Ask for LiSi - Modern Dentistry Media

Satnam Singh VirdeeEndodontic retreatment of a maxillary first molar

Howard Gluckman and Jonathan Du ToitConsecutive treatment failures of an immediatemaxillary canine implant and the subsequentreplacement and reconstruction of the site

Catiara Terra da Costa, Isadora Luana Flores,Fernanda Al-Alam, Manuela Souza e Silva,Priscila Martins, Thalita Goulart, Diana Tremea, Maria Laura Menezes BonowThe bow divider is an appropriate method to space measurement in mixed dentition byundergraduate students

Shiehfung Tay and Nicola Di VitaleBiological width in the periodontic-restorativeinterrelationship

Douglas Terry and Mark StankewitzSimplifying composite placement in theinterproximal zone

Ricardo Machado, Gustavo Almeida, Thâmara Silva Santos, Brunna PresminiBarbosa, Guilherme Augusto Moreira andAlberto Porto JuniorPulp revascularisation in a traumatised and necrotic tooth

Crispian ScullyMaking sense of mouth ulceration: Skin disorders

VOL. 12 NO. 1

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ContentsVolume 12 No. 1

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42

4 Clinical Endodontic retreatment of a maxillary first molar Satnam Singh Virdee

12 Clinical Consecutive treatment failures of an immediate maxillary canine implant and the subsequent replacement and reconstruction of the site Howard Gluckman and Jonathan Du Toit

24 Clinical The bow divider is an appropriate method to space measurement in mixed dentition by undergraduate students Catiara Terra da Costa, Isadora Luana Flores, Fernanda Al-Alam, Manuela Souza e Silva, Priscila Martins, Thalita Goulart, Diana Tremea, Maria Laura Menezes Bonow

32 Clinical Biological width in the periodontic-restorative interrelationship Shiehfung Tay and Nicola Di Vitale

42 Clinical Simplifying composite placement in the interproximal zone Douglas Terry and Mark Stankewitz

52 Clinical Pulp revascularisation in a traumatised and necrotic tooth Ricardo Machado, Gustavo Almeida, Thâmara Silva Santos, Brunna Presmini Barbosa, Guilherme Augusto Moreira and Alberto Porto Junior 58 Clinical Making sense of mouth ulceration: Skin disorders Crispian Scully

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VOL. 12, NO. 1 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION 1

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Vol. 12 No. 1ISSN 2071-7962PUBLISHING EDITOR Ursula Jenkins

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Stanley Bergman, Chairman and CEO of Henry Schein, has beenawarded an Honorary Doctor of Commerce by the University of theWitwatersrand, Johannesburg, South Africa. A Wits alumnus, Bergman wasrecognised for his contribution to business, philanthropy and support for thearts, education and universities around the world.

Born in Port Elizabeth, South Africa, Bergman is admired for hisstewardship of one of the world’s leading healthcare distribution companies.He has combined his business success with the pursuit of social justice tohelp expand access to healthcare globally. Bergman, his medical specialistwife, Dr Marion Bergman - also a Wits alumna - and their two sons havemade a difference to the lives of numerous people in the United States,Africa and many other developing regions in the world.

Bergman serves as a board member or advisor for many institutions, andis an honorary member of the American Dental Association and the AlphaOmega Dental Fraternity. He also holds many awards including anHonorary Fellowship of King’s College, London and the InternationalCollege of Dentists.

Henry Schein Cares, the company’s global corporate social responsibilityprogramme, has expanded access to healthcare for underserved and at-risk populations, as well as advancing diversity in the healthcare professionglobally.

When asked to share the formula for his company’s success, Bergmansays the following:

“ Success is all about caring about people. The most successful, enduringbusiness people and leaders in the world are the ones who care aboutpeople. I learned from my late mother growing up in Port Elizabeth that ifyou treat people how you want to be treated, things work out. From mylate father I learned to always look for the good in people and beoptimistic. I strongly believe that the more you give, the more you get back.I’m not talking about getting back financially, I’m talking in terms of theinspiring people you meet and the enriching experiences you have.”

Professor Adam Habib, Vice-Chancellor and Principal of the Universityof the Witwatersrand, confers an Honorary Doctorate of Commerce onStanley Bergman, Chairman and CEO of Henry Schein.

Stanley Bergman, CEO of Henry Schein,awarded Honorary Doctorate

Stanley Bergman Graduation ceremony.




Endodontic retreatment of a maxillaryfirst molar Satnam Singh Virdee1

IntroductionMr DS, a 36-year-old photographer, was referred from his general dental practitioner

(GDP) to the local restorative department for endodontic retreatment of a previously rootfilled maxillary first molar. This report aims to discuss the examination, treatment planningand endodontic management of this tooth, which present several complicating features.

HistoryPresenting complaint – persistent dull pain arising from the upper right area of the

mouth.History of complaint – Mr DS complained of a well localised, moderate, but constant

dull ache arising from the right maxillary first molar (UR6). This started nine months agofollowing an acute episode that was managed by his GDP with antibiotics and isexacerbated only by masticatory forces with no sensitivity to thermal stimuli.

The pain, which fortunately does not disturb his sleep, was being managed by over-the-counter analgesics.

He recalls that the tooth in question had previously undergone root canal therapyapproximately nine years ago as a result of extensive caries. This was allegedlycompleted over a single visit, with no recollection of rubber dam use and, uponcompletion, was coronally restored with a direct restoration.

Relevant dental and social history – Mr DS regularly attends his GDP and hasadopted an excellent oral hygiene regime, a low cariogenic diet, has never smokedand presents little to no anxiety or parafunction.

Relevant medical history – no relevant medical history or known drug allergies.Examination – an extraoral assessment concluded a right submandibular

lymphadenopathy.

Intraoral assessment • Soft tissues – nothing abnormal detected• Hard tissues – a moderately restored dentition with no evidence of caries (Figure 1)• Periodontal – BPE all 0s with very good oral hygiene and no mobility, recession or

furcations• Occlusal – Class I incisors and group function on lateral excursions with no

interferences.

C L I N I C A L

1 Satnam Singh VirdeeRestorative Dental Core Trainingpost, Cardiff Dental Hospital, UK Part-time private practice,Birmingham, UK

Figure 1: Dental charting.



a previous but infected root canal filling (Abbott, Yu, 2007).

