an articulator that
simulates the jaw movements of
the mandible (Fig. 2).
The digital laboratory
As restorative dentistry evolves
into the digital world of image
capture, computer design and
the creation of dental restorations through robotics, the dental laboratory must evolve as
well. To fully understand this
concept, a laboratory must be
clearly defined.
At first thought, it may seem that
a laboratory is the place where a
dentist sends his or her patient’s
impressions to (Fig. 3) be processed into restorations, which
are sent back to the dentist for
adjustment and delivery. This
definition fits well with the traditional concept of a laboratory/
dentist workflow.
However, just as the Internet has
forever changed the landscape
of communication through related computer technology, the
possibility to use CAD/CAM res-

In the digital laboratory, impressions will still be received from
the client. Instead of taking days
or weeks to go through several
processes, we will be able to accomplish the same process in
two to three days.

Imagine that the laboratory is
not a physical place, but exists
only in (Fig. 4) the talents of
those performing the restorative process: the dentist and the
technician. The equipment used
to create the restoration may
be located centrally, remotely
or both. The laboratory is essentially a workflow, which is
as flexible as the abilities of the
dentist, the technician and the
equipment will allow.
The primary decision becomes
where the handoff from one
partner to another should occur. The dentist, who has the
ability to optically scan teeth for
impression making and chooses
CAD/CAM restorations as the
best treatment option for his or
her patients, has enhanced freedom as to where the hand-off
to the technician should occur.
As a result, the laboratory is no
longer a place, it is rather to a
great degree, virtual.

Digital diagnostic
and treatment planning The basis for all long-term success in
restorative dentistry is a comprehensive diagnosis and treatment
plan. The ability to preview a
case from start to finish, communicate and co-diagnose with
other specialists and specialties
about dental patients via the virtual world is the true power and
capability of digital dentistry.

Fig. 4

About the author
Lee Culp, CDT, is the chief
technology
officer
at
DTI
Technologies, where he guides
the development of the DTI
digital technologies program
and its applied applications to
restorative dentistry. Lee is also
the editor in chief of Teamwork
and associate editor of Spectrum.
He is also on the editorial boards
of Practical Procedures and
Aesthetic Dentistry, Compendium
and Inside Dentistry. Culp’s
professional
memberships
include the American College
of Prosthodontics, American
Equilibration Society, American
Academy of Cosmetic Dentistry,
Academy of CAD/CAM Dentistry
and the American Prosthodontic
Society. Culp is an accredited
member of the American
Academy of Cosmetic Dentistry.

Fig. 5

The Proof is in the Numbers

Communication is key
The ability to facilitate communication between the dentist and
the lab is of utmost importance
and what makes the E4D system
stand out. Tools such as the E4D
Sky network enable E4D clinical
operators to communicate and
facilitate the transfer of data to
technicians whenever laboratory involvement is required.
With just a click, the entire case
(whether scanned or completely designed) can be sent from
chairside to the laboratory for
fulfilment of t9 dental professionals with basic knowledge of
dental anatomy and occlusion to
make modifications to the design, and then sends it through
to the automated milling unit.
For the dental lab profession,
the introduction of digital technology effectively automated
or even eliminated some of the
more mechanical and laborintensive procedures (waxing,
investing, burnout, casting, and/
or pressing) involved in the conventional fabrication of a dental
restoration, allowing the dentist
and technician the ability to create functional dental restorations with a consistent, precise
method.
Linear versus vertical manufacturing The successful laboratory
of the future will need to focus
not just on the quality of the end
product, but also more efficient
production methods to reduce
turnaround time within the
laboratory process. Digital technology will allow the laboratory

Once the impression is received
at the laboratory, the impression
can be scanned and data sent to
several digital production stations at the same time. This will
potentially allow the model, the
restorations (both framework
and waxup) and the final ceramic restoration to be completed at
the same time (Fig. 6).

