DT Middle East and Africa No. 6, 2014
Ten years of successful continuing dental education: 2005 – 2015
/ News
/ Utilizing the Tempcap abutment with CAD/CAM
/ The aesthetic challenge
/ News
/ Concepts - goals and techniques for successful orthognatic surgery
/ The importance of cementation: A veneers case using a new universal cement
/ Conservative approach to multidisciplinary aesthetic dental treatment
/ A multi-disciplinary approach to minimally invasive functional aesthetic dentistry
/ Qualident Dental Lab
/ 6th DENTAL FACIAL COSMETIC International Conference Dubai
/ CBCT and CAD/CAM allow for one-day restoration of Tooth #9
/ Porcelain laminate veneers – avoiding complications
/ Case report surgical correction of a class III malocclusion in an adult
/ Dental implant competitors shake things up amidst economic uncertainty
/ SameDay Dental Implants® & Teeth A Surgical & Prostho Protocol
/ Beirut International Dental Meeting 2014
/ Saliva and Oral Health
/ New 3Shape advisory board develops plan to improve patient care
/ Hygiene Tribune Middle East & Africa Edition
/ Lab Tribune Middle East & Africa Edition
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[1] =>
c
i
t
e
m nce
s
Co fere
l
cia Con
a
l F al
a
nt tion
e
th D
na
r
6 te
In
www.dental-tribune.me
Printed in Dubai
nternational Conference
10 years anniversary
ORGANIZED BY
DAR
Joint Meeting with
Ten years of successful
continuing dental
education: 2005 – 2015
ORGANIZED BY
UBAI
CO-ORGANIZERS
>Page 1, 18
pmea.com/cadcam9
E: events@cappmea.com
November-December 2014 | No. 6, Vol. 3
6th dental facial
mCME
14-15 November 2014
Jumeirah Beach Hotel
DUBAI, UAE
Utilizing the Tempcap...
& Concepts, goals and
techniques...
NOVEMBER 14-15, 2014
JUMEIRAH BEACH HOTEL
DUBAI, UAE
M: +971502793711
>Insertion
www.cappmea.com
>Page 6-7, 10, 11, 37-38
Ten years
of successful
continuing dental
education:
2005 – 2015
By Centre For Advanced
Professional Practices
D
UBAI, UAE: May 2015
will mark a significant
milestone in the history
of the Centre for Advanced Professional Practices (CAPP) in
Dubai. CAPP will be celebrating
its tenth anniversary of successful continuing dental education not only in the United Arab
Emirates but also across the
Middle East. Through the hard
work of its colleagues, sponsors,
partners and supporters, CAPP
has been able to establish first-
Celebrate the 10 th Anniversary at the Jumeirah Beach Hotel, DUBAI
class standards for continuing
dental education programmes
over the past decade. Participants and followers of CAPP
programmes have also helped
develop professional training
according to the needs of the region with their open feedback.
CAPP is an ADA CERP-recognised provider that specialises in
continuing medical and dental
education programmes (conferences, hands-on courses,
> Page 18
Health authorities offer Ebola guidance for dentists
By Dental Tribune International
A
TLANTA & CHICAGO,
USA: In close collaboration with the Centers for
Disease Control and Prevention
(CDC) and the Organization for
Safety, Asepsis and Prevention,
the American Dental Association (ADA) has released infor-
mation for dental professionals
on Ebola virus disease, which is
epidemic in West Africa. Among
other recommendations, it provides advice on the treatment of
patients recently returned from
the region.
CDC and its partners are currently working to help prevent
Ebola and other infectious diseases from being introduced
into and spread in the U.S. As of
> Page 5
[2] =>
2 NEWS
Dental tribune Middle East & Africa Edition | November-December 2014
Procter and Gamble Oral Care renews
endorsement partnership with the Lebanese
Dental Association in Beirut
GrOUP EDITOr
Daniel Zimmermann
newsroom@dental-tribune.com
+49 341 48 474 107
CLINICAL EDITOr
Magda Wojtkiewicz
ONLINE EDITOrS
Yvonne Bachmann
Claudia Duschek
COPy EDITOrS
By Crest & Oral-B
Sabrina Raaff
Hans Motschmann
B
EIrUT, Lebanon: During the 24th Beirut International Dental Meeting
(BIDM 2014), held under the
High Patronage of His Excellency the President of the Lebanese
Parliament, Mr. Nabih Berry, a
ceremony was organized to announce the renewal of the ofkCIAL PARTNERSHIP BETWEEN 0'
Oral Care and the Lebanese
Dental Association, LDA at Biel
Convention Center.
PUBLISHEr/PrESIDENT/CEO
Torsten Oemus
CHIEF FINANCIAL OFFICEr
Dan Wunderlich
BUSINESS DEvELOPmENT mANAGEr
Claudia Salwiczek
EvENT mANAGEr
Lars Hoffmann
mArkETING SErvICES
Nadine Dehmel
SALES SErvICES
Nicole Andrä
“Oral hygiene is a topic
that quite often is
overlooked”
EvENT SErvICES
Esther Wodarski
mEDIA SALES mANAGErS
Dr. Ashhad Kazi, Professional
& Academic Relations Consultant – AP representing Crest and
Oral B commented on the occasion: “The vision of Procter and
Gamble Oral Care is to improve
oral health of more people in
more parts of the world more
completely. This collaboration
with the Lebanese Dental As-
Prof. Maalouf, President of the Lebanese Dental Association with Dr. Ashhad Kazi, Professional &
Academic Relations Manager - AP for Crest & Oral-B
sociation is one of the initiatives
that we are proud of and keen
on sustaining.”
Professor Elie Azar Maalouf,
President of Lebanese Dental
Association (LDA), stressed on
the advantages of such a part-
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NERSHIP IN BENEkTING THE /RAL ACCOUNTING
Karen Hamatschek
Care segment in Lebanon. He Anja Maywald
ADDED g7E ARE SPECIkCALLY
thrilled about the unique ben- ExECUTIvE PrODUCEr
EkTS THAT THIS COLLABORATION BE- Gernot Meyer
tween the LDA and Crest and
DENTAL TrIBUNE INTErNATIONAL
Oral B will provide to the retire- Holbeinstr. 29, 04229 Leipzig, Germany
ment fund for dentists in Leba- Tel.: +49 341 48 474 302
Fax: +49 341 48 474 173
non.”
The ceremony took place in the
presence of the president and
members of the Saudi Dental
Syndicate, whereby Dr. Kazi presented Professor Maalouf with
the newest innovation from Kornberg, Germany, a Bluetooth
enabled Power Brush: The OralB White Pro 7000 that has just
been released in the UK.
info@dental-tribune.com
www.dental-tribune.com
rEGIONAL OFFICES
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THE AmErICAS
Tribune America, LLC
Dr. Kazi added, “Oral hygiene is 116 West 23rd Street, Ste. 500, New York,
a topic that quite often is over- N.Y. 10011, USA
looked and not given its due im- Tel.: +1 212 244 7181
portance in our daily lives, with Fax: +1 212 244 7185
newer oral care technologies
DENTAL TrIBUNE
now at our disposal, it can be a
mIDDLE EAST & AFrICA
GAME CHANGER IN THE kGHT FOR
maintaining good oral health. EDITION EDITOrIAL BOArD
Crest and Oral B have a long Dr. Aisha Sultan Alsuwaidi, UAE
history of high quality research Dr. Ninette Banday, UAE
Dr. Nabeel Humood Alsabeeha, UAE
as such, they offer a compre- Dr. Mohammad Al-Obaida, KSA
hensive line-up of toothpastes, Dr. Meshari F. Alotaibi, KSA
mouthwashes, toothbrushes and Dr. Jasim M. Al-Saeedi, Oman
lOSSES WHICH PROVIDE CONSUM- Dr. Mohammed Sultan Al-Darwish
ers with innovative, targeted Prof. Khaled Balto, KSA
Dr. Dobrina Mollova, UAE
solutions designed to meet all Dr. Munir Silwadi, UAE
GENERAL AND SPECIkC ORAL CARE Dr. Khaled Abouseada, KSA
Aiham Farah, CDT
needs.”
Dr. Rabih Abi Nader, UAE
Dr. George Sanoop, UAE
Retty M. Mathew, UAE
Rodny Abdallah, Lebanon
Victoria Wilson, UK
With this collaboration for the
second term, both Crest and Oral
B and the Lebanese Dental Association will not only be establishing more awareness about the PArTNErS
right routine for good oral hy- Emirates Dental Society
Saudi Dental Society
giene and its maintenance, but Lebanese Dental Society
ALSOPROVIDINGUNIQUEBENEkTSTO Qatar Dental Society
the retirement funds of dentists Oman Dental Society
in Lebanon.
DIrECTOr OF mCmE
Contact Information
KaVo Dental GmbH · Mobile +971 56 175 7141 · Phone +971 4 550 8600 · Fax +971 4 550 8781 · www.kavo.com/MEA
For more information contact:
Haneen Joudiyeh
PR Consultant
Impact Porter Novelli
h.joudiyeh@ipnbeirut.com.lb
Dr. Dobrina Mollova
mollova@dental-tribune.me
+971 50 42 43072
DIrECTOr
Tzvetan Deyanov
deyanov@dental-tribune.me
+971 55 11 28 581
DESIGNEr
Kinga Romik
k.romik@dental-tribune.me
[3] =>
SIRONA.COM
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Kuwait Contact: Sirona Dental systems GmbH, Dr. Mostafa Al. Khouly
Office: +965 2 224 6063, Mobile: +965 9 800 2225
[4] =>
4 news
Dental Tribune Middle East & Africa Edition | November-December 2014
“CEREC Desert Fest 2014” in Dubai, UAE
By Sirona
B
ENSHEIM,
Germany:
Sirona and the Centre for
Advanced
Professional
Practices (CAPP) organized the
first ever “CEREC Desert Fest”
connection between our knowhow and the experiences of
CEREC users in these spectacular surroundings. Professional
exchanges are important for the
advancement of digital dentistry.
We wanted to provide a stage for
“We can proudly say that the event was a great success” - Dr. Amro Adel, Area Manager GCC, & Pakistan, Country Manager Saudi Arabia, Sirona Dental
GmbH
Dr. Todd Ehrlich presenting his Summer of CEREC in
Dubai
Sirona presented the CEREC
Desert Fest for the first time at
The Palace Hotel Downtown
Dubai, a beautiful hotel located
in the city’s Old Town. More than
200 dental professionals took the
chance to share their aspirations
for Digital Dentistry and their
experience with Sirona’s CAD/
CAM system with dental colleagues from all over the world.
In addition to pioneer and future CEREC users, dentists and
dental technicians from the
UAE, professionals from Bahrain, Egypt, Greece, Iran, Iraq,
Kuwait, Lebanon, Oman, Qatar,
Saudi Arabia, Sudan and The
Netherlands attended the event.
Dr. Ninette Banday during the Chairside Indirect
Veneers, Inlays, and Onlays: A – to – Z Table Clinic
Presentation
Dr. Todd Ehrlich presenting Summer of CEREC Table
Clinic Presentation
with exciting discussions about
the newest insight in digital dentistry, real-time demonstrations
and an entertaining social program. The event held in Dubai
from September 12–13 was
aimed at both potential CAD/
CAM users and experienced
CEREC users.
Dr. Daniel Vasquez demonstrates the speed of the new
CEREC Software
The audience was well entertained at the CEREC Desert Fest in Dubai
“The guests clearly enjoyed this new
signature networking event.”
Dr. Josef Kunkela, CZ presenting CEREC meets SMILE DESIGN
Volker Vellguth, Vice President
Sales Russia, CIS, Middle East
and Africa at Sirona: “With the
CEREC Desert Fest we wanted
to establish and strengthen the
creative discussions for dental
professionals and the more than
200 guests took advantage of this
opportunity. We can proudly say
that the event was a great success for us and CEREC!”
The guests clearly enjoyed this
new and signature networking
event. Filled with entertainment,
panel shows, real-time CERECdemonstrations, desert safaris
and table clinic presentations in
a beautiful Arabian flavored ambiance in the heart of Dubai.
Dr. Daniel Vasquez, San Diego
“What a wonderful experience,
we had a great time. When I
started my presentation I asked
how can I bring Dubai to San
Diego or San Diego to Dubai;
it is simple, I made many new
friends and I hope I can stay in
the heart of many of the attendees and of course in all of you.”
Contact Information
Please visit the event’s website:
http://cerecfest.cappmea.com.
Open Discussion between Dr. Bernd Reiss, Germany, Dr. Todd Ehrlich, USA, Dr. Daniel
Vasquez, USA and Prof. Wael Att, Germany
“Professional exchanges are important for
the advancement of digital dentistry.”
The Panelists listening to questions from the audience
Exploring CEREC Omnicam with Dr. Daniel Vasquez Table Clinic Presentation
[5] =>
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 1
Oct. 17, the ADA advises dental
professionals of the following:
A person infected with Ebola is
not considered contagious until
symptoms appear. Owing to the
virulent nature of the disease, it
is highly unlikely that someone
with Ebola symptoms will seek
dental care when he or she is
severely ill. However, according
to CDC and the ADA Division
of Science, dental professionals
are advised to take a medical
history, including a travel history, from their patients with
symptoms in whom a viral infection is suspected.
As recommended by the ADA
Division of Science, any person
within 21 days of returning from
the West African countries Liberia, Sierra Leone and Guinea
may be at risk of having contacted persons infected with Ebola
and may not exhibit symptoms.
If this is the case, dental professionals are advised to delay routine dental care of the patient
until 21 days have elapsed from
their trip. Palliative care for serious oral health conditions, dental infections and dental pain
can be provided if necessary after consulting with the patient’s
physician and conforming to
standard precautions and physical barriers.
In general, providers of dental health care services should
continue to follow standard infection control procedures in
the clinical setting as described
in CDC’s 2003 Guidelines for
Infection Control in Dental
Health-Care Settings, the organization stated.
Signs and symptoms of Ebola
include fever greater than 38.6
C or 101.5 F and severe headache, muscle pain, vomiting,
diarrhea, stomach pain, or unexplained bleeding or bruising.
CDC emphasized, “The virus is
spread through direct contact
with blood and body fluids of an
infected person, or with objects,
like needles, that have been
contaminated with the virus.
> Page 36
news
5
[6] =>
6 mCME
Dental Tribune Middle East & Africa Edition | November-December 2014
Utilizing the Tempcap abutment with CAD/CAM
Combination of Tempcap, in-office CAD/CAM and e.max allows
for final restoration
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. Les Kalman, USA
T
he E4D in-office CAD/
CAM unit (Editorial note:
Planmeca E4D Technologies) has been employed in an
investigative laboratory study
to design and mill an unconventional IPS e.max restoration
that would be coupled with the
Tempcap as a final implant-supported crown. The combination
of the Tempcap, in-office CAD/
CAM procedures and IPS e.max
allows the clinician to create
an immediate final restorative
product with ideal characteristics.
The procedure is a simple, efficient and effective solution for
the restoration of implants.
Introduction
The temporization of a dental
implant following surgery, particularly in the anterior region,
is a necessary procedure. The
temporization allows for surgical healing, preservation of the
gingival architecture and, most
important, replacement of a
tooth in the edentulous space
for patient acceptance. Several
techniques for the temporization
exist, but the process has proved
to be time-consuming and frustrating. The Tempcap abutment
and the process for temporization were created to provide a
simple yet effective approach.1
With the advent of CAD/CAM
technology and e.max, the potential of the Tempcap to act as
a final abutment seemed likely
and suitable for investigation.
Background
Following the surgical placement of a dental implant, several requirements must be met
to maximize healing and osseointegration of the implant body
to bone:
– Minimal forces, if any, should
be exerted on the implant body,
permitting proper healing and
preventing a non-osseous union.2
– The gingival architecture must
be managed meticulously to prevent contamination, minimizing
the risk of peri-implantitis and
possible failure.3
– There must be sufficient time
for the process of osseointegration.4
– Temporization and immediate
restorations should not violate
these factors.5
Fig. 1. Tempcap abutment.
Fig. 5. Temporization form and function.
The Tempcap is a healing cap
and restorative platform combined (Fig. 1). It has an all-metal
construction, and it contains two
to three retentive pin projections
(Fig. 2). Tempcap is available in
different widths and heights to
accommodate different implant
sizes (Fig. 3) and is compatible
with existing instrumentation
(Fig. 4).
The function of the Tempcap is:
– to allow for optimal gingival
healing;
– prevent contamination of the
surgical field;
– minimize forces and microvibrations on the implant;
– facilitate the simple yet successful restoration of the implant
(Fig. 5).
CAD/CAM stands for computeraided design and computer-aided manufacturing. CAD enables
the individual to digitally capture
an image of a prepared tooth or
structure and then design an indirect (out of the mouth) restoration by using software.6
After the ideal restoration has
been produced, the design is
then fabricated out of a material
by a milling machine. In-office
Fig. 2. Retentive pins.
Fig. 6. Tempcap on soft-tissue model with
Ankylos implant (DENTSPLY Implants).
Fig. 9. Tempcap digitized.
Fig. 10_ Digitized delineation of Tempcap.
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.
E4D units (Editorial note: Planmeca E4D Technologies) are
currently available to allow for
immediate chairside fabrication
without the use of a commercial
laboratory.
IPS e.max (Ivoclar Vivadent) is a
relatively new metal-free dental
material used in indirect restorations. It is an aesthetic material composed of lithium disilicate and has ideal physical and
aesthetic properties, allowing it
to be the first choice for CAD/
CAM restorations. IPS e.max has
strength second only to gold and
has the ability of detailed CAM
production.7
Methodology
The Tempcap was selected and
placed on an Ankylos (DENTSPLY Implants) implant body (master cast with soft tissue) (Fig. 6).
Digitization was achieved by
using an E4D camera (Editorial
note: Planmeca E4D Technologies) (Fig. 7), in which several
images were captured to compile an accurate image (Figs. 8
& 9). CAD design was used with
E4D software (Editorial note:
Planmeca E4D Technologies) to
determine and delineate margins (Fig. 10).
Fig. 3. Tempcap with Straumann implant.
Tooth design was initiated incorporating several parameters:
– ideal aesthetics and emergence profile (Fig.11);
– adequate proximal contacts;
– appropriate occlusal scheme;
_material thickness requirements;
– internal surface morphology to
adapt to Tempcap;
– design that can be milled via
CAM technology.
Numerous design iterations
were required to achieve the desired design requirements (Figs.
12–14). IPS e.max was selected
for milling (Fig. 15) and was
executed by an E4D CAM unit
(Editorial note: Planmeca E4D
Technologies) (Fig. 16). Milling
limitations, such as bur contact
and prosthesis fracture, required
CAD design modifications. Reiterations in CAD/CAM design
were carried out until a successful restoration was achieved
(Fig. 17).
The unfired IPS e.max crown
was tried for fit and aesthetics and then subsequently fired
(Fig. 18), resulting in its colour
change. The crown was further
stained, glazed and fired (Fig.
Fig. 4. Use of existing instruments.
Fig. 7. Digitization with E4D camera
(Editorial note: Planmeca E4D Technologies).
Fig. 8. Digitized images of arch.
Fig. 11. Development of emergence profile.
Fig. 12. Occlusal view of restoration.
> Page 7
[7] =>
mCME
Dental Tribune Middle East & Africa Edition | November-December 2014
7
< Page 6
Fig. 13. Lingual view of restoration.
Fig. 14. Facial view of restoration.
Fig. 15. IPS e.max CAD/CAD block (Ivoclar Vivadent).
Fig. 16. E4D CAM unit (Editorial note:
Planmeca E4D Technologies).
Fig. 17. Milled IPS e.max restoration.
Fig. 18. Ivoclar furnace.
Fig. 19. Staining and glazing.
Fig. 20. Facial aspect of final restoration.
Fig. 21. Internal aspect of restoration.
Fig. 22. Final CAD/CAM IPS e.max
restoration.
Fig. 23. Ankylos implant with complex
Tempcap and milled IPS e.max crown.
Fig. 24. Internal aspect of IPS e.max
crown for three-pronged Tempcap.
The IPS e.max prosthetic crown was further assessed for fit,
taking into account
marginal fit, occlusion
and proximal contacts
(Fig. 22).
Fig. 25. Final implant-supported IPS
e.max crown with Tempcap.
19), resulting in a highly aesthetic final restoration (Fig. 20).
The restoration’s internal aspect
(Fig. 21) was assessed for path of
insertion, retention and fit.
A secondary investigation utilized a more
complex Tempcap to assess the
limit of the CAD/CAM unit’s capability. A stand-alone Ankylos
(DENTSPLY Implants) implant
body was coupled with a Temp-
mCME SELF INSTRUCTION PROGRAM
CAPP together with Dental Tribune provides the opportunity with
its mCME- Self Instruction Program a quick and simple way to meet
your continuing education needs. mCME offers you the flexibility to
work at your own pace through the material from any location at any
time. The content is international, drawn from the upper echelon
of dental medicine, but also presents a regional outlook in terms of
perspective and subject matter.
Membership:
Yearly membership subscription for mCME: 600 AED
One Time article newspaper subscription: 200 AED per issue.
After the payment, you will receive your membership number and
Allowing you to start the program.
Completion of mCME
•
m
CME participants are required to read the continuing
medical education (CME) articles published in each issue.
Each article offers 2 CME Credit and are followed by a quiz
•
Questionnaire online, which is available on http://w w w.
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cap abutment with three retentive pin projections (Fig. 23). The
abutment was digitized with the
same methodology as described.
An IPS e.max crown was executed and assessed (Figs. 24 & 25).
Discussion
This study has determined that
the Tempcap can be successfully and accurately digitized
and milled by in-office CAD/
CAM technology (Editorial note:
Planmeca E4D Technologies) to
create an ideal prosthetic crown
from IPS e.max within a laboratory setting. CAD software can
be manipulated to generate
forms beyond the scope of the
unit.
Complex units, such as the
three-pronged Tempcap may
be successfully designed and
milled. IPS e.max has the capability to be milled in complex
patterns, while still maintaining
its structural integrity.
However, further laboratory
studies, quantitatively assessing
stresses and strengths and utilizing a larger sample size, are
required to validate the concept.
Subsequent clinical investigations are required to assess the
clinical significance and viability
of the Tempcap with CAD/CAM
technology. The potential to
fabricate the Tempcap entirely
from e.max should also be considered.
Articles are available on w w w.cappmea.com after the publication.
For more information please contact events@cappmea.com or
+971 4 3616174
Conclusions
In-office CAD/CAM technology
can be utilized and manipulated
to generate digitized forms beyond the scope of the morphogenesis. CAM manufacturing
has limiting factors that must be
realized when producing modified prostheses. CAD modifications must account for these
discrepancies. IPS e.max has the
ability to be milled in extremely
detailed designs.
FOR INTERACTION WITH THE WRITERS FIND THE
CONTACT DETAILS AT THE END OF EACH ARTICLE.
The Tempcap can be optically
scanned and digitized in order to
The answers and critiques published herein have been checked
carefully and represent authoritative opinions about the questions
concerned.
design and create a CAD/CAM
IPS e.max restoration using E4D
technology. The utilization of the
Tempcap as a successful provisional abutment has been documented1; the utility of the abutment as a simple, efficient and
cost-effective component seems
promising. These advances simplify the procedure and reduce
the cost, ultimately allowing a
greater accessibility for both patients and clinicians.
Editorial disclaimer: Dr Les Kalman is the co-owner of Research
Driven and the inventor of the
Tempcap.
This article was originally published in implants CE magazine
1/2013.
References
1. Kalman, L. Technique for the
temporization of an anterior implant. Dentistry Today. 2011. Vol.
30, No.10: 128–130.
2. Mijiritsky, E., Mardinger, O.,
Mazor, Z. and Chaushu, G. Immediate provisionalization of
single-tooth implants in freshextraction sites at the maxillary
esthetic zone: up to six years follow-up. Implant Dentistry. 2009.
Vol. 18, No.4: 326–330.
3. Mijiritsky, E. Plastic temporary
abutments with provisional restorations in immediate loading
procedures: A clinical report.
Implant Dentistry. 2006. Vol. 15,
No. 3: 236–238.
4. Romanos, G. Bone quality
and the immediate loading implantscritical aspects based on
literature, research, and clinical
experience. Implant Dentistry.
2009. Vol. 18, No. 3: 203–206.
5. Vela-Nebot, X., RodriguezCiurana, X., Rodado-Alonso, C.
and Segela-Torres, M. Benefits
of an implant platform modification technique to reduce crestal bone resorption. Implant
Dentistry. 2006. Vol. 15, No. 3:
313–318.
6. Berlin, M. Wowing the patient with chairside CAD/CAM.
Dental Economics: 2008; 98(4):
92–96.
7. Ivoclar Vivadent: IPS e.max
lithium disilicate: The Future of
All-Ceramic Dentistry. 2009;
1–15.
> next mCME on page 10
About the Author
Dr Les Kalman, DDS, graduated
from the University of Western
Ontario with a doctor of dental
surgery degree in 1999. He then
completed a GPR at the London
Health Sciences Centre. He has
been involved in general dentistry within private practice
since 2000. He has served as the
chief of dentistry at the Strathroy-Middlesex General hospital.
In 2011, he transitioned to fulltime academics as an assistant
professor at the Schulich School
of Medicine and Dentistry. Kalman’s research focuses on medical devices, including the Virtual
Facebow and the Tempcap. Kalman is also the Director of the
Dental Outreach Community
Services (DOCS) program, which
provides free dentistry within the
community.
Dr Kalman has authored articles ranging from pediatric impression to immediate implant
surgery in both Canadian and
American journals. He has been
a product evaluator for several
companies, including GC America and Clinician’s Choice. Dr
Kalman is the co-owner of Research Driven, a company that
deals with intellectual property
development. He is a member
of the American Society for Forensic Odontology, International
Team for Implantology, Academy
of Osseointegration, American
Academy of Implant Dentistry
and the International Congress
of Oral Implantology. He has
been recognized as an Academic
Associate Fellow (AAID) and
Diplomate (ICOI). In his spare
time, Kalman enjoys photography as an accredited MotoGP
photojournalist.
He can be contacted at:
man@uwo.ca.
lkal-
[8] =>
8 clinical
Dental Tribune Middle East & Africa Edition | November-December 2014
The aesthetic challenge
By Dr. Mohamed El Sayed
Hassanien, Egypt
P
atient’s satisfaction has always been the main goal
achievement of dental
professionals particularly with
esthetics. As the popularity of
esthetic dentistry increases, a
growing number of patients are
seeking treatment for improvement of unaesthetic anterior
dentition.
Accordingly several treatment
options have been proposed to
restore the pleasant esthetic appearance that the patients are
always seeking.
Based on the conservative approach and minimal invasive
dentistry protocols, ceramic
laminate veneers have been introduced to satisfy the patients
growing esthetic demands.
Many construction techniques
have been utilized in the dental
market whether directly or in directly to fabricate ceramic laminate veneers.
CAD/CAM being state of the
art dental technology offers lots
of merits for both the clinician
Figure 3
Figure 1
Figure 2
Figure 5
Figure 6
and the patient. Being a chair
side same day procedure, utilizing intra oral scanning avoiding
conventional physical impressions, and long-term provisional
restorations thus producing an
esthetic all-ceramic restoration
with highest degrees of accuracy
and precision.
Case presentation
A twelve year girl, medically
healthy, denies taking any medi-
Figure 4
Figure 7
Figure 8
Figure 9
cations visited my clinic complaining of fractured upper two
central incisors Fig. 1 & 2. After
clinical and radiographic examination, which revealed complete
root formation, two ceramic veneers for both central incisors
were proposed as a treatment
Figure 10
option to solve her complaint.
Tooth preparation
Tooth preparations were made
using the depth-guided diamond wheel no. 018 to indicate
the facial reduction amount of
0.4 mm for both teeth. The labial
diamond bur no. 016 was used to
complete the preparation on the
labial surface and precisely reproduce the cervical finish line
located just below the free gingival margin Fig. 3.
Incisal preparations were made
with type two-veneer preparation design ending with a butt
joint on the Incisal edge and
not involving the palatal wrap
around.
Finally finishing bur no. 014 was
used to finish and smooth all the
preparation surfaces Fig. 4.
All teeth preparations were
made with loupes of magnification 2.5 X for better precision.
CAD/CAM fabrication steps
In lab SW 4.2.3 was used to scan,
design and mill these two veneers.
The case was administrated as
two veneers on tooth number 8
and 9; with the bio-generic individual design technique, materials were selected from Ivoclar
Vivadent Empress Cad Fig.5.
Intra oral scanning
Sirona Omnicam was used to
scan the upper, lower and buccal catalogues to formulate the
3D virtual colored model. Margins were determined for each
tooth separately and insertion
axis were determined depending on their corresponding path
of insertion.
Virtual design
The virtual design was proposed
with the SW, both veneers were
virtually linked as a group so
they were both virtually active.
The bio generic variation tool
was used to give the best morphological proposal to match
with the adjacent teeth. The
Grid tool was used to show the
veneers proportions to ensure
Figure 11
that the two veneers showed
similar length to width relations
Fig.6.
With the two veneers linked, restoration virtual translucency tool
was used to check the amount of
ceramic extension in relation to
the underlying tooth preparation
Fig.7.
SW 4.2 showed a new colored
model tool, which enables the
operator to see both veneers
with the same color match for
more valid size comparison
Fig.8.
Shade matching
Visual shade matching was used
for this case. Where the adjacent
sound teeth showed A1 shade.
Empress Cad blocks being a
Lucite reinforced ceramic material was chosen for this case
with a low translucency in order
to mimic the adjacent shade of
the teeth. Try in stage was done
for the patient before glazing to
check for proper seating and accuracy of the margins.
Glazing and characterization
Both veneers were seated properly with the object to fix putty
material for better handling during glaze and stain process.