Prognosis and treatment planNg et al (2011) reported the presence of a preoperativeperiapical lesion considerably reduced periapical healingand is a significant prognostic factor, which is consistent withlandmark Toronto studies (Ng, Mann, Gulabivala, 2011a;Farzaneh, Abithol, Friedman, 2004). Additionally, it wasfound that the size of the apical lesion also had a statisticalsignificance on treatment outcomes, with those less than 5mmhealing more favourably as opposed to those that werelarger (Ng, Mann, Gulabivala, 2011a).

Unfortunately, these features were all present in this case,reducing overall prognosis. However, the tooth alsopossessed several features that have been shown to improvetreatment outcomes, such as the presence of a technicallyinadequate root filling, substantial natural tooth structure andadequate periodontal health with the absence of anyperforations, sinus tracts or apically extruded root fillingmateria (Ng, Mann, Gulabivala, 2011a; Farzaneh, Abithol,Friedman, 2004).

The preoperative prognosis, therefore, was deemedslightly more favourably as ‘guarded’ and conveyed to thepatient, as well as all relevant options, which included:• Leave• Orthograde retreatment• Referral to specialist endodontist• Extract and accept space• Extract and fill space.

Mr DS still wished to retain the tooth and agreed upon thefollowing treatment plan:

Right maxillary first molar assessment• Visual – a moderately sized mesiocclusal amalgam

restoration with an intact mesial contact, but marginalditching on the occlusal aspects. There was no evidenceof caries, cracks, periodontal pocketing or mobility andapproximately 60% of natural tooth structure remained(Figure 2)

• Pulpal – repeated negative readings to electrical andthermal sensibility testing

• Periodontal – no pocketing, mobility, recession or furcationinvolvement

• Apical – moderate tenderness to apical percussion particularlyon the mesiobuccal cusp tip. Although there was no apicalswelling or sinus tract, on palpation there was tenderness onthe attached buccal mucosa adjacent to the UR6

• Radiographic – an intraoral periapical radiograph takenusing a long cone paralleling technique revealed a wellcorticated apical radiolucency greater than 5mm,associated with a significantly curved mesiobuccal root(>40o) and no evidence of MB2 instrumentation.Additionally, the coronal restoration extends to the floor ofthe pulp chamber. Assessing against the quality guidelines,the previous root filling could be improved as it was poorlycondensed and not extended to the appropriate length(European Society of Endodontology, 2006). Furthermore,there was a close anatomical relationship between the rootapices and maxillary sinus (Figure 3).

Diagnosis Using the classification system set out by Abbot and Yu(2007), the diagnosis was chronic apical periodontitis with

C L I N I C A L

Figure 2: Clinical photograph of UR6. Figure 3: Preoperative long- cone periapical radiograph ofUR6.


Identifying canalsOnce access was gained, the pulpal floor was inspected forexisting injuries and uninstrumented canals. Four canals wereidentified, three had been previously obturated and the MB2was left uninstrumented. Estimated working lengths for eachcanal were established using the preoperative radiographand then a glide path was established in the MB2 using ISOsize 8-20 K-files and a Protaper Universal Sx file withlubricant (Figure 5; Table 1).

Gutta-percha removalThe estimated length of gutta-percha (GP) was establishedfrom the preoperative radiograph. Gross GP was initiallyremoved by a combination of Gates Glidden burs andHedstrom files set to the length of GP. Fine remnants werethen retrieved by introducing solvents into each orifice andusing large paper points in a ‘wicking’ motion until all canalswere patent and no further GP residue was visible on theterminal third of the paper points. Using an Electronic ApexLocator (EAL) and an ISO size 10 K-file, zero length readingsfor each canal were established (Table 1). For each reading,0.5mm was subtracted to establish the true working length

• UR6 orthograde endodontic retreatment • Direct composite core and coronal restoration• Clinical and radiographic 12-monthly reviews.

Treatment protocol First appointmentIsolation and endodontic accessUpon achieving profound anaesthesia, single tooth isolationwas achieved using a winged molar clamp, rubber dam,floss and a caulking agent (Figure 4). The absence of anyleaks into the oral cavity on water application from the tripleair syringe confirmed a hermetic seal. Prior to access, thepreoperative radiograph was studied closely to estimate thedepth of the amalgam core restoration (Figure 3). A basicoutline of an orthodox access cavity was then scribed intothe amalgam surface and the predetermined depth was usedto orientate a round-ended, tapered, cooled diamond burduring access to prevent causing iatrogenic injury. At thefloor of the pulp chamber, a safe-ended tungsten carbide burwas used to remove the roof the pulp chamber, ensuring theminimally invasive access cavity permitted good visibility,was a reservoir for irrigants and straight-line access to allcanal orifices.

V I R D E E


Figure 4: Single tooth isolation of UR6. Figure 5: Endodontic access.

Canal

Mesiobuccal one

Mesiobuccal two

Distobuccal

Palatal

Estimated working lengths

(MM)

19mm to the MB cusp tip


22mm to the DB cusp tip

25mm to the MP cusp tip

Table 1: Estimated working length, zero length readings and true working lengths of all four UR6 canals

Zero length reading

(MM)



21mm to the DB cusp tip

25mm to the MP cusp tip

True working lengths

(MM)

19.5mm to the MB cusp tip

19.5mm to the MB cusp tip

20.5mm to the DB cusp tip

24.5mm to the MP cusp tip



the critical component to a successful outcome. Followingshaping, the tooth was temporised with non-setting calciumhydroxide paste and a distinctly coloured glass ionomertemporary restoration.

Second appointmentTrial cone radiographAfter regaining access and single tooth isolation, canalswere dried using paper points followed and the respectiveGP cones were inserted to assess for tug back at themeasured true working lengths. A trial cone periapicalradiograph was then taken to confirm the shaping wascompleted to a satisfactory standard and to the correct lengthprior to obturation (Figure 8).

Irrigation activationRegardless of its many favourable properties, sodium

and then confirmed with a true working length long coneperiapical radiograph (Table 1; Figure 6).

Chemomechanical debridementAll canals were shaped to length using the ProtaperUniversal Rotary system with the mesiobuccal one,mesiobuccal two and the distobuccal canals shaped to anISO 25 F2 and the palatal shaped to an ISO 30 F3. Thevarying taper of these files allowed the author to monitorshaping technique throughout the procedure. If carried outcorrectly, the shaper files should present with dentinal debrisin the coronal aspect of the instrument, whereas this shouldbe located in the apical region of finisher files (Figure 7).All shaping was conducted in the presence of copiousirrigation (sodium hypochlorite 5.5%) to aid removal ofdebris from the canal, lubricate files to prevent separationand to chemically disinfect the root canal system, which is

V I R D E E


Figure 6: True working length radiograph. Figure 7: Gutta-percha removed and all canals shaped.