Reduced Treatment Time*

Fewer Patient Visits*

Your All-inclusive Solution with customized brackets, wires and placement trays.
Optimize your practice with the award-winning Insignia™ Advanced Smile Design™
, providing
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• Delivers Precise and Predictable Outcomes
• No Inventory Costs
• Combine with Lythos Digital Impression system for Greater Savings and
More Streamlined Workflow
• Grow your Practice with Digital Technology

For more information please contact:
Tarek Haneya – Area Sales Manager
Tarek.haneya@ormcoeurope.com
Tel: + 971 56 1746 575

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Or contact your local distributor, list is availablesat

* Weber II, Dennis J., Koroluk, Lorne D., Phillips, Ceib, Nguyen, Tung, Proffit, William R.,
“Clinical Effectiveness and Efficiency of Customized vs. Conventional Preadjusted Bracket
Systems”, Journal of Clinical Orthodontics, Volume XLVII, No. 4 (2013): 261-266.

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[38] =>

38 n ews

Dental Tribune Middle East & Africa Edition | March - April 2014

Sirona Group receives another Top Employer Award
made significant gains in the
past two years.
Employee success stories

Fig 1: Sirona China is delighted to receive the Top Employer
China 2014 award and together with the other 40 winners, it’s
difficult to tell who is the happiest.

By Sirona

S

ALZBURG, Austria:
Since receiving the
Top Employer Awards
for Germany, Austria and Engineers in 2013,
Sirona’s excellent human resources policy and very good
working conditions have also
earned it international recognition in 2014. In an award
ceremony in Shanghai, Sirona China was given the “Top
Employer China 2014” award
in mid-January. The company’s German employees have
also been successful at the
Chinese site.

In a multi-phase analysis and
auditing process, the Top
Employer Institute (formerly
CRF Institute) designates outstanding employers around
the world every year. Some of
the key criteria include excellent working conditions, promoting talent, and continuous
development of human resource management. Sirona
China was given the highest
award “Top Employer China
2014” along with 40 other
employers. Michael Elling,
Vice President Corporate Human Resources of the Sirona
Group, expressed his satisfaction: “Our employees are the

Fig 2: Michael Elling, Vice President Corporate Human Resources
of the Sirona Group (2nd from right), Daisy Zhang, HR Manager
China (3rd from right) and Henning Müller, Vice President
Sales China, Hong Kong, South East Asia (1st from left), proudly
accepted the “Top Employer China 2014” award from the event
host (right).

heart of our company. The
Top Employer Award for Sirona China is an acknowledgment of our local and global
efforts to support our employees. It is part of our global
growth strategy, it increases
our attractiveness as employers, and it motivates our employees to work at Sirona in
Germany and abroad.”
Growth and development at
Sirona China
In 2006, Sirona began to develop the business in China
with just 30 employees. Today, eight years later, there

are more than 150 employees here – a success story,
also with respect to personnel development. “Employee
satisfaction is the basis of our
success at Sirona China. This
is why we find it important to
have an excellent team, promote team spirit, and motivate continuing development
among our employees. It is
rewarding to see how many
employees successfully climb
the career ladder,” explains
Henning Müller, Vice President China and South East
Asia. A strong growth that is
reflected in the market, Sirona China is the number one
company for dental treatment
chairs. Digital dentistry and
CAD/CAM products have also

Sirona offers many opportunities and promotes young
talent among students as
well. For example, the German student Verena Schütter
spent four months at Sirona in
Asia during her International
Business studies at BadenWürttemberg
Cooperative
State University. There she
became familiar with the international company and the
Shanghai location, and she
helped develop the Singapore
location that was opened in
November 2013. A career opportunity open to all employees at Sirona fostered by the
Talent Excellence Program
encompasses individual advanced training, project assignments across positions
and locations, and targeted
international postings and career advancement in one of its
worldwide subsidiaries.