Empress Cad paste glaze was
the material of choice for glazing the two veneers. In order to
match the adjacent teeth, Empress Cad white stain was used
on the middle and Incisal areas
in a scattered pattern with a thin
brush to give the natural white
stain effect. Single cycle was
used for staining and glazing together Fig.9
Cementation procedures
• Ceramic veneer surface treatment:
HF 4 % Empress etching gel was
> Page 30
[9] =>
NEWS
Dental Tribune Middle East & Africa Edition | November-December 2014
KaVo MASTERsurg LUX Wireless:
Redefining the best
tal surgeons, no matter what
their different individual needs
are, will find the perfect solution for their surgical work. The
KaVo MASTERsurg surgical unit
convinces through outstanding
comfort. It is offering a wireless
foot control, allowing the user
a great freedom of movement.
The data documentation function supports procedure by real
time displaying of the torque
and other important digital data
and saving it concurrently.
MASTERsurg
By KaVo
W
ith the successful
launch of the EXPERTsurg LUX surgical unit
and the SURGmatic instruments
KaVo recently celebrated its
comeback as a main player in
the dental surgery field. As one
of the world market leaders the
dental company now presents
another highlight: The MASTERsurg LUX wireless surgical
unit. Thereby KaVo confirms its
market position as a leading and
innovative international dental
player.
The new KaVo MASTERsurg
now completes the attractive
KaVo surgical portfolio and
redefines surgical standards.
Therewith all dentists and den-
Nobel
Biocare
to join
Danaher
dental
business
By Dental Tribune International
Z
URICH,
Switzerland/
CHARLOTTE, N.C., USA:
Today, Danaher, a US
health care conglomerate of
brands from various industries,
and Swiss dental manufacturer
Nobel Biocare announced that
the two companies have entered
into a definitive transaction
agreement. In order to further
expand its global dental business, Danaher has offered to
buy Nobel Biocare, which is the
second-largest supplier of dental
implants worldwide, for CHF2
billion (US$2.1 billion).
As reported by Dental Tribune
ONLINE earlier this year, Nobel
Biocare confirmed that it had
been approached at the end of
July by third parties with a potential interest in acquiring the
business. Now, the company’s
board of directors has unanimously decided to recommend
that Nobel Biocare’s shareholders accept the offer, which in-
> Page 35
KaVo MASTERsurg makes it
real: a customizable surgical
unit that adapts to dentists’ and
dental surgeons’ individual requirements. E.g. multiple programs, each with up to 10 treatment steps, maximum speed,
maximum torque and even
more parameters can individually be defined and saved.
The new INTRA LUX S600 LED,
one of the lightest and smallest
surgical motors in the world,
enables to work with high power
and precision.
When it comes to performance
and comfort, KaVo continues to
set the benchmark with the EXPERTsurg and the MASTERsurg
controllers, the SURGmatic instruments (now available with
hexagon clamping system with
optimized head gearing) and the
INTRA LUX S600 LED motor. All
these components combine to
a system for dental surgery that
is not only easy to use but that
provides save and highly precise tools for dentists and dental
surgeons to face their daily challenges.
Scan & Discover
Contamct 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
ORTHOPANTOMOGRAPH®
OP300 Maxio
A new member of the legendary product family
Precise positioning
Automatic Dose Control (ADC)
Five field-of-views (FOV)
Low Dose Technology™ (LDT)
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Professional software tools
www.instrumentariumdental.com
9
[10] =>
10 mCME
Dental Tribune Middle East & Africa Edition | November-December 2014
Concepts, goals and techniques for successful
orthognatic surgery
mCME articles in Dental Tribune have been approved by:
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.
HAAD as having educational content for 2 CME Credit Hours
CAPP designates this activity
for 2 CE credits.
DHA awarded this program for 2 CPD Credit Points
By Dr. Theodore D. Freeland,
USA
I
n this article, you will be introduced to the concepts,
goals and techniques needed to diagnosis surgical cases,
when surgical cases should
be started and how to gain the
knowledge needed to create
successful results.
We’ll delve into joint status, softtissue analysis, surgical treatment objectives, pre-treatment
surgical setups and surgical
setups. We’ll then follow-up
by looking at the concepts of
natural head position, the axishorizontal plane and the true
vertical line will be introduced.
By the end of this article, you
should have:
– An overview of the knowledge
needed for successful treatment.
– An introduction into what,
when and how to perform successful cases.
– An overview of joint health.
– A summary of the soft-tissue
analysis.
– An outline of the surgical treatment objective.
– An overview of diagnostic and
surgical setups.
Remember that this article is an
introduction only; it’s not intended to teach you how to do surgical cases. Advanced training will
be needed to master successful orthognathic surgical cases.
So with no further ado, let’s get
started.
Joint status
Starting with the first area, you
need to know the joint status. Is
the joint healthy, is it degenerating, is there a disc problem? This
means you’ll need to apply not
only a good clinical exam, but
also articulated models that can
measure the difference between
centric occlusion and centric relation.
Soft-tissue analysis
You’ll need to know how to analyze the soft tissue. You’ll need
this because you are looking
at everything from a soft-tissue standpoint, or put another
way, you’re recording the basic
measurements that come from
soft tissue, not hard tissue. If you
deal with hard tissue only, then
you will come up short in the
soft tissue. Ignoring the soft tissue will result in a face that’s not
improved, just different.
Surgical treatment objective
You need to know how to do a
surgical treatment objective.
You’ll need to know the technique, and you’ll need to know
how to apply it because the surgical treatment objective allows
you to treat the face, the occlusion, in a two-dimensional medium.
Functional occlusion
The goal is to obtain functional
occlusion. Before treatment, you
have to determine if you have an
orthognathic surgery case. You
don’t want to begin orthodontic treatment with the idea that
if orthodontics fails, we will do
surgery.
Pre-surgical
setup/surgical
setup technique
Once you have established what
you’ll need to do from the surgical treatment objective, you will
need to do what we call a presurgical setup. Otherwise you’ll
need to apply the knowledge
you’ve gained from the patient,
soft-tissue analysis and the surgical treatment objective, and
perform a three-dimensional
workup to make sure what you
have planned will work with the
joints, muscles and nervous system.
You’ll see in Figures 1–3 that this
case involves every facet of dentistry. Changes occurred not only
in the facial features, but also in
the teeth themselves. It involved
orthodontic and orthognathic
surgery, but also lengthening
the front teeth by the restorative
dentist to achieve the natural
smile in balance (Figs. 1-2). To
this end, we need to look at five
areas:
Surgery
Finally, you need to know surgery. I recommend that the orthodontist be in the operating
room so you know what the surgeon is doing, and how the surgery goes. It’s very important to
know that the surgeon gets the
joints seated in a passive manner. If the joint is stressed, then
there’s a good chance that we’ll
have some surgical relapse.
– joint status,
– soft-tissue analysis,
– surgical treatment objective,
– pre-surgical setup/surgical
setup technique,
– surgery.
Joint status
Joint analysis will include three
portions: history, a clinical examination and imaging.
We’ll give you a brief overview
of the goals for each of the areas,
then do an in-depth look into
each of them individually.
Building a history will be similar to traditional patient assessment. We need to know if there
are any family members who
exhibit TMJ problems. If yes,
then there’s a good chance the
patient will develop significant
Fig. 1a. Patient profile.
Fig. 1b. Patient frontal.
Fig. 1c. Patient oral casting.
Fig. 2. Joint degeneration.
Fig. 3. A state of degeneration: a condyle that is
actually changing.
joint issues that will affect the
outcome of treatment.
After an oral investigation, a
thorough clinical examination
of the joints will need to occur.
We’ll be on the lookout for any
type of injuries to the mandible.
If the patient has had any injury
that involves the chin, there’s a
good chance that the joint may
have been damaged.
Finally, we need to look into any
past treatment. Has the patient
had orthodontics before? Has
the patient had a lot of restorative dentistry? This is important
because all of the above have a
tendency to affect joint status.
Clinical examination
Next is the clinical examination.
Clinical examination includes
the following:
– range of motion,
– symmetry of jaw motion,
– palpation,
Fig. 4. Overlaid soft tissue on top of hard tissue.
– auscultation,
– muscle splinting,
– CR position.
Range of motion should be between 45 mm and 55 mm on
opening and includes assessing
movement. We’re looking for
a symmetrical mandible motion — meaning the chin should
not deviate to the left or right on
opening — and it should be relatively free of dental interference.
Now check for palpation of the
muscles of mastication. If you
don’t check the muscles that
move the mandible, then there’s
a good chance that you’ll miss
some sort of functional bite issue.
We also listen to the joint with a
stethoscope, and we apply some
anterior pressure to the disc
through external auditory meatus to make sure the disc is functioning properly.
When trying to manipulate the
mandible, one can feel the muscles. If the muscles will not let
you obtain a centric joint position, then we cannot do a diagnosis because the muscles aren’t
holding the condyle out of the
socket. This is usually due to
some inflammation.
Finally, we’ll check what we
call the centric relation position,
which you should be able to feel.
It should feel solid and the patient should be able to open from
this position with relative ease,
and there should be no noises.
Imaging
The clinical examination will
tell us a lot about the joint status.
The use of imaging will help us
build our base of case-specific
intelligence. We’ll use two types
of imaging: MRI and cone beam.
> Page 11
[11] =>
mCME 11
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 10
LCBCT
Most of the time, we start with
cone beam because it’s easy to
obtain a 3-D image of the joints.
Thanks to the work of Rickets
and Dr Ikeda, we have a way to
measure joint position and get
an idea if the condyle is basically
seated. With cone beam, we can
measure the health of the condyles.
Our imaging showed a joint that
is in a state of degeneration. The
condylar head has changed in
vertical height. Therefore, we
would expect to see an asymmetrical opening where the chin
deviates to the affected side. In
all three views (saggital, coronal
and axial), we have a condyle
that is actually changing, especially when you make a comparison to the left condyle (Fig. 3).
In a side-by-side presentation,
you can see that the left side is
definitely in a lot better shape,
having a more rounded effect to
it. The size of the coronal view
is one that shows a definite symmetric outline to it as compared
to the other side. The axial view
confirms this; you see that the
shape is better and has a more
dense outline.
Thus, our basic imaging system
helps us determine that, in this
case, one side is going to be the
problem side, especially as it
pertains to orthognathic surgery.
If we go to the two-dimensional images created in the cone
beam, we can see that the right
joint has definitely lost vertical
height, and we definitely have
a joint spacer that is excessive
(Figs. 4 & 5).
In the coronal view, we can even
see that there may be some sort
of cyst formation. When you
compare the right side to the left
side in the coronal view, you get
a more traditional image, which
is what we’d like to see. However, there have been some changes that have occurred, because
we’re starting to see a “birdbeaking” effect in the left joint.
The images of the joint are ones
that are important in determining if we should proceed with
any kind of a surgical correction.
In the saggital view, the right
side, the joint looks pretty normal. However, if we look at it in
a transverse direction, you’ll see
less joint space laterally than you
do medially, something we see
in both the left and right joints (a
much bigger joint space). That’s
why it’s important that you not
only look at a saggital view,
but you also need to look at the
coronal view to see if you have
a transverse problem occurring
in the joints.
Soft-tissue analysis
When we’re trained in orthodontics, we’re trained in hardtissue analysis, otherwise all of
our cephalometric analysis are
based on hard structures. If you
use hard structure to determine
soft-tissue corrections, then
you’ll come up short of good facial aesthetics. That’s why a softtissue analysis is so important
Using soft-tissue markers with
3-D facial mapping, we are able
Fig. 5. Establishing the true vertical line
based on natural head position.
Fig. 6. Glabella to subnasale (SN).
Fig. 7. Establish the horizontal position.
Fig. 8. Surgical treatment objective.
Fig. 9. Completed the extrusion of the maxillary segment and balanced the occlusal
plane.
Fig. 10. Establishing the true vertical line.
to diagnose the soft tissue, and
we can also relate it to the hard
tissue.
In Figure 4, we’ve overlaid the
soft tissue on top of the hard tissue. With the markers on, after
we convert it to a two-dimensional X-ray, we can see where
the sub-pupal area is, where the
cheekbones are and where the
alar base is. In addition, you will
see a marker that we call a hinge
access marker, which comes
from establishing the true hinge
axis of the patient. There is also
a marker that’s placed on the
nose that we call the horizontal
point.
We are going to analyze everything from a basic coordinate
system of a true vertical to an
axis horizontal.
The image is orientated from
the axis horizontal plane and
the true vertical plane, which is
based on the patient’s natural
head position.
Figure 5 shows how these two
corners are at 90 degrees from
each other. In this analysis,
we’re going to record all the softtissue measurements, both horizontal and vertical, and we’re
going to base them on the line
that runs through the subnasale
(SN). This establishes the true
vertical line based on natural
head position.
Furthermore, we’re including a
few hard-tissue measurements
that will tell us about the architecture of the mandible. These
come from Rickets and from the
Jarabak analysis. With this analysis, we can cover the basis that
we need for orthodontics, but we
can also cover what we need in a
surgical workup.
We also need a frontal analysis,
which is taken from the patient’s
face. Most of the frontal workup
is done in examining the patient
clinically. This enables us to look
at the orbital rim, cheekbone,
sub-pupil, alar bases, nasal bases and canthus of the eyes.
All of this enables us to assess
if we have transverse asymmetries, where the occlusal
plane is canted instead of level.
This also holds true with the
mandibular plane, which we
may also find is canted. This is
especially true in cases where
there’s a degenerative process
happening in one joint.
articulator. This allows us to orientate the CBCT data with the
articulator mounting.
Head position, profile and
frontal analysis
The natural head position is
different for each individual
patient. This will make the distance recorded for Glabella to
the true vertical line different.
In the example we are using, the
patient has a mandible that has
an architecture problem, which
causes her to occlude only on
the molars with an anterior open
bite.
To measure how far Glabella is
from SN (true vertical line), we
first need to establish the patient’s natural head position (Fig.
6). To do so, we have the patient
stand in front of a mirror. First,
the patient is asked to close his
eyes and bob his head up and
down three times.
After this is complete, the patient is asked to open his eyes
and look himself directly in the
eyes in the mirror. After we have
established the natural head position, we then use the measurement gauge. Our goal is to make
sure the leveling bubble is in the
lines. This will allow us to take a
measurement from the true vertical line to Glabella.
Keep in mind that everybody’s
head position is a bit different.
The further that Glabella is from
the true vertical line will affect
how we look at the lower third
of the face.
Now we need to establish the
axis-horizontal plane (Fig. 7).
First, we establish the horizontal
position using the ear bow. We’ll
use the pointer on the ear bow to
make a mark on the nose when
the bow is level.
We have previously established,
through axiopath tracing, the
hinge axis position on the patient’s right and left sides. In
combining the horizontal point
with the two axis points, the
axis-horizontal plane can be established. The axis-horizontal
plane is then transferred to the
Now we have the true axishorizontal plane and the true
vertical line combined, and now
facial, skeletal and functional issues can be assessed.
This is precisely the kind of case
where you should be looking for
degenerative joint disease. All of
the above enables us to establish
the parameters and coordinates
we need to analyze the face and
occlusion and then apply the
correct treatment so the patient
will have a functioning stable
occlusion with the necessary facial improvements.
Soft-tissue analysis
The treatment objectives are
based on the soft tissue. You perform the surgical treatment objective in this order.
1) Establish the position of the
upper lip to the true vertical line
in a vertical and horizontal manner.
2) Determine what you need to
do with the anterior teeth to create the correct upper lip position.
3) Once you established the anterior part of the maxilla, then
proceed to the posterior part of
the maxilla and determine if you
need to do an intrusion or extrusion of the posterior segments to
level the occlusal plane.
In most cases where there’s a
retrusive chin and a skeletal
open-bite, the patient has an occlusal plane, measured from the
true vertical line that is somewhere between 102 and 108 degrees. By leveling the occlusal
plane, based on the anterior
tooth position, you can set the
mandible to the maxilla. This
will usually balance the lower
third of the face. If you still find
the chin is too far forward or too
far back, you may need to do
genioplasty.
In the example case (Fig. 8), we
have performed a surgical treatment objective, established the
true vertical line and we have
our axis-horizontal plane. In
this patient, we need to move
the anterior teeth up because in
the frontal analysis the patient
showed too much tooth structure and too much gingival tissue. To fix this, we balance the
maxillary anterior teeth based
on the upper lip position.
Once we’ve established the correct tooth position in the anterior, we’re able to set up our
occlusal plane at 95 degrees,
showing us what we need to do
with the posterior segment. In
the example case, we need to
extrude the posterior segment.
Figure 9 shows how we’ve
completed the extrusion of the
maxillary segment, and we’ve
balanced the occlusal plane.
The next objective is to place
the mandible with the correct
overbite. This is not 2 mm but 4
mm. This is because you want
to have an adequate overbite to
create adequate disclusion. In
establishing the mandible, you
can see in our example how the
lower part of the face is placed
normally enough with the true
vertical line (Fig. 10).
In establishing the surgical treatment objective, we see that we
want to place the anterior section in the superior direction and
the posterior in the inferior direction. These are all the measurements we need to establish a
surgical setup. Hopefully, this is
performed pre-treatment so the
patient has a good idea of what
needs to be done.
Pre-surgical and surgical setups
The pre-surgical and surgical
setups are techniques that do
require the clinician’s time. It’s
> Page 37
[12] =>
12 CLINICAL
Dental Tribune Middle East & Africa Edition | November-December 2014
The importance of cementation:
A veneers case using a new universal cement
By Kerr
E
sthetic options in dentistry are the prevailing
choice of most patients
today. Veneers and bleaching
in particular have become buzzwords in popular culture, and
TV sitcoms, film and magazine
advertising have turned these
cosmetic techniques into household names. As a result, dental
teams must accommodate the
demands of their patients, becoming highly versed in placing
metal-free restorations.
Practitioners can find a multitude of educational articles and
courses teaching the science
and technology of porcelain, zirconia and composite. But while
emphasis is frequently placed
on the final prosthesis or direct
restoration, often overlooked
are the increasingly important
auxiliary materials that contribute equally to the clinical success of these new materials and
restorations: impression and
provisional materials, bonding
agents and cements. Education
is imperative because cementation and bonding are two areas
of esthetic dentistry that have
evolved through generations
of products and techniques.1
These processes are essential
in making esthetic restorations
both functional and comfortable.
That’s why veneering can be an
optimal, conservative alternative
to crowning teeth, since preservation of tooth structure is important to dentists and patients
alike. The highly esthetic results
are due to the fact that ceramics have a translucent finished
surface texture similar to that of
natural enamel.2 Dentists, assistants and lab technicians spend
vast amounts of time and effort
perfecting veneers and avoiding fracture through painstaking preparation, material and
shade selection, fit and fabrication. Yet even after such arduous
processes, clinical failure and
patient dissatisfaction can readily occur with errors in cementation.
Cementing veneers is a delicate
process with a historical litany
of potential problems – color
instability, insertion difficulty,
handling and cleanup issues,
unsatisfactory radiopacity, low
translucency after curing, mismatch between try-in gels and
final cements, and debonding, to
name a few. Cement selection in
certain applications necessitates
knowledge of the chemistry and
physical properties of the particular cement type, and insertion
requires an exacting technique
for successful clinical results.3
This article outlines a veneer
case using NX3 Nexus® Third
Generation—a new, universal
cement from Kerr. The subject
is a long-standing patient-of-record with a current radiological
and medical chart. This focus is
on the steps and techniques implemented at final cementation
of the prostheses.
Clinical Case
A female patient in her midfifties presented a chief complaint of being unhappy with her
smile. An examination of her
hard tissues revealed immediate
concerns of multiple fractures,
hypocalcification, shortened anterior teeth due to wear and an
asymmetrical smile line (Figures 1 and 2).
After proposing a first phase
treatment plan to restore all of
her compromised upper anterior teeth, the patient consented
to restoring only teeth numbers
6-11. The patient ultimately
qualified for and accepted veneers as the mode of indirect
restorative treatment.
Prior to preparation, the tissue
around tooth No. 8 was recontoured. Then, the teeth were
prepared for pressed ceramic
veneers and provisionalized
in the standard manner. Occlusal analysis and adjustments
were performed over a period
of weeks and the veneers were
tried-in. After the requisite steps
were completed preceding insertion and the veneers were
finalized, the provisionals were
removed and the teeth were
cleaned (Figure 3).
Expasyl™ was used for gingival retraction and hemostasis
in order to gain cervical access
and control bleeding in that area
(Figure 4).
The teeth were then etched
for 15 seconds with Kerr Gel
Etchant, which is composed of
37.5% phosphoric acid (Figure
5), and then rinsed and slightly
air-dried. (Note: While a totaletch technique was used, NX3
works with both total-etch and
self-etch protocols, adding to the
distinctiveness of the product.)
Per manufacturer directions,
OptiBond Solo™ Plus (Kerr) was
brushed onto to the tooth surfaces for 15 seconds (Figure 6),
air-thinned for 3 seconds, and
cured for 10 seconds using the
L.E. Demetron II curing light
(Kerr) (Figures 7 and 8).
After etching and bonding, the
veneers were cemented using
NX3 light-cure cement in the
clear shade (Figure 9). The cement was dispensed directly
onto the internal surface of the
veneer and was expected to
ooze from all margins when the
veneers were placed onto the
prepared teeth. With the choice
of either the single-syringe
light-cure veneer cement or the
dual-syringe dual-cure resin,
the light-cure method was used
because the veneers were not
inordinately thick. NX3 allows
veneers to be cemented all at
once (as opposed to cementing
centrals first, laterals second,
and so on) because of its unique
“thixotropic” properties, which
enable them to stay where they
are placed prior to light-curing.
This feature makes adjustments
and proper placement easier
while decreasing the need to adjust the veneers interproximally
if space is needed once they are
cured.
Figure 1: Pre-op
Figure 2: Anterior upper pre-op
Figure 3: Temps off-teet #232DC4
Figure 4: Expasyl-preven #232DC3
Figure 5: Kerr etch
Figure 6: Optibond Solo Plus
Figure 7: Curing Solo Plus
Prior to final curing, the restorations were spot-cured for
several seconds to allow the
excess cement to be cleaned
(Figure 10). The veneers then
were light-cured for 40 seconds
per surface (Figure 11). (Note:
Figure 8: Cured bonding agent
Figure 9: Veneers w NX3 #232DB6
Figure 12: Final shot-da#232DC8
Figure 13: Post-op
Manufacturer instructions allow
for 10-second cures with the L.E.
Demetron II. In this case, however, the doctor’s discretionary
use was 20-second cure times.)
Occlusion was adjusted using a
fine diamond bur and the lingual aspects of the teeth were
finished and polished using
CeraGlaze® Porcelain Polishing
System (Axis Dental), rendering
a very satisfied patient (Figures
12 and 13).
Conclusion
Cementation is an important
aspect of functional aesthetics.
An understanding of chemistry,
technology and physical properties are all essential to proper usage and clinical success. Cement
selection was the driving factor
in choosing the bonding system
for this case. NX3 Nexus® Third
Generation cement is free of
amines—organic
compounds
containing nitrogen as their
key atoms—which were largely
blamed for the colour shifts so
prevalent with earlier cement
formulations. In an earlier use of
the product the cement proved
to be “thixotropic,” the consistency of non-drip paint; the restorations were seated and adjusted
before curing with no dripping
or running. Color stability, easeof-use and cleanup, color match
and optimum retention are
some of the attributes necessary
when choosing a cement—NX3
met all of these expectations.
References
1. Kugel G, Ferrari M: The science of bonding: from first to
sixth generation. J Am Dent Assoc. 2000 June;131 Suppl: 20S25S.
2. Touati B, Miara P: Light transmission in bonded ceramic restorations. J Esthetic Dent 1993;
5:11–18.
3. Sheets C, Taniguchi T: Advantages and limitations in the use
of porcelain veneer restorations.
J Prosthet Dent 1990; 64:406–
411.
About the Author
Figure 10: Cleaned cement#232DC7
For more information, kindly visit the first dedicated Middle East website for Kerr Corporation
www.kerrdental.ae.
Dr. Mitch Conditt, a 1985 graduate of Baylor College of Dentistry
in Dallas, TX, lectures internationally and has published numerous articles reviewing all aspects of restorative and cosmetic
dentistry.
Figure 11: Cleaned cement#232DC7
[13] =>
Aesthetics 13
Dental Tribune Middle East & Africa Edition | November-December 2014
Conservative approach to multidisciplinary aesthetic
dental treatment
Tooth (#)
13
12
11
21
22
23
Length (mm)
9.1
6
8.5
9.8
Missing
9
Width (mm)
7.4
4
8.2
8.5
Spaces
By Kostis Giannakopoulos, Greece
T
he aesthetic performance
of dental restorations has
always been a factor of
utmost importance in the success or failure of the treatment.
Lately, as aesthetic awareness
of the population increases and
the evolvement of dental materials have made new techniques
possible, optimal aesthetics can
be achieved following less invasive restorative procedures.
In many cases, multidisciplinary treatment is necessary so
that the best possible outcome
is achieved with a minimum
degree of compromise between
invasiveness and aesthetics.
Every complex case should be
treatment planned by a team of
specialists, so that every detail
and limitation from each point
of view is taken into account.
The restorative dentist usually
designs the smile and oversees
each phase of the treatment by
all other specialists.
Congenitally missing lateral
incisors are a common dental
problem that can be esthetically
dealt in three different ways1:
1. canine substitution, 2. tooth
supported restoration, and 3.
implant supported restoration.
Tooth auto transplantation (usually premolar) and removable
partial dentures are other, less
commonly applied treatment
options. In the case of only one
lateral incisor missing, an additional problem of symmetry
between the right and left side
usually exists and needs to be
addressed.
Peg shaped lateral incisors pose
another aesthetic problem2 that
is usually restored with as follows:
1. all ceramic crowns, 2. porcelain veneers, and 3. direct or
indirect composite veneers. Additional to the inadequate width
and length of the peg shaped lateral, many times there is also a
gingival aesthetic problem that
can lead to a square looking
restoration and too much gingival tissue display if not properly
treatment planned with either
orthodontic intrusion or gingivoplasty/gingivectomy before
the restoration is fabricated.
In this article, a case is reported of a young patient with one
congenitally missing and one
peg shaped lateral incisor. The
patient was treated with a combination of orthodontics, periodontal surgery and aesthetic
– restorative dentistry interventions.
Case report
A 22 year old Caucasian female
presented to the clinic asking
for aesthetic improvement of
her smile. The patient was single and a student of law school.
The medical history was unremarkable with no pathologies
and no known allergic reactions
reported to any kind of medica-
tion. No medications were taken
on a systematic basis by the patient. The dental history was also
unremarkable with only preventive and minor operative dentistry interventions and prophylaxis
in the past. The patient mentioned a history of congenitally
missing teeth in her family.
The chief complaint of the patient was spaces between the
teeth and specifically the missing upper left lateral incisor
tooth, the irregularly shaped
upper right lateral incisor, and
the diastema between teeth #11
and 21. Also, she was concerned
about asymmetries in her smile
and misalignment of her teeth.
Finally, the patient stated she
would like to have a brighter
smile (Figures 1-3).
The dental examination revealed no pathological findings
or signs of dental disease. The
DMFT was low and the comprehensive periodontal examination was within normal limits;
soft tissue examination resulted
in no pathological findings; radiographic bitewing examination
revealed no pathological findings as well.
The aesthetic evaluation of her
smile resulted in the following
issues that would need to be addressed in the treatment plan: 1.
peg shaped lateral incisor #12, 2.
congenitally missing lateral incisor #22 with diastema between
#11 and 21, 3. dental midline
transmitted to the right by 4mm,
4. asymmetry between the left
and right side, especially in the
space between 11-13 and 21-23,
5. gummy smile, especially on
the area of #12 and the missing
tooth #22, and 6. the gingival zenith was asymmetrical between
#11 and 21 (Figures 4-6, Table
1). The occlusion was Class I.
The base shade of the teeth was
A3 on the upper central incisors
and A3,5 on the upper canines
with the Vita Classic shade guide
(Vita Zahnfabrik, Bad Sackingen, Germany).
Photographs and alginate impressions were taken in the
exam appointment to fabricate
study models. Then the team
of aesthetic/restorative dentist,
orthodontist and periodontist
treatment planned the case. The
recommended treatment plan
was accepted by the patient in
favor of the alternative treatment plans.
Orthodontic phase
The orthodontic treatment goals
were as follows: 1. intrude #11
to align the incisal edges of the
centrals, 2. equalize the spaces
between #11-13 and #21-23, 3.
transfer the dental midline to
the left, and 4. correct misalignments and minor rotations in
different areas. Some composite
resin was bonded on the facial
surface of tooth #12 to facilitate
bracket placement. The composite was white in shade to
Notes
13 - 11: 7.1mm
7.5
23 - 21: 2.7mm
23 - 24: 2mm
Peg Shaped
Dental midline
Overerruption
1.4mm incisally 4mm right
Ging. zenith
3.3mm incisally
to 21
Table 1. Teeth and spaces between them were measured. The proportions of the teeth (length to width
ratio) and the arrangement of the spaces are crucial information in treatment planning, especially
in patients with a high lip line.
Figure 1 - 3: The unaesthetic smile of the patient before treatment.
Figure 4 - 6: Retracted view of the teeth before treatment. Note the peg shaped #12, the missing #22
and the asymmetry of the spaces between teeth #11-13 and 21-23.
Figure 7 - 9: Photographs of the patient during the orthodontic phase of the treatment.
> Page 16
[14] =>
14 Aesthetics
Dental Tribune Middle East & Africa Edition | November-December 2014
A multi-disciplinary approach to minimally invasive
functional aesthetic dentistry
Case report
A patient presented complaining that “his two front teeth [old
upper anterior crowns] felt as
if they were too large and were
always hitting the lower teeth”.
In addition, his bite never felt
“right” (Figure 1). He also wanted to try to improve the appearance of his teeth. He was aware
of what could be done with porcelain veneers, but wanted to
Examination
On inspection, it was clear there
were several issues:
1. Occlusion - The irregular
alignment of the lowers and
the thickness of the upper old
crowns were adding to the problem of unbalanced anterior contacts. The back of the crowns,
especially the upper left central,
were hitting the front of his lower teeth, in particular the lower
left central.
A heavy, not long centric contact was present in MIP, which
was causing slight deflection
of the central. This meant that
the upper central crown had
been placed quite labially and
because it was metal ceramic,
made it feel particularly thick.
2.