Figure 8: Trial gutta-percha radiograph. Figure 9: Obturated canals.


ObturationA warm vertical condensation technique was used toobturate the canals after the canals were thoroughly dried.Initially, the GP was coated with a calcium hydroxide basedsealer (AH+). When it was then inserted into the canal tolength, the System B tip was activated to 5mm short of thetrue working length. At this length, the tip was deactivatedand the excess coronal GP removed on withdrawal. Theremainder of the canal was then obturated with thermoplasticGP in 2mm increments using the Obtura system (Figure 9).

Coronal sealA definitive restoration was immediately placed afterobturation, as Chugal et al (2007) reported those of atemporary nature result in higher failure rates. Initially, 3mmof flowable composite was used to seal the orifices of thecanals and then a direct hybrid composite restoration wasused to restore the lost tooth substance (Figure 10).Although there was no mesial marginal ridge, a substantialamount of natural tooth structure was preserved and theremaining cusps retained a critical thickness of 2.5mm.Additionally, the tooth was not at the terminus of the archand was occlusally protected against excessive axialforces during excursive movements. These are all featuresthat have been shown to improve the healing and long-term survival of the tooth and so a conservative directcomposite coronal restoration was deemed appropriate(Polesel, 2011; Ng, Mann, Gulabivala, 2011b).Following this, a postoperative periapical radiograph wastaken to assess the quality of the endodontic root filling(Figure 11). This showed that the GP was obturated to thecorrect length; there were no voids, extrusions or overfills.Additionally, the radiolucency does not appear to haveincreased in size.

hypochlorite is still unable to dissolve the inorganiccomponent of the smear layer (American Association ofEndodontists, 2011). This mineral film, which coversinstrumented walls, can harbour residual microorganisms andimpede the ability of sodium hypochlorite to penetrate deepinto the dentine tubules, reducing its overall antimicrobialeffect (Violich, Chandler, 2010). Therefore, to achieve amore thorough disinfection, a one-minute penultimate rinseof 17% EDTA was carried out upon completion of allmechanical instrumentation. This combination is a recognisedtechnique and has shown to significantly improve thetreatment outcomes of teeth undergoing endodonticretreatment (Ng, Mann, Gulabivala, 2011a).

With the smear layer now effectively removed, a final rinseof 5.25% sodium hypochlorite was administered. For eachcanal, a corresponding GP cone was inserted for manualdynamic activation of the irrigant before they were thoroughlydried and then finally obturated. Throughout the procedure,any change in solution was preceded by a saline flush toneutralise the effects of the former irrigant.

V I R D E E


Figure 10: Direct composite coronal restoration. Figure 11: Postoperative radiograph.

Figure 12: 12-month post-operative radiograph.


ConclusionOverall, this case encompassed a combination of severalcomplicating factors that challenged the author’s endodonticclinical skills and knowledge. The author has learnt to beinsightful and critical of his own work, employ a systematicstrategy to manage complications, and the value of using theliterature to overcome challenges and develop as a clinician.

Award-winning caseSatnam Singh Virdee won the Young Dentist EndodonticAward 2016 for this case. Find out more at bit.ly/2jiuSLd.

ReferencesAbbott PV, Yu C (2007) A clinical classification of the status of the

pulp and the root canal system. Aust Dent J 52:S17-31American Association of Endodontists (2010) AAE Endodontic Case

Difficulty Assessment Form and Guidelines [online]. Available at:<www.aae.org/caseassessment> [Accessed: 16/06/2016]

American Association of Endodontists (2011) Root canal irrigants anddisinfectants [online]. Available at: <bit.ly/2juUcwD> [Accessed16/06/2016]

Byström A, Happonen RP, Sjögren U, Sundqvist G (1987) Healingof periapical lesions of pulpless teeth after endodontic treatment withcontrolled asepsis. Endod Dent Traumatol 3:58-63

Chugal NM, Clive JM, Spångberg LSW (2007) Endodontictreatment outcome: effect of the permanent restoration. Oral Surg OralMed Oral Pathol Oral Radiol Endod 104: 576-582

Eriksen HM, Ørstavik D, Kerekes K (1988) Healing of apicalperiodontitis after endodontic treatment using three different rootcanal sealers. Endod Dent Traumatol 4: 114-117

European Society of Endodontology (2006) Quality guidelines forendodontic treatment: consensus report of the European Society ofEndodontology. Int Endod J 39: 921-930

Falcon HC, Richardson P, Shaw MJ, Bulman JS, Smith BGN (2001)Restorative dentistry: Developing an index of restorative dental treatmentneed. Br Dent J 190: 479-486

Farzaneh M, Abitbol S, Friedman S (2004) Treatment outcome inendodontics: the Toronto study. Phases I and II: Orthograde retreatment.J Endod 30: 627-33

Friedman S, Mor C (2004) The success of endodontic therapy –healing and functionality. J Calif Dent Assoc 32: 493-503

Ng YL, Mann V, Gulabivala K (2011a) A prospective study of thefactors affecting outcomes of nonsurgical root canal treatment: part 1:periapical health. Int Endod J 44: 583-609

Ng YL, Mann V, Gulabivala K (2011b) A prospective study of thefactors affecting outcomes of non-surgical root canal treatment: part 2:tooth survival. Int Endod J 44: 610-625

Ørstavik D (1996) Time-course and risk analyses of the developmentand healing of chronic apical periodontitis in man. Int Endod J 29: 150–155

Polesel A (2011) The conservative restoration of single posteriorendodontically treated teeth. Ital J Endod 25: 3-21

Violich DR, Chandler NP (2010) The smear layer in endodontics – areview. Int Endod J 43: 2-15

Reprinted with permission by Endodontic PracticeFebruary 2017

ReviewAt six and 12 months, Mr DS presented with no symptomsand had stated that there had not been any postoperativeacute episodes. The tooth was now functional as he wasable to eat on this side without feeling any pain.Clinically, the coronal restoration was intact, and therewas no evidence of active infection. Radiographicexamination revealed the apical lesion had significantlyreduced in size (Figure 12). Due to the absence of anysymptoms and radiographic evidence of healing, the casewas deemed as being successful and Mr DS wasdischarged back to his GDP and advised to be re-referredshould any issues occur.