Contact Information
Sirona Dental GmbH
Sirona Straße 1
A-5071 Wals bei Salzburg
Austria
P +43 (0) 662 / 2450-0
F +43 662 2450-109590
contact@sirona.com
www.sirona.com

< Page 35
pressure is applied on it.”
Also, the maintenance of
the device is care-free. The
mill’s own computer calculates the service life of the
tools, monitors wear and reports on them via the user interface. It also calculates the
time that milling will take
and lets the user know when
the tools or water should be
replaced. “Similar to a car, a
mill requires maintenance at
certain intervals and notifies
the user of this.”
An ideal solution also for
laboratories
For dental laboratories, Planmeca offers a comprehensive
solution utilising the open
STL file format. Planmeca
PlanScan® Lab scanner is
an accurate desktop scanner
utilising blue light for scanning gypsum models and impressions. The device scans
gypsum models fast and effortlessly with an accuracy of
15 micrometres.
Designing takes place in the
open Planmeca PlanCAD®
Premium laboratory software, which can be used for
the design of all prosthetic
pieces, ranging from onetooth units to full-arch structures. The software can also
be used to design individual
abutments, implant bridges
and bars for cemented and
screwed solutions.
Designing begins with de-

fining the margin line, after
which the path of insertion
is selected and the structure
designed. Several automatic
functions assist in the design
work, and as the design progresses, the software shows
the contact areas, material
thickness and distance to the
antagonist or adjacent tooth.
A diagnostic wax-up made in
the laboratory or anatomic
models saved in the software
can be utilised in the design
work.
The software has an Order
Manager page that brings efficiency to the workflow by
reporting the stage of each
work. In this way, several
work orders can be entered
in the software in one go. The
last phase is always saved in
memory so working can be
continued freely at the most
suitable time. In addition,
precise values can be set to
each work for the cement gap
and milling unit’s blade.
An open STL file is created as
a result of the design work,
and it can be manufactured
with all milling units supporting the open file format,
including
the
Planmeca
PlanMill® 50. This milling
unit can be used for the milling of all most common materials, excluding metals. In
addition, the open file can be
sent to a milling centre for
manufacturing, such as Plandent’s own PlanEasyMill™
milling centre.

[39] =>

speci a l 39

Dental Tribune Middle East & Africa Edition | March - April 2014

< Page 5
So saliva collected at a constant flow rate for 2 minutes
will have a different composition from saliva collected at
the same flow rate for 10-15
minutes.
• Nature of the stimulus –
Different stimuli have an effect on salivary composition,
mainly because of their effect on the rate of flow. Acid is
the most potent stimulus for
salivary secretion and leads
to production of an alkaline
saliva.

The buffering ability of saliva
Bicarbonate is the most important buffering system in
saliva but only at high flow
rates, when it is an important
buffer against acid produced
by dental plaque. Its concentration varies from less
than 1 mmol/l in unstimulated parotid saliva to almost
60 mmol/l at very high flow
rates, with whole saliva elicited by chewing gum having
a bicarbonate concentration

of about 15 mmol/l. Thus, in
unstimulated saliva, the level
of bicarbonate ions is too low
to be an effective buffer.

pH and a low salivary buffering capacity because of the
low bicarbonate concentration.

Additionally, salivary pH is
dependent on the bicarbonate
concentration, an increase in
which results in an increase
in pH. At very low flow rates,
the pH of parotid saliva can
be as low as 5.3, rising to 7.8
at very high flow rates. Individuals with hyposalivation
will thus have a low salivary

Conclusion
Saliva not only plays a pivotal
role in the maintenance of a
healthy homeostatic condition in the oral cavity, but
contributes to one’s overall
health and wellbeing. Components from saliva interact
in different ways with the
dentition to protect the teeth.
Patients who lack sufficient
saliva suffer from many oral
diseases, of which caries is
only one. To alleviate discomfort they are advised to
use saliva stimulants and
substitutes which have the
function of lubricating the
oral surfaces. Chewing gum
is increasingly being viewed
as a delivery system for active
agents that could potentially
provide direct oral care benefits, as it promotes a strong
flow of stimulated saliva.
The fourth edition of Saliva
and Oral Health is available
in hard copy or e-book format
at www.shancocksltd.com. A
full list of references is included in the book.
*Underwriting costs for this
Saliva and Oral Health edition were provided by Dr. Michael Dodds and The Wrigley
Company.