Thickness/aesthetics
of
crowns - The occlusion meant
that the upper crowns had been
placed quite labially and because they were metal ceramic,
made them feel particularly
thick. They also appeared rather
opaque.
Alternative options
Alternative options were discussed. Fixed braces were discounted because of the cost,
the difficulty in simultaneous
whitening and added difficulty
in having the crowns as temporaries through treatment. The
patient’s posterior occlusion was
also good. Full anterior veneers
were discussed, but after the
patient understood how simply
and quickly the alignment could
be done, seemed a completely
ridiculous and unethical solution.
Figure 1. Close view before.
Figure 2. Crowns removed.
Figure 3. Temps in place.
Figure 4. Lowers before.
Figure 5. Lowers after 7 weeks.
Figure 6. Retraction before.
Figure 7. Retraction with temps.
Figure 8. Retraction after emax
crowns.
Figure 9. Side close before.
Figure 10. Side close after.
By Dr. Tif Qureshi, UK
S
imple tooth alignment is
rapidly becoming accepted
as the norm in cases that
previously would have been
treated with porcelain veneers.
However, patients often present
with a mix of problems such as
previous metal ceramic work,
the treatment of which should
be integrated as part of the treatment plan. Timing becomes a
vital part of the treatment when
mixing restorative care, alignment, tooth whitening and oc-
clusal planning. The following
case illustrates an effective approach to treatment.
try to make the best of his own
teeth.
3. Lower crowding - The patient was also keen to improve
the aesthetics of the lower teeth
as the incisors had an irregular
outline. The incisal edges appeared to be of different heights.
This was down to the varying
anterior-posterior position.
4. Colour - The old crowns had
been made at A3/A3.5 and the
natural teeth had darkened a little with age.
Treatment plan
A combination of techniques
and good timing can make sure
we optimize the opportunity for
treatment. In this case, the treatment plan was as follows:
1. Remove the two upper crowns
and replace them with temporary composite crowns;
2. Simultaneously fit a lower Inman Aligner to align the lower
incisors into a better functional
position, while using bespoke
clear aligners to slightly tilt the
uppers into better alignment.
The rationale for using upper
clears and a lower Inman was
that only 1 mm of movement
was needed for the uppers and
about 2.5mm of movement was
required for the lowers. Inman
Aligners are much faster than
clear aligners with these kinds of
movements. And 2-3 clear aligners can be just as quick with very
small movements of 1 mm and
be a little more cost effective if
made bespoke. It would also allow us to treat both arches more
or less simultaneously.
3. Whiten the teeth (during last
phase of alignment). 4. Change
the composite temps to all ceramic crowns to match.
5. Retain the lower arch.
Our aim was to try to treat these
multiple issues simultaneously
so that treatment could be completed over a few months.
Treatment
On the initial appointment the
two old crowns were removed
(Figure 2). The preps were
merely cleaned and treated as
conservatively as possible. Temporary crowns, which could be
adjusted, were placed (Figure
3). Upper and lower impressions
were taken for upper clear aligners and for a lower Inman Aligner. A prescription of the tooth
movement using SpacewizeTM
software was given to the technician so they were aware of exactly where we wanted the teeth
to be moved. Spacewize also calculates a figure for the amount
of crowding present giving us an
idea of the total amount of space
that would need correcting and
whether the case is suitable for
Inman Aligners or not.1
Two weeks later, the patient returned. The Inman Aligner and
clear aligner were fitted on the
lower and upper teeth respectively. Minimal interpromixal
reduction (IPR) was started.
Despite knowing how much we
are likely to need, with Inman
Aligner treatment, we never
complete all the IPR in one go.
Despite calculating the amount
of crowding present, the IPR is
never carried out in one go. Only
IPR strips or discs are used. This
gives the opportunity to ensure
the stripping is far more anatomically respectful than using
burs or heavy discs. This massively reduces the risks of excess
space formation, gouging or
poor contact anatomy. No more
than 0.13 mm per contact on the
anterior teeth were adjusted on
this single visit. The contacts are
smoothed and fluoride gel is applied each time.2-9
> Page 15
[15] =>
Aesthetics 15
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 14
Figure 11. Upper occlusal before.
Figure 12. Upper occlusal after.
Figure 16. Side smile after.
Figure 17. Side smile after closed.
The patient was then sent home.
The Inman Aligner was worn for
16-20 hours per day with the patient removing it for eating and
rest. 20 hours a day is the maximum needed wear and this intermittent wear reduces the risk
of root resorption.10,11 On return
2 weeks later, it was clear that
the contacts had closed tight and
the teeth had moved a little.
tic technician. The temporary
crowns were removed and new
IPS e.max HT (Ivoclar Vivadent)
crowns were bonded using Variolink II (Ivoclar Vivadent) and
OptiBond FL (Kerr). The occlusion against the aligned lower
teeth was checked. The patient
was extremely happy with the
end result and felt his teeth
looked natural (Figures 6-12).
More IPR was carried out on
both the uppers and lowers.
The occlusal contacts of the
upper temporary crowns were
adjusted to allow clearance for
the lower teeth to move and
the lower left lateral to advance
particularly and the patient was
then sent away again for 2-3
weeks. The temporaries were
also facially contoured to ensure
they were flush with the natural
teeth. On the subsequent return
visit, it was clear that the teeth
were aligning rapidly and especially well (Figures 4 and 5).
We then decided to start some
simultaneous tooth whitening.
Impressions were taken, even
though the result was still 25%
from completion. Sealed, rubber trays were made and careful
instructions given to the patient.
While the patient is concentrating on using the Inman Aligner,
they are always highly receptive to using bleaching trays. It
adds greatly to motivation and
often means they achieve a far
better result. DayWhite from
Oral Healthcare (Formely Discus Dental) is used so that the
patient only needs to wear the
bleaching trays 35-45 minutes
a day.
Discussion
The case is another example
of why a progressive form of
smile design can be so essential
in any case where a patient is
looking to improve their smile.
At every point, the patient sees
their smile improving, first with
alignment and then with whitening. If they are still keen to have
full ceramics, then at least the
teeth are straight and light, so
less invasive and more translucent veneers can be used. More
often than not, patients prefer a
more natural result where we
make “their own teeth look as
good as they can”. In a case like
this with previous metal ceramics, one can see how integrating
alignment, and whitening can
enhance aesthetics and simplify
restoration dramatically. This
makes a stable and aesthetically
pleasing outcome far easier to
achieve (Figures 13-17).
The patient returned after another 3 weeks and was happy
with the degree of whitening
achieved. Upper and lower
alignment was now complete.
An impression was taken for a
lower retainer wire to be fitted
later. The temporary crowns
were removed, the preps
cleaned with CHX and new impressions were taken after some
minor adjustments to the buccal
margins.
A new lower impression was
taken of the final lower occlusion to ensure the crowns could
be made with a good long centric contact. The temps were
replaced and impressions sent
to the laboratory. The patient
booked in for a shade one week
later and two weeks after cessation of bleaching where colour
and tooth morphology was explained and discussed with the
patient. Two weeks later, the patient returned. A retainer wire1215
was bonded to the lower incisor teeth using a preformed wire
on a jig made by the orthodon-
Conclusion
In each of our practices, there
must literally be hundreds of
patients who have issues similar
to this gentleman’s complaint.
Previously, conventional solutions often placed a barrier to
treatment, adding time and cost
into what was already an expensive treatment. Most patients
just could not be bothered and
would live with it. Now, simple
anterior alignment can be so
much quicker and more cost effective. I’m amazed at the sheer
volume of patients who will
have treatment like this done if
they are suitable. Being able to
combine whitening because the
aligners are removable is just
another bonus so we can capitalize on the patient’s current compliance and get an even better
result. Of course, case selection
is absolutely vital! Understanding what is treatable and what
should be referred to a specialist orthodontist is essential. This
means that patients must be
fully consented and understand
the risks and disadvantages of
not treating any posterior issues
if just concentrating on anterior
alignment.
Disclosure
Dr Qureshi runs courses with Dr
James Russell and Dr Tim Bradstock-Smith and lectures on the
Figure 13. Lower occlusal before.
Figure 14. Lower occlusal after.
Figure 15. Side smile before.
Inman Aligner worldwide.
6. El-Mangoury N, et al. In vitro
remineralization after air-rotor
stripping. J Clin Ortho 25 (2):7578,1991.
7. Radlanski R.(1991) Morphology of interdentally stripped
enamel 1 year after treatment.
J Clin Ortho 23 (11) 748-750,
1991. 8. Heins PJ. The relationship of interradicular width and
bone loss. J Periodont 59 (2):7379,1988.
9. Tal H. relationship between
the interproximal distance of
roots and the prevalence on intrabony pockets. J Periodont 55
(10):604-607 1984
10. Inactivated periods of constant orthodontic movement
forces related to desirable tooth
movement in rats. T. Kameyama
et al. Tokyo Medical and dental
university, Tokyo, Japan. For information contact the author at
Kame.orts@tmd.ac.jp
11. Apical root resorption in upper anterior teeth :Brita Ohm
Linge and Leif Linge.The European Journal of Orthodontics
1983 5(3):173-183; doi:10.1093/
ejo/5.3.173 © 1983 by European
Orthodontic Society.
12. Reprinted: Case CS. Principles of retention in orthodontia.
Am J Orthod Dentofacial Orthop
2003;124(4):352-61.
13. Little RM, Reidel RA, Artun
J. An evaluation of changes in
mandibular anterior alignment
from 10 to 20 years post retention. Am J Orthod Dentofacial
Orthop 1988.
14. (6) Blake M, Bibby K. Retention and relapse: A review of the
literature. Am J Orthod Dentofacial Orthop 1998;114:299-306.
15. Becker A, Goultschin J. The
multistrand retainer and splint.
Am J Orthod 1984; 85:470-4.
Acknowledgements
The author thanks Inman Aligner Certified Laboratory, Pearl
Healthcare, Hampton, Victoria;
Donal Inman CDT and the Inman Orthodontic Laboratory;
Nimrodental Inman Aligner Lab,
London; Tony Knight at Knight
Dental Design; and Middle East
Dental Laboratory, Dubai.
References
1. Hancher P Orthodontics for
Esthetic Dentistry Part 1. Journal of Cosmetic Dentistry Winter
2005 (20) 4.
2. Sheridan, J.J.: Air-rotor stripping update. J. Clin. Orthod.
21:781-88, 1987.
3. Sheridan, J.J.; Ledoux P.M.:
Air-rotor stripping and proximal
sealants: an SEM evaluation. J.
Clin. Orthod. 23:790-94, 1989.
4. Crain, G.; Sheridan, J.J.: Susceptibility to caries and periodontal disease after posterior
air-rotor stripping. J. Clin. Orthod.24:84-85, 1990.
5. Sheridan, J.J.: Hastings, J: Airrotor stripping and lower incisor
extraction treatment. J. Clin. Orthod.26:18-22, 1992.
Contact Information
Dr. Tif Qureshi is Immediate Past
President of the British Academy
of Cosmetic Dentistry. He has a
special interest in minimally invasive cosmetic dentistry and
presents hands-on courses and
lectures on the Inman Aligner
worldwide.
Dr. Tif Qureshi teaches Inman
Aligner Training.
Inman Aligner courses can be
booked at:
www.inmanalignertraining.com
For course info visit:
www.inmanalignertraining.com
or email: inman@mdentlab.com
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[16] =>
16 Aesthetics
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 13
make it easier to distinguish and
completely remove it after the
orthodontics was completed. After treatment, the goals set were
accomplished (Figures 7-9).
Surgical phase
As stated previously, the dental
team decided to align the incisal edges of #11 and 21 and
not intrude further #11 to align
the gingival zeniths. This decision was based on the fact that
Figure 10: After removal of the
orthodontic devices the spaces
are properly distributed. Note
the gingival asymmetries.
Figure 11: Immediately after
the periodontal surgery the gingival improvement is apparent.
the teeth showed no signs of
wear, in which case the worn
tooth would be intruded more
to be back in its original prewear position and then would be
treated restoratively. The goals
of the periodontal surgery were:
Figure 12: CBCT radiograph
verifies that there is not adequate bone to place an implant
and a GBR procedure would be
needed.
Figure 13: After ZOOM whitening the smile appears significantly brighter.
Figure 14: An e.max press crown
and an e.max press Maryland
type all ceramic bridge with
wings are fabricated.
Figure 15 - 17: The smile of the patient after completion of the treatment appears significantly improved
esthetically.
Figure 18 - 21: Retracted and palatal view of the case completed.
1. align the gingival zeniths of
teeth #11 and 21, 2. gingivectomy with osseous reduction on
#12 to reduce as much as possible the gingival display without
compromising the long term
prognosis of the tooth due to loss
of periodontal support, 3. gingivectomy in mostly all the upper
teeth to bring the gingival display to a more pleasing appearance. After surgery, a healing
period of 8 weeks was recommended by the periodontist before the restorative procedures
start (Figures 10, 11). The option
of a single implant placement
for the missing lateral incisor
#22 was rejected before surgery,
as an additional bone grafting
procedure would be required
and this was not accepted by the
patient (Figure 12).
Aesthetic/Restorative phase
Six weeks after the periodontal
surgery, in office whitening was
performed so the patient’s desire
for brighter teeth is met (Philips
Zoom, Philips Oral Healthcare,
Stamford, USA). The shade of
the teeth 10 days after the whitening was completed was A1 for
the upper centrals and A2 for the
canines (Figure 13).
After proper healing of the periodontal tissues was confirmed
with the periodontist, tooth #12
was prepared for an all ceramic
lithium disilicate crown and
teeth #21 and 23 were prepared
for an all ceramic lithium disilicate Maryland type bridge with
wings (e.max, Ivoclar Vivadent,
Schaan, Lichtenstein). The latter
was selected because of the conservative approach and the minimal preparation required only
on the palatal surfaces of the
abutment teeth, as the occlusion
was favorable and the patient
had no parafunctional habits.
This type of restoration appears
to be a viable solution in selected cases, as it does not have the
problems of the conventional
Maryland bridge with frequent
debondings and the metal showing through thin and translucent
central incisors. After gingival
retraction with a retraction paste
(Astringent Retraction Paste, 3M
ESPE, Seefeld, Germany), a final
impression was taken with polyether heavy and light body impression material (Permadyne,
3M ESPE, Seefeld, Germany)
on a full arch metal tray. The
bite registration was recorded
and an alginate impression was
taken of the opposing dentition.
Temporization was performed
conventionally for #12 with an
adjusted and relined prefabricated acrylic crown and for the
abutment teeth #11 and 23, with
spot etching in the middle of the
preparations and clear from the
margins and pink composite so
it could be distinguished easily
when removed before try-in so it
did not affect the sit of the restoration. A temporary for #22 was
added in the Essix orthodontic
retainer after a denture tooth
was fitted on the model and
glued in the retainer.
After the restorations were fabricated (Figure 14) and the temporaries were removed, they were
tried in and the fit and contacts
were verified. Another try in
was performed with a glycerin
based paste (KY Jelly) so that
the shade, contour and surface
texture were assessed and approved by the dentist and the patient. At the same appointment
the restorations were bonded
after the porcelain was etched
with 9% hydrofluoric acid and
silanated (Ultradent Products
Inc, South Jordan, UT, USA), and
the teeth cleaned with pumice.
A 3 step etch and rinse adhesive (All Bond 2, Bisco, Schaumburgh, IL, USA) and a dual cure
resin luting cement (Duolink,
Bisco, Schaumburgh, IL, USA)
were used. Spot curing was performed and excess cement was
removed and after light curing
for 60 sec each surface, the cement was left for 5 additional
minutes to complete the chemical cure mode as well. Final
finishing, adjustments of occlusion and polishing were performed with finishing diamonds
(KOMET, Lemgo, Germany),
rubber points (Astropol, Ivoclar
Vivadent, Schaan, Lichtenstein)
and finishing strips (Soflex, 3M
ESPE, Seefeld, Germany). Finally, a diamond polishing paste
was used (Ultradent Products
Inc, South Jordan, UT, USA) on a
Flexibuff (Cosmedent, Chicago,
IL, USA). An alginate impression was taken to fabricate a
new Essix orthodontic retainer
in the in-house lab within 1
hour. Oral hygiene and maintenance instructions were given to
the patient and a follow up appointment was scheduled after 4
weeks (Figures 15-21).
A multidisciplinary approach
in treatment planning and performance, as well as the use of
contemporary restorative materials and techniques allow for a
conservative, yet very aesthetic
final result.
References
1. Managing congenitally missing lateral incisors. Part I: Canine substitution. Kokich VO Jr,
Kinzer GA, J Esthet Restor Dent
2005;17(1):5-10
2. Prevalence of peg-shaped
maxillary permanent lateral incisors: A meta-analysis. Hua F et
al. Am J Orthod Dentofacial Orthop. 2013;144(1):97-109
The Author would like to thank
the Orthodontist, Dr. Evita Iakovidi and the Periodontist, Dr.
Alexis Bakopoulos for their contribution to the treatment of this
case.
Contact Information
Dr. Kostis Giannakopoulos
DDS, PhD
Assistant Professor,
AEGD Program Director
European University College
Dubai Health Care City
Ibn Sina Building, No. 27
Block D, 3rd Floor, Office 302
P.O. Box 53382, Dubai – UAE
Email: Kostis.g@euc.ac.ae
[17] =>
[18] =>
18 news
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 1
VIP’s at the 8th CAD/CAM & Digital Dentistry Int’l Conference
at Marriott Marquis – World’s tallest Hotel in Dubai
The Indirect Veneers Hands-On Course with Dr. Munir Silwadi 5th Dental Facial Cosmetic International Conference in 2013 at
the Jumeirah Beach Hotel
Dr. Dobrina Mollova, Founder and
Managing Director of Centre For
Aesthetic Dentistry Mena Award 2012 and I Love My Dentist Award 2012
Advanced Professional Practices (CAPP)
The winners of the Aesthetic Dentistry Mena Award 2012 and I Love My
Dentist Award 2012
1st Iraqi Dental Reunion 2011
2nd Asia-Pacific, CAD/CAM & Digital Dentsitry
International Conference Singapore
Dental Technician Forum – Part of IDEM 2014
workshops and self-instruction
programmes). For the past ten
years, CAPP has facilitated over
350 continuing education programmes with over 52,000 international participants. With the
opening of CAPP Asia in 2012,
CAPP’s reach has expanded to
the Asia Pacific region and beyond.
In 2012, CAPP joined the global
family of 96 publishers by becoming the proud owner of the
Dental Tribune Middle East &
Africa edition, and has since
been delivering six print editions
annually to over 20,000 dental
professionals in the Middle East
and Africa region and has delivered 24 newsletters to more
than 41,000 active subscribers.
Through its international website, the latest industry news
reaches the largest dental community worldwide—an audience of over 650,000 dentists.
CAPP started out in Dubai ten
years ago as a centre for professional training. It quickly grew
and developed two very important international conferences:
the CAD/CAM and Digital Dentistry International Conference
and the Dental-Facial Cosmetic
International Conference.
Next year, the tenth CAD/CAM
and Digital Dentistry International Conference will be celebrated together with the CAPP
anniversary. The last decade has
been a journey with challenges
in keeping pace with the incredibly fast growth of the industry
combined with new technologies, particularly in digital dentistry.
Ten years ago, it would have
been difficult to imagine the
kind of opportunities presently
available to change dentistry and
improve overall patient care, including diagnostics, planning
and treatment, in terms of precision, treatment and healing
time, and aesthetics.
What has been accomplished
in the past ten years has been
significant and CAPP would like
to thank all of its business partners, sponsors and supporters
for together making CAPP the
success it is today. CAPP would
especially like to acknowledge
all who have worked at and continue to be with the CAPP office
and share the challenges and
passion. Thanks also go to all of
the dentists, dental technicians,
Visit us at
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dental hygienists and dental assistants who have followed us in
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technology.
Contact Information
Dr. Dobrina Mollova
Managing Director
CAPP
info@cappmea.com
www.cappmea.com
www.dental-tribune.me
[19] =>
news 19
Dental Tribune Middle East & Africa Edition | November-December 2014
Our new digital product family
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using CADCAM
digital impressions
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DENTAL LABORATORY
CAD-CAM INNOVATION
by QUALIDENT
Order online at qualident-online.com or Call +971 4 342 7576
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By Qualident
I
nvesting in technology is a
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process. With new developments and advancements nearly
every week, as a business it can
be hard to keep you and you
don’t want to shell out hundred
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new is produced – if only there
was a way to keep up with market and demand without the
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Qualident has been providing
the dental community with unsurpassed dental prosthesis and
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believe there are no short cuts in
producing a high quality dental
restoration. This means using
the best materials, the most talented technicians, and the newest digital technologies.
“Restoration of implants
is increasingly more
common in dental clinic
practice”
Q-Bridge
Restoration of implants is increasingly more common in
dental clinic practice. For restorations of implants, Q-bridge
technology had ensures an accurate measurement into the
patient mouth by its 3D Oral
Scanning technique.
Qualident Laboratory with the
help of PicDental had established the perfect solution for
immediate loading implant
prosthesis with excellent passive
fit, which leads to an absence of
stress, and better care and maintenance of the soft and hard tissues.
Q-bridge screw mounted structures can be manufactured with
any number of connections and
can be made in various materials; Cobalt Chrome, Zirconia,
Titanium and PMMA.
A temporary prosthesis could be
delivered in less then 24 hours
with good pre-op planning.
All these high quality materials
provide exceptional biocompatibility and also help care for the
soft tissue.
3 Easy Steps
1. Screw Pic abutments on patient implants at the day of surgery.
2. Automatic image capture with
PIC camera, and send to dental
laboratory.
3. CAD/CAM design, mill, send
for patient passive fit prosthesis
loading.
Custom Made Abutment
Implantology is full of challenges. Impossible time constraints,
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placed too deep sub-gingivally,
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Abutments from Qualident.
During seating with the locator
male pivots inside the denture
cap, the systems’ self-aligning
design centers the male of the
attachment before engagement.
This allows the locator to selfalign into place. Once seated,
the male remains in static contact with the attachment, while
the denture cap enable the full
range of rotational movement
over the male for the resilient
connection of prosthesis.
Contact Information
For more information, contact:
Dr. Noor Aswad: +971 5 679 45588
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Locator Over Zircon Bar
The use of overdentures with
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Overdenture restoration provides improved chewing, esthetic, phonetics and comfort for patients that can’t adapt dentures.
The locator with zircon bar attachment delivers a low attachment profile and superb retention with a self-aligning design.
In addition to the design that
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[20] =>
Dentures contain surface pores in
which microorganisms can colonise.1
Corega® cleanser is proven to penetrate the biofilm*
and kill microorganisms within hard-to-reach surface pores.2
Help your patients eat, speak and smile
with confidence with the Corega® denture
care regime.
SEM images of denture surface.
*In vitro single species biofilm after 5 minutes soak
References: 1. Glass RT et al. J Prosthet Dent. 2010; 103(6): 384-389.
2. GSK Data on File, Lux R. 2012.
Date of preparation: June 2014.
Ref: CHSAU/CHPLD/0008/14c
Arenco Tower, Media City, Dubai, U.A.E.
Tel: +971 4 3769555, Fax: +971 3928549 P.O.Box 23816.
For full information about the product, please refer to the product pack.
For reporting any Adverse Event/Side Effect related to GSK product
please contact us on contactus-me@gsk.com.
[21] =>
6th DENTAL FACIAL COSMETIC International Conference
14-15 NOVEMBER 2014 . Jumeirah beach hotel, dubai, uae
D BY
NOVEMBER 14-15, 2014
JUMEIRAH BEACH HOTEL
DUBAI, UAE
Joint Meeting with
ORGANIZED BY
IZERS
E: events@cappmea.com
Dubai, UAE
M: +971502793711
www.cappmea.com
www.cappmea.com/aesthetic2014/
Dear Colleagues of
Dear Friends
and Colleagues, the Dental Team,
This 6 edition of our DFCIC
features a joint meeting with
the American Academy of Implant Dentistry. During this
session, the AAID will share
with us their vast knowledge
and experience as well as the
latest in the field of Implant
Dentistry.
th
tunities the event offers. The
interdisciplinary meeting brings
together the dental and medical professionals with common
interests in facial aesthetics and
cosmetics exchanging knowledge for the best quality of patient care.
N
This year’s conference will cover
several subjects related to Aesthetic Dentistry enlightening all
delegates with experiences from
over 23 International Key Opinion Leaders who have gathered
in Dubai Participants will also
have the unique chance to see
the latest equipment which will
be showcased at the product display made available by the top of
the dental industry. We sincerely
hope that this meeting will let
participants immerse themselves in plenty of knowledge
exchange and share opportunities with one another.
ovember is upon us once
again. This year for the
sixth consecutive time
the amazing Jumeirah Beach
Hotel in Dubai will host the
Dental-Facial Cosmetic International Conference for a two day
scientific weekend offering all
dental professionals the latest
research and developments in
the field of Aesthetic Dentistry.
The Dental-Facial Cosmetic In- On behalf of Emirates Dental
ternational Conference has be- Society, I would like to wish you
come a vital platform for the suc- an enjoyable and educational
cess and perception of dentistry 6th Dental Facial Cosmetic Int’l
in the Middle East region. Yearly Conference which is filled with
hundreds of top dental profes- 24 cutting-edge presentations,
sionals, practitioners, research- 12 hands-on workshops and a
ers and industry players gather Dental Hygienist Day.
together to listen to the latest
world acclaimed professional
Key Opinion Leaders as well as
Dr. Aisha Sultan
discuss hot topics through the President Emirates Dental Society
interactive networking opporPresident of the Conference
10
WELCOMING
Dr. Aisha Sultan
President Emirates Dental
Society
President of the Conference
Dr. Munir Silwadi
Conference Chairman &
Scientic Advisor
> Page 1
AGENDA
Speaker Highlights
Scientific Conference
Dental Hygienist Day
Hands-On Courses
I
t is my honor and pleasure
to welcome you all to our
6th Dental - Facial Cosmetic
International Conference.
Our specialized conferences
are evolving into land marks
in the field of Continuous
Dental Education. We offer
a unique blend of Science,
Clinical Knowledge, and Cutting Edge Technology in the
field of Dentistry and beyond.
All of us, organizers, speakers,
and sponsors spare no time or
effort to put bring to you the
most up to date developments
in various fields of Dentistry.
I am sure that this conference
will be of the greatest help to
develop our knowledge and
sharpen our skills in pursuing the goal that we all share,
to provide our patients with
the best possible solutions for
their esthetic needs.
We will continue this unsurpassed cooperation to bring
to our audience the most recent updates of technology in
the dental field with few ‘’surprised’’ as well.
See you all in the dynamic
Emirate of Dubai.
Dr. Munir Silwadi
BDS, MRCDSO, DUSS, FADI, FICD
Conference Chairman & Scientic Advisor
th
Jumeirah Beach Hotel
08-09 May 2015
DUBAI, UAE
ORGANIZED BY
CO-ORGANIZERS
www.cappmea.com/cadcam10
Show Edition
> Page 2
GAME PLAN
See the industry
> Page 3
PLANMECA
Planmeca’s Implant
ning made Easy
plan-
> Page 4
OFFICIAL
MEDIA
PARTNER
[22] =>
DAY ONE
FRIDAY | 14 NOVEMBER 2014 | CONFERENCE DAY | MAIN AUDITORIUM
SATURDAY | 15 NOVEMBER 2014 | CONFERENCE DAY | MAIN AUDITORIUM
08:00 – 09:00
08:00 – 09:00
BREAKFAST WITH THE SPONSORS / REGISTRATION
09:00 – 09:45
A
DAY TWO
Dr. Gaetano Paolone, Italy
09:00 – 09:45
Accessible Aesthetic Dentistry
09:45 – 10:30
Prof. Swaid Sami, Germany
Minor & Major Augmentation in Oral- and Maxiillofacial Surgery and Implantology,
new perspectives with Norian phosphate cement
09:45 – 10:30
The Aesthetics of In-surgery CAD?CAM Dentistry
Zirconia vs. glass-ceramics – pro et contra
11:15 – 11:30
11:30 – 12:15
Dr. Costa Nikolopoulos, Greece
09:45 - 11:00
Simple, Fast & High Quality Implant Dentistry
An Introduction to Digital Impassioning and the Digital Workflow
15:00 – 15:45
Dr. Richard John Simonsen, USA
11:15 - 12:00
1000
Dr. Petros Yuvanoglu, Greece
Lecture
Victoria Wilson,
Communication & Implant
Dr. Björn Tittel, Germany
Dental Hygiene
Maintenance
Innovative
Solutions
Therapist,
UK & Surgery in Aesthetic Dentistry
Prof. Carina Mehanna Zogheib, Lebanon
16:30 – 17:15
Teeth whitening from A –Z
Prof. Carina
Dr.
Emilio Rodriges,
SpainTeeth Whitening from A to Z...
Mehanna
Zogheib,
LebanonLoad with Aesthetic and Functional Restoration
Immediate
Dr. Gary Severance, USA
18:00 –18:15
Chairside Restorative Dentistry – Control Your Future
18:15 –18:30
DISCUSSIONS
18:30 – 19:00
POSTER PRESENTATION
Dr. Gary Severance, USA
12:00
- 12:45
Lecture
The
Landscape
of Digital Dentistry
Prof. Khaled Balto, KSA
16:45 – 17:30
The Effect of manufacturing features of rotary NiTi files on their performance: A clinical approach
for analysis
17:30 – 18:15
800
15:45 –16:30
DISCUSSIONS
16:00 – 16:45
Lectures
The Science & Art of Restoring Immediately Loaded Implants
Photography – Clinical for Dentistry, and Nature for Hobby
15:45 – 16:00
500
13:00 – 14:15
LUNCH / MEET
THE SPONSORS
Management
of The Orthodontic
Prof. Mary Rose
Patient
14:15
– 15:00
Pincelli
Boglione, Dr. Marcus Engelschalk, Germany
Italy
The
intraoral scan in prosthodontic
–new
workflows
for more
Polishing
will
Brighten
Yourpredictibility
Smile!