DiscussionIf the aim of root canal therapy is to resolve infection, thenit could be assumed that the strict definition of endodonticsuccess is to achieve complete resolution of apicalperiodontitis. This would mean that even in the absence ofclinical symptoms and the presence of a comparativelyreduced radiographic apical lesion, this case would stillbe considered a failure. However, it is well recognised thathealing is a dynamic process that can take between twoto five years to occur and an appropriate follow-up periodis required to truly determine if success has been achieved(Eriksen, Ørstavik, Kerekes, 1988; Byström et al, 1987;Ørstavik, 1996). This is echoed in the quality guidelines,which recommend an annual follow-up period for up tofour years, at which only then can failure be determined(European Society of Endodontology, 2006). Therefore, atthis stage, describing outcomes dichotomously as asuccess or failure may not be representative of the dynamichealing process that is occurring.

However, one such classification system that does take thisinto account is the one set out by Friedman and Mor (2004)where endodontic outcomes are described as being either‘healed’, ‘healing’ or ‘diseased’. The most appropriate termfor this case would be ‘healing’ due to the absence of clinicalsymptoms and the significant reduction in the mesiobuccalperiapical radiolucency at the 12-month review. Thisrestoration of function would translate to an overall ‘good’outcome and will require further review to assess if the wellcorticated apical lesion has completely healed, which wouldthen become an ‘excellent’ outcome. Technically, the outcomemeets all of the desirable criteria outlined in the qualityguidelines and would be considered an ‘excellent’ outcomein this context (European Society of Endodontology, 2006).

V I R D E E





Consecutive treatment failures of an immediatemaxillary canine implant and the subsequentreplacement and reconstruction of the site

Howard Gluckman,1 Jonathan Du Toit2

IntroductionThe approach to treating an edentulous or partially edentulous jaw presents bothclinician and patient with a clinical challenge addressed by several treatment options.1

Restorative implant treatment is among the more advanced options, and yet it is highlypredictable and potentially very rewarding for the patient. Fundamental principles,though, are to be adhered to.2

Chief among these is thorough, concise, evidence-based treatment planning.3 Theclinician is cautioned not to overlook the crucial importance thereof. All too oftenneglected are the most basic of examinations and thorough history taking. The readermay challenge him or herself, asking when last did I carry out a standard, full mouthperiodontal examination to identify any periodontal disease that requires treatmentbefore embarking on implant therapy?4

Thorough implant treatment planning almost always necessitates the use of specialinvestigations and additional diagnostic aids. Whilst costly, the value of a cone-beamcomputed tomography (CBCT) scan to visualize the edentulous ridge or site in its 3-dimensional aspects cannot be stressed enough.5 The treating clinician is to be cognizantof the recommended tissue parameters needed to support the dental implant and itsrestoration. The clinician is required to diagnose the need to augment these.6-8

The above-mentioned by no means addresses the entirety of the possible implanttreatment planning aspects. However, the main shortcomings are highlighted, drawingattention to the case presented here and what led to the treatment failure.

C L I N I C A L

1 Howard Gluckman BDS, MChD (OMP)Specialist in periodontics andoral medicine, director of theImplant and Aesthetic Academy

2 Jonathan Du Toit BChD, Dipl.Implantol., Dip Oral Surg, MSc DentDepartment of Periodontics andOral Medicine, School ofDentistry, Faculty of HealthSciences, University of Pretoria

AbstractImplant therapy is a valuable and reliable treatment in the restorative and reconstructive dentistry milieu. Many of thetechniques employed are advanced and yet implant dentistry is routine in today’s specialist and general dental practices.The volume of treatment delivered though should never disregard the importance of thorough and concise treatmentplanning. A lack of knowledge and misapplication of fundamental implant therapy principles is demonstrated hereafterwhere an edentulous space at a missing maxillary canine was treated by an implant-supported crown, yet the completefailure of adequate treatment planning resulted in a bizarre clinical outcome requiring significant revisions to correct.Paramount to the implant dentist and surgeon are the treatment planning principles highlighted by this case.

Keywords: Dental implant, implant therapy, treatment planning



C L I N I C A L

Figure 3: Preoperative CBCT showed a dental implant withabout half the body inserted into the nasal cavity, a root remnantbuccal, and an angled abutment as long as the implant fixed toa crown restoration.

Figure 4: Full-thickness flap exposure of the site revealed anextensive buccofacial bony defect and soft tissue encapsulationof the implant abutment.

Figure 1: The preoperative presentation. Figure 2: A draining sinus was noted buccal to the implantcrown at 13.

a period of healing. Subsequent to the chronic draining sinusbuccal to the implant, the patient was advised by his generaldentist to seek a third opinion. Clinical examination of thepatient noted a screw-retained, implant-supported crownat site 13. Circumferential probing of the implant exceeded15 mm, with bleeding upon probing, and exudate drainingfrom a sinus midfacial at the implant site (Figs. 1, 2).

CBCT examination noted a custom abutment that extendedabout 8-10 mm in length, screw-retained to an externalconnection implant. The implant-abutment interface waspositioned at approximately as deep as the root apices ofthe adjacent teeth, with about half the implant bodypenetrating into the nasal cavity (Fig. 3). There was alsoevidence of a root fragment adjacent to the implant. Theextended custom abutment supported a cement-retainedcrown in the occlusal position. The mesial of tooth 14 had

Case reportA 21-year-old male presented with the main complaint of apersistent infection around an implant that had been placedabout 1 year prior. The patient was a non-smoker, healthy,with a clear medical history and currently not taking anychronic medication. According to the patient’s history, theinfection had persisted and the practitioner who placed theimplant advised the patient the situation was not a problem.The patient’s history entailed a retained deciduous caninewith a congenitally missing tooth 13. The deciduous toothwas removed and an immediate implant was inserted at thesite. The implant developed an infection and was removed.A second implant was placed at the time of the first’sremoval. This implant also became infected and wassubsequently removed. The patient then saw a differentpractitioner who placed a third implant and restored it after


G L U C KMAN / D U T O I T


copiously rinsed with saline. Platelet-rich fibrin (PRF)membranes were placed within the defect and the sitesutured closed with 6/0 nylon.