References
Dawes C. Physiological factors affecting salivary flow
rate, oral sugar clearance,
and the
sensation of dry mouth in
man. J Dent Res 1987; 66:
648-653.
2
Dawes C. Rhythms in salivary flow rate and composition. Int J Chronobiol 1974; 2:
253-279.
3
Ono K, Morimoto Y, Inoue
H, Masuda W, Tanaka T, Inenaga K. Relationship of the
unstimulated whole saliva
flow rate and salivary gland
size estimated by magnetic
resonance image in healthy
young humans. Arch Oral
Biol 2006, 51: 345-349.
4
Watanabe S, Dawes C. The
effects of different foods and
concentrations of citric acid
on the flow rate of whole saliva in man. Arch Oral Biol
1988; 33: 1-5.
5
Simons D, Brailsford SR,
Kidd EAM, Beighton D. The
effect of medicated chewing
gums on oral health in frail
older people: a 1-year clinical trial. J Am Geriatrics Soc
2002; 50: 1348-1353.
6
Dawes C. The effects of flow
rate and duration of stimulation on the concentrations of
protein and the main electrolytes in human parotid saliva. Arch Oral Biol 1969; 14:
277-294.
1

< Page 1
a broad range of products and
brands,” Van Duijnhoven said.

brands to local customers and
individual markets.

The group includes KaVo, Kerr,
Kerr TotalCare, Pentron, Axis,
SybronEndo, Orascoptic, Pelton
& Crane, Marus, DCI Equipment, Gendex, DEXIS, Instrumentarium Dental, SOREDEX,
i-CAT, NOMAD, Implant Direct
and Ormco. Their services and
products primarily serve the
general practitioner, dental specialist, hygienist, institutional
and special markets customers
in virtually every dental market
in the world, including North
America, Latin America, Europe, the Middle East, and the
Asia Pacific region.

According to Matt Garrett, vice
president of marketing for KaVo
Kerr Group, it will be presenting 20 new products in celebration of its formation at this year’s
Chicago Dental Society Midwinter Meeting, which is being held
until tomorrow.

Danaher also stated that each
company will continue to market itself under its current

Nineteen dental consumable, equipment,
high-tech and specialty companies have
formed KaVo Kerr Group. (Photo: baranq/
Shutterstock)

[40] =>

40 e n do tribu n e

Dental Tribune Middle East & Africa Edition | March - April 2014

Biological and conservative root canal instrumentation
with BT-Race file system

Fig. 1: Median canal diameters.

Fig. 2: Benefits of Race files.

Fig. 3: The BT and normal tip: localisation of the
cutting point.

Fig. 4: Efficiency of the normal tip and the BT in the
canal: the path of the tip, with a guide.

Fig. 5: BT-Race sequence.

Fig. 6: BT-Race XL for finishes at sizes 40 and 50.

By Drs Gilberto Debelian &
Martin Trope

Rooter, light up your work

LED
Ergonomic
and light

250 – 1200 rpm

Auto-reverse
disengage mode
10 presetable
torque/speed
programmes

FKG Dentaire SA
www.fkg.ch

FKG distributors, Middle-East and Africa
Algeria

Kuwait

Oman

Sri Lanka

MDI MAGHREB DENTAL INDUSTRY
contact@mdi-dentaire.com

MEDICARE CORPORATION
mcco@ecarekw.com

DUBAI MEDICAL EQUIPMENT
dt_uae@emirates.net.ae

RELIANCE TRADE AGENCIES
reliance@vinet.lk

Armenia

Lebanon

Pakistan

Syria

ALENDENT
info@alendent.am

DROGUERIE TAMER S.A.L
dental@tamerholding.com

WESTERN GROUP
kalimbaig@westerngroup.com.pk

DROGUERIE TAMER S.A.L.
dental@tamerholding.com

Egypt

Libya

Qatar

Tunisia

ONE DENTAL SOLUTION
info@onedentalsolution.com

ELRAJA PHARMACEUTICAL AND
MEDICAL EQUIPMENT TRADING
CO., LTD
elraja_dent_c@yahoo.com