Dr. David Claridge, UK
15:00 – 15:45
Dr. Anton Lebedenko, Russia
Dr. Marcus Engelschalk, Germany
12:15 – 13:00
Double Scan vs. Single Scan – Two different workflows for essential improvement in fixed prosthetic
600
reconstruction in implantology
LUNCH / PRAYER TIME
14:15 – 15:00
Lecture
Dr. Carine
Oral Health Management:
Bulk Fill – Behind the Scenes
Taberani, UAE
Between Myth and Reality
In-surgery CAD/CAM Dentistry – Fact or Fiction
13:40 – 14:15
300
MEET THE SPONSORS / COFFEE BREAK
09:00 - 09:45
Dr. Julian Caplan, UK
12:15 – 13:40
Dr. Julian Caplan, UK
10:30 –11:15
Dr. Anton Lebedenko, Russia
11:30 –12:15
Dr. Michael Apa, USA
Advances in Interdisciplinary Aesthetic Dentistry
MEET THE SPONSORS / COFFEE BREAK
10:45 – 11:30
N
Dr. James Russell, UK
Adhesive esthetic solutions in anteriors and posteriorss teeth
10:30 – 10:45
D
BREAKFAST WITH THE SPONSORS / REGISTRATION
MEET THE SPONSORS / COFFE BREAK
DISCUSSIONS
VENEERS vs. CROWNS
THE
CHALLENGE
SMILE
2.75
HAAD
CME | 4INCME
ADADESIGN
CERP
Dr. Eduardo Mahn, Chile
12 November 2014 (09:00 – 17:30)
JBH, Dubai, UAE
DATE: 14 & 15 November 2014
E
ESTHETIC IN SAMEDAY DENTISTRY (DENTISTS)
13:00 - 16:30
Aiham Farah, CDT, UAE
13 November 2014 (09:00 – 17:30)
JBH, Dubai, UAE
LASER IN MODERN DENTAL PRACTICES
Taher Agha, UAE
09:00Dr.
- Manaf
09:45
Lecture
13 November 2014 (09:00 – 17:30)
JBH, Dubai, UAE
Dr. Carine
Taberani, UAE
300
Notification in writing by 01 Apr
Oral Health Management:
Between Myth and Reality
500
A
G
DIRECT VENEERS: THE SHADES DILEMMA
Dr. Eduardo Mahn, Chile
13 November 2014 (09:00 – 17:30)
09:45JBH,
- 11:00
Dubai, UAELectures
09:00 - 09:45
Lecture
Dr. Carine
Taberani, UAE
Oral Health Management:
Between Myth and Reality
09:45 - 10:30
Lecture
Prof. Mary Rose
Pincelli Boglione,
Italy
Management of The Orthodontic
Patient
10:30 - 11:15
Lecture
Victoria Wilson,
Dental Hygiene
Therapist, UK
Communication & Implant
Maintenance
11:15 - 11:45
Lecture
Prof. Mary Rose
Pincelli Boglione,
Italy
Polishing will Brighten Your Smile!
300
500
600
800
1000
600
800
Management of The Orthodontic
Prof. Mary Rose
Patient
Pincelli Boglione,
Italy INDIRECT VENEERS
Polishing
will Brighten Your Smile!
Dr. Munir Silwadi,
UAE
1000
13 November 2014 (09:00 – 17:30)
3M Innovation Centre Dubai Internet City, UAE
11:15 - 12:00
Lecture
Victoria Wilson,
Communication & Implant
PERIODONTAL
INSTRUMENTATION
Dental Hygiene
Maintenance
Prof. Mary Rose P. Boglione, Italy
Therapist,
UK
14 – 15 November 2014 (13:00 – 16:30)
JBH, Dubai, UAE
12:00 - 12:45
Lecture
FACE AND SMILE ANALYSIS
Prof. Carina
Dr. Eduardo Mahn,
ChileWhitening from A to Z...
Teeth
Mehanna
Zogheib,2014
15 November
(15:30 – 19:30)
Lebanon
JBH, Dubai, UAE
ESTHETIC IN ONE-LAYER METAL CERAMIC & COMPOSITE GINGIVA
(DENTAL TECHNICIANS)
Aiham Farah, CDT, UAE
15 – 16 November 2014 (09:00 – 17:30)
JBH, Dubai, UAE
2.75 HAAD CME | 4 CME ADA CERP
INDIRECT VENEERS
Dr. Munir Silwadi, UAE
16 November 2014 (09:00 – 17:30)
3M Innovation Centre, Dubai Internet City, UAE
DATE: 14 & 15 November 2014
13:00 - 16:30
11:45 - 12:30
Lecture
Prof. Carina
Mehanna Zogheib, Teeth Whitening from A to Z...
Lebanon
VENEERS vs. CROWNS THE CHALLENGE IN SMILE DESIGN
Dr. Eduardo Mahn, Chile
16 November 2014 (09:00 – 17:30)
JBH, Dubai, UAE
LASER IN ESTHETIC DENTISTRY
Dr. Manaf Tahar Agha, UAE
16 November 2014 (09:00 – 17:30)
JBH, Dubai, UAE
2.75 HAAD CME | 4 CME ADA CERP
Notification in writing by 01 April 2014 -
[23] =>
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Helps stop bleeding gums
In ‘bleeding on probing’ trials over 4 weeks, parodontax®
demonstrated significant effects in reducing bleeding
gums by 22% (p<0.01)
Bleeding on probing increased after 4 weeks of brushing
with the fluoride control toothpaste
Reduced bleeding on probing index after 4 weeks with parodontax®9*
Change vs baseline in bleeding
on probing index after 4 weeks
30.00
22%
reduction in
bleeding
25.00
(p<0.01 vs. baseline)
20.00
15.00
10.00
5.00
0.00
4 weeks
Fluoride-containing
control toothpaste
Baseline
4 weeks
parodontax®
Helps stop bleeding gums
Adapted from Saxer et al 1994. All interdental spaces from 6+ to +6 were tested at baseline and 4 weeks for bleeding on probing on the
right side (buccal) and left side (lingual). Findings were recorded as 0=no bleeding; 1=slight/isolated bleeding; 2=marked bleeding. Mean
scores were determined. N=22.
Baseline values [Mean SD]: Control (fluoride-containing toothpaste) group 24.75 (6.34); parodontax® group 25.40 (6.80). After 4 weeks:
Control (fluoride-containing toothpaste) group 26.00 (9.14); parodontax® group 19.80 (7.38). *parodontax® vs control p<0.05.
OH/CA/00/13/003
Baseline
[26] =>
22 clinical
Dental Tribune Middle East & Africa Edition | November-December 2014
CBCT and CAD/CAM allow for one-day restoration of Tooth #9
By Robert Pauley, USA
evident, but the tooth did have
a pinkish tint on the lingual. No
mobility was noted and no periase Overview
Our office received a fran- apical changes or root fractures
tic phone call from the were obvious at this time. The
mother of one of our twelve- new American Association of
year-old patients, who stated Endodontists guidelines recomthat her daughter fell while in mend taking one occlusal and
P.E. class and broke a front tooth. two periapical radiographs with
We advised her to bring her different lateral angulations for
daughter to the office as soon as all dental injuries, including
possible. Immediately after her crown fractures. If cone beamarrival a periapical radiograph computed tomography is availof tooth #9 and extraoral photo- able, it should be considered to
graphs were obtained (Fig. 1). reveal the extension and direcUpon clinical examination and tion of the fracture.1
review of the digital radiograph, Dr. Edward Mills in his presenI saw tooth #9 was horizontally tation on Site Development and
CS3500 A4 advert:Layout 1 06/08/2014 10:49 Page 1
fractured at the middle third. Implant Protocol Based on EtiolThere was no pulp exposure ogy of Tooth Loss refers to a sim-
C
Figure 2
Figure 1
ilar traumatic injury in which
CT images revealed not only a
root fracture within the bone but
a fracture of the lingual plate.2
CS 3500
A limited field 3D scan 5cm x
NO
impression material
5cm at 300 voxels was taken
with the CS 8100 3D to rule out
buccal or palatal plate fractures
(Fig. 2). None were evident on
the scan. While her parents
were upset that she had been
NO
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In the new reality, the CS 3500 intraoral scanner creates highly accurate, true color
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• Truly handheld, portable with no trolley and plug and play
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injured, the ability to view a 3D
image reassured them that the
damage appeared to be limited
to the tooth’s coronal structure.
Treatment Plan
The patient’s treatment options
were: 1) do nothing; 2) restore
with a composite restoration,
realizing that this would have
a questionable long-term prognosis due to size of fracture;
3) restore with a CAD/ CAM
milled crown. The patient and
her parents were advised that
cases where teeth have been
injured traumatically such as in
this case, one might experience
a post traumatic irreversible
pulpitis at a period of time beyond the initial trauma. In some
cases, this condition may be
treated by endodontic treatment
and crown restorations but in
other cases root resorption may
take place precipitating the loss
of the teeth. These teeth will be
monitored every 6 months over
several years with periapical
radiographs. Every appropriate
effort to maintain the tooth in
place and avoid the need of an
implant until the patient reaches
maturity. Dental implants in adolescent patients may affect vertical growth and development of
the alveolar ridge because the
osseointegrated implant acts as
an ankylosed tooth. At a focus
conference on Advanced Dental
Implant Studies, Dr. Mills summarized that jaw growth in a
young adolescent patient may
compromise the outcome of the
oral rehabilitation using an implant supported prosthesis even
if implants successfully integrated. After presentation of the
treatment plan and discussion
of risks, benefits, options, and
alternatives; the parents and patient elected to restore tooth #9
with a CAD/CAM crown.
The parents understand this
crown will likely need to be replaced once she reaches adulthood for the best cosmetic appearance, as her teeth and face
will change with further growth
and development.
Tooth # 9 was anesthetized and
prepared for a ceramic crown.
I utilized the CS 3500 intraoral
scanner to scan the prepared
maxillary anterior quadrant and
the opposing mandibular anterior quadrant as well as obtain
a bite registration (Figs 3, 4).
CS Restore software was then
utilized to design the anterior
crown (Figs. 5-7). The CS 3000
milled the crown from an Ivo-
© Carestream Health, Inc. 2013.
> Page 34
[27] =>
aesthetics 23
Dental Tribune Middle East & Africa Edition | November-December 2014
Porcelain laminate veneers – avoiding complications
By DCDM
that the estimated survival rate
over a 5 year period is at 95%, at
8 years is 94%; at 10 years is 86%
and at 20 years is 83% (Beier et
al, 2012). It should be noted that
these were veneers placed after
adequate tooth preparation.
D
ental Veneering is the
process of covering the
facial surfaces of teeth
by using various types of dental
materials. Most commonly used
are porcelain veneers which are
thin shells of porcelain that are
shaped like the outer layer of the
teeth and are used to cover the
teeth, aiming to enhance their
appearance.
Many celebrities opt for this esthetic treatment to achieve what
may seem like a picture-perfect
smile. This may lead people to
a false expectation that everyone is a good candidate for veneers. However, from a dental
clinician’s perspective preparing and planning for veneers is
very challenging, and if proper analysis of the patient and
proper techniques in preparing
the teeth are not used, multiple
complications can occur. These
include gingival inflammation,
chipping and breaking or even
complete de-bonding of the veneers.
To decide whether a patient is
a good candidate for veneers
many factors should first be assessed; the condition of the patient’s teeth, habits, periodontal
condition and most importantly
the patient’s expectations and
willingness to maintain their veneers after they are placed.
We should start by analysis of
the teeth. This involves assessing their shape and proportion;
diastemas, and analysis of the
occlusion. Regarding shape and
dimension, there should be sufficient tooth structure to retain
the veneer, otherwise the longevity can be severely affected.
In teeth with small surface areas
such as lower incisors, or teeth
with multiple cavities and fillings which decrease the available surface for bonding, there is
an increased chance of the early
displacement of the veneer. In
such cases full crowns may offer a better long term option
(H.Serdar Cotert et al, 2009).
In terms of diastemas, if these
are too large veneers can only
partly reduce the space, otherwise gingival inflammation and/
or recession can occur due to the
bulkiness of the veneer (Weisgold and Cohen, 1981) Additionally, a tooth which is unnaturally
wide for its height looks unattractive. Orthodontics may be
more appropriate to close gaps
than veneers. When assessing
a diastema the clinician must
establish if it is stable or increasing since the latter may indicate
periodontal bone loss or a harmful habit.
Finally in tooth analysis the occlusion must be considered. For
veneers to have a longer survival rate they should not have
excessive biting forces on their
edges as is common in patients
with an edge-to-edge occlusion
which can lead to chipping and
breaking of the veneers. Care
must also be taken in patients
with missing posterior teeth, as
The clinician must consider all
these factors before choosing to
place veneers if complications
are to be minimised and patient
satisfaction achieved.
References are available from the
authors.
About the Author
Figure 1. A significant staining of the veneer margins as a result of smoking and high coffee consumption.
this increases the loading on the
anterior teeth. Patients’ habits
must also be considered. Nighttime grinding or heavily clenching, often related to stress, or
even biting or chewing on fingernails or objects like pens,
create high horizontal forces
impacting on survival of the veneers at a rate 8 times higher
than patients who don’t have
such habits. Such forces can
readily lead to fracture, chipping or total de-bonding of the
veneer. We should also consider
the patient’s high consumption
of dark or acidic foods as well as
smoking habits which can lead
to dark stains around the margins of the veneers (Fig 1). Since
patients with dark stained teeth
will often consider veneers as a
solution, habits should be identified changed after veneer placement to maintain the esthetics of
their veneers (Beier et al, 2012).
Marginal stains can be minimised by brushing or rinsing after smoking and consumption of
dark colored foods.
The patient’s oral hygiene must
also be assessed, which leads us
to the last key point of gingival
health. Veneers should not be
prepared on bleeding inflamed
gingiva, which indicates poor
oral hygiene. If this is done,
complications which arise include placing the veneer margin too deep due to gingival enlargement, and bleeding during
preparation and bonding leading to poor marginal seal and
marginal staining after veneer
placement. Eventually gingival
recession or worsening inflammation will result. Good oral hygiene and gingival health should
be achieved before veneers are
started. All of these factors need
to be considered during the initial assessment to avoid complications.
Additional complications can
arise during the preparation of
teeth. There are two common
approaches to placing porcelain
veneers, one is done without altering the natural teeth - bonding the porcelain veneers to unprepared teeth. This might seem
a conservative choice avoiding
alteration to tooth surfaces,
but it inevitably creates a bulky
over-contoured appearance and
increases the risk of the veneer
de-bonding and gingival complications. Alternatively teeth
are prepared for veneers by
changing external contour, removing less than a millimetre
of the facial surfaces and around
2 mms of the incisal edges, thus
porcelain replaces the tooth
structure removed, ensuring
the porcelain is seated properly
onto the tooth with enough bulk
of porcelain at the edge to minimise chances of chipping and
breaking . Studies have shown
that the overall success and survival of the first method is much
lower than the second method.
The commonest complications
with veneers are breaking and
chipping (H.Serdar Cotert et al,
2009)(Layton and DPhill, 2013)
(Akoglu et al, 2011).
A study analyzing the overall survival rate of porcelain veneers
over a 20 year period concluded
Dr. Nadia Tufenkeji is a second
year resident at Dubai College
of Dental Medicine (DCDM),
Prosthodontic MSc. Program.
Located in Dubai Healthcare
City (DHCC)
Dr. Fatemeh Amir Rad is a lecturer of Prosthodontics at Dubai
College of Dental Medicine
(DCDM).
Prof. Crawford Bain is the Director of the Periodontics MSc.
programme at Dubai College of
Dental Medicine (DCDM).
[28] =>
24 CLINICAL
Dental Tribune Middle East & Africa Edition | November-December 2014
Case report surgical correction of a class III
malocclusion in an adult
By Dr. Fabien Depardieu
T
his case report describes
a successful orthognathic treatment of a skeletal Class III malocclusion with
mandibular prognathism in an
adult individual. The patient
with Class III malocclusion,
having mandibular excess in
sagittal and vertical plane was
treated with orthodontics, bilateral sagittal split osteotomy.
The surgical-orthodontic combination therapy has resulted
in near-normal skeletal, dental
and soft tissue relationship, with
marked improvement in the facial esthetics in turn, has helped
the patient to improve the selfconfidence level. The interdisciplinary approach is the treatment of choice in most of the
skeletal malocclusions (1).
Keywords: Class III malocclusion, decompensation, Orthognathic Surgery, Bilateral sagittal
split osteotomy, prognathism,
surgical orthodontic treatment.
Introduction
The Skeletal Class III malocclusion is characterized by mandibular prognathism, maxillary de-
ficiency or both. Clinically, these
patients exhibit a concave facial
profile, a retrusive nasomaxillary area and a prominent lower
third of the face. The lower lip is
often protruded relative to the
upper lip. The upper arch is usually narrower than the lower,
and the overjet and overbite can
range from reduced to reverse.
The effect of environmental
factors and oral function on the
etiological factors of a Class III
malocclusion is not completely
understood. However, there is
a definite familial and racial
tendency to mandibular prognathism. For many Class III malocclusions, surgical treatment can
be the best alternative. Depending on the amount of skeletal
discrepancy, surgical correction
may consist of mandibular setback, maxillary advancement
or a combination of mandibular
and maxillary procedures. After
surgical correction of the skeletal discrepancy, the occlusion is
usually finished orthodontically
to a Class I relationship. However, if surgical treatment is not
performed, and the final molar
relationship is Class III or Class
I, there are challenges specific to
Figure 1. Pre-treatment extra-oral
Figure 2. Pre-treatment intra-oral
the static and functional Class III
occlusion that must be considered. Sometimes a Class III relationship is caused by a forward
shift of the mandible to avoid
incisal interferences. This is a
pseudo-Class III malocclusion.
In these cases, it is important to
establish the inter-occlusal relationship with the teeth in the
retruded contact position.
In this paper, the surgical orthodontic treatment of a young
adult patient with a Class III
malocclusion is illustrated
Diagnostic and Etiology
The patient was a 28 year-old
man who had a Class III facial
type and slight crowding with a
complete Class III relationship.
His chief complaint was an unesthetic facial and un-even bite.
His medical history showed no
contraindication for orthodontic
therapy and orthognathic treatment. No one in his direct family
had a skeletal Class III features.
The pretreatment extra-oral
photographs showed symmetric facial structures (Fig 1). The
patient had a concave profile, a
decreased nasolabial angle and
a protusive lower lip.
The intra-oral photographs (Fig
2) showed a Class III occlusion
on each side with an anterior
crossbite and without apparent
crowding. Overjet was -2.0 mm,
and overbite was -3,5 mm. His
maxillary anterior teeth were
prognathic, with inadequate display when smiling.
The mandibular dental midline was deviated 2,5 mm to the
right, although the maxillary
dental midline was coincident
with the facial midline.
There were no signs or symptoms of temporomandibular
joint dysfunction. Mandibular
movements, such as maximal
opening and lateral and anterior displacement were within
normal limits. No deviation and
pain were discovered during the
border movement of the mandible.
A cephalogram and a panoramic
radiograph were taken before
treatment. The cephalometric
analysis and its tracing showed
that the mandible protruded
relative to the cranial base (SNB
angle, 82; ANB angle -2). The
panoramic radiograph showed
no other abnormal signs.
After the analysis of the photographs, the casts and radiographs, it was decided to
approach his problems as a
skeletal Class III malocclusion
with an anterior cross bite and a
lower deviated midline (2).
Treatment Objectives
The treatment objectives (3)
were to obtain a harmonious
facial profile by decreasing the
protusion of the mandible, improve the occlusion, including
correction of the anterior crossbite, establishment of ideal overjet and overbite, achievement of
a functional molar relationship;
and place the dental midlines in
the middle of the patient’s face.
We planned:
• To set back the mandible to
correct the prognathism and the
midline deviation.
• To relieve the proclined maxillary incisor position and to relieve the dental compensations.
• To relieve the dental compensations by straightening the
mandibular incisors to an upright position over basal bone.
Treatment Alternatives
The first alternative was orthodontic treatment with extraction
of 4 premolars. Through the retraction of the mandibular anterior teeth, the anterior crossbite
and Class III molar relationships
would be corrected and the
concave facial profile would be
camouflaged. Nevertheless, the
mandibular incisors were not
suitable for much distal movement because of the thin trabecular bone in the mandibular
anterior area that could damage
the periodontal tissues by gingival recession, fenestration or
dehiscence.
The second alternative was
combined surgical and orthodontic treatment. The anterior
crossbite would be corrected
with a single-jaw surgery: a
mandibular setback. The concave profile would be improved
> Page 25
[29] =>
CLINICAL 25
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 24
as well. It was decided to extract
the upper second premolars to
relieve the dental compensations by repositioning the upper
incisors.
The third alternative was to correct the class III malocclusion by
miniscrew –assisted mandibular
dentition distalization. However
we decided that the skeletal
problem was too excessive and
required orthognathic surgery.
After we discussed the three alternatives with the patient. He
chose the second option.
Treatment Progress
The preoperative orthodontic
preparation began on December 2011.
Before the levelling and alignment procedures (4), the maxillary second premolars were
extracted to decompensate the
maxillary incisor inclination and
to reduce the acute nasolabial
angle.
Pre-adjusted 0.022-in edgewise
brackets were bonded to all
teeth. The preoperative orthodontic treatment was achieved
in 12 months, ending with 0.018
x 0.025 stainless steel surgical
archwires for the maxillary and
mandibular arches.
The orthognathic surgery involved a set back of the mandible with a bilateral sagittal split
osteotomy. This was performed
to improve the mandibular protusion and establish an Angle
Class I canine position with ideal
overjet and overbite.
After the surgery, the patient
was placed in intermaxillary fixation for 2 weeks. Two
months after surgery, finishing
was performed with maxillary
and mandibular 0.016 x 0.022in titanium-molybdenum alloy
archwires.
The appliances were removed
after 18 months of active treatment. Bonded lingual retainers were fitted to the lingual
surfaces of the anterior teeth in
both arches. Maxillary and mandibular essix retainers were delivered with instructions to wear
them full time for two weeks and
then night time.
Treatment Results
The post treatment photographs
(Fig.3) showed that facial aethetic was improved, and ideal occlusion was achived with proper
overjet and overbite. The maxillary dental midlines coincided
with the facial and mandibular
midlines.
The occlusion was finished to a
therapeutic Class II.
Discussion
The decision for surgical orthodontic treatment for this patient
was based on the fact that his
primary concern was his facial
profile.
Before the single-jaw surgery:
a mandibular setback, preoperative orthodontic treatment,
including decompensation of
the malocclusion, is necessary.
The dental decompensation
we performed was intended to
retract the proclined maxillary
incisors to a normal axial inclination. Lack of optimal dental
decompensation compromises
the quality and quantity of an
orthognathic correction. The
patient’s teeth were decompen-
Figure 3. Post treatment photographs
sated by extracting the upper
second premolars and levelling
the mandibular arch. This phase
was achieved in 12 months
Conclusion
This case report describes the
surgical orthodontic treatment
of a young adult man with dental and skeletal class III relationships. The orthognathic treatment was the best option for
achieving an acceptable occlusion and a good esthetic result.
An experienced multidisciplinary team approach ensures a
satisfactory outcome.
Presurgical orthodontics re-
moves all the dental compensations and suggests the extent of
the skeletal discrepancy. Normal skeletal base relationship
is achieved by osteotomy and
setback of the prognathic mandible, postsurgical orthodontics
guides the normal occlusal rehabilitation by correcting any
emerging dental discrepancies
(2).
2. Radha Katiyar, G K Singh, Divya Mehrottra, Alka Singh. Natl
L Maxillofac Surg. 2010 Jul-Dec;
1 (2): 143-149
3. Yan Jing, Xianglong Han,
Yongwen Guo, Jingyu Li, and
Ding Bai. Am J orthod Dentofacial Orthop 2013; 143:877-87.
4. Sung-Hwan Choi, Chung-Ju
Hwang. Am J Orthod Dentofacial Orthop 2013; 144:737-46.
References
1. Ravi M S, Shetty NK, Prasad
RB. Orthodontics-surgical combination therapy for Class III
skeletal malocclusion. Contemp
Clin Dent 2012;3:78-82.
Contact Information
Dr. Fabien Depardieu
Orthodontist specialist at Dr Roze
& Associates Dental Clinic
fabien@dradubai.com
LET’S SHARE
WHAT WE KNOW
Take part in one of our upcoming seminars.
Wednesday 26th November 7:30pm
Restorative Dentistry/Orthodontics Relationship:
How to improve the communication
At Dr. Roze & Associates, we’re early adopters. When it comes to the latest
technologies, techniques and processes, we never stop learning. Since we’re
a referral clinic, many rely on us for oral surgery and orthodontic treatments.
But what’s knowledge unless it’s shared?
We’d like to invite you to attend our unique seminars, so we can help you
bring even more value to your practice.
Please confirm your attendance by 20th November to info@dradubai.com
For more information call 04 388 1313 or visit dradubai.com
Coming up soon:
Orthodontic Seminars – by Dr Fabien Depardieu
Restorative/Orthodontic interface: Working together
to get the best results for our patients
Orthodontics in 2015: What’s new
Facial Aesthetics
Orthognathic surgery
Oral surgery seminars – by Dr David Roze
Immediate implant into a fresh socket
Oral surgery in the dental clinic: Review and results
Implant crown restoration
[30] =>
26 implant tribune
Dental Tribune Middle East & Africa Edition | November-December 2014
Dental implant competitors shake things
up amidst economic uncertainty
By Kristina Vidug, USA
I
n 2013, the global dental implant
market—composed
of the sale of dental implant
fixtures, final abutments and
other devices—was valued at
over US$3.7 billion. The European market, valued at nearly
one-third of the global market at
close to US$1.2 billion, contracted through 2014, as uncertain
economic conditions continued
to reduce procedure volumes
and as more low-cost competitors entered the market, driving
down prices.
These factors hampered the expected economic recovery and
resumption of growth projected
for 2013.1 As a result, the dental
implant market will continue
its decline before stabilising in
2015. Only then will the European market slowly begin to recover. Factors such as low gross
domestic product growth and
high unemployment continue
to render dental implant procedures—which are primarily paid
out of pocket by patients—cost
prohibitive, while alternatives,
such as bridges and dentures,
that are perceived as more af-
fordable will represent attractive
options.
Dental implants were invented
in Sweden; as a result, it is not
surprising that a great number
of premium manufacturers are
based in Continental Europe.
In the past, premium manufacturers, such as Straumann and
DENTSPLY Implants, were able
to rely on their long-standing
reputations in the market and
the high quality of their products
to command higher prices than
did some of their competitors.
More recently, however, some of
the premium competitors have
employed strategies to appeal
to increasingly cost-conscious
consumers. For instance, Straumann has reduced the price of
its titanium implants by 15 per
cent in Austria, Germany and
Switzerland. While the price
change only came into effect in
the first quarter of this year, the
strategy appears to have been
effective because the company
reported a 6 per cent rise in
first-quarter revenue2 compared
with a 6 per cent decrease in the
same period last year.3
The price reduction has come at
a perfect time: while economic
conditions begin to slowly improve, consumers are still extremely price sensitive. These
price cuts therefore allow dental
professionals to offer premium
implant products to their patients at a reduced rate.
Straumann’s price reduction is
not its only foray into the value
market. In the first quarter of
this year, the company purchased US$30 million worth
of bonds from low-cost South
Korean dental implant manufacturer MegaGen. The investment, which will be converted
to shares in 2016, will help bolster Straumann’s revenue while
allowing it to participate in both
the premium and value segments, thus appealing to a wide
range of practitioners and patients alike.
Straumann is not the only company shaking things up in the
world of dental implants. Zimmer Dental recently announced
its acquisition of rival Biomet.
While both companies are better known for their orthopaedic
products, they are fairly significant competitors in the dental
industry as well. Lay-offs are
not uncommon when companies merge, especially when the
companies in question offer the
same types of products. This can
have a negative impact on sales
in the short term, as the newly
conjoined companies’ sale force
decreases, leading clients to
switch to other competitors.
However, this will not be the
case with the Zimmer–Biomet
merger, at least not in the short
term, as the sales teams from
both companies are expected to
be retained through the merger.
The cost of retaining both sales
teams has been estimated at
US$400 million. While the effect of this acquisition on the
market remains to be seen, the
fact that the sales force will not
be decreasing bodes well for the
newly merged companies, likely
resulting in an increased market
share in the dental implant segment.
There is discussion of merger
and acquisition activity among
other companies in the segment
too, with Nobel Biocare reportedly in talks to sell to private equity firms and strategic buyers.
While these talks are still in the
very early stages, what is certain
is that there has been a great
deal of activity in the competitive landscape in the past several
years.
This, combined with the aforementioned economic factors, is
turning this once stable and mature market into a dynamic, action-filled space. With the dental
implant market set to rebound
in Europe and with revenues
expanding in other countries—
particularly in the rapidly developing BRIC and Middle Eastern
markets—the global industry is
poised for even further change,
and the competitive landscape
could look entirely different a
few years from now.
About the Author
Kristina Vidug is Market
Research Analyst at Decision
Resources Group, a US-based
market information provider.
[31] =>
implant tribune 27
Dental Tribune Middle East & Africa Edition | November-December 2014
SameDay Dental Implants® & Teeth
A Surgical & Prostho Protocol
By Costa Nikolopoulos Oral &
Maxillofacial Surgeon (S.A.)
& Petros Yuvanoglu Specialist
Prosthodontist (U.S.A.)
T
he original Branemark
protocol advocated the
use of a two stage surgical approach where the turned
(smooth) implants were buried
for several months under the
mucosa. With the advent of surface enhanced and tapered implants the protocol later evolved
into a one stage approach.
Several clinicians then proceeded to immediately load these
one stage implants with good
success provided good primary
stability (more than 45Ncm)
was achieved at time of implant
placement and provided micromovements could be limited
to 100μm. Ample reports have
been published on immediate
loading of dental implants showing an initial unloaded period of
3 – 6 months is not necessary.
From a patient’s point of view
the reduction of treatment time
between implant placement &
installation of a functional prosthesis leads to increased patient
satisfaction & treatment acceptance. This gain in time for the
patient implies an economical
benefit especially for professionally and/or socially active
patients.
High treatment acceptance and
patient satisfaction are the most
important advantages of immediate loading and immediate
function.