After 8 weeks of healing the edentulous site was re-approached and treatment planned from start. This includedamong many others a thorough clinical exam, periodontalexamination, a holistic documentation of all pathologies andtreatment needs, concise photographic documentation, studycasts, restorative mock-up, and special investigative adjunctsincluding CBCT. The diagnostic list for the patient includeda Class I malocclusion, recession defects, a mild fluorosis,and a missing 13. Diagnosing the healed, edentulous siteat 13 noted a significant ridge defect, both horizontal andvertical, with a deficit of both hard and soft tissues. The softtissue already showed significant scarring, recession distalto 12, and severe recession mesial to 14 with complete lossof the papillae (Figs. 9, 10). There was insufficient attached,keratinized tissue at the 14 with a Class IV recession defect.

The treatment planning entailed a bone augmentation of

been reduced to accommodate the implant crown. A detailed examination predicated the diagnosis of a

severely malpositioned implant with a chronic peri-implantitisand unacceptable restoration. The treatment planningproposed removal of the implant and restoration, allowingfor a period of healing and resolution of infection, and a re-assessment of the site’s treatment needs.

The site was anaesthetized and a full-thickness flap wasraised over the implant at 13, exposing soft-tissueencapsulation of the abutment extending to the apices of theadjacent teeth (Fig. 4). The pathologic soft tissue wasremoved to send for histological examination, and the extentof the bony destruction at the area was exposed (Fig. 5).Bone appeared eroded at the surfaces proximal to theimplant. The buccal bone had a large defect yet the palatalbone remained coronal. The prosthesis and restoration weretorqued and fractured from the implant and thereafter theimplant torqued out (Figs. 6-8). The root fragment was alsolocated and removed, the area meticulously debrided and

Figure 7: The infective tissue at the implant and root remnant. Figure 8: After removal, the restoration and abutment to implantratio could be appreciated.

Figure 5: Removal of the pathological soft tissue revealed theextent of the bony destruction.

Figure 6: The abutment was torqued to fracture, revealing anexternal hex connection implant.



G L U C KMAN / D U T O I T


the hard tissue defect, augmentation of the soft tissue deficit,and implant placement to restore with a screw-retainedcrown. Tooth 14 was first restored to re-establish a normalemergence profile and anatomy (Fig. 10). CBCT and virtual

implant planning indicated that implant placement in therestoratively correct 3-dimensional positioning withsimultaneous augmentation with an autogenouscorticocancellous bone block was a viable option. After local

Figure 11: Re-entry at the site illustrated the extent of thehorizontal defect.

Figure 12: The radiographic-surgical guide in position andzenith of the pontic at the correct height. A severe vertical ridgedeficit is not evident.

Figure 13: Placement via the guide confirmed a restorativelyplanned implant positioning for a screw-retained crown.

Figure 14: The implant fully inserted with an extensive buccaldehiscence that required augmentation.

Figure 9: After initial healing of the site. Note the mesial of tooth14 that was cut away. And the horizontal defect, as well as theextensive scarring is evident.

Figure 10: Tooth 14 was restored. Occlusal view accentuatesthe buccal defect.


G L U C K M A N / D U T O I T


anaesthesia a full-thickness flap was again raised at the siteand the implant osteotomy was prepared via a restorative-planned surgical guide (Figs. 11, 12). A morse-taper,conical internal connection implant, 3.5 x 10 mm(NobelActive, Nobel Biocare) was inserted at the correctrestoratively planned level, 2 mm below the palatal crest

(Figs. 13, 14). A corticocancellous bone block was thenharvested from the left mandibular ramus, and split into twoblock veneer grafts as per Khoury’s protocol (Figs. 15, 16).9

The blocks were thinned with a bone scraper (Safescraper,Geistlich) further harvesting autogenous bone shavings (Fig. 17).The blocks were then secured to the ridge buccal to the implant

Figure 15: Harvesting of the ramus block. Figure 16: The ramus block sectioned into two thinner grafts.

Figure 17: Bone shavings harvested by scraping and refiningthe block grafts.

Figure 18: The blocks fixed to the bony ridge buccal to theimplant.

Figure 19: Buccal view of the bone blocks fixed in place. Figure 20: The harvested autogenous bone shavings werepacked beneath and around the blocks.

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with fixation screws, and the bone shavings packed within thedefect between the implant and blocks (Figs. 18-20). PRFmembranes were layered over the bone augmentation and thetension-free flap repositioned and sutured with 6/0 nylon (Figs.21, 22). The site was then restored with a provisional partialdenture free of pressure to the underlying augmentation site.After 12 weeks of healing the implant was exposed and

its implant stability quotient (ISQ) checked – 78D 75M 75B

(Fig. 23-26). The buccal soft tissue was undermined by atunneling approach, creating a split-thickness envelope. Aconnective tissue graft (CTG) was harvested from the palateand transferred into the pouch, sutured in position, therebyaugmenting the soft tissue buccal and coronal to the site(Figs. 26-28). The implant was then restored with aprovisional restoration to begin developing the soft tissueprofile. At 4 weeks of healing a black triangle was evident

Figure 21: PRF membranes were layered atop the completedbone augmentation.

Figure 22: Site closure with 6/0 nylon sutures.

Figure 25: CBCT scan showed the healed bone augmentationbuccal to the implant 2.2 mm thick.

Figure 26: ISQ readings indicated high stability, positivelyconfirming osseointegration.

Figure 23: Immediate postoperative periapical radiograph.This short, wide healing abutment is not ideal.

Figure 24: 12 weeks of healing.





investigations where necessary, a review of the patient’s riskfactors, all to derive accurate diagnoses.6, 16 It is evident fromthe failed case presented here that these principles were notadhered to. The site and its retained root were not diagnosedproperly and thus the patient went through multiple andunnecessary procedures that ultimately required extensivereconstruction to rehabilitate the site. The ridge deficits werenot diagnosed correctly and the need for bone and soft tissueaugmentations was not identified. The value of a CBCT scanin planning implant treatment cannot be over-emphasized.14,15, 17 Literature does not necessitate CBCT as an absolute forevery implant treatment case planned, but it is difficult toidentify a planned implant, verifying adequate bonecircumferential to the implant, to locate anatomical structuresof risk, to orientate a correct restoratively planned placementpositioning.16, 18

Sound knowledge of implant dentistry principles areessential when delivering such treatment to a patient and theclinician is required to have a thorough understanding ofanatomy, biology, prosthodontics, and implant hardware.

where the distal papilla was absent. A further 8 weeks ofhealing allowed time for soft tissue in-fill of the area (Figs.28-31). At final restoration of the implant a bulk of ridge tissue

buccal to the implant could be noted, with near completerestitution of both mesial and distal papillae (Fig. 32).Functional treatment goals were realized and adequateaesthetic rehabilitation of the previously failed treatment wasachieved. The patient was satisfied, with the tissues andoutcomes remaining stable at the 2-year recall (Fig. 32).