DOHA MEDICAL
info@dohamedical.com

PROMOSCIENCES
promosciences@planet.tn

Reunion Island

United Arab Emirates

Morocco

ENDO TECH PLUS
endotechplus@sfr.fr

DUBAI MEDICAL EQUIPMENT
dt_uae@emirates.net.ae

Saudi Arabia

Turkey
TURAN UYSAL DIS MLZ. CHZL
ITHALAT
turanuysal@tnn.net

EIO EGYPTIAN IMPORT OFFICE
Egypt, contact_eio@alexandria.cc
India
CONFIDENT SALES INDIA PVT. LTD
cdelblr@dataone.in

DENTAL EXPRESS
dentalexpress@gmail.com

Iran

ABC DENTAIRE
slaoui@abcdentaire.ma

COMATE LTD
info@comate.com

MEHR TABAN CO
info@mehrtaban.com

Nigeria

South Africa

CHUBARAS ENTERPRISES
nicholas@chubaras.com

ACCESS DENTAL CC
roymarshall@icon.co.za

Jordan
ROSE DENT COMPANY
info@rose-dent.com

ACCESS DENTAL COASTAL CC
gavin@accessdentalcoastal.co.za

Uzbekistan
AP COMPANY
dentaluz@yandex.ru

oot canal instrumentation is one of the major tools for ensuring
the long-term success
of root canal therapy.1,2 The
aim is to mechanically disrupt as much biofilm as possible so that with the addition
of irrigants and/or intra-canal
medicaments a very low microbial count can consistently
be achieved before the filling
of the root canal. Another aim
or challenge of root canal instrumentation is to achieve
the microbial reduction goals
mentioned above without unnecessarily weakening the root
by over-instrumentation, for
example through the reduction
of the dentinal wall thickness.
Preservation of native structure, especially in the cervical
region of the tooth has been
demonstrated to correspond to
better long-term survivability
from a loading and restorative
standpoint. It is well established that as the remaining
dentine thickness decreases
so does the root’s resistance to
fracture.3
In evaluating anatomical studies, it is striking that they are
consistent. Figure 1 best summarises the anatomical aims for
a mandibular molar. The mesiobuccal and mesiolingual canals
are at the 1mm measurement
from the apical foramen, which
corresponds most closely to the
dentinocemental junction. In the
mesiodistal direction, the diameters are 0.21 and 0.28mm respectively, thus finishing at a 25

file would appear to be sufficient
when viewed on a periapical radiograph, since the mesiodistal
direction is what we see on the
radiograph. However, when we
look in the buccolingual direction, the correct files sizes are
between 35 and 40. For the distal
canal, a size 35 would appear adequate on the radiograph (mesiodistal view) but the correct size
would be 50.
In order to achieve the goals
mentioned above, we should
aim for 35, 40 or 50 apical sizes
with no more than a 0.04 taper.4–6
These biological sizes with the
addition of an adequate irrigation protocol will ensure a consistently low microbial count for
maximal success.
BT-Race system
BT-Race files (FKG Dentaire) are
sterilised in individual blisters
so that sterility is maintained
for every file. The biological
sizes mentioned above can be
achieved with three files every
time once a glide path has been
established. The system was designed in such a way that these
sizes are attained with minimal
removal of dentine coronally
to maintain the strength of the
root. Moreover, the Race file has
a non-screw-in design and triangular cross-section to increase
flexibility and cutting efficiency.
It is also electropolished to decrease the effects of torsional and
cyclic fatigue (Fig. 2).
The Booster Tip (BT; Fig. 3) is
the key feature of these files
however. It allows them to follow
curvatures in canals without undue stress on the file or the root.