Surgical Protocol
The surgical protocol of immediate loading of dental implants
with same day teeth is based on
the following:
Avoid Bone Grafts
This is in line with Prof. P.I.
Branemarks
philosophy
of
“Lesser Surgery to Treat More
Patients” (Fig 1).
Fig 1. Dr. Costa and Dr. Petros
in line with Prof. Branemark’s
philosophy of “Lesser Surgery
to Treat More Patients”.
With increased costs and patient
morbidity due to bone grafting,
an increased patient resistance
to implant treatment has been
noted. An alternative method of
treating implant patients who
have suboptimal bone volume
without bone grafting is made
possible by using:
1) Angled implants in a titled
manner placed into available
bone anterior and posterior to
the maxillary sinus (Fig 2).
2) Wider and appropriately
shaped implants placed into immediate extraction molar sockets thereby avoiding socket or
sinus grafting (Fig 3).
High Primary Stability
An important factor for immediate loading success is high primary implant stability (greater
than 45Ncm) which can be
achieved by using a surface enhanced tapered implant design
to enhance lateral compression
of bone.
By underprepping, high insertion torque and primary stability
can be achieved even in cases
of decreased bone density such
as is often the case in maxillary
alveolar bone and as well as in
osteoporotic patients. Primary
stability can easily be measured
during implant placement with
a torque wrench (Fig 4).
If 45Ncm insertion torque is not
achieved, the implant should be
removed and without further
bone preparation a 1mm wider
implant is placed.
This usually results in adequate
primary stability of 45Ncm for
immediate loading. If 45Ncm
insertion torque is still not
achieved then again the implant
can be removed and replaced
with an even wider diameter
implant if the available bone
width permits. This usually results in adequately high insertion torque and primary stability
greater than 45Ncm. If despite
this, adequate primary stability
is not achieved then immediate
loading is not recommended.
Fig 2. Angled implants placed
into available bone anterior
and posterior to the maxillary
sinus.
Fig 7. The silicone key can direct the implant surgeon.
Fig 6. Silicone key of a diagnostic wax up.
Fig 11. The single implant
with a Zirconia screw retained
crown.
Fig 12. Palpation of the extraction socket walls with a periodontal probe.
Prostho Driven Implant Placement
By using a silicone key of the
facial surfaces of the existing
teeth (Fig 5) or a silicone key of
a diagnostic wax up (Fig 6), it is
possible to place the implant in
the correct position and angle so
that the screw access hole can
exit in the correct place to allow
for screw retention.
In order not to loose significant
orientation, extractions are not
performed all at once prior to
implant placement but are rather performed one at a time followed by implant placement so
that the silicone key can direct
the implant surgeon (Fig 7).
It is very often necessary to use
an implant with a built in angle
of 12o, 24o or even 36o so that the
case can be screw retained.
Screw retention is an absolute
requirement for biological reasons (to avoid risk of inflammation due to excess cement) as
well as the ease of handling of
immediate loading in a surgical
environment.
Bite registration is started prior
to extraction of all the teeth in
the full mouth/arch case so as
not to loose the centric relation
and vertical dimension (Fig 8).
The remaining extractions are
then performed, further implants are placed and the bite
registration is completed with
addition of bite registration material onto the remaining healing caps.
One Abutment One Time
After bone milling to remove
any interfering bone, in multiple implant cases transmucosal
multi-unit abutments are placed
on the implants and torqued to
45Ncm at the time of surgery.
These abutments are placed and
torqued onto a “clean” implant
platform with no interfering
bone or soft tissue and are never
removed again.
Scientific research shows less
bone loss, better bone levels and
peri-implant soft tissues when
Fig 3. Immediate molar replacement implants.
Fig 8. Bite registration is started prior to extraction of all the
teeth and is completed with addition of bite registration material onto the remaining healing
caps.
Fig 13. In healed sites where
possible the “punch” technique
is used.
the transmucosal abutments are
placed at time of surgery and
never removed (Fig 9).
Healing caps are then placed on
the multi-unit abutments (Fig
10). After abutment placement,
at the same surgical appointment, the impression is taken at
abutment level and provisional
acrylic screw retained fixed
teeth are placed in the same day
as the implant surgery.
In single implant cases the healing abutment is placed directly
at implant level. An implant
impression is taken and six
hours later a full ceramic/zirconia screw retained crown is
then connected and torqued to
45Ncm directly on to the implant
without an intermediate/transmucosal abutment (Fig.11).
No multi-unit abutment is indicated or placed in the single
implant case as the multiunit
abutment has no anti-rotation
feature.
Flapless/Minimal Flap Surgery
In extraction cases no mucoperiosteal flap is reflected. The
integrity of the extraction socket
walls is inspected and assessed
with a 15mm or 20mm periodontal probe placed into the
extraction socket. Palpation of
the extraction socket walls is
performed with the probe (Fig
12) and this is complemented
by good vision with magnifying
loops and light illumination.
In healed sites where possible
the “punch” technique is used
(Fig 13).
Alternatively minimal flaps are
raised where indicated.
This flapless/punch technique/
minimal flap approach results in
minimal or no soft tissue changes thereby allowing the restorative dentist/prosthodontist to
proceed with the provisional
acrylic screw retained teeth in
the same day and permanent
ceramic screw retained teeth in
1 week in the case of multiple
implants. In the case of the single implant the permanent full
Zirconia screw retained tooth
can be delivered in 6 hours on
the same day.
plants (figs 14 & 15) are placed
per arch depending on:
1) Bone volume & quality
2) Implant length & diameter
3) Implant distribution
(A-P spread)
4) Patient’s age
5) Patient’s finances (cost to benefit ratio)
Prosthodontic Protocol
The Prosthodontic protocol of
SameDay Dental Implants &
Teeth is focused and designed
around the patient’s needs. It’s
fast, efficient and doesn’t compromise quality. The patients
are never left without teeth for
more than six hours. As a result
treatment acceptance is high.
All implants with good primary
stability (>45Ncm) are immediately loaded with screw-retained
teeth. For single implant cases,
the final all ceramic screw retained tooth is fabricated and
delivered to the patient within
six hours. For multiple implants
cases, temporary screw retained
acrylic teeth are fabricated within six hours and the permanent
screw retained all ceramic or
metal ceramic teeth are delivered one week later.
Timing of Immediate Loading
Dental implants either should
be loaded the earliest possible
(never exceed ten days after
surgery) or alternatively two
months after placement. This
is because the so-called initial
“primary stability” (mechanical
stability) that an implant has,
starts to drop gradually and the
implant become more prone to
failure if forces are applied. Fortunately, simultaneously a “secondary stability” (Osseointegration) starts to build up. The sum
of the two “stabilities” which
is demonstrated on the stability graph (Fig. 16), gives us the
“total stability”. As a golden rule
implants ideally should never be
disturbed during the “stability
dip” period.
Preoperative Preparation
In order to achieve this protocol, preoperative screening and
detailed surgical and prostho-
Number of Implants
In edentulous cases 4 to 6 im-
> Page 28
Fig 4. 45Ncm Primary Stability measured during implant
placement.
Fig 5. Silicone key of the facial
surfaces of the existing teeth.
Fig 9. Good peri-implant tissues
with “One Abutment One Time”
approach.
Fig 10. Healing caps placed on
abutments.
Fig 14. All-On-4
Fig 15. All On-6
[32] =>
28 implant tribune
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 27
Fig. 17. Before/After Digitally Designed Smile
Fig. 18. Preoperative and implant impressions, bite registrations and silicone keys, right
after surgery.
Fig. 21. The Mutually Protected
Occlusion.
Fig. 23. The Passive Abutment.
Fig. 16. Implants should not be
loaded during the “Stability
Dip” period.
Fig. 22. The Anterior Custom
Made Guiding Table.
Fig. 20. Periapical x-ray, verifying perfect fit of the all ceramic
crown onto the implant.
Fig.25. Adaptation of the final
prosthesis onto the mature soft
tissues, two months after surgery.
dontic treatment planning is imperative.
From the prosthodontic point
of view, each patient’s smile,
mouth and occlusion are evaluated with the help of photos and
videos (dynamic picture). Impressions are taken and the diagnostic models are mounted. If
needed, the digital smile design
(DSD) (Fig. 17) concept is used
in order to proceed with a diagnostic wax-up. From the waxed
models, “silicone keys” of the
buccal/lingual surfaces of the
teeth, are fabricated, which will
be used during the surgery to
guide the implant placement.
Impression During Surgery
An impression of the implants is
taken during the surgery, either
at implant level for single implants or at abutment level for
multiple implant cases.
It’s imperative to make sure that
the impression copings are seated all the way onto the implants
(periapical x-rays can be used
for verification).
For the impression, the open
tray technique is recommended
with the use of very hard addition cured silicon impression
material.
At the end of each surgery, preoperative impressions, impression of the implants and bite
registration are provided to the
dental lab (Fig. 18). The dental
technician mounts the implant
models and starts the fabrication
of the implant prosthesis.
Single Implant Reconstruction
For single implant cases the
permanent, screw retained, all
ceramic zirconia teeth are fabricated immediately with the use
of prefabricated zirconia cores
(Fig. 19). They are available in
different sizes and shapes, according to the prosthetic platform of the implant in use and
the available prosthetic space,
between the adjacent teeth.
While the patient is waiting in
the recovery room the dental
technician grinds and shapes
Fig. 26. Final Full Contour ZIRCONIA prosthesis on implants.
Fig.27. SameDay Dental Implants® & Teeth with Angled
and Wide implants.
the zirconia core and eventually
bakes the porcelain on to it.
Four to six hours later the permanent tooth is placed into the
mouth of the patient and the
prosthetic screw is torqued
down to 45Ncm. A periapical
x-ray helps to verify the perfect
fit (5μ) on to the implant (Fig.
20). Occlusion is checked and
verified with the help of 8μ thick
“schimstock” articulating paper.
The prosthetic access hole is obturated with a two layered filling
(teflon tape + opaque composite
resin) to allow easy access for
retrievability in the future but
simultaneously excellent esthetics.
Two months later upon maturation of the soft tissues and osseointegration, an additional x-ray
is taken and if needed modifications are made to the prostheses.
Once all necessary modifications are made and the patient is
satisfied, we need to convey all
newly established parameters
to the dental technician. This is
achieved by:
i) taking photos and videos to
record the esthetic result, in the
mouth and
ii) using the so-called “Clinical
Remounting Procedure”, in the
laboratory.
Alginate impressions and bite
registration are taken from the
temporary teeth, which are removed from the mouth and remounted again on the articulator. From the newly remounted
temporary teeth the dental technician fabricates:
i) a series of silicon keys which
will guide him to fabricate the
permanent teeth and ii) an “Anterior Custom Made Guiding
Table” (fig 22) which will allow
him to reproduce the occlusal
scheme of the temporary teeth
to the permanent teeth.
Twenty minutes later the temporary teeth are placed again in
the mouth of the patient and the
prosthetic screws are torqued to
20 Ncm. He is instructed not to
bite hard onto the acrylic teeth
and oral hygiene instructions
are provided to him.
2) Permanent Teeth Fabrication
The dental lab, with the help of
i) the interchangeable implant
and temporary models, ii) the
silicon keys, iii) the anterior custom made guiding table, iv) the
photos and v) the videos starts to
fabricate immediately the permanent screw retained porcelain teeth.
The permanent teeth need to be
ready in one-week’s time and
should have perfect fit onto the
implants. This is one of the most
important prerequisites for optimal implant longevity.
The material of choice, used by
our dental lab, for the past 20
years, is porcelain fused to metal. The fabrication of the metal
ceramic prosthesis involves a
series of technique sensitive
procedures. Inevitably in each
step, small “3 dimensional inaccuracies” are introduced into the
prosthesis. The sum of these inaccuracies is never zero. As a result, at the end of the fabrication
procedure, the final prosthesis
will never have a perfect fit onto
the implants.
The use of the “Passive Abutment” (Fig. 23), which is a tita-
Multiple Implants Reconstruction
1)Temporary Teeth
For multiple implant cases
(three unit bridges to full mouth
reconstructions), the temporary
screw retained acrylic teeth are
fabricated by the in house dental
lab within five to six hours and
are delivered immediately to the
patient on the same day.
Providing the temporary teeth
immediately, isn’t only a great
service to the patient but is also
the best “diagnostic tool” for the
restorative dentist to record all
necessary information for the
fabrication of the permanent
teeth. If needed modifications
are easily made to the acrylic
teeth either directly in the mouth
or in the dental lab.
The patient should be evaluated for esthetics, phonetics and
occlusion. Midline, plane of occlusion and buccal corridors
are established. The “S” and “F”
sounds are checked. The occlusal scheme is adjusted. For
extensive cases the “mutually
protected occlusion” (Fig. 21) is
established which means that in
centric occlusion, all teeth are
touching but the posterior teeth
have slightly heavier contacts
compared to the anterior and on
lateral and protrusive excursive
movements the anterior teeth
are touching/guiding and there
are no posterior “working” or
“non-working”
interferences
(anterior guidance). X-rays are
taken in order to verify the passive fit of the prosthesis.
nium machine-cut interfacial
component/cylinder, offsets all
the 3D inaccuracies, provided
that the implant model is accurate. The passive abutment is
cemented by the dental technician onto the fitting surface of
the prosthesis, in the lab. The
master implant model is used as
a blueprint for the cementation.
Based on our experience over
the past 15 years of using passive abutments, the metal try-in
procedure is not needed, thus
speeding up the fabrication of
the final prosthesis.
3)Placement of the Permanent
Teeth
One week after the implant surgery the patient returns for the
placement of the permanent
teeth.
The temporaries are removed,
the prosthetic platform of the
implants is cleaned, dried and
immediately the permanent
teeth are screwed onto the implants.
There is a big benefit having to
work only with “one piece screw
retained” (Fig. 24) prosthesis.
There are no multiple custom
abutments to be positioned first,
the retrievability of the “one
piece prosthesis” makes adjustments much easier, there is no
excess cement to deal with during cementation that can cause
significant complications if left
accidentally under the immature tissues.
Fitting of the prosthesis is assessed with x-rays. Like with the
temporary teeth all parameters
(esthetic, phonetics, occlusion)
are checked again and adjustments are made. The prosthetic
screw is torqued down to 32Ncm
and the prosthetic access holes
are obturated. A night guard is
provided and the patient is instructed to use it every night.
Oral hygiene instructions are
demonstrated and their importance is emphasized.
Follow up
Two months later the osseointergration of the implants is radiografically and mechanically
evaluated. In case of soft tissue
recession, a pick up impression
of the prosthesis is done. A new
soft tissue model is fabricated
and the dental technician can
add porcelain accordingly (Fig.
25). The patient is followed up
every six months for the first two
years and thereafter according
to his/her oral hygiene level.
Complications
The majority of the prosthodontic complications are porcelain
fractures/chipping. These are
easily repaired by removing the
teeth and rebaking the porcelain.
Fig. 19. Prefabricated Zirconia
Cores in different shapes and
sizes.
Fig. 24. The “One Piece Screw
Retained” Prosthesis.
CAD/CAM Advancements
Recently in order to eliminate
this problem, at SameDay Dental Implants® Clinic, CAD/CAM
full contour zirconia screw retained implants prostheses are
used in selected patients (Fig.
26). Only the front 6 teeth are
layered (buccaly) with porcelain
to optimize esthetics and passive abutments (titanium) are
utilized to eliminate zirconia to
titanium wear problems.
Even though zirconia is a technique sensitive material, the
first results (one year) are very
promising. However, only time
will tell, if zirconia will be the
material of choice. The advancements in digital impressions and
CAD/CAM technology will further reduce the manufacturing
time but most importantly will
increase the accuracy and quality of the dental prostheses.
Conclusion
By using tapered angled implants as well as wide immediate
molar replacement implants in a
prosthetically driven fashion it is
possible in most cases to avoid
bone grafts, achieve high primary stability and treat patients
with implants and passively fitting, screw retained teeth all in
the same day (Fig 27).
This reduction in treatment
time, immediate function and
cost saving leads to high patient
satisfaction and increased treatment acceptance by patients.
Contact Information
Dr. Costa Nicolopoulos BDS
cum laude, FFD (SA) MFOS
Dr. Petros Yuvanoglu DMD summa
cum laude, Cert. Prosth (TUFTS, USA)
SameDay Dental Implants®
Brånemark Osseointegration
Center Dubai
Building 39, Dubai Health Care
City
tel: +971(0)44275010
email: info@samedayme.com
web: www.samedayme.com
[33] =>
[34] =>
30 news
Dental Tribune Middle East & Africa Edition | November-December 2014
Beirut International Dental Meeting 2014
The Exhibition
“Planning for the Future” we
encourage all Lebanese living
in Lebanon and abroad, as well
as all Arab and foreign dentists
to attend this highly regarded
meeting, in an effort to plan for
a better future, not just scientifically, but culturally and politically.“
BIDM 2014 Opening Ceremony
By Dental Tribune MEA
U
nder the high patronage of his Excellency
the President of the Parliament of Lebanon Mr. Nabih
Berry, Lebanese Dental Association known by its yearly BIDM
(Beirut International Dental
Meeting) has organized the 24th
BIDM 2014 in collaboration with
the Saudi Dental Society at BIEL
in Beirut on 11-13 September
2014.
Pre-congress courses and workshops took place on September 10 at “USJ” - University St.
Joseph - Faculty of Dentistry
which was managed by Profes-
sor Ghassan Yared and Professor
Carina Mehanna, under the supervision of Prof. Nada Naaman,
Dean of Faculty of Dentistry.
On the first day of the event the
attendees witnessed the ribboncutting ceremony followed by a
tour of the exhibition exploring
the latest dental technologies,
equipment and services displayed by numerous key industry leaders and dental manufacturers.
The BIDM 2014 not only opened
the doors to open-discussions
and learning for the region but
allowed the participants to build
their skills and use the oppor-
< Page 8
used to etch the fitting surface
of each veneer for 60 seconds as
recommended by the manufacturers to obtain a clean ceramic
surface for durable bonding.
Empress ceramic primer Monobond-S was used as a silane-coupling agent for one minute and
then air dried for five seconds
according to the manufacturers
instructions. One layer of Excite
bonding agent was applied on
the fitting surface of each veneer
for 60 seconds then air thinned
for 5 seconds Fig 10.
• Tooth structure surface treatment:
Transparent strips were used
on the proximal surface of adjacent teeth to avoid etching effect. Phosphoric acid 35 % was
used to etch the enamel margins
of the tooth preparations for 30
seconds and 15 seconds for the
dentin areas. Copious air water
spray was used to remove the
acid for 20 seconds. One layer
of Excite bonding agent was
applied on the tooth structure
and air thinned for five seconds.
LED light curing unit was used
for curing.
Vario-link Veneer light activated
resin cement was used for ce-
mentation of the two laminate
veneers. Optra Sticks were used
for holding the labial surface of
the veneer for better handling
processes during cementation.
Initial polymerization was made
and excess cement was removed
with a sharp tip of a probe, Dental floss was used to ensure that
there is no trapped cement in
between the embrasures. Final
polymerization was completed.
Intra oral proximal strips were
used for better smooth proximal
margins Fig.11.
About the Author
Dr. Mohamed Hassanien
B.D.S –M.D.S –P.H.D
Fixed Prosthodontics dept.
Faculty of Dentistry – Cairo
University
I.S.C.D Certified Cerec Trainer
tunity for networking by up-todate knowledge and sharing
experiences in the application
of technology throughout the
event.
President of Lebanese Dental
Association, Prof. Elie Maalouf
discussed during the opening
ceremony: “With the theme
Prof. Maalouf further announced, “We should all denounce terrorism and extremist
behavior. Attending this meeting
and especially in this dire time
will tell the world that we are
strong together and will show
them that no matter how hard
they try to separate us we will
always find a platform to meet.
Lebanon is a small country but it
has always reflected to the world
a sense of modern civilization
and openness to all cultures and
religions. Lebanon does not tolerate extremist behavior and
will not allow negative media
to taint its reputation. Holding
ambitious annual dental meetings with world renowned international and local speakers will
show the world that we are competing with first world countries
regarding scientific achievements”.
> Page 31
[35] =>
news 31
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 30
Scientific Session
Dr Elie Maalouf LDA President ,Dr Mohamad El
Obaida SDS,Dr Ibrahim Tarwneh Jordanian dental
association president
Dr Rahil Doueihy LDA-Tripoly President
With Former President of Lebanese republic General
Michel Sleiman (400x267)
Welcome dinner to delegates at Sultan Restaurant
Gala Dinner BIDM 2014
The general secretary of LDA,
Dr Walid Khattar further declared during the ceremony:
“Efforts exerted leading to this
conference were colossal, we
did very important team work
as council members, committee members, professional and
competent employees, to accomplish this conference. I hope
that you will benefit from interesting scientific topics adding
therefore to dental medicine a
new scientific corner stone.”
The conference further proved
to be a vital platform for the par-
ticipants to share ideas, explore
the potential of new advances in
technology and foster closer ties.
The BIDM 2014 gathered under
one roof of 6, 000 square meters
more than 4, 500 dental professionals in the dental field.
The
scientific
conference
brought together more than 2,
300 dentists registered to the
event program from Lebanon
and the region and more than
1000 have been registered as
visitors to the exhibition area.
This year, despite the difficult
situation in the region, the event
gathered 36 highly esteemed
guest speakers from 16 countries around the world (USA,
India, France, Germany, United
Kingdom, Italy, Bulgaria, Libya,
Greece, Spain, Lithuania, and
from the Arab countries Kuwait, Sultanate of Oman, Egypt,
Kingdom of Bahrain and KSA) in
addition to an interesting panel
of Lebanese talented lecturers
will attempt to clarify during 3
exciting days some of the most
important issues and dilemmas
arousing today. They highlighted on areas of ongoing develop-
ments and frontiers of research
challenges in treatment planning, clinical performance and
sustainable measures that are
essential for a long-term treatment success. The event also
received sponsorship by major
market players and dealers in
the region and the world leading
companies, more than 137 companies were part of a unique
huge space offered this year.
The event came to a conclusion
with 13 lucky draws sponsored
by Lebanese Dental Association
during the closing ceremony.
Overall, The BIDM 2014 was a
resounding success with nothing but positive feedback from
the visitors.
The courses this year covered
a variety of topics including:
Endodontology, restorative dentistry, pedodontology, laser in
dentistry, Surgery and implant
loading. Each course received
specific continuing education
hours in collaboration with
CAPP (Center for Advanced Professional Practices) which is an
ADA CERP recognized provider.
iRace sequence,
Quick, effective and safe
For most cases, iRace sequence includes
3 instruments for finishes of ISO 30/.04*
Mastered metal
fatigue
Optimal cutting
efficiency
No screwing-in effect
Improved resistance
to torsion and fatigue
Precision guiding
*for bigger apical size preparations, please visit www.fkg.ch
Sterile and
non-sterile
FKG Dentaire SA
www.fkg.ch
[36] =>
32 oral health
Dental Tribune Middle East & Africa Edition | November-December 2014
Saliva and Oral Health
By Michael Edgar, Colin
Dawes & Denis O’Mullane and
contributed to by Mahvash
Navazesh
Excerpt from Saliva and Oral
Health-An Essential Overview
for the Healthcare Professional
E
xcerpt from Saliva and
Oral Health-An Essential
Overview for the Healthcare Professional, 2012, by Michael Edgar, Colin Dawes &
Denis O’Mullane and contributed to by Mahvash Navazesh.
The 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 deterioration of oral
health but also has a detrimental
impact on the quality of life for
the sufferer.
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 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.
The following article provides
an overview of oral complications associated with salivary
gland hypofunction, and aetiology, diagnosis, clinical implications and management of xerostomia.
Xerostomia and Salivary
Gland Hypofunction
Saliva plays a significant role in
the maintenance of oral-pharyngeal health. Subjective complaints of a dry mouth (xerostomia) and objective evidence of
diminished salivary output (salivary gland hypofunction) are
common conditions, particularly in medically compromised
older adults. They can result in
impaired food and beverage intake, a sundry of oral disorders,
and diminished host defence
and communication. Persistent
salivary gland hypofunction can
produce permanent oral and
pharyngeal disorders and impair a person’s quality of life.1, 2
Global estimates of xerostomia
and salivary gland hypofunction are difficult to ascertain
due to varying study design, differences in study populations,
usage of the terms xerostomia
and salivary gland hypofunction
interchangeably, utilisation of
different diagnostic criteria and
saliva collection methods, and
small sample sizes.
However, overall, the prevalence of xerostomia and salivary
gland hypofunction increases
with age and affects approximately >30% of the population
aged 65 years and older.
There are multiple causes of
xerostomia and salivary gland
hypofunction, the most common
being drug-induced, since most
older adults are taking at least
one medication that causes salivary gland hypofunction. It is difficult, however, to estimate the
true prevalence of xerostomia in
older adults taking medications.
The prevalence of xerostomia
is nearly 100% among patients
with Sjögren’s syndrome, an
autoimmune exocrinopathy affecting between 1-4% of older
adults.
Estimates of the prevalence of
xerostomia in adult ambulatory
and nursing home populations
range from 16-72%.3 Combining the prevalence of xerostomia associated conditions with
the percentage of adults with
these conditions who complain
of xerostomia yields the abovementioned general estimate of
approximately 30% xerostomia
prevalence among adults 65
years and older.
Approximately 80% of all persons over age 65 have at least
one chronic condition and 50%
have at least two. Hypertension
and heart diseases, diabetes, arthritis and cancer are the most
frequently occurring conditions
among older adults. These conditions, and the medications often prescribed for their management, could impact the structure
and function of salivary glands
leading to complaints of xerostomia or clinical evidence of salivary gland hypofunction.
Diagnosis of xerostomia and
salivary gland hypofunction
Subjective responses and
questionnaires
The establishment of a diagnosis
of xerostomia may be initiated
with patients’ complaints and
can be advanced with the use
of questionnaires. It should be
noted that a patient’s presenting
complaint may not be dry mouth
in spite of the presence of salivary gland hypofunction. Therefore, lack of complaint should
not be perceived as presence of
adequate saliva secretion. Many
of the common oral symptoms
of dry mouth are associated with
mealtime: altered taste, difficulty eating, chewing, and swallowing, particularly dry foods,
and especially without drinking
accompanying liquids. Patients
complain of impaired denture
retention, halitosis, stomatodynia, and intolerance to acidic
and spicy foods.4 Night-time xerostomia is also common, since
salivary output normally reaches its lowest circadian level during sleep and may be exacerbated by mouth breathing.5
General oral examination
Extraoral findings associated
with salivary gland hypofunction
may include dry and cracked
lips that are frequently colonised
with Candida species (angular
cheilitis). Visible and palpable
enlarged major salivary glands
occur secondary to salivary infections and obstructions (e.g.
bacterial parotitis, mumps, and
Sjögren’s syndrome). A swollen
parotid gland can displace the
earlobe and extend inferiorly
over the angle of the mandible,
whereas an enlarged submandibular gland is palpated medial
to the posterior-inferior border
of the mandible.
There are numerous intraoral
complications associated with
salivary gland hypofunction.
Oral mucosal surfaces become
desiccated and easily friable.
The tongue can lose its filiform
papillae and will appear dry,
erythemic, and raw with an irritated dorsal surface. Mucosal
tissues are susceptible to developing microbial infections,
the most common being candidiasis. This intraoral fungal
infection manifests itself as erythematous candidiasis beneath
prostheses and as pseudomembranous candidiasis, which produces a white plaque that can be
removed from mucosal surfaces. Clinicians can also observe a
decrease or an absence of saliva
pooling in the anterior floor of
the mouth.
A second frequent problem is
dental caries that occurs both on
coronal and root surfaces. New
caries lesions can develop on
surfaces not normally affected
(e.g. incisal edges of anterior
teeth), and recurrent lesions are
prevalent on the margins of existing restorations. Edentulous
and partially dentate adults using removable prostheses have
diminished denture retention,
which will adversely impact
chewing, swallowing, speech,
and nutritional intake. Denturebearing tissues can develop erythematous candidiasis and traumatic and painful lesions due to
tissue trauma.
Saliva Collection
Numerous investigators have
attempted to define the lower
limits of ‘normal’ salivary flow
rates. However, there is substantial variability in flow rates that
makes it difficult to define diagnostically useful ranges of glandular fluid production. In studies of healthy persons across the
lifespan, unstimulated fluid secretion varies 10-100 fold, while
stimulated secretion varies 1020 fold.6, 7
In patients considered to be
at risk for developing salivary
gland hypofunction, it would be
useful to monitor salivary flow
rates over time. Most investigators consider a diagnosis of
salivary gland hypofunction if
the unstimulated whole salivary
flow rate is less than 0.1 ml/min
using standardised techniques.
Unstimulated secretions are
probably more indicative of salivary gland hypofunction compared with stimulated secretions, since saliva is produced
under unstimulated conditions
during most of the hours a person is awake. The most common collection technique for
CAUSES OF XEROSTOMIA AND SALIVARY GLAND
HYPOFUNCTION:
• MEDICATIONS
• ORAL DISEASES
• SYSTEMIC DISEASES
• HEAD AND NECK RADIOTHERAPY
unstimulated whole saliva is
to have a patient refrain from
eating, drinking, smoking, or
performing oral hygiene for at
least 60 minutes prior to saliva
collection. The patient is seated
in a quiet environment with the
head tilted forward. Immediately before the test begins the
patient should swallow any residual saliva that may be in the
mouth. The time is recorded and
the person is instructed to allow
saliva to flow gently into a preweighed test tube or other container placed under the chin for
five minutes without swallowing or spitting. At five minutes
the person is instructed to expectorate the remaining saliva
into the container. The volume
is recorded gravimetrically and
expressed as ml/min.
Stimulated whole salivary flow
rates of less than 0.5 ml/min are
also considered to be suggestive
of salivary hypofunction. The
most common technique for
collecting this form of saliva is
with the use of a standard piece
of paraffin wax or unflavoured
gum base (typically 1-2 g). A
test tube or similar container
with the paraffin or gum base
is weighed prior to saliva collection. The person is instructed
to swallow any residual saliva
that may be in the mouth before
the saliva collection begins. A
timer begins and the person is
instructed to chew the wax or
gum base at a rate of 60 chews/
minute. Without swallowing, the
patient expectorates all saliva
into the pre-weighed container
placed under the chin at each 60
second interval. At five minutes
the person is instructed to expectorate the remaining saliva
and wax into the container and
the collection is completed. The
volume is recorded gravimetrically, and expressed as ml/min.