DiscussionIt is likely that with the ever-increasing availability of implanttreatment, a greater number of implant procedures willproduce increasing implant failure data.10, 11 Implanttreatment has become commonplace in daily practice, yetthe practitioner should never discount the importance of acorrect approach and health care fundamentals.12-15 Thefoundation thereof is a comprehensive patient history,thorough clinical examination, the use of special adjunct

Figure 27: The connective tissue graft (CTG) harvested from thepalate positioned over the recipient site.

Figure 28: The implant exposed with CTG inserted and suturedinside a split-thickness tunnel flap.

Figure 29: 10-day follow-up with the provisional restoration inplace. The soft tissue augmentation healing without complication.

Figure 30: 4-week follow-up, soft tissues healed, provisional inplace, yet the absence of a distal papilla is obvious.





Evident in the original failed treatment, a knowledge of theminimum bone required to accommodate the implant insertedat the correct height and position to ensure long-term tissuestability was lacking.6 Recognizing the need for a soft tissueaugmentation that in turn supports healthy bone at theimplant, that can be developed and sculpted to frame theimplant restoration, potentially creating pseudopapillae aswith the revised rehabilitation presented here, was alsolacking.19 The attempt at placing a non-internal conicalconnection implant, and attempting to restore at occlusallevel via a highly unconventional customized abutmentcontributed to the failure. Compromising established,evidence-based, reliable procedures and opting for analternative compromise introduces a debate for clinicalinnovation versus jeopardizing treatment. But in this case the3rd implant placement and restorative approach were bothindisputably unacceptable. It is accepted clinical practice to

place an implant beyond the sinus or nasal floor cortexcontained within an intact membrane and most often a boneaugmentation, when a vertical ridge deficiency presents inthe maxilla.20, 21 But entirely perforating into the nose, andplacing a large portion of the implant body unsupported byaugmented bone is not clinically acceptable and does notcontribute to the integration of the implant. Of greatestconcern in the case presented here was the disregard forprinciples of beneficence and non-maleficence.22 Thepersistent infection was not addressed and the underlyingcause, likely the infected root fragment, was not diagnosed.The failure of the previous two implant treatment attemptsshould have been investigated. Moreover, tooth 14 shouldnot have been cut away to accommodate the implantrestoration.Managing increased crown height space to implant ratio

is acceptable and common at resorbed, post-extraction sites.

Figure 31: A further 8 weeks allowed for soft tissue maturationand infill of the distal interproximal space.

Figure 33: 2-year follow-up, tissues stable with adequate aesthetic andfunctional results.

Figure 32: The final screw-retained crown in place. Adequatebulk of tissue buccal to the implant restoration.




Diagnosis, instrumentation, harvesting, techniques and surgicalprocedures. In: Khoury F, Antoun H, Missika P, Bessade J, editors. BoneAugmentation in Oral Implantology. London: Quintpub; 2007. p. 169-83.

10. Derks J, Schaller D, Hakansson J, Wennstrom JL, Tomasi C,Berglundh T. Effectiveness of Implant Therapy Analyzed in a SwedishPopulation: Prevalence of Peri-implantitis. Journal of dental research.2016;95(1):43-9.

11. Tarnow DP. Increasing Prevalence of Peri-implantitis: How WillWe Manage? Journal of dental research. 2016;95(1):7-8.

12. Kuchler U, von Arx T. Horizontal ridge augmentation inconjunction with or prior to implant placement in the anterior maxilla: asystematic review. The International journal of oral & maxillofacialimplants. 2014;29 Suppl:15.

13. Tahmaseb A, Wismeijer D, Coucke W, Derksen W. Computertechnology applications in surgical implant dentistry: a systematicreview. The International journal of oral & maxillofacial implants.2014;29 Suppl:25.

14. Bornstein MM, Scarfe WC, Vaughn VM, Jacobs R. Cone beamcomputed tomography in implant dentistry: a systematic review focusingon guidelines, indications, and radiation dose risks. The Internationaljournal of oral & maxillofacial implants. 2014;29 Suppl:55-77.

15. Bornstein MM, Al-Nawas B, Kuchler U, Tahmaseb A. Consensusstatements and recommended clinical procedures regardingcontemporary surgical and radiographic techniques in implant dentistry.The International journal of oral & maxillofacial implants. 2014;29Suppl:78.

16. Buser D, Chappuis V, Belser UC, Chen S. Implant placementpost extraction in esthetic single tooth sites: when immediate, when early,when late? Periodontology 2000. 2017;73(1):84-102.

17. Nunes LS, Bornstein MM, Sendi P, Buser D. Anatomicalcharacteristics and dimensions of edentulous sites in the posteriormaxillae of patients referred for implant therapy. The International journalof periodontics & restorative dentistry. 2013;33(3):337-45.

18. Harris D, Horner K, Grondahl K, Jacobs R, Helmrot E, Benic GI,et al. E.A.O. guidelines for the use of diagnostic imaging in implantdentistry 2011. A consensus workshop organized by the EuropeanAssociation for Osseointegration at the Medical University of Warsaw.Clinical oral implants research. 2012;23(11):1243-53.

19. Linkevicius T, Apse P. Biologic width around implants. Anevidence-based review. Stomatologija. 2008;10(1):27-35.

20. Mazor Z, Lorean A, Mijiritsky E, Levin L. Nasal floor elevationcombined with dental implant placement. Clinical implant dentistry andrelated research. 2012;14(5):768-71.

21. Sanz M, Donos N, Alcoforado G, Balmer M, Gurzawska K,Mardas N, et al. Therapeutic concepts and methods for improvingdental implant outcomes. Summary and consensus statements. The 4thEAO Consensus Conference 2015. Clinical oral implants research.2015;26 Suppl 11:202-6.

22. Health Professions Council of South Africa. General EthicalGuidelines for the Health Care Professions [Online]. Pretoria: HPCSA;2008 [updated 2008; cited 2017 19/01]. Available from:http://www.hpcsa.co.za/Conduct/Ethics.