> Page 41

[41] =>

Dental Tribune Middle East & Africa Edition | March - April 2014

en do t r i bu n e 41

< Page 40
The BT starts as a non-cutting
tip from 0–0.15mm diameter
and the cutting edges start from
0.15mm and upwards on the file
(Fig. 4). Essential steps for the
successful use of the BT-Race sequence are the following:
Glide path
In order to guarantee a minimal
number of file breakages, a glide
path to size 15.02 is essential.
Hand files can usually achieve
this aim. However, if a 6 or 10 file
is extremely difficult to take to
working length, ScoutRace files
allow one to achieve this requirement more quickly.
Speed of 800–1,000 rpm
A high speed reduces the risk of
breakage due to torsional fatigue.
As these files are for use with
individual patients only, the possibility of breakage from cyclic
fatigue is also reduced.
BT1 (10.06 file)
This file (Fig. 5) establishes the
final glide path and determines
the coronal diameter. In any canal in which a 15.02 glide path
has been established, the file will
contact mainly the coronal third
of the canal. At 12mm from the
working length, the diameter
will be 0.82mm.
These files have no BT, since the
tip diameter is already 0.10mm
and smaller than the glide path
established with a 15.02 K-file.
BT2 (parallel 35 file with BT)
The BT2 file (Fig. 5) is used to
prepare the apical third of the canal. It is extremely flexible owing

to its non-tapered design,
yet penetrates into the narrow canal easily and efficiently with the BT.
BT3 (35.04 file with BT)
This file (Fig. 5) is used to
join the coronal and apical
preparations created by the
BT1 and BT2 files and thus
create a 35.04 final shape
that allows maximal irrigation and a tight cone fit. The
file is able to go to working length with minimal
stress, since the coronal
third has been cleared with Fig. 7: Clinical case. (Courtesy: Dr. Gilberto Debelian,
the BT1 file and the api- Norway)
cal third with the BT2 file.
Importantly in this canal,
the maximum diameter
at the 12 mm level is 0.83
mm. Consequently, the removal of coronal dentine is
minimal, allowing for the
strongest root possible after
restoration.

Fig. 8: Clinical case. (Courtesy: Dr. Gilberto Debelian,
Norway)

BT-Race XL: BT 40 (40.04
file) and BT 50 (50.04 file),
600–800 rpm
These two instruments
(Fig. 6) enable finishes at
ISO 40 and 50 when adFig. 9: Clinical case. (Courtesy: Dr. Gilberto Debelian,
Fig. 10: Clinical case. (Courtesy: Dr. Gilberto
equate apical sizes require
Norway)
Debelian, Norway and Dr. Johan Ulstad, Norway)
larger sizes. If even larger
apical preparations than ISO 50 The BT ensures that the origiContact Information
are required, the Race range of nal canal shape is maintained,
instruments is recommended thus keeping even the larger files
in the required sizes, preferably centred in the canal. Through
For more information on the Dubai training center:
with a small taper of 0.02. With this advantage, in addition to
mea@fkg.ch or get in touch with your local FKG Dentaire
this unique file system, all canals the minimal taper required to
distributor, for all other enquiries:
FKG Dentaire SA
can be conservatively instru- achieve these biological sizes,
Crêt-du-Locle 4, 2304 La Chaux-de-Fonds, Switzerland
mented to the correct biological the canal is maximally cleaned
T +41 32 924 22 44, info@fkg.ch / www.fkg.ch
sizes while maintaining maxi- without weakening or stressing
mum cervical tooth structure. the root.

Biological &
Conservative

FKG Dentaire SA
www.fkg.ch

[42] =>

42 n ews

Dental Tribune Middle East & Africa Edition | March - April 2014

KaVo Dental GmbH:
Success at AEEDC
By KAVO

D

UBAI, UAE: For 3
consecutive days,
KaVo Dental GmbH
MEA took part in
the 18th Edition of AEEDC
Dubai 2014. We displayed a
brand new Patient simulator
for Universities that will be
launched in spring 2014 as
well as the complete range of
ESTETICA treatment units.
Guests were also invited to
gain valuable hands-on experience with the new Leica
M320 microscope with full
HD integrated camera with