Values below 45% of normal levels can be used to define salivary
gland hypofunction. It is also
generally accepted that when
glandular fluid production is decreased by about 50%, patients
will begin to experience xerostomia.8 The best strategy is simply
to monitor a patient’s salivary
health (both objectively and subjectively) over time to determine
whether there are demonstrable
changes.9
Clinical implications of xerostomia and salivary gland hypofunction
Dental caries and dental erosion
One of the most common oral
conditions that develop as a result of salivary gland hypofunction is new and recurrent dental
caries. In the presence of persistent salivary gland hypofunction,
the inability of the salivary system to restore oral pH towards
neutrality and inhibit certain
bacteria after food and beverage ingestion leads to an oral
environment conducive to microbial colonisation with cariesassociated microorganisms and
enamel demineralisation. The
margins of existing restorations
are also vulnerable to recurrent
decay. Salivary hypofunctionassociated root surface caries is
a particularly difficult condition
to diagnose and treat and, therefore, identification of patients at
risk will allow measures to be
taken to preserve the dentition.
With deficient remineralisation, dental erosion is a more
frequent occurrence in patients
with salivary gland hypofunction. The cervical regions of
teeth occasionally receive greater abrasion from tooth brushes
and are susceptible to dental
erosion. Occlusal and incisal
surfaces exposed to attritional
and traumatic forces can also
undergo greater loss of enamel
and dentine when there is insufficient saliva to permit remineralisation.
Gingivitis
The increase in salivary output
during and immediately after
the consumption of foods and
fluids assists in the lavage of the
oral cavity and the removal of
food particles from oral surfaces.
Conversely, salivary gland hypofunction is frequently associated
with retained food particles,
particularly in interproximal regions and beneath denture surfaces, and can cause gingivitis.
Long-standing gingivitis may
develop into periodontal loss
of attachment, so patients with
chronic hyposalivation are at
risk for developing gingival and
periodontal problems.
Interestingly, most studies have
not demonstrated significantly
greater levels of periodontal disease in patients with Sjögren’s
syndrome
compared
with
10
healthy controls, which may be
due to greater attention to oral
health and more frequent use of
professional dental services. In
addition, while several studies
have demonstrated significantly greater numbers of cariesassociated mutans streptococci
and lactobacilli in patients with
salivary gland hypofunction
compared with healthy controls,
similar levels of micro-organisms associated with gingival
inflammation were detected in
both populations.11 Therefore,
the primary dental problem in
patients with salivary gland hypofunction is dental caries, with
less risk (but greater than that
for healthy individuals) for developing gingival and periodontal problems.
Impaired quality of life
Many of the oral-pharyngeal
sequelae of salivary gland hypofunction and chronic xerostomia lead to an impaired quality of life. Dentoalveolar and
oropharyngeal infections can
rapidly lead to systemic disease,
particularly in medically complex patients. Desiccated and
friable oral mucosal tissues are
more likely to develop traumatic
lesions, especially in denturewearing older adults, which
cause pain and interfere with
nutritional intake. Also, dysgeusia (taste function), dysphagia
> Page 33
[37] =>
oral health 33
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 32
(difficulty swallowing), and difficulty chewing food secondary to
salivary gland hypofunction can
lead to changes in food and fluid
selection that compromise nutritional status. The speech and
eating difficulties that develop
can impair social interactions
and may cause some patients to
avoid social engagements. Dysphagia increases susceptibility to aspiration pneumonia and
colonisation of the lungs with
Gram-negative anaerobes from
the gingival sulcus.12
Management of xerostomia
and salivary gland hypofunction
The initial step in the management of xerostomia is the establishment of a diagnosis. This
frequently involves a multidisciplinary team of health care providers who communicate effectively, since many patients have
concomitant medical conditions
and frequently experience complications of polypharmacy. The
second step is scheduling frequent oral health evaluations
due to the high prevalence of
oral complications.13
are advised to use saliva stimulants and substitutes which have
the function of lubricating the
oral surfaces. Chewing sugar
free 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
1. Jensen SB, Pedersen AM, Vis-
sink A, Andersen E, Brown CG,
Davies AN, et al.A systematic review of salivary gland hypofunction and xerostomia induced by
cancer therapies: management
strategies and economic impact.
Support Care Cancer 2010; 18:
1061-1079.
2. Jensen SB, Pedersen AM, Vissink A, Andersen E, Brown CG,
Davies AN, et al. A systematic review of salivary gland hypofunction and xerostomia induced by
cancer therapies: prevalence,
severity and impact on quality of
life. Support Care Cancer 2010;
18: 1039-1060.
3. Thomson WM, Chalmers
JM, Spencer AJ, Ketabi M. The
occurrence of xerostomia and
salivary gland hypofunction in a
population-based sample of older South Australians. Spec Care
Dent 1999; 19: 20-23.
4. Atkinson JC, Wu A. Salivary
gland
dysfunction:
causes,
symptoms, treatment. J Am Dent
Assoc 1994; 125: 409-416.
5. Dawes C. Circadian rhythms
in the flow rate and composition
of unstimulated and stimulated
human submandibular saliva. J
Physiol 1975; 244: 535-548.
6. Ship JA, Fox PC, Baum BJ.
How much saliva is enough?
Normal function defined. J Am
Dent Assoc 1991; 122: 63-69.
7. Ghezzi EM, Lange LA, Ship
JA. Determination of variation of
stimulated salivary flow rates. J
Dent Res 2000; 79: 1874-1878.
8. Dawes C. Physiological factors
affecting salivary flow rate, oral
sugar clearance, and the sensation of dry mouth in man. J Dent
Res 1987; 66 (Spec Issue): 648653.
9. Ship JA, Fox PC, Baum BJ.
How much saliva is enough?
Normal function defined. J Am
Dent Assoc 1991; 122: 63-69.
10. Jorkjend L, Johansson A,
Johansson AK, Bergenholtz A.
Periodontitis, caries and salivary
factors in Sjögren’s syndrome
patients compared to sex- and
age-matched controls. J Oral Rehabil 2003; 30: 369-378.
11. Almståhl A, Wikström M.
Oral microflora in subjects with
reduced salivary secretion. J
Dent Res 1999; 78: 1410-1416.
12. Loesche WJ, Schork A, Terpenning MS, Chen YM, Stoll J.
Factors which influence levels
of selected organisms in saliva
of older individuals. J Clin Microbiol 1995; 33: 2550-2557.
13. Atkinson JC, Wu A. Salivary gland dysfunction: causes,
symptoms, treatment. J Am Dent
Assoc 1994; 125: 409-416.
Maintenance of proper oral hygiene and hydration (water is
the drink of choice) are helpful.
Several habits, such as smoking, mouth breathing, and consumption of caffeine containing
beverages, have been shown
to increase the risk of xerostomia. Limiting or stopping these
practices should lessen the severity of dry mouth symptoms.
A lowsugar diet, daily topical
fluoride use (e.g. fluoride toothpaste and mouth rinses), antimicrobial mouth rinses, and use
of sugar-free gum or candy to
stimulate salivary flow, help to
prevent dental caries.
Patients must be instructed on
the frequent use of fluids during
eating, particularly for dry and
rough foods. Eating and swallowing problems secondary to
salivary gland hypofunction can
impair the intake of fibre-rich
foods, restricting some older
adults to a primarily soft and
carbohydrate diet. Accordingly,
patients must be counselled on a
well-balanced, nutritionally adequate diet and the importance
of limiting sugar intake, particularly between meals.
If there are remaining viable
salivary glands, stimulation
techniques using sugar-free
chewing gum, candies (sweets),
and mints can stimulate salivary output. Chewing sugarless gum is an extremely effective and continuous sialogogue,
since it increases salivary output
and increases salivary pH and
buffer capacity. Buffered xylitolcontaining chewing gums or
mints are often recommended,
because xylitol has an anti-cariogenic effect.
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
Visit us at:
IDS COLOGNE, 10–14 March 2015, Hall 11.2 – Booth N30 & O31
Inibsa_A4_DTMEA614.pdf 1
17.10.14 11:42
[38] =>
34 clinical
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 22
Figure 4
Figure 3
Figure 5
clar Vivadent e.max shade A1
size 12 ceramic block. We tried
in the crown and took a digital
PA radiograph to verify the margination, and made a slight occlusal adjustment on the lingual
surface. The patient and parents
were pleased with the appearance of the unglazed product.
We polished, glazed, and added
the bone pattern and periodontal ligament space surrounding
the damaged tooth. In addition,
the 3D scan, taken at a 5 cm x
5 cm field of view and 300 voxels, allowed us to rule out buccal
or palatal plate fractures before
finalizing the treatment plan.
The various voxel settings let us
select the best exposure time to
image the structures we desire
to view. This would not have
been possible in the past with
a panorex or digital 2D radiograph system.
The fact that we were able to
provide the patient and her parents with a three-dimensional
CBCT of tooth #9 gave them the
opportunity to see and understand what was going on under
the surface; ultimately resulting in positive acceptance of the
treatment plan. I find that the
CS 8100 3D unit gives me an
incredible level of detail with actual size images that I can view
from any angle or cross-section
to get the best possible diagnos-
Figure 6
a slight white line on the buccal
of #9 to mimic natural tooth #8.
The crown was fired in the Ivoclar Programat Oven on e.max
glazing setting. After a final tryin, the crown was cemented in
place using variolink translucent
base and catalyst. We cleaned
off the excess cement, verified
the final occlusal scheme, and
captured a final periapical image verifying cement removal
(Fig. 8).
Post-operative instructions were
given. The patient and parents
were advised to call immediately
if there was sensitivity, swelling,
questions or concerns. I spoke
with the parents and checked
Figure 7
tic image. CS Solutions (CS 3500
intraoral scanner, CS Restore
software and CS 3000 milling
unit) allows my office the opportunity to fabricate same-day
permanent restorations. My
patients appreciate the fact that
our office is staying up to date
with new available technology
and giving them a safer environment with less radiation.
Figure 8
Figure 9
About the Author
on the patient one day and one
week postoperatively. She was
proud of her new tooth and said
it felt “awesome” (Fig. 9).
Testimonial
Carestream Dental products
helped me gather valuable clinical information, diagnose, monitor treatment status, and provide better care for this patient.
The digital radiographs initially
captured by the CS 8100 3D to
evaluate the tooth were clear
and beneficial to determine fracture and position of nerve tissue.
This clarity allowed us to see
Robert Pauley, Jr., DMD
Dr. Pauley has been practicing
dentistry in the Atlanta area since
graduating from the University of
Kentucky College of Dentistry in
1988. Currently enrolled in the
Advanced Dental Implant Studies, Dr. Pauley is an Associate
Fellow of the American Academy
of Implant Dentistry and a Fellow
of the International Congress of
Oral Implantologists.
Would you like to know more?
Visit us on the web at
www.carestreamdental.com or
call 800.944.6365.
[39] =>
news 35
Dental Tribune Middle East & Africa Edition | November-December 2014
New 3Shape advisory board develops plan
to improve patient care
By Dental Tribune International
C
OPENHAGEN,
Denmark: 3Shape, a global
provider of digital 3-D
solutions for dental laboratories
and dental clinics, has formed a
dental advisory board made up
of 12 prominent dental professionals from around the world.
The new board will provide the
company with insight and direction in digital technology and
product development, as well as
help the company move towards
its goal of improving dental patient care.
best practices in the use of digital technologies; (2) to define
actual needs for better dentistry
based on cases and experience;
(3) to support the research and
development of and innovation
in dental technologies; and (4) to
promote education and awareness of digital dentistry.
own 3-D scanners and CAD/
CAM software.
“The way dentists care for patients has changed dramatically
over the past few years, with digital technology driving much of
this change. Digital workflows
enable dental professionals to
work more efficiently and accuAll board members are respect- rately, with digital case handling
ed leaders in the use of digital now in many cases surpassing
dental solutions and intra-oral analogue treatment in quality.
scanning. Members work with The creation of the board will
a variety of the digital dental serve to improve patient care
CS81003D A4:Layout 1 06/08/2014 10:32 Page 1
systems
available on the mar- even further and strengthen
ket and not necessarily 3Shape’s 3Shape’s reputation as an indus-
try leader. At the two-day meeting we got a sense of 3Shape’s
passion not only from their willingness to listen to the expertise
and insight of the professionals
gathered, but also from their
commitment to taking action
and applying our recommendations to create better solutions
and improve patient care,” said
Ferencz.
The 3Shape Dental Advisory
Board comprises 11 dentists and
one dental laboratory owner.
Board members are from Australia, Brazil, Denmark, France,
South Korea, Spain, Switzerland
and the US. Plans for the board
include biannual meetings to
ensure the success of the fourpoint plan, as well as to assess
both the industry and 3Shape
product development.
Ferencz likened support for
3Shape in the industry to that
of IT giant Apple: “I think there
is a passion that users have for
3Shape that is analogous to the
passion that Apple users have
for their products. 3Shape is
driven by innovation much the
same as Apple. And like Apple,
they make products that are
more useful, beneficial and incidentally, look cool too.”
“The 3Shape Dental Advisory
Board provides 3Shape with a
unique opportunity to work with
the dental industry’s top digital
experts to develop our technology and solutions and better answer real needs for dentists. Our
goal is to improve patient care.
Working alongside these industry leaders brings us one step
closer to this,” said Flemming
Thorup, President and CEO of
3Shape.
The group met for the first time
earlier this month in Copenhagen. Leading digital dentistry
advocate and practitioner Dr
Jonathan Ferencz from the US
chaired the two-day meeting.
The advisory board developed
a four-point plan to achieve the
following objectives: (1) to share
THE WAIT
IS OVER
Visit us at:
6th Dental Facial
Cosmetic Int’l
Conference
Jumeirah Beach Hotel Dubai
[40] =>
36 NEWS
Dental Tribune Middle East & Africa Edition | November-December 2014
Interview: “The Emirates Clinic is unique”
systems or CAD/CAM scanners
is becoming more and more an
integral part of the dental surgery. It is clear that when feedback has been provided to the
manufacturers of problems being faced with new technology,
this feedback is being listened to
so as to improve the functionality of this technology. I am of the
belief that the digital technology
available nowadays justifies the
investment required by dental
clinics.
By Dental Tribune MEA
D
UBAI, UAE: The Emirates Group provides
in-house medical and
dental services for eligible staff
members and their families via
its own Emirates Clinic, located
at the famous Sheikh Zayed
Road in Dubai, UAE.
Dental Tribune MEA had the
pleasure of interviewing the Vice
President of the Dental Clinic
Services, Dr. Brendan James
Carr to find out more about the
Emirates Dental Clinic Services
and its uniqueness. The dental
team comprises of dentists, dental hygienists and dental nurses
who provide the highest standards of dental care for company
staff and their dependents on a
routine and emergency basis.
Supported by dental hygienists
and surgery assistants, dentists
not only monitor dental health
across the Group, but also participate in preventative dental
programs and/or education for
employees.
Dental Tribune MEA: Dr.
Brendan Carr, thank you for
your time. Could you share
with us your background and
the road to becoming VP at
the Dental Clinic Services in
Dubai?
Dr. Brendan Carr: I graduated from Glasgow University in
1998 and worked in the NHS for
3 years before accepting a position in a large private practice in
the Gold Coast Australia. After
working and living in Australia
for 4 years I took up a position
in a private practice in West
London for a further 3 years. I
moved to Dubai in 2009 having
been very fortunate to be selected for a position in the Emirates
Airline dental clinic which has
been a great move and a clinic
[41] =>
mCME 37
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 11
Fig. 11. Shows true hinges access mounting.
Fig. 12. Open bite on hinge axis mounted
model.
not something that can be outsourced to a lab. You need to
spend the time in doing these
setups to determine if it’s something that can be treated. Remember, there are cases where
you cannot achieve the goals.
Before we get to the setup, it’s
worth examining the three basic
concepts that this whole system
is based on. That’s not just orthognathic surgery, but orthodontics itself.
Concept No. 1: You need to start
with a seated congular position.
You will need to learn techniques to know when you have
a seated condyle, and if it’s in a
stable position.
Concept No. 2: You can’t believe
what you see in the mouth.
This is foreign to what we’re
taught in the orthodontic profession. We’re trained that when
we finish a case we have the
patient bite down, and we say
that the occlusion looks good or
it doesn’t. However, you need to
understand that this is a learned
muscle position. It’s not a position that is usually conducive to
normal joint function.
Concept No. 3: Quit trying to do
the impossible with orthodontic
tooth movement.
This is where orthognathic surgery comes into play. Don’t try
to fix skeletal aberrations with
orthodontic tooth movements.
Too often cases are treated with
a compromised treatment plan,
but due to the skeletal dysplias it
is impossible to establish a functioning occlusion, thus resulting
in failure.
We need a ruler to measure
how we come up with a diagnosis and then we need the same
ruler to measure our successes.
So in the sample case, the ruler
consists of five goals: joints, face,
perio, teeth and function.
In a pre-surgical diagnostic setup, which is a trial treatment,
the case can be diagnosed and
treated before you start. This
way you have the result in mind
before beginning (five goals).
The orthodontic, surgical and
restorative modalities can all be
Figs. 13a–h. Diagnostic setup.
Fig. 14. Measuring Glabella to
subnasale.
Fig. 15. Surgical models mounted according to axis-horizontal plane.
combined pre-treatment. This
way the patient knows what is
needed to solve his or her particular malocclusion.
created while trying to find the
terminal hinge axis of this patient allowed us to look at the
angle of eminence. What we
like to see is a steep angle of eminence as that helps disclude the
posterior teeth in lateral border
movements. Moreover, we like
to see nice, smooth curved lines
in the jaw motion, as that tells us
the condyle and disc are working in harmony with each other.
These pre-treatment setups are
based on the VTO (tooth movement) and the STO (skeletal
movement). Once all treatment
modalities have been tried, the
clinician will know if orthognathic surgery will work for the
patient.
The surgical setup is performed
just before surgery to determine
the skeletal changes needed to
correct the skeletal malocclusion and see if the prediction
setup is correct. We use our ruler again to make certain that the
five goals are obtainable. The
surgical splint can also be constructed from the surgical setup.
The surgical splint is used to
place the skeletal parts in their
correct position.
Steps in pre-surgical setups
First, we need to get the maxilla
positioned in the articulator. We
still recommend that you use the
articulator as a tool to do your
setup. Virtual setups tend not to
include the patient’s true functioning hinge axis. If you don’t
have the axis, you’re liable to
setup an arc of closure that distracts the condyle.
We establish the functioning terminal hinge access of the patient
on both the left and right. We’re
then transferring the hinge access to the side of the face. Once
we have it on the side of the face,
we can do our axis-horizontal
transfer. The dot shows the
functioning hinge axis on the
patient, represented on both the
right and left sides.
The axio-path tracing that we
Figs. 16a & b_ Intermediate surgical splint.
We determine the best centric
relation position in the mouth.
Nevertheless, remember, you
can’t believe what you see in
the mouth. That means this may
even be worse, especially when
we do a true hinges-axis mounting.
Figure 11 shows a true hingesaxis mounting. We have the true
hinge axis, we have the axishorizontal plane and we have
the teeth position according to
this setup. That means the pin,
which was removed for the photograph, would be the true vertical line. The articulator mounting is now the same as the CBCT
imaging.
What we see in the next image
is that this patient only hits on
the left side. Nothing touches
on the right. As you can also
see, the open bite is even worse
on hinge-axis mounted models
(Fig. 12)
Diagnostic setup
The diagnostic setup we’ve
been discussing is based on the
VTO, STO and the articulated
cast mounting. The orthodontic
setup, as well as a surgical setup,
can be done on the same set of
hinge-axis mounted models. We
can also include in the diagnostic setup the correct arch form so
a mutually protected occlusion
can be obtained (Fig. 13).
condyles up and forward.
Surgical setup
The surgical setup allows us to
plan the surgery case before we
go to the operating room. We
perform this after we’ve finished
the pre-surgical orthodontics
and we’re getting ready for the
surgery itself.
We then get into our surgical
correction. We’ve corrected the
maxilla. To maintain the proper
torque of the anterior teeth, we’ll
need a four-part maxilla. Now
we have our anterior segment
(lateral to lateral) and two posterior segments (cuspid to second molar) and the palate. The
anterior segment is positioned
vertically and horizontally to the
maxillary relaxed lip position. In
addition, we take into account
the tooth and gingival display
the patient exhibits.
What you should find when
you compare the pre-treatment
setup with the surgical setup is
that the bony part should look
very similar on the articulated
mounting as the pre-treatment.
In this case, we’ve leveled the
occlusal plane as part of our
surgical setup. In doing so, we
gained a large correction of the
mandible without doing genioplasty. Again, this is based on
the axis horizontal and the true
vertical line.
Now that the surgical orthodontics has been completed, and the
patient is now ready for surgery,
we go back and do the natural
head position and measure how
far Glabella is from SN. We then
do our axis transfer and place
the markers. Then we double
check that we have the natural
head position (Fig. 14).
Next, we do our axis transfer,
placing the maxilla exactly how
it’s related to the axis-horizontal
plane. This is important because
it enables us to place the maxilla
on the articulator exactly as it
exists on the patient, to the functioning axis.
Figure 15 shows the surgical
models mounted according to
the axis-horizontal plane. We
use a centric bite to position the
mandible to the maxilla, allowing the musculature to seat the
Figs. 17a & b_ Adjustments.
We’ve done the correction in
the maxilla, putting the uncorrected mandible on. This shows
the discrepancy you see once
you’ve leveled the maxillary occlusal plane. Now we position
the mandible. If we’ve done our
pre-treatment surgical orthodontics correctly, things should
fit together. Thus, after the mandibular correction is completed
in the setup, an uncorrected
maxilla is placed on the articulator. You should see a large posterior open bite.
This is also an easy way to construct our intermediate surgical splint, which you can see in
Figures 16a & b. Note how we
changed the plane of the mandible. This is based on doing the
mandible first. By placing the
mandible correctly in all three
planes of space, we can establish
the functional axis of the mandible.
This helps eliminate some of the
errors that occur in orthognathic
surgery. If we do the mandible
first, and we know the vertical
> Page 38
[42] =>
38 mCME
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 37
will learn how to establish these
on patients. They are not time
consuming. Normally, establishing a hinge axis in the axio-path
tracing and transfer takes no
more than six or seven minutes,
so the clinician is not using a lot
of his or her time to establish a
correct hinge-axis mounting.
The instructors will demonstrate
how it’s done, and then have you
perform the procedures. Under
the proper guidance, you can
learn these techniques and apply them in an office setting in
an economical manner.
Fig. 18. Post-treatment intra-oral and extra-oral photos.
measurement that we need, it’s
easy to place the maxilla correctly to the mandible.
There are certain surgical techniques that need to be applied to
accomplish the surgical corrections. By following the proper
surgical techniques, the postsurgical relapse can be kept to a
minimum.
The other thing that we can do
is establish even centric stops,
according to the axis position.
That’s why in Figures 17a & b
the models are painted red. We
can do an occlusal analysis and
equilibration and establish a stable tooth fit before surgery; all of
which is based on the true terminal hinge axis.
We’re able to get a Class I and
we’re able to gain enough overbite. We will need to do some
postsurgical orthodontics to finish the occlusion, but the image
shows the hinge axis closer on
the articulator.
If you were able to hold the model, you would notice that there’s
no rocking. Everything is stable.
You don’t want the patient to
come out of burger and find that
the patient has trouble finding a
stable maximal intercuspation
with the joint seated.
In order to gain even stops,
we had to remove some tooth
enamel around the upper and
lower arches. That’s what we do
in the operating room before we
begin the operation. We do the
equilibration when the patient is
asleep and before the operation
begins.
As you can see in the post treatment intra-oral and extra-oral
photos (Fig. 18), the facial
changes include a shortening
of the lower facial third. An adequate overbite has been established so a mutually protected
occlusion can seen. The proper
disclusion, where the back teeth
separate by at least 2 to 3 mm,
has been established.
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Fig. 19. Cone-beam data, both pre- and post treatment.
If we apply the second concept
(“you can’t believe what you
see in the mouth”), we need to
go to post treatment hinge-axis
mounted models. Figure 19
shows the cone-beam data, both
pre- and post treatment. Note
the double plates on the mandible to establish a stable platform
to position the maxilla.
Surgery
One of the most important takeaway lessons from this article is
that you need to know your surgeon. Establishing a one-on-one
relationship with your surgeon
can be challenging. If the orthodontist does not know what
the surgeon goes through, then
in the planning stage pre-treatment, the teeth may be placed in
a position that the surgeon will
have trouble establishing in the
correct skeletal position. This is
a relationship that simply takes
time.
Once you have knowledge of the
surgeon, then you need to know
what happens at the hospital
because this becomes an important part, especially during
recovery.
The people who are handling
recovery need an exceptional
level of compassion, and they
need to be able to handle emergencies. Oftentimes the patient
will get sick, and his or her teeth
are held together with elastic
and wires. The healing period
normally lasts 10 weeks. It may
be longer depending on how the
segments are healing. The point
is that we don’t get into postsurgical orthodontics before the
segments have stabilized
Additional considerations
We know that you need to know
the joint status. You’ll need to
know how to do a soft-tissue
analysis and how to establish
a surgical treatment objective.
You’ll need to know how to do
pre-treatment setups and surgical setups. You need to apply all
of these techniques on all patients (mixed dentition, adolescent or adult).
If the teeth aren’t in the correct
position in the jaw, then there’s
no way the surgeon can place
the parts correctly, resulting in
surgical failure. Most surgical
failures happen because of or-
thodontics.
One of the things you need to
keep in mind in your pre-treatment surgical orthodontics is
that you established the correct
arch form. Without the correct
arch form, it’s difficult to put the
parts together.
Without the coaching, these procedures can feel like too much
of a chore. Moreover, without
coaching, there’s no way to do a
surgical workup for the benefit
of the patient, which of course,
is the main reason you need to
know these procedures.
It also helps if you work with
the surgeon and the restorative
dentist because it’s the restorative dentist who obtains the final
outcome, and he or she needs to
finish the case from where you
left it.
The other thing to keep in mind
is the actual 3-D position of the
teeth. If you have up-righted the
upper anterior teeth, the surgeon will have a difficult time
fitting the mandible to this.
It takes some time and it takes
some effort to learn these protocols. But once you do learn
them, and you have the technique, your surgical cases will
be more stable, and you’ll cut
down the instances of surgical
relapse that you see.
If you have tipped the lower anterior teeth back too far — such
as in a Class III — then you cannot obtain a good maximum
intercuspation because of the
incorrect torque of the anteriors.
The setup part of the procedure
will give you this information.
Above all, remember this is all
for the benefit of the patient. You
need to spend time learning and
you need to spend time in the operating room to know the problems the surgeon encounters.
Then you need to spend time in
the diagnoses and workup.
Age
If it’s an adolescent patient, you
can do the presurgical orthodontic and establish the correct axial
position of the teeth in each jaw.
However, do not try to fix the occlusion. That means the teeth
will be in the proper positions
when you approach the surgery.
However, the benefit is for the
patient, who winds up with a
functioning occlusion and improved face, and the gingival
tissues are healthy and the jaw
functions correctly.
As a rule, I won’t get into a surgical case before a female is in
her early 20s, and with males
in their mid 20s. I’ve seen cases
where they were done earlier
and actually grew out of the correction.
Learning these techniques
We all need to be taught to do
these things, and it needs to be
from someone who has done
them for a number of years
so you can be certain that the
methods you are learning will
work. They are taught in the
Advanced Education in Orthodontics (AEO) course, and we do
practice them.
That includes surgical setup,
orthodontic setup, soft-tissue
cephalometric analysis and surgical treatment objective. They
need to be practiced a number
of times. It’s not something you
can learn on your own. You need
a mentor who will teach you all
the characteristics you’ll need.
In the lab phase of the AEO
class, we do get into mounting
cases on the true hinge axis. You
About the Author
Dr Theodore D. Freeland, DDS,
MS, is a board-certified orthodontist in Gaylord, Mich. After
graduating from Albion College
in 1967, he attended the University of Detroit Mercy, earning
a dental degree in 1971 and his
master’s of science in orthodontics in 1978. Freeland has completed Dr. Gene Williamson’s
course in occlusion and TMJ and
the Roth/Williams course in advanced orthodontics.
In addition, Freeland has served
as an adjunct professor in orthodontics at the University
of Detroit Mercy, and held appointments at the University of
Detroit in fixed prosthetics and
orthodontics; the Roth/Williams
Center as a clinical instructor;
and the Advanced Education in
Orthodontics Group as director
and instructor.
Freeland is an accomplished author who lectures nationally and
internationally.
[43] =>
Modern life can be
challenging
Modern, healthy lifestyles and dietary habits often mean an increase in the
consumption of acid-rich foods and drinks. However, experts believe that as few
as 4 acidic challenges a day can put patients at risk of Acid Wear.1-3 In addition to
giving behavioural advice (e.g. diet and brushing), your patients may also benefit
from a daily toothpaste that can protect enamel from these multiple acid challenges.
Pronamel is proven to reharden acid-softened enamel and provide ongoing
protection from the effects of Acid Wear.4-6
Daily protection from the effects of Acid Wear
References: 1. Murakami C et al. Caries Res 2011; 45:121-129. 2. Lussi A, et al. Caries Res 2004; 38(suppl 1): 34-44. 3. Dugmore CR,
et al. Br Dent J 2004; 196(5): 283-286. 4. Hara AT et al. Caries Res 2009; 43: 57-63. 5. Fowler C et al. J Clin Dent 2006; 17: 100-105.
6. Fowler C et al. J Clin Dent 2009; 20(Spec Iss): 186-191.
Date of Preparation: June 2014
Arenco Tower, Media City, Dubai, U.A.E.
Tel: +971 4 3769555, Fax: +971 3928549 P.O.Box 23816.
For full information about the product, please refer to the product pack.
For further information please contact your doctor/healthcare professional.