23. Anitua E, Alkhraist MH, Pinas L, Begona L, Orive G. Implantsurvival and crestal bone loss around extra-short implants supporting afixed denture: the effect of crown height space, crown-to-implant ratio,and offset placement of the prosthesis. The International journal of oral& maxillofacial implants. 2014;29(3):682-9.

24. Canullo L, Pellegrini G, Allievi C, Trombelli L, Annibali S, DellaviaC. Soft tissues around long-term platform switching implant restorations:a histological human evaluation. Preliminary results. Journal of clinicalperiodontology. 2011;38(1):86-94.

But extending a customized abutment transgingivally to bringthe crown into occlusion as with this case is not acceptable.The cantilever forces exerted in the failed treatment are notconducive to health.23 Moreover, the soft tissues when healedat the neck of an implant crown seek to establish a biologicalzone, commonly of long junctional epithelium with underlyingconnective tissue along the abutment.19 A tissue seal andattachment along the entirety of the failed abutment here wasunlikely. As such, the long junctional epithelium may allowfor bacterial plaque ingress and colonization along thelength of the abutment that cannot be cleaned by the patient,resulting in the infective, granulation tissue seen at theimplant’s removal.24

ConclusionA lack of sound knowledge in implant dentistry and anattempt at a compromise resulted in a drastic failure thatrequired several additional procedures to rehabilitate. Thefailure presented here underpins the importance of basic andfundamental principles when approaching any treatment.Key are proper examinations, diagnoses, and treatment pl-anning, that substantiate ethical treatment options.

References1. Misch CE. Chapter 21 - Single-Tooth Implant Restoration: Maxillary

Anterior and Posterior Regions. Dental Implant Prosthetics (SecondEdition). St. Louis: Mosby; 2015. p. 499-552.

2. Moraschini V, Poubel LA, Ferreira VF, Barboza Edos S. Evaluation ofsurvival and success rates of dental implants reported in longitudinal studieswith a follow-up period of at least 10 years: a systematic review. Internationaljournal of oral and maxillofacial surgery. 2015;44(3):377-88.

3. Thalji G A-TS. Prosthodontic considerations in the implantrestoration of the esthetic zone. In: Sadowsky S, editor. Evidence-basedImplant Treatment Planning and Clinical Protocols. Iowa: John Wiley &Sons; 2016. p. 109-22.

4. Cho-Yan Lee J, Mattheos N, Nixon KC, Ivanovski S. Residualperiodontal pockets are a risk indicator for peri-implantitis in patientstreated for periodontitis. Clinical oral implants research.2012;23(3):325-33.

5. Du Toit J, Gluckman H, Gamil R, Renton T. Implant Injury CaseSeries and Review of the Literature Part 1: Inferior Alveolar Nerve Injury.The Journal of oral implantology. 2015;41(4):e144-51.

6. Levine RA, Huynh-Ba G, Cochran DL. Soft tissue augmentationprocedures for mucogingival defects in esthetic sites. The Internationaljournal of oral & maxillofacial implants. 2014;29 Suppl:155-85.

7. Puisys A, Linkevicius T. The influence of mucosal tissue thickeningon crestal bone stability around bone-level implants. A prospectivecontrolled clinical trial. Clinical oral implants research.2015;26(2):123-9.

8. Urban IA, Jovanovic SA, Lozada JL. Vertical ridge augmentationusing guided bone regeneration (GBR) in three clinical scenarios priorto implant placement: a retrospective study of 35 patients 12 to 72months after loading. The International journal of oral & maxillofacialimplants. 2009;24(3):502-10.

9. Khoury F, Khoury C. Chapter 6 - Mandibular bone block grafts:



The bow divider is an appropriate method to spacemeasurement in mixed dentition by undergraduate studentsCatiara Terra da Costa,1 Isadora Luana Flores,2 Fernanda Al-Alam,3 Manuela Souza e Silva,3 Priscila Martins,1

Thalita Goulart,3 Diana Tremea,4 Maria Laura Menezes Bonow1

IntroductionThe mixed dentition (MD) is a dynamic phase subject to disturbances in its normal

development, its analysis being an important aspect for orthodontic diagnosis andtreatment planning.1 The main perturbation in MD is the early loss of deciduous teethleading to a decrease in arch perimeter and in space for the correct alignment of thepermanent teeth, causing malocclusion.1 In orthodontic evaluation, the models of dentalrecords are a main source of information as they allow a thorough assessment,complementary to the clinical examination.2 The plaster models are used to determinethe relationship between the amount of available space in the dental arch (leewayspace) and the amount of required space for the proper alignment of all permanentteeth.2,3

The bow divider (BD) and brass wire (BW) are recommended methods to analyzethe leeway space through plaster models in MD.3 This space is determined by theavailable value in millimeters for the eruption of permanent teeth which are mesiallypositioned to the first permanent molars.3 The BD method evaluates the dental archdividing the model in segments and the BW assesses the entire arch of the mesial molarto the other side.9 Due to the technical variability of both methods, the importance ofevaluating an accurate, more practical and simpler measurement method is essential.This effort can minimize the errors as well as the distortion of the results, and does notcompromise the diagnosis, the treatment plan, and consequently the prognosis. Theobjective of this study was to compare two measurement tools, BW and BD, used todetermine the leeway space in MD, and to verify whether the two methods areequivalent, and which is performed with greater accuracy by dentistry undergraduatestudents.

C L I N I C A L

1 DDS, MSc, PhD1 Department of Social andPreventive Dentistry, PelotasDental School, Federal Universityof Pelotas, Brazil2 DDS, MSc, PhD. Semiologyand Oral Pathology area, DentalSchool, Federal University of Juizde Fora, Brazil3 DDS 3 Manuela Souza e Silva, DDS, MSc3 Private dental clinic 4 Diana Tremea Undergraduate Student. PelotasDental School, Federal Universityof Pelotas, BrazilCorresponding Author:Dr Isadora Luana FloresFaculdade de Odontologia,Universidade Federal de Juiz deFora – UFJF. Campus GovernadorValadares, Avenida DoutorRaimundo Monteiro de Rezende,330 – Centro, CEP 35010-173Governador Valadares – MG -Brazil. Tel.: +55 33 3340-0430E-mail: [email protected]