KaVo DIAGNOcam

Mrs. Natalia Lebedeva, Commercial Manager for Leica
Microscopes.
And to further demonstrate
the high tech product range
of KaVo, the CAD/CAM systems, Arctica and Everest
were also showcased by our
product manager, Mr. Mohamad Abdallah, KaVo Dental
GbmH Middle East & Africa.
We also hosted several exciting lectures with Dr. HeinzTheo Luebbers, head of the
Dental Radiology Dpt. of the
University of Zurich; who
enlightened us about CBCT

technology. As part of our
dental imaging portfolio,
we showcased the Gendex
GXDP-700 3D machine with
Pan + Ceph, Pan + 3D, and
Pan + Ceph + 3D, options that
make it suitable for any dental imaging purpose.
In addition, Dr. Thorsten
Wegner from Germany introduced the DIAGNOcam
for modern caries detection
without X-ray, which has recently received an innovation award from the German
magazine “ZahnarztWoche”
and Pluradent”

The stand attracted the attention of a diverse crowd of
professionals in the dental
industry and it was a pleasure
for us to meet all of them.

Contact Information
KaVo Dental GmbH
Alexia Valera
9th Floor Rotana Arjaan Tower
Dubai Media City, UAE
Tel. +971 4 4332186
Mob. +971 56 1757141
E-Mail: alexia.valera@kavo.com
www.kavo.com/MEA

Mr. Anwar Dagher, Sales Director Middle East & Africa
KaVo Dental GmbH, Mrs. Ulrike Nagorr, Product Trainer
KaVo Dental GmbH, Ms. Alexia Valera, Sales & Marketing
Communication Manager Middle East & Africa KaVo Dental
GmbH

View of the stand

View of the stand

[43] =>

[44] =>

) [page_count] => 44 [pdf_ping_data] => Array ( [page_count] => 44 [format] => PDF [width] => 808 [height] => 1191 [colorspace] => COLORSPACE_UNDEFINED ) [linked_companies] => Array ( [ids] => Array ( ) ) [cover_url] => [cover_three] =>

[cover] => DT Middle East and Africa No. 2, 2014

[toc] => Array ( [0] => Array ( [title] => Handing over ceremony [page] => 01 ) [1] => Array ( [title] => CAD/CAM dentistry and the laboratory technician: Partners in success [page] => 01 ) [2] => Array ( [title] => Leading dental companies form KaVo Kerr Group [page] => 01 ) [3] => Array ( [title] => Brilliant technology for diagnostics: KaVo DIAGNOcam: A new look at caries [page] => 02 ) [4] => Array ( [title] => Saliva and Oral Health [page] => 04 ) [5] => Array ( [title] => Clinical and diagnostic advantages of PreXion 3-D imaging system [page] => 06 ) [6] => Array ( [title] => Clinical digital photography. Part 1: Equipment and basic documentation [page] => 08 ) [7] => Array ( [title] => Using Cone Beam (CBCT) in Implantology [page] => 10 ) [8] => Array ( [title] => Interview: Vanik Kaufmann explains the advantages of KaVo’s new ARCTICA CAD/CAM system [page] => 12 ) [9] => Array ( [title] => The Inman Aligner: A progressive approach to smile design - Part 2 [page] => 14 ) [10] => Array ( [title] => Philips Sonicare FlexCare Platinum [page] => 16 ) [11] => Array ( [title] => Case presentation: OptiBond™ XTR [page] => 17 ) [12] => Array ( [title] => Two phase treatment of a Class II division 1 patient complicated by traumatic upper incisor intrusion: A Case Report [page] => 18 ) [13] => Array ( [title] => Invisalign®: clear benefits for your patients [page] => 25 ) [14] => Array ( [title] => Periodontitis - Diabetes and Smoking [page] => 27 ) [15] => Array ( [title] => Get to Know the IFDH [page] => 28 ) [16] => Array ( [title] => Launch of Dental Hygienists Supplement in the Dental Tribune Middle East [page] => 29 ) [17] => Array ( [title] => Celebrating World Oral Health Day 20th March 2014 [page] => 29 ) [18] => Array ( [title] => Industry [page] => 30 ) [19] => Array ( [title] => News [page] => 33 ) ) [toc_html] =>

Table of contents

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