For reporting any Adverse Event/Side Effect related to GSK product
please contact us on contactus-me@gsk.com.
CHSAU/CHSENO/0011/14a
[44] =>
1SENSITIVITY
COMPLETE
TOOTHPASTE
Sensodyne® understands that dentine
hypersensitivity patients have differing needs
Sensodyne® Complete Protection helps
maintain good gingival health4-6
Sensodyne® Complete Protection, powered by NovaMin®,
offers all-round care with specially designed benefits to meet
your patients’ different needs and preferences. With twice-daily
brushing, Sensodyne Complete Protection:
Good brushing technnique can be enhanced with the use of a
specially designed dentifrice to help maintain good gingival health.18,19
Clinically proven to provide dentine hypersensitivity relief1-3
In clinical studies, NovaMin® containing dentifrices have shown up
to 16.4% improvement in plaque control as well as significant reduction
in gingival bleeding index, compared to control toothpastes.4-6
Contains fluoride to strengthen enamel
Significant reduction in gingival bleeding index (GBI)
over 6 weeks with a NovaMin® containing dentifrice4
Helps to maintain good gingival health4-6
Sensodyne® Complete Protection, powered
by NovaMin® – an advanced approach to
dentine hypersensitivity relief
In vitro studies have shown that the hydroxyapatite-like layer starts
building from the first use7-9* and is up to 50% harder than dentine.9,14
The hydroxyapatite-like layer binds firmly to collagen within
exposed dentine10,15 and has shown in in vitro studies to be
resistant to daily physical and chemical oral challenges,9,14-17
such as toothbrush abrasion16 and acidic food and drink.14-17
with a NovaMin® containing dentrifrice4
1.4
1.2
Mean GBI*
NovaMin®, a calcium and phosphate delivery technology,
initiates a cascade of events on contact with saliva7-12 which
leads to formation of a hydroxyapatite-like restorative layer
over exposed dentine and within dentine tubules.7, 9-13
58.8% reduction from baseline in 6 weeks
p<0.001
p=ns
Baseline
6 weeks
NovaMin® containing
dentifrice
Baseline
6 weeks
Placebo control
1.0
0.8
0.6
0.4
0.2
0
Adapted from Tai et al, 2006.4 Randomised, double-blind, controlled clinical study of 95
volunteers given NovaMin® containing dentifrice or placebo control (non-aqueous dentifrice
containing no NovaMin®) for 6 weeks. All subjects received supragingival prophylaxis
and polishing and were instructed in brushing technique.4 *GBI scale ranges from 0–3.
In vitro studies show that a hydroxyapatite-like layer forms
over exposed dentine and within the dentine tubules:7,9,10,12,13
Hydroxyapatite-like
layer over exposed
dentine
Hydroxyapatite-like
layer within the
tubules at the surface
5 µm
Adapted from Earl et al, 2011 (A).13 In vitro cross-section SEM image of hydroxyapatite-like layer
formed by supersaturated NovaMin® solution in artificial saliva after 5 days (no brushing)13
All-round care for dentine hypersensitivity patients1-6
References:
1. Du MQ et al. Am J Dent 2008; 21(4): 210−214. 2. Pradeep AR et al. J Periodontol 2010; 81(8): 1167−1113. 3. Salian S et al. J Clin Dent 2010; 21(3): 82-87. Prepared November 2011, Z-11-496. 4. Tai BJ
et al. J Clin Periodontol 2006; 33: 86-91. 5. Devi MA et al. Int J Clin Dent Sci 2011; 2: 46-49. 6. GSK data on file (study 23690684) 7. LaTorre G, Greenspan DC. J Clin Dent 2010; 21(3): 72-76. 8. Edgar WM.
Br Dent J 1992; 172(8): 305-312. 9. Burwell A et al. J Clin Dent 2010; 21(Spec Iss): 66–71. 10. Efflandt SE et al. J Mater Sci Mater Med 2002; 26(6): 557-565. 11. de Aza DN et al. J Mat Sci: Mat in Med 1996;
399–402. 12. Arcos D et al. A J Biomed Mater Res 2003; 65: 344–351. 13. Earl J et al. J Clin Dent 2011; 22[Spec Iss]: 62-67. (A) 14. Parkinson C et al. J Clin Dent 2011; 22(Spec Issue): 74-81. 15. West
NX et al. J Clin Dent 2011; 22(Spec Iss): 82-89. 16. Earl J et al. J Clin Dent 2011; 22(Spec Iss): 68-73. (B) 17. Wang Z et al. J Dent 2010; 38: 400−410. 18. “Dentifrices” Encyclopedia of Chemical Technology
4th ed. vol 7, pp. 1023-1030, by Morton Poder Consumer Products Development Resources Inc. 19. van der Weijen GA and Hioe KPK. J Ciul Periodontal 2005; 32 (Supp 1.6): 214-228. Date of Preparation:
July 2013, Code: CHSAU/CHSENO/0008/13
Arenco Tower, Media City, Dubai, U.A.E.
Tel: +971 4 3769555, Fax: +971 3928549 P.O.Box 23816.
For full information about the product, please refer to the product pack.
For reporting any Adverse Event/Side Effect related to GSK product please contact us on contactus-me@gsk.com.
Code: CHSAU/CHSENO/0008/13
[45] =>
hygiene tribune
Dental Tribune Middle East & Africa Edition | November-December 2014
1B
From novel to normal
Review of power toothbrushes considers safety issues
By Shelly L. Campbell, RDH,
MPH
T
he cabbage soup diet.
NASA-inspired space food
sticks. The belt massager
machine to “jiggle away the
pounds.” How are these things
connected? These health and
fitness offerings from the 1960s
quickly faded from the public
eye after failing to live up to their
hype, or by causing safety concerns.
Another health improvement
introduction in the ’60s – the
electric toothbrush – could have
met a similar fate because early
prototypes were bulky, unreliable, and even capable of causing electric shock. But unlike
other inventors of health fads
destined for obscurity, undaunted electric toothbrush manufacturers continued to evolve more
streamlined and technologically
advanced power toothbrush
models over the next several
decades.
Today, many children and adults
have permanently replaced their
manual brush with an electric
model, having been won over
by the electric brush’s reliable
cleaning efficiency and ease of
use. Value-based battery brushes, as well as premium multifeature rechargeable electric
toothbrushes (also referred to as
power toothbrushes), are now
mainstream, their popularity
reflected in exponential growth
over the last decade.1 Interestingly, a recent survey showed
only 14% of women surveyed
would consider giving up their
power brush as a budget-saving
sacrifice.2 It’s safe to say that
power brushes are here to stay.
Dental professionals see improvements in the oral hygiene
and gingival health of patients
who use power toothbrushes,
both anecdotally and in large
surveys.3,4 Additionally, clinical
research over several decades
has shown that in general, power brushes provide noticeable
plaque removal benefits, with
one brush technology — oscillating-rotating (O-R) — standing
apart when statisticians crunch
the numbers to analyze the results of the clinical research.5,6,7
In 2005, the wellrespected international Cochrane Collaboration Oral Health Group published a review of 42 of these
published clinical investigations,
where power toothbrushes,
including those with counterrotational (e.g., Interplak®),
oscillating-rotating (e.g., Braun/
Oral-B®),
and
side-to-side
(e.g., Sonicare®) modes of action, were directly compared to
manual toothbrushes for clinical
effectiveness in thousands of patients. From their systematic review and meta-analysis [see Systematic analysis in a nutshell],
the Cochrane Group concluded
that one brush type produced
statistically significantly superior benefits: “Powered toothbrushes with a rotation oscillation action reduce plaque and
gingivitis more than manual
toothbrushing.”7
The safety question
Power toothbrush effectiveness is seldom debated, but are
safety concerns involved? Could
the documented connection between power toothbrushing and
greater patient compliance8-11
lead to more gingival abrasion
caused by longer brushing times
or increased brushing frequency? Does power toothbrushing
result in more hard tissue wear
compared to manual brushing?
Will enthusiastic power brush
users apply too much force and
compromise their gingival tissues or promote recession?
Although the Cochrane review
didn’t evaluate safety as the primary objective, it did state, “Any
reported side effects were localized and temporary.”7 Other
studies and literature reviews
have generally come to the same
conclusion.12-14 Case closed. Or
is it?
Lingering questions about the
safety of power brushes on hard
and soft tissues have persisted
in some quarters.15 Hygienists
and dentists know their patients
take their professional product
recommendations seriously, and
they want to ensure they’re suggesting the most effective and
safe oral commercial products
and regimens.
The goal should be evidencebased recommendations as opposed to speculation, but keeping up with all of the literature
and assessing the quality and
relevance of each individual
power toothbrush study requires a significant commitment
of time and effort for professionals who already have a lot on
their plates.
In search of an answer
Systematic reviews of health topics (see sidebar) can be a great
asset to busy professionals who
don’t have time to comb through
the literature themselves. To
address the power toothbrush
safety question, a recently published systematic review in
the Journal of Periodontology
considered theoretical safety
concerns about power versus
manual toothbrushes through
a comprehensive analysis of all
relevant published reports. The
article is “Safety of OscillatingRotating Powered Brushes Compared to Manual Toothbrushes:
A Systematic Review” by Van
Der Weijden et al.16
Here are the key findings:
What research was included?
O-R power toothbrush safety
research was chosen for comparison to manual toothbrushes
based on the Cochrane findings.7
All published English language
titles and abstracts through May
2010 were included in a full
search of three major databases
(e.g., PubMed-Medline), resulting in 899 potential publications
that were evaluated, with 35
meeting all predetermined eligibility criteria. The 35 studies in
the final review were designed
to measure soft and/or hard tissue safety by tracking either primary (gingival recession) or secondary parameters (observed or
reported adverse events or hard
tissue effects), or a surrogate parameter (stained gingival abrasion or brushing force).
What patients and toothbrushes were involved?
There was considerable diversity among the nearly 2,000
patients included in the 31 randomized and blinded human
subject clinical trials, which
ranged from four days to three
years. These included adults
with and without elevated
plaque, gingivitis and/or bleeding, children with and without
orthodontia, and periodontal patients. Braun/Oral-B or Philips/
Jordan manufactured the power
brushes in the reviewed studies, while 10 various comparator
manual brushes were also represented. The majority of toothbrushing was unsupervised in
the home setting.
Were O-R power toothbrushes
associated with more gingival
recession?
No. A meta-analysis [see sidebar]
of two six-month clinical trials
focusing exclusively on gingival
recession showed there were no
significant recession differences
between the power and manual
toothbrush groups.
Did O-R power brushes use
more force than manual
brushes?
No. In the two force investigations, the average O-R power
brush brushing force was significantly lower than the average manual toothbrush brushing force.
Was there more gingival abrasion with use of the O-R power
toothbrushes?
Gingival abrasions that could
potentially be caused by toothbrushing were found in both the
manual and O-R power toothbrush groups, but the authors
of the published reports described them as either negligible/not clinically significant, or
occurring with about the same
frequency in the manual and
power brush groups, and not
significantly different when statistically tested.
How important is in vitro
data? Did the in vitro studies
show greater wear with O-R
brushes?
Since there is currently no standard methodology with enough
sensitivity for long-term clinical
assessment of hard tissue brushing damage, in vitro studies are
a valuable step in identifying
potential safety concerns (like
abrasion potential) that are challenging to discover clinically.
Four in vitro (laboratory) investigations met eligibility criteria
and were included in the review.
The three trials evaluating human dentin found similar or less
wear with use of the O-R power
toothbrushes, compared with
manual brushes used under
simulated clinical conditions.
The authors of the fourth study
suggested that bovine enamel
loss after an acidic attack may
be increased with use of certain power brushes when used
at the same brushing force. But
understanding the clinical implications is difficult, given that
toothbrushing forces have been
> Page 2B
[46] =>
2B hygiene tribune
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 1B
Systematic analysis in a nutshell
• What is it? A systematic review
asks a research question(s), and
then scours the literature to
identify all relevant, well-conducted research that speaks to
the question. The resulting data
are combined when possible,
and analyzed (statistically and/
or with a qualitative method) to
give a summary conclusion.
• Why do it? While well-controlled, individual clinical studies give important insight, synthesizing the combined results
of multiple, high-quality investigations will deliver the most definitive answer to the question.
• How rigorous is it? If done
correctly, it is very rigorous. All
procedures are explicit and predetermined so that the process
can be replicated. The literature
search is exhaustive. Multiple,
independent data screeners/an-
alysts are used to prevent bias.
• What is a meta-analysis?
When different studies with
similar designs have common
clinical measures, the data (results) can sometimes be combined and statistically analyzed
for a more powerful estimate of
the effect.
• Why aren’t more systematic
reviews done? These reviews
can be quite time-intensive, requiring dedicated manpower to
design and execute searches of
the literature and appraise the
results.
• What does it mean to me?
If you’ve read a well-conducted
systematic review, then you can
feel confident you’re up to speed
on the bottom line of the highest
quality research currently available, and your patient product
recommendations can be evidence-based.
shown to be significantly higher
when manual brushes are used.
tematic review of a large body of
published research in the preceding two decades consistently showed oscillating-rotating
toothbrushes to be safe when
compared with manual brushes,
and collectively indicated that
they do not pose a clinically relevant concern to either hard or
soft tissues.”
What’s the bottom line?
Oscillating-rotating
power
toothbrushes were not shown to
have a greater safety risk when
compared head-to-head with
manual brushes. The review authors concluded that, “This sys-
References
1. Power brush sales whirring as
prices drop. Chain Drug Review.
Available at: http://findarticles.
com/p/articles/mi_hb3007/
is_3_31/ai_n31357545/.
Accessed 15 April 2011.
2. “Toothbrush effect” helps
Brits smile through the recession. PR Newswire Europe
Ltd. Available at: http://www.
prnewswire.co.uk/cgi/news/
release?id=257225 Accessed 15
April 2011.
3. Warren PR, Landmann H,
Chater BV. Electric toothbrush
use. Attitudes and experience among dental practitioners in Germany. Am J Dent
1998:Sep;11(Spec No):S3-6.
4. Warren PR, Ray TS, Cugini
M, Chater BV. A practice-based
study of a power toothbrush: assessment of effectiveness and
acceptance. J Am Dent Assoc
2000;Mar;131(3):389-94.
5. Van der Weijden GA, Timmerman MF, Danser MM, van
der Velden U. The role of electric toothbrushes – advantages
and limitations of electric toothbrushes. In: Lang NP, Attström
R, Löe H, eds, Proceedings European Workshop on Mechanical
Plaque Control, Berlin: Quintessence Publishing; 1998a.: pgs.
138-155.
6. Sicilia A, Arregui I, Gallego M,
et al. A systematic review of powered vs manual toothbrushes in
periodontal cause-related therapy. J Clin Periodontol 2002;29
Suppl 3:39-54; discussion 90-1.
7. Robinson P, Deacon SA, Deery
C, et al. Manual versus powered toothbrushing for oral
health. Cochrane Database of
Systematic Reviews 2005, Issue 2. Art. No.: CD002281. DOI:
10.1002/14651858.CD002281.
pub2.
8. Walters PA, Cugini M, Biesbrock AR, Warren PR. A novel oscillatingrotating power
toothbrush with SmartGuide:
designed for enhanced performance and compliance. J Contemp Dent Pract 2007;8:1-9.
9. Stålnacke K, Söderfeldt B, Sjödin B. Compliance in use of electric toothbrushes. Acta Odontol
Scand 1995;53:17-19.
10. Van der Weijden FA, Timmerman MF, Piscaer M, et al. A
comparison of the efficacy of a
novel electric toothbrush and a
manual toothbrush in the treatment of gingivitis. Am J Dent
1998;11(Spec No):S23-28.
11. Hellstadius K, Asman B,
Gustafsson A. Improved maintenance of plaque control by
electrical
toothbrushing
in
periodontitis patients with low
compliance. J Clin Periodontol
1993;20:235-237.
12. Heasman PA, McCracken
GI. Clinical evidence for the efficacy and safety of powered
toothbrushes. Adv Dent Res
2002;16:9-15.
13. Addy M, Hunter ML. Can
tooth brushing damage your
health? Effects on oral and dental tissues. Int Dent J 2003;53
Suppl 3:177-86.
14. Rajapakse PS, McCracken
GI, Gwynnett E, et al. Does tooth
brushing influence the development and progression of noninflammatory gingival recession?
A systematic review. J Clin Periodontol 2007;34:1046-1061.
15. Slim L. Power brushing
and recession. RDH. Available at: http://www.rdhmag.
com/index/display/articledisplay/2574033117/articles/rdh/
volume-30/issue-6/columns/
poweredbrushing_and.html)
Accessed 15 April 2011.
16. Van der Weijden FA, Campbell SL, Dörfer CE, et al. Safety
of oscillating-rotating powered brushes compared to
manual toothbrushes: a systematic review. J Periodontol
2011;82(1):5.24. Epub 2010 Sep
10.
Use of oral probiotics
has a harder time harboring the
bacteria that we associate with
dental disease. Harnessing this
pH characteristic of biofilm goes
right up into the face of traditional methods -- brush ‘n’ floss.
Adjusting the pH allows your patients a way to manage their biofilm without having the dexterity
and laser-focused education of a
dental hygienist.
Originally published in RDH
Magazine, January 2012.
Reprinted with permission from
PennWell.
About the Author
Shelley L. Campbell, RDH, MPH,
of Teneriffe Research Associates,
has worked in the oral health
clinic research field for over 20
years. She writes from her home
in Lee’s Summit, Mo., and occasionally does medical writing for
Procter & Gamble.
Oral Probiotics – Overview
By Victoria Wilson, UK
O
ral probiotics are live
bacteria that are similar
(or identical) to the beneficial microorganisms found
naturally in the oral cavity. The
addition of oral probiotics to an
oral care regimen can restore
the natural balance of beneficial
bacteria, which can be depleted
by diet, stress, medication, illness or other factors. Oral probiotics support tooth and gum
health, whiten teeth and freshen
breath.
How on earth did the words
“brush” and “floss” come to define our entire profession? Did
we spend almost 3,000 grueling
hours learning only how to
teach people to brush ‘n’ floss? I
don’t think so. What we learned
is how to bring the mouth to
health. What we learned is more
accurately achieved today by
health promoting products such
as oral probiotics, making dietary changes, and neurogenesis.
The brain is plastic in that it’s
moldable and new pathways
can be built, which is a process
called neurogenesis. Providing
the brain opportunities for neurogenesis is important to brain
health. It turns out that playing
Sudoku doesn’t stimulate brain
fitness; it helps a person become
really good at Sudoku. It is kind
of like telling patients to brush
‘n’ floss the same way over and
over -- you become really great
at explaining the mechanical removal of plaque.
To start your own neurogenesis
mission, stop the brush ‘n’ floss
default story. Focus on the term
biofilm management instead.
Learn about and then talk to
your patients about biofilm.
Then talk about how oral probiotics can reduce oral biofilm,
particularly in the secret spots
where a brush and floss cannot
reach. All probiotics work in the
digestive system, but only a few
can function in the first six inches of the mouth.
Oral probiotics are a little different than their counterparts. Probiotics for the gut must make it
past the hostile environment of
the stomach. For example, yogurt is teeming with excessive
numbers of live bacteria. This
is so an appropriate number of
live bacteria can make it to the
intestines where they can do
their work. Probiotic tablets are
specially coated to help them
stay together until they get to the
right part of the digestive system, where the friendly bacteria are released. Oral probiotics
must be activated in the mouth.
Most people immediately think
that the tablets or capsules are
teeming with motile bacteria.
Not so. The bacteria are freezedried so that they can reanimate
under moist conditions.
When using products containing freezed dried oral probiotics
in the mouth, saliva causes their
activation with the release of
live, active bacteria that attaches
themselves both on the surface
of the teeth and deep beneath
the gum line. These colonies become a basecamp of beneficial
bacteria to support oral health.
With daily replenishment, these
probiotic bacteria re-establish
the natural microbial balance
in the mouth and create whiter
teeth, fresher breath and healthier teeth and gums.
In the oral cavity, harmful bacteria convert sugar and carbohydrates into lactic acid. Lactic
acid is the bacterial byproduct
which is responsible for dental
caries and the erosion of tooth
enamel. Without requiring lifestyle changes, the addition of
oral probiotics can positively
affect the long-term health and
wellness of the mouth and the
other health systems dependent
on oral health.
Some oral probiotic strains are
beneficial in promoting healthy
teeth due to their lactic-acid deficiency. A byproduct of other
probiotic strains are natural low
doses of hydrogen peroxide,
which safely supports healthy
gums, fresher breath and whiter
teeth.
Caries
The ecological plaque hypothesis states that caries and periodontitis, the 2 most common biofilm- associated diseases in the
world, originate from a disturbance in the balance and diversity in the biofilm. Contributing
causes may be inadequate oral
hygiene, incorrect diet, stress
and/or other factors which determine the micro-ecology. Caries is caused by the presence of
acidogenic and aciduric bacteria
(mainly mutans streptococci)
metabolizing dietary sugars to
create a low local pH environment which can de-mineralize
enamel. Oral probiotics are able
to naturally alter the oral ph levels.
Oral probiotics and gut probiotics share a common health goal.
To achieve that goal they use
health-promoting bacteria to
crowd out the disease-promoting bacteria. That’s how the oral
probiotics, such as ProBiora3
and Blis K12/M18 work. The
ProBiora3 complex is a grouping
of early biofilm colonizers that
build a much smaller biofilm
because they are not aciduric
(don’t make acid).
Pathogenic biofilm has a couple
of requisites, and one is a low
pH. So a biofilm with early colonizers that doesn’t make acid
This pH alteration is energized
by one particular friendly bacteria in the ProBiora3 family. Streptococcus oralis KJ3 and
Streptococcus uberis KJ2 give
off hydrogen peroxide. Take a
shade guide picture before starting your patients on these probiotics and see if you notice a difference. Are the teeth lighter?
In the early days of caries bacterial studies, it was learned that
when Streptococcus mutans
were fed sucrose, they would
excrete massive amounts of the
sticky goo called glycomatrix or
mucopolysaccharide. This goo
of the biofilm protects the population in order to survive unmolested by such things as antibiotics, toothbrushes, and floss.
Supplying the mouth with the
ProBiora3 complex populates
the niche previously inhabited
by Streptococcus mutans faster
than Strep. mutans can.
> Page 4B
[47] =>
[48] =>
4B hygiene tribune
Dental Tribune Middle East & Africa Edition | November-December 2014
< Page 2B
The story of oral probiotics gets
better! This way of biofilm management is not the wave of the
future any longer.
tablished and the dental office
procedure will have been successful (Socransky and Hafajee,
1992, J. Perio, p. 322).
Recommending oral probiotics with natural strains from
healthy mouths may be the ticket for patients who cannot or will
not remove their own biofilm to
dental hygienist standards.
Oral probiotics can provide a
deep impact by rebalancing the
oral flora in a simple, painless,
non-invasive daily routine. No
other consumer product impacts
oral health below the gum line
to get to the root of the problem.
When giving brush ‘n’ floss directions, we end up focusing
only on the teeth, and we miss
the elephant in the room -- the
tongue. Tongue coating is not innocuous, nor is it only a cosmetic
concern. Biofilm on the tongue
releases planktonic bacteria in
what’s called a planktonic storm.
A coated tongue sends new biofilm to the rest of the mouth.
So it’s time for the tongue to be
included in discussions about biofilm management and prophylaxis and it is here that probiotics
plays a very important role due
to their activity in all oral biofilm.
Gum and Tooth Health
If harmful, disease-causing bacteria are allowed to colonize
in the periodontal pocket, the
result is advanced periodontal disease. To address this, it is
increasingly more common as
well as very painful to have dentists clean teeth below the gum
line. Research has revealed that
even after the aggressive process of scaling to clean out the
periodontal pockets, the future
oral health of the patient is determined by the type of bacteria
that colonizes first in the base of
that clean pocket. If the harmful
bacteria are first to colonize, the
disease condition will quickly
return.
If the beneficial bacteria are first,
then good oral health will be es-
In clinical trials, twice-daily administration of Streptococcus
rattus JH145™, S. oralis KJ3™
and S. uberis KJ2™ substantially
affected the levels of harmful
bacteria in the mouth. The studies found that simply by using
these oral probiotics, the levels
of harmful bacteria were reduced in plaque samples taken
from below the gum line, at the
bottom of the periodontal pocket.
Existing mouthwashes and
toothpastes that typically contain an antibacterial agent are
able to only affect those areas of
the mouth that the rinse is able
to directly contact, which limits their effectiveness to contact
with plaque above the gum line.
Furthermore, the antibacterial
agent is quickly washed from
the mouth while the Probiotic
bacteria have high substantivity;
i.e., they have a prolonged duration of contact with disease-susceptible surfaces in the mouth
and thus a prolonged beneficial
activity.
Oral care products and foods
developed using this probiotic
approach can safely maintain
and promote oral health by normalizing the balance of the indigenous flora in favor of microorganisms associated with both
healthy teeth and periodontal or
gum tissues.
Fresher Breath
In general, amino acids are the
main substrate for the production of oral malodorous compounds. As freshly secreted human saliva contains low levels
of free amino acids, halitosis occurs as a result of bacterial putrefaction by several anaerobic
species found in the oral cavity.
The most widely used strategies
in the treatment of halitosis are
comprehensive oral hygiene,
including tongue scraping and
brushing, as well as the use of
mouth rinses containing antibacterial agents. Antibacterial mouthwashes and breath
fresheners promote killing up to
99.9% of bacteria and germs in
the mouth. These products indiscriminately wipe out both the
essential, good bacteria along
with the harmful bacteria.
Within several hours after using
an antibacterial mouthwash or
breath freshener, the surviving
.1% of the bacteria remaining
in the mouth will repopulate
the full level of harmful bacteria
that was present in the mouth
before the product was used.
This indiscriminate destruction
of bacteria creates ongoing imbalances in the microflora that
naturally inhabit the oral cavity.
Antibacterial mouthwashes and
breath fresheners simply mask
the malodor and can never effectively address the issue on the
causal level.
Oral probiotics are natural antagonists to the malodor-creating bacteria, quickly colonizing to create a healthy balance
of micro flora and resulting
in longer lasting, truly fresher
breath . The use of benign, commensal probiotics could therefore offer a complementary and
more long-term treatment strategy to combat bad breath.
Whiter Teeth
A natural by-product of oral probiotics is a low-dose of hydrogen
peroxide. As this good bacteria
is replenished daily, it creates a
gradual teeth whitening effect
with the full benefits of long contact times, delivering 24 hour
per day coverage of balancing
and brightening.
Yellowing, surface discoloration
or staining are all results of lifestyle choices: tobacco use, coffee, tea, beets, etc. Anything that
stains will affect the color of the
teeth. Tooth enamel is porous,
filled with microscopic cracks
and pores that hold onto staining products. Commercial tooth
whiteners employ extremely
high levels of harsh, chemical
hydrogen peroxide which can
actually damage the tooth and
create a roughness on the tooth’s
surface. This increases the film
that builds up on the tooth surfaces and in the micro cracks
and is available to hold on to
stains much better.
S. oralis KJ3 binds to the surface
of the teeth, crowding out harmful bacteria by competing for
the same nutrients and surface
spaces. In laboratory studies,
the low-dose hydrogen peroxide produced by the S. oralis KJ3
created a continuous whitening
benefit that did not plateau over
the duration of the study. With
daily use, the colonization of S.
oralis KJ3 provides a constant
and expanding population for
gradual and continual whitening effects.
The hydrogen peroxide metabolites of S. oralis KJ3 also contribute to the breath-freshening
features of oral probiotics by
inhibiting the growth of harmful bacteria. The decrease in
these harmful bacteria results
in a substantial reduction in the
volatile sulfur compounds associated with bad breath.
Unlike other whitening products, oral probiotics are completely safe for veneers, caps
and dentures.
Reexamination
Now ask yourself -- if you cannot
motivate someone to achieve total dental biofilm removal with a
toothbrush, can you get them to
incorporate one single probiotic
tablet a day into their routine?
Using these tools addresses the
forgotten reality of how much
room a biofilm needs, the complexity of a mature biofilm, and
the size of human cells. Stop
wearing the badge of “Floss
Nag” with pride. Serve yourself
and your patients better by offering scientifically proven oral
health-promoting products like
oral probiotics.
References
1. Dr JJ Smith, (B.CH.D ) Dental
Expert and founder of Cleanition Oral Care
2. John Nosti , DMD, FAGD ,
FACE: Cosmetic case protection
and oral health- Dental Town
Dec 2010
3. Shirley Gutkowski, RDH ,
BSDH, FACE: An in-depth view
of oral probiotics- Dentistry IQ
4. Am. J Clin. Nut.r 2000:71
5. www.oragenics.com
Contact Information
Ms. Victoria Wilson, Dental
Hygiene Therapist, UK
Dr. Roze & Associates Clinic
wilson@dental-tribune.me
Hygiene safety for your dental practice
Quattrocare Plus
By KaVo
I
nfection control is becoming
more and more of a priority due to stricter laws and
guidelines. For many years,
KaVo has appealed to its customers with a comprehensive,
efficient hygiene approach with
validated hygiene systems in
the treatment units and a (360°)
RKI-compliant KaVo hygiene
workflow for tools.
As a leading dental company, KaVo is offering
comprehensive, all-inclusive infection protection
and more security for the
patient and dental practice
team All KaVo units have
an automatic ongoing
and intensive sterilisation
function which ensures
the continuous germ reduction of the systems
which convey water and
prevents the formation of
microorganisms in periods of stagnation.
In addition, the dental instrument rinsing function ensures that the tools are rinsed
before beginning treatment and
after each patient treatment automatically and in a RKI-compliant manner. Of course, handles,
instrument shelves, spittoon
bowls and suction cannulas can
be removed easily and without
difficulty for cleaning and disinfection.
The smooth, closed and hygiene-friendly surfaces of the
dental units also play a role in
reducing the infection risk.
The KaVo ESTETICA E70 and
E80 dental units also have with
OXYmat and DEKAmat a fully
automatic hygiene system: the
manual, time-consuming mixture or refilling sterilisation and
disinfectants are thereby a thing
of the past. In the KaVo ESTETICA E50, the optionally available CENTRAmat takes over
the central supply of the unit
with DEKASEPTOL gel which
ensures high-efficient cleaning
and disinfection of the suction or
drainage system which is subject to contamination.
With OXYGENAL 6, KaVo also
offers
an
environmentally
friendly water-based sterilizer
based on hydrogen peroxide
which has proven its effectiveness, material compatibility and
user-friendliness in daily practice.
In addition to the treatment
units, the tool portfolio of KaVo
is also appealing due to numer-
Dekaseptol Gel
Oxygenal 6
ous hygiene effects: effective resuction stops, for example, prevent contamination of the inside
of the tools and thereby support
hygiene safety The Plasmatec
coating of the tools not only offers excellent gripping properties but is also easy to clean. For
decades, KaVo tools and turbines
are thermally disinfective and
sterilisable. Minimal gap dimensions also make hygiene safer
and more efficient.
With the QUATTROcare Plus,
KaVo is offering an excellent
tool for a validated, RKI-compliant and cost-efficient interior
cleaning and the maintenance
of instruments. Because: to effectively prevent infections, dental transfer elements must be
cleaned and disinfected inside
and out.
Due to its many years of experience with dental practice
hygiene, the proven and coordinated hygiene system (360°
competence) with proven effectiveness and excellent stability of
the materials used, KaVo is your
top choice as partner when it
comes to hygiene safety, also for
instruments.
Contact Information
For more information visit:
www.kavo.com/MEA
Or email us: info.mea@kavo.com
[49] =>
There are a number of reasons to choose Philips Sonicare.
Removes up to
more plaque between teeth and overall*
Performs up to
brush strokes per minute
The
most-recommended sonic power toothbrush by dental professionals worldwide
Shield_White_2013
Ask your dentist about Philips Sonicare today!
Version 1.1 – 25 October 2013
*
FlexCare Platinum and DiamondClean compared to a manual toothbrush.
[50] =>
6B hygiene tribune
Dental Tribune Middle East & Africa Edition | November-December 2014
Philips introduces its best brush yet:
Sonicare DiamondClean, helping users achieve
brushing brilliance every time
By Philips
D
UBAI, UAE - Philips
is proud to present the
new Sonicare DiamondClean – a brush that takes
sonic tooth brushing to its most
sophisticated level and which
delivers Sonicare’s best clean
yet removing up to 100% more
plaque in hard to reach places
than a manual toothbrush.
Sonicare DiamondClean harnesses Philips Sonicare’s patented sonic technology to
produce a powerful dynamic
cleaning action for a difference
users can see and feel. It is gentler on teeth and gums than a
manual toothbrush, helping to
keep teeth stronger and healthier for longer. Philips Sonicare
gently whips toothpaste into an
oxygen-rich foamy liquid and
directs it between and behind
00_Anzeigenstand_A4_Layout 1 26.09.14 16:36 Seite 1
teeth and along the gumlinewhere plaque bacteria flourish.
Sonicare DiamondClean is
clinically proven to remove up
to 100% of plaque from hard
to reach places and to improve
gum health in just 2 weeks. It is
also clinically proven to whiten
teeth in 1 week; and its gentle
technology actually helps protect against gum irritation and
recession to help reduce sensitivity. Now is the perfect time
to give your teeth the celebrity
treatment and switch to Sonicare to really experience the
difference.
The brush is able to deliver
a unique whole mouth clean
feeling thanks to its five brush
modes that allow you to tailor
your brushing according to
your needs as well as your dental professional’s advice. The
brush modes range from:
• Clean – the standard mode
Quattrocare Plus
Dental Tribune International
The World’s Largest News and
Educational Network in Dentistry
www.dental-tribune.com
for a whole mouth clean
• White – removes surface
stains to whiten teeth
• Polish – brightens and polishes teeth to bring out their
natural brilliance
• Gum Care – gently stimulates and massages gums
• Sensitive – an extra-gentle
mode for sensitive teeth
Highly charged
DiamondClean’s chrome base
also features a unique charging glass that can be used for
mouth rinsing, but also incorporates the latest in inductive
charging technology to charge
the toothbrush as it rests in the
glass – making it stylish enough
to display in the most fashionforward bathroom.
Not only is Sonicare DiamondClean Philips’ most advanced
brush yet, it’s also our most
easy to use and stylish. DiamondClean’s power handle has
a ceramic finish and a chrome
accent ring highlights the elegant neck of the brush. The
technology in the handle is
hidden so that the sleek matte
white finish of the brush is uncluttered by electronic visual
displays. Only when the on button is pressed are the brushing
modes illuminated to reveal
the array of options. These are
then simply selected by scrolling down using a one button
action.
When travelling or on the go,
Sonicare DiamondClean is designed for convenience with
users being able to keep their
brush fully charged using a revolutionary USB travel case that
can be plugged into almost any
lap top computer and saves the
hassle of having to pack plugs
and adaptors. But only the most
intrepid travellers need worry
about this advanced feature as
Sonicare DiamondClean holds
an impressive three weeks
charge.
Brilliant cut
Sonicare
DiamondClean
brush heads also sport a new
diamond-cut tuft formation
to provide you with an even
more efficient brushing experience. The uniquely designed
diamond bristle heads have
44% more bristles than Philips
Sonicare’s standard sized ProResults brush heads, providing
you with both superior plaque
removal and whiter teeth. The
heads come in two sizes – Standard and Compact – for focused
cleaning in areas of special
need, for orthodontic patients
and those with smaller mouths.
Contact Information
For more information about
Philips Sonicare DiamondClean
or the Philips Sonicare range,
including copies of clinical studies, visit www.mea.philips.com/e/
oralhealthcare/ar
[51] =>
Dental Tribune Middle East & Africa Edition | November-December 2014
hygiene tribune
7B
Infection control in dentistry
has never been more essential
By Dr. Safura Baharin, Malaysia
D
emand for dental treatment has been increasing in recent years as
people have become more
aware of their oral health and
the benefits of good dental aesthetics. Maintaining and practising stringent cross-infection
control procedures therefore
have never been more essential
to ensure the health and safety
of dentists, dental hygienists and
assistants, as well as other supporting staff who may be indirectly involved in the treatment
process.
Dental professionals are at high
risk of cross-infection. A report
published in 1999 has shown
that in developing countries, for
example, the number of dental
staff contaminated during treatment is increasing by almost 6
per cent each year.[1] Research
has shown that infectious microorganisms can be transmitted
by blood or saliva via direct or
indirect contact, aerosols, or
contaminated instruments and
equipment.[2] As stated by the
US Centers for Disease Control
and Prevention (CDC) in their
2003 guidelines, the transmission of infectious disease can occur in four ways: direct contact
with blood or body fluids, indirect contact with contaminated
objects or surfaces, contact with
bacterial droplets or aerosols,
and inhalation of airborne micro-organisms.[3]
The most likely mode of transmission in dentistry is through
inhalation of bacterial aerosols
or splatters. Their potential
health hazards are well documented and acknowledged.[4–9]
Both can be host to a large variety of micro-organisms and viruses, which can be infectious to
susceptible individuals. During
treatment, the dentist’s face and
patient’s chest are most affected
by splatter, as the majority of the
splatters are radiated towards
them.[10, 11] According to studies, the most contaminated area
on the dentist’s face during treatment is around the nose and inner corner of the eyes.[11]
Splatter consists of large particles of greater than 100 µm generated during the use of dental
equipment, such as turbines,
ultrasonic scalers, or water and
air syringes. Owing to this, splatter tends to travel in a trajectory,
thereby contacting objects in its
path. Aerosol consists of smaller
particles that can remain in the
air for a long time and travel
with air currents. Most dental
aerosols are less than 5 µm in diameter; therefore, they are able
to penetrate and stay within the
lung, causing respiratory or other health problems. Among dental procedures that produce high
aerosol concentration are ultrasonic scaling, tooth preparation
using high-speed handpieces,
and dental extraction involving
bone removal via a dental handpiece.[8]
The World Health Organization (WHO) has reported a rise
in airborne infections worldwide. Tuberculosis in particular
has increased in the developing
world.[12] It has been stipulated
that the risk of exposure to tuberculosis in susceptible DHCP
is greater than in healthy individuals. Bennett et al. concluded
that dentists and their assistants,
who are exposed for approximately 15 minutes during peak
aerosol concentration, have a
slightly higher risk of exposure
to Mycobacterium tuberculosis
than the general public does.[9]
During this period, the DHCP
inhales about 0.014–0.12 µl of
aerosolised saliva, which may
contain viable pathogens that
can have a detrimental effect on
the health of susceptible DHCP.
With all of this in mind, it is the
responsibility of DHCP to adhere
strictly to recommended infection control guidelines and policies. Several measures should
be taken to reduce and control
airborne contamination in the
dental clinic. For example, it has
been demonstrated that the use
of a mouthrinse, high-volume
evacuation or a combination
of both methods significantly
reduces the number of colonyforming units in aerosols emitted during ultrasonic scaling.
[13] Routine use of rubber dam
isolation provides a clean and
dry area for placement of dental
restorations, prevents salivary
and blood splatter, and protects
the patient’s mouth and airway.
Using personal protective equipment (PPE), such as surgical
masks (with at least 95% efficiency against particles 3–5 µm
in diameter; changed for every
patient or every 20 minutes in an
aerosol environment or 60 minutes in a non-aerosol environment), safety glasses with lateral
protection to prevent contact
with eyes, as well as disposable
gowns and gloves to reduce the
penetration of or contact with
bacterial aerosols and splatters,
is vital.
Regular maintenance of the airconditioning system is recommended too, as good ventilation
has a diluting effect on the airborne microbial load, especially
at night when the clinic is closed.
[14] Air samples taken at different times at a multi-chair dental clinic showed that bacterial
aerosols are more concentrated
during treatment and that there
is higher concentration of circulating bacterial aerosols at the
beginning of the day, which may
be related to reduced ventilation.[14] Residual bacterial aerosols can be removed through air
filters or ultraviolet light.
As splatters can travel as far
as the door or supply counter
in the middle of a multi-chair
dental clinic,[14] all clean, unused instruments and equipment should be kept in closed
cabinets or drawers to prevent
contamination. Other important
measures that must be taken to
prevent cross-infection include
adequate sterilisation of dental instruments, disinfection of
work surfaces before and after
each dental procedure, disinfection of all dental materials and
work sent out to the laboratory,
and regular maintenance of the
dental water lines and equipment, which has the potential
to harbour bacteria. All dental
water lines should be purged at
the beginning of each day for
between 5 and 10 minutes and
flushed thoroughly with water,
as residual water may become
contaminated overnight and biofilm may develop along the inner side of the tube. Purging will
result in a significant decrease
in bacterial counts.[15, 16]
The Canadian Dental Association recommends running highspeed handpieces for 20–30
seconds after each treatment to
purge all potentially contaminated air and water. This procedure
has been proven to reduce the
bacterial load in the water line
significantly.[17] Blood cells, as
well as bacterial and viral par-
Using personal protective equipment such as surgical masks, safety glasses
as well as disposable gowns and gloves is vital. (Photo Tyler Olson/
Shutterstock)
ticles, can survive inside handpieces even after disinfection.
They must therefore be sterilised between patients.[17, 18]
The clinic floor should be disinfected and cleaned with an antimicrobial disinfectant solution
at least twice per day to eradicate any bacterial residue from
splatter or aerosols.
It is a well-known fact that private dental clinics sometimes
employ dental assistants who
have not received certified training. Improperly trained personnel, however, may lead to poor
infection control practices. It is
the responsibility of every dentist
to educate and train his or her
assistants in the standard procedures. Furthermore, DHCP im-
munisation status should be up
to date.
Eliminating the risk of exposure to dental aerosols remains
a difficult task. The best way to
reduce the risks, however, is to
employ routine cross-infection
protocols recommended by the
health authorities, such as the
CDC, WHO and ministries of
health. To date, various infection
control reports and procedures
have been published to inform
and educate dental health care
personnel (DHCP) about the importance of practising adequate
infection control.
Editorial note:
A complete list of references is
available from the publisher.
The world is very small
Diseases can spread easily if infection control measures are not adhered to. (Photo: lightpoet/Shutterstock)
By Dr. Raghu Puttaiah, USA
T
he Middle East Respiratory Syndrome (MERS) is
a respiratory condition associated with a specific strain of
coronavirus called MERS-CoV.
The clinical scenario includes
severe respiratory illness, fever,
cough and shortness of breath,
leading to death in about a third
of those infected. While MERS
was first reported in 2012 on the
Arabian Peninsula, cases have
now been reported in over three
dozen countries, spanning Asia,
Europe and North America.
While this disease has been noted to spread from those infected
to their caregivers or those living in close contact, it has not
yet been found to spread in
community settings as seen during the severe acute respiratory
syndrome (SARS) outbreak in
Asia that saw over 8,000 people
infected, resulting in about 9 per
cent mortality. Only two cases
have been detected in the US,
both of whom had a recent history of travel to Saudi Arabia.
resolve. We should also inform
patients prior to their appointment that, if they are not feeling
well, they should reschedule the
appointment.
The Centers for Disease Control and Prevention (CDC) and
the World Health Organization
(WHO) are concerned about
the potential of MERS to spread
globally and therefore are providing information and control
measures similar to those provided during the SARS and influenza A (H1N1) outbreaks. With
respect to dentistry, if there is a
vaccine available for any infectious disease of public health
concern, we must take it before
it affects us. With regard to infection control, if we as dental care
providers feel ill or feel that we
are about to fall ill, we must not
go to work but stay away from
people, including co-workers
and patients, until the symptoms
Basic infection control measures, such as frequent handwashing, wearing a mask, and
following standard and additional precautions, the last being specific to MERS, must be
adhered to strictly. The world is
very small with respect to travel
and the spread of disease from
one continent to another can
happen within a day. Keeping
abreast with rapidly changing
information on diseases such
as MERS from reliable sources,
such as the CDC, WHO, Association for Professionals in Infection
Control and Epidemiology, and
Organization for Safety, Asepsis
and Prevention, is necessary for
the dental team.
[52] =>
[53] =>
Dental Tribune Middle East & Africa Edition | November-December 2014
lab tribune 1D
More flexibility in the lab
By Ivoclar Vivadent
S
CHAAN,
Liechtenstein:
The extended product
range of the IPS InLine metal-ceramic system from Ivoclar
Vivadent offers dental professionals an even greater choice of
application options.
It is often the small things that
render the daily lab work more
comfortable and flexible. This
also applies to the IPS InLine
System Powder Opaquer which
makes alternative application
techniques accessible.
The IPS InLine System includes
a manageable number of components and an extensive range
of applications according to the
respective prosthetic situation.
The system is suitable for every
processing technique – from the
easy one-layer and the conventional multi-layer to the presson-metal technique. The new
IPS InLine Powder Opaquer
meets this high level of flexibility as it is compatible with all system components.
Furthermore, users benefit from
many economic and technological advantages: The Powder
Opaquer is equally suitable for
the conventional application
with a brush or application instrument as well as for the sprayon technique. What is more, the
same IPS InLine System Powder
Opaquer Liquid is used irrespective of the application technique.
(IPS InLine System Powder Opaquer & Liquid.jpg)
Fig: The new Powder Opaquer and the corresponding Powder
Opaquer Liquid
Fast veneering of all CAD/
CAM-fabricated and cast metal frameworks
The homogeneous structure of
the new Powder Opaquer with
optimized grain size distribution
ensures a high application and
firing stability.
Thanks to the optimally coordinated opacity and colour
saturation, the desired shade is
easily achieved with the Powder
Opaquer. Frameworks, fabricated with either conventional
casting methods or digital processes, are quickly masked even
with only thin layers due to the
material’s excellent masking
strength.
IPS InLine® is a registered
trademark of Ivoclar Vivadent
AG.
Contact Information
For additional information,
please contact:
Ivoclar Vivadent AG
Bendererstr. 2
FL-9494 Schaan
Phone: +423 235 35 35
Fax: +423 235 33 60
E-mail:
info@ivoclarvivadent.com
www.ivoclarvivadent.com
[54] =>
2D lab tribune
Dental Tribune Middle East & Africa Edition | November-December 2014
The necessity of (Dental Technician-Patient) interaction
for a successful esthetic material selection
Extreme white
By Aiham Farah, Syria
M
ore important than the
indications of a certain
case, (especially when
the need behind the treatment
plan is the bleach-esthetic part
in the first place), is to understand the patient’s needs and
expectations.
As a dental technician, you have
to give your insights about a possible solutions from the technical standpoint, and whether
these solutions can be done to
the extent of the patient’s esthetic visualization, or if they will
compromise another functional
or phonetics parameters.
Bright Decent
Finding out more about the
patient’s personality and what
needs to be expressed with his/
her smile, will add a lot of judgment on our decision as to what
to choose of restorative esthetic
material. Like how bright the
color should be? Is it a concern
of how natural the outcome
looks? Or on the contrary, what
matters is how prominent and
visible to everyone it is?
This can be done only if we allow the dental technician to interact with the patient’s personality that is hidden behind his
replica plaster-working model!
Therefor; I divide the esthetic-
Back to Natural
seeking people, who show up
to the dental studios asking for
a change in their smiles (based
on the intensity of bleach color
required, and the concern of
how life-like those ceramic teeth
should look like) to a three categories:
Back to Natural – Bright decent
– extreme white. Then I relate
that to the most used esthetic restorative material system in the
world, the IPS e.max system.
So The dental team can easily
rely on certain factors in choosing:
1st. their restorative ingots ac-
Back to Natural
cording to a scale of bright-dark
shades and transparent-opacity
range.
technique is recommended,
(MO0 & LT BL1) ingots are recommended.
2nd. the working technique to
be carried out.
Never to forget that the above
mentioned is always relative to
the thickness of the material.
For (Back to Natural) patients.
The Layering working technique is a must, (Value & LT &
MO1) ingots are recommended.
For (Bright decent) Patients
Either the Cut-back working
technique Or layering, (LT BL2,
BL3 & MO0) ingots are recommended.
For (extreme White) Patients
Full press & Staining working
Contact Information
Aiham Farah. CDT
Technical Training Consultant
Near East & Orient
IvoclarVivadent
Email:
aiham.farah@ivoclarvivadent.com
Interview: “One cannot just replace a technician
with a machine”
Interview with the Agnini brothers, dentists and prominent specialists in fixed prosthetics,
periodontology, and implantology
By John Battersby, Singapore
B
rothers Dr Andrea Mastrorosa Agnini and Dr Alessandro Agnini presented
a series of lectures on digital
dentistry and mastering the fully
digital workflow at IDEM Singapore 2014 in April. The doctors
were two of the star speakers at
the Dental Technician Forum
introduced for the first time at
this year’s IDEM Singapore. Between their packed schedule of
lectures and open panel discussions, the brothers took time out
to answer some questions on
their experiences in Asia, the
current state of digital dentistry,
CAD/CAM, and 3-D printing,
and the direction in which they
see these technologies developing in the future.
John Battersby: Have you observed any difference between
Asian and European techni-
cians when it comes to their
familiarity with and adoption
of the latest digital dentistry
technology?
Dr Andrea Mastrorosa Agnini:
We have not really had the opportunity to work closely with
any Asian technicians yet, so we
do not know with which technologies they are familiar or which
technologies have already been
widely adopted in Asia. What we
have seen is that there is massive and growing interest in all
> Page 3D
[55] =>
Dental Tribune Middle East & Africa Edition | November-December 2014
lab tribune 3D
< Page 2D
Figs. 2 & 3. Digital workf low by Drs Agnini
Fig. 1. Drs Allesandro Agnini and Andrea Mastrorosa Agnini
“... one still needs a dental technician who
is well trained in using all these
new digital technologies...”
aspects of digital dentistry, not
only among technicians but also
among all members of the modern dental team.
Dr Alessandro Agnini: Yes, this
is why there are more events like
the Dental Technician Forum at
IDEM Singapore and other similar events around Asia, just like
one sees in Europe and the US.
We were here in Singapore last
November for the CAD/CAM
conference and we will be back
again later this year for another.
How did you find your Asian
audiences at IDEM Singapore? We (Asians) have a reputation for being very shy when
it comes to asking questions;
did you have many questions
or much feedback?”
Dr A. Agnini: Actually, we had
quite a few questions from the
floor and via the SMS system
they used for the Dental Technician Forum. The audience can
text any questions they have to
a number and we can answer
them after the presentation during the Q & A session.
Dr A.M. Agnini: “The SMS system worked really well because
people could ask us anything
and often they asked us about
something we had not had time
to cover in the presentation or
had not included because we
were not sure whether it would
interest people. With such questions, we thus could cover such
topics too.”.
in using all these new digital
technologies; it is not easy for
anyone to use these new digital
technologies for the first time.
One needs a great deal of training to fabricate a final restoration that is precise, predictable
and of the same quality as that
achieved via traditional protocols and craftsmen technicians.
Software can help the clinician,
the technician and the patient,
but on its own cannot solve the
problem; one still needs a skilled
person behind the machines to
tell them what to do.
Dr A. Agnini: The machine
does not know what to do; it
cannot look at a restoration and
see where we need more support, or whether a molar needs
to be done this way or another
way. We need a person with the
skills, knowledge and training to
decide how to shape this framework if we are to achieve the
outcome of long-term predictable restorations.
But now, a well-trained and
knowledgeable technician using CAD/CAM can dramatically improve his or her productivity.
It has been suggested that Asia
might not be as quick to adopt
digital technologies as Europe
and the US because skilled labour costs here are still comparatively low, so there are
not the same savings to be
made by giving some of the
technicians’ jobs to machines.
Do you think that is true?
Dr A. Agnini: That is true, one
advantage of CAD/CAM is one
can speed up production. Another advantage for the dental technician is that one can reduce the
variables without reducing the
quality. The third advantage is
that it can level the playing field
between technicians and make
standards more homogeneous.
Before, especially for large restorations, the technicians’ skill
with their hands was crucial in
producing high-quality restorations, but with new technologies
perhaps technicians who are
less skilled in traditional manual
manufacturing techniques can
produce high-quality restorations.
Dr A.M. Agnini: One cannot just
replace a technician with a machine. In Europe or anywhere
else, one still needs a dental
technician who is well trained
While everyone agrees that
digital dentistry is the way of
the future, there does seem to
be one area where not everyone agrees. Everyone agrees
that the first two steps of the
process, that is the acquisition
of data via some form of scanning and CAD, are essential,
but when it comes to the CAM
component, there seems to be
a divergence of opinions.
One of the other speakers
at IDEM Singapore, Mr Rik
Jacobs, seems to think that
3-D printing can already cope
with most laboratory manufacturing and, once the latest biologically compatible
materials currently being developed have been tested and
approved, 3-D printing will be
able to do everything, including implants. Do you see that
happening or do you think
precision milling will be with
us for many years to come?
Dr A. Agnini: We do not have
much experience with 3-D
printing machines. For sure,
they will one day revolutionise
the future of dentistry, but right
now I do not think they can
match the precision achieved by
milling machines. For the time
being, I think milling machines
are a gold standard that will be
difficult to surpass.
As scanning and CAD/CAM
technologies, and especially
the software that links the
three stages, improve, do you
think more dentists or at least
the larger dental practices will
start to do more manufacturing in-house rather than using
external laboratories? And if
that is the case, what can laboratories and technicians do
to retain their customers?
Dr A.M. Agnini: The in-house
milling process is a hot topic
nowadays in dentistry. Everything has to begin and end with
the quality of the final restoration in mind, and that will always have to be the deciding
factor. Today, the clinician has
the option of organising his or
her work as he or she prefers,
but doing everything by himself or herself is, in our opinion,
something that is not convenient
or practical.
It is a different matter if the clinician has in his or her clinic a
well-trained dental team who
can manage the digital workflow
Fig. 4. Surgical guide made with 3-D printer (Objet Eden260V,
Stratasys) on the model.
Fig. 5. Surgical guide made with 3-D printer (Objet Eden260V,
Stratasys) in patients mouth.
“One needs a great deal of training to fabricate a
final restoration that is precise...”
from beginning to end. Such
a team would have to include
an expert dental technician devoted to studying and mastering
all of the latest digital possibilities. Only this way can this quality be achieved and the clinician
be satisfied from a business and
economic standpoint.
if the dental laboratories want
to keep themselves in business,
they have to incorporate the latest digital solutions into their
practice, understand and invest
in them, and work out how to
make the most of them. It is the
only way dental laboratories will
survive this digital dentistry era.
Another solution is to team up
with an external expert laboratory that can design, customise
and produce the prosthetic elements. This way, one does not
have to invest in the initial startup costs involved in setting up a
dental laboratory.
“The buzzwords at this year’s
IDEM Singapore were definitely “CAD/CAM” and “3-D
printing”, but what do you
predict the buzzwords will be
in 2018?”
In summary, on the one hand,
the craftsmanship of the dental
technician cannot be replaced
by digital dentistry; it will still be
necessary to work with someone
in-house or externally who is
capable and up-to-date with the
technology. On the other hand,
Dr A. Agnini: I think in 2018
the buzzword will be “full
digital workflow”, meaning a
completely predictable digital
process, and “full-arch rehabilitation”. Today, it is still too early
to manage complex cases with
the intra-oral scanner; the average error is still too large.
[56] =>
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.
CAD/CAM & DIGITAL DENTISTRY INTERNATIONAL CONFERENCE
10
08 - 09 MAY, 2015
06-10 MAY, 2015: HANDS-ON COURSES
JUMEIRAH BEACH HOTEL
DUBAI, UAE
14 CME HOURS
th
www.cappmea.com/cadcam10
DENTAL TECHNICIANS INTERNATIONAL MEETING 2015
Part of the
10th CAD/CAM & Digital Dentistry
International Conference
08 - 09 MAY, 2015
JUMEIRAH BEACH HOTEL
DUBAI, UAE
www.cappmea.com/cadcam10
7 th DENTAL - FACIAL COSMETIC INTERNATIONAL CONFERENCE
13 - 14 NOVEMBER, 2015
11-15 NOVEMBER, 2015: HANDS ON COURSES
JUMEIRAH BEACH HOTEL
DUBAI, UAE
MEET THE
14 CME HOURS
DEDICATED
COURSES
DENTAL HYGIENIST DAY 2015
Part of the
7th Dental - Facial Cosmetic
International Conference
3 RD
A
S
I
A
14 NOVEMBER 2015
JUMEIRAH BEACH HOTEL
DUBAI, UAE
-
P A C I F I C
E D I T I O N
CAD/CAM & DIGITAL DENTISTRY INTERNATIONAL CONFERENCE
04 - 05 DECEMBER, 2015
SUNTEC
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UP TO DATE 2015: ORAL-B SCIENTIFIC EXCHANGE SEMINARS
DUBAI
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DENTAL TRIBUNE MIDDLE EAST & AFRICA
In 2012 CAPP joined a global family of 95 publishers by becoming the proud owner of the Dental Tribune Middle East & Africa
edition, and since then we have been delivering 6 print publications to over 20, 000 Dental Professionals and in the MEA region,
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)
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[title] => Ten years of successful continuing dental education: 2005 – 2015
[page] => 01
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[1] => Array
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[title] => News
[page] => 01
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[2] => Array
(
[title] => Utilizing the Tempcap abutment with CAD/CAM
[page] => 06
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[3] => Array
(
[title] => The aesthetic challenge
[page] => 08
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[4] => Array
(
[title] => News
[page] => 09
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[5] => Array
(
[title] => Concepts - goals and techniques for successful orthognatic surgery
[page] => 10
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[6] => Array
(
[title] => The importance of cementation: A veneers case using a new universal cement
[page] => 12
)
[7] => Array
(
[title] => Conservative approach to multidisciplinary aesthetic dental treatment
[page] => 13
)
[8] => Array
(
[title] => A multi-disciplinary approach to minimally invasive functional aesthetic dentistry
[page] => 14
)
[9] => Array
(
[title] => Qualident Dental Lab
[page] => 19
)
[10] => Array
(
[title] => 6th DENTAL FACIAL COSMETIC International Conference Dubai
[page] => 20
)
[11] => Array
(
[title] => CBCT and CAD/CAM allow for one-day restoration of Tooth #9
[page] => 26
)
[12] => Array
(
[title] => Porcelain laminate veneers – avoiding complications
[page] => 27
)
[13] => Array
(
[title] => Case report surgical correction of a class III malocclusion in an adult
[page] => 28
)
[14] => Array
(
[title] => Dental implant competitors shake things up amidst economic uncertainty
[page] => 30
)
[15] => Array
(
[title] => SameDay Dental Implants® & Teeth A Surgical & Prostho Protocol
[page] => 31
)
[16] => Array
(
[title] => Beirut International Dental Meeting 2014
[page] => 34
)
[17] => Array
(
[title] => Saliva and Oral Health
[page] => 36
)
[18] => Array
(
[title] => New 3Shape advisory board develops plan to improve patient care
[page] => 39
)
[19] => Array
(
[title] => Hygiene Tribune Middle East & Africa Edition
[page] => 45
)
[20] => Array
(
[title] => Lab Tribune Middle East & Africa Edition
[page] => 53
)
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[toc_html] =>
[toc_titles] => Ten years of successful continuing dental education: 2005 – 2015
/ News
/ Utilizing the Tempcap abutment with CAD/CAM
/ The aesthetic challenge
/ News
/ Concepts - goals and techniques for successful orthognatic surgery
/ The importance of cementation: A veneers case using a new universal cement
/ Conservative approach to multidisciplinary aesthetic dental treatment
/ A multi-disciplinary approach to minimally invasive functional aesthetic dentistry
/ Qualident Dental Lab
/ 6th DENTAL FACIAL COSMETIC International Conference Dubai
/ CBCT and CAD/CAM allow for one-day restoration of Tooth #9
/ Porcelain laminate veneers – avoiding complications
/ Case report surgical correction of a class III malocclusion in an adult
/ Dental implant competitors shake things up amidst economic uncertainty
/ SameDay Dental Implants® & Teeth A Surgical & Prostho Protocol
/ Beirut International Dental Meeting 2014
/ Saliva and Oral Health
/ New 3Shape advisory board develops plan to improve patient care
/ Hygiene Tribune Middle East & Africa Edition
/ Lab Tribune Middle East & Africa Edition
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