AbstractBackground: The mixed dentition (MD) phase is dynamic and prone to disturbances in its normal development that mightresult in a decrease of the perimeter of the dental arch. None of the analyses of MD is sufficiently accurate, especially forundergraduate students. Objective: The objective of this study was to compare two measuring instruments used to determinethe leeway space: brass wire (BW) and bow divider (BD), to verify whether the two methods are equivalent or whetherone is more accurate for undergraduate students. Methods and Materials: Five undergraduate students from the DentalSchool, Federal University of Pelotas, and an orthodontist expert (the gold-standard) performed the measurement of leewayspace using BW and BD on the inferior dental arch in thirty-five plaster models. A Bland-Altman and paired Student t testwere used for statistical analysis. Results: Both methods showed statistical agreement. No significant statistical differencewas obtained in the measurements of the BD method between the gold-standard and the students measurements. However,there was a difference between the gold standard measurements and two students' measurements using the BW method.Discussion: The results show the high practicality and simplicity of the BD method. Conclusions: Both methods areequivalent when used by trained professionals, but the BD method is more accurate for undergraduate students. Clinicalsignificance: The selection of a easily and reliable method for orthodontic measurements by beginner professionals.

Keywords: brass wire, bow divider, leeway space, measurements, mixed dentition

Short Title: Bow divider is a method for undergraduate students



C L I N I C A L

leeway space.Two separate measurements of the thirty-five plaster models

were taken by the gold standard, and the average of eachwas calculated using both methods. These averagesconstituted the standard values which allowed thecomparison between the two methods for the gold-standardthemselves, as well as the comparison between the goldstandard (professor of orthodontics) and other examiners(undergraduate students), in both methods. The gold-standardmeans were subjected to Bland-Altman statistical analysis toassess the agreement between the two methods, BW andBD. Using the paired Student’s t-Test, the comparison of themeans of the measurements between the gold standard andthe undergraduate students was analyzed. A significancelevel of 0.05 was considered for both statistical tests.

Results The measurements for the two methods obtained by the goldstandard and the five examiners are shown in Table 1. Theaverage values of the gold-standard for the BW and BD areshown in Table 2. No statistical difference was observedbetween the two methods for the gold-standard measurements(p=0.82). Moreover, a correlation of 99.4% was foundbetween the two methods, with a mean difference of 0.17 mm( Chart 1 and 2).No significant statistical difference was found between the

measurements for the BD method between the gold-standardand undergraduate students. Nevertheless, with regard tothe BW method, statistically significant differences werefound between the specialist and two undergraduateexaminers: C (value p = 0.0389) and D (value p =

Materials and methodsThis study was carried out at the Dental School of the FederalUniversity of Pelotas, Pelotas, Rio Grande do Sul, Brazil. Fiveundergraduate students and a professor of orthodonticsperformed two techniques of measuring the leeway spaceand the available space of the lower dental arch in plastermodels. The methods used were BW and BD. Thirty-fiveplaster models of the lower dental arch of patients in the MDphase were selected from the archives of the orthodonticclinic of the Pelotas Dental School with no additionalinformation. The models were identified by numbers from 01to 35; the examiners were identified by capital letters: A, B,C, D, E, and gold-standard. All examiners were supervised by the gold standard to

perform the research. The dental arch was measured toevaluate the leeway space with the BW (0.027” inchdiameter, Morelli) passing over the buccal cusps and incisoredges of the lower teeth from the mesial surface of the firstpermanent molar on one side to the mesial surface of the firstpermanent molar on the opposite side. The wire was bentand measured with a millimeter ruler. The values obtainedwere recorded on an annotation card. To evaluate theleeway space with the BD, the plaster model was dividedinto six sections: from the mesial contact point of the firstpermanent molar to the mesial of the first deciduous molar;from the mesial contact point of the first deciduous molar tothe distal contact point of lateral incisor, and from the distalcontact point of lateral incisor to the contact point betweencentral incisors. The same areas were completed on theopposite side. All measurements were transferred to theannotation card and the sum of the values indicated the

Chart 1 - Bland-Altman plot of concordance analysis of measurements obtained by thegold standard. Mean difference: 0.17mm (p value = 0.0004¬).


D A C O S T A E T A L


Model

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

Measurementmethod

Bow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wireBow dividerBrass wire

Table 1 – Measurements obtained by the examiners in thirty-five plaster models.

74.0 74.0 73.5 74.0 68.0 68.0 71.5 71.0 70.5 71.0 72.0 72.0 71.0 71.0 70.5 71.0 76.0 76.0 68.0 68.5 72.0 72.0 71.5 72.0 77.0 77.0 71.0 71.0 76.0 76.0 70.0 71.0 76.0 76.0 66.0 66.5 72.0 72.0 71.0 71.5 73.5 73.0 74.5 74.5 79.0 79.0 70.0 70.0 71.0 71.5 76.0 76.0 69.0 69.5 66.567.571.0 72.068.569.071.071.069.068.571.072.071.0 72.0 65.066.0

74.0 74.0 74.0 74.0 68.0 68.0 71.5 71.5 70.5 70.5 72.0 72.0 71.0 71.0 71.0 70.5 76.0 76.0 68.5 69.0 72.0 72.0 72.0 72.5 77.0 77.0 71.0 71.0 76.0 76.0 70.0 70.0 76.0 76.0 66.5 66.5 72.0 72.5 71.0 71.0 74.0 73.5 75.0 75.0 79.0 79.0 70.0 70.0 71.0 72.0 76.0 76.0 69.0 69.0 67.0 67.0 71.0 71.0 69.0 69.0 71.0 71.0 69.0 69.0 71.0 71.0 71.0 71.5 65.0 65.5

73.0 74.5 73.0 72.0 69.0 65.0 70.0 70.5 70.0 71.5 71.0 72.0 71.0 73.0 70.0 72.0 75.5 75.0 68.0 70.0 72.0 72.0 69.5 71.5 75.0 73.0 72.5 72.0 74.0 72.0 68.5 69.5 72.0 75.0 66.0 68.5 72.0 72.0 73.0 72.0 73.0 76.0 73.0 75.0 77.0 77.0 69.0 70.0 69.0 71.0 75.0 76.0 68.0 73.0 65.5 66.0 70.0 74.0 68.5 69.0 70.0 71.0 69.0 69.0 70.0 74.0 68.5 68.0 66.0 65.0

74.0 74.0 74.0 75.0 67.0 67.0 74.0 75.0 71.0 71.5 72.0 72.0 69.0 72.0 69.5 72.0 77.5 77.0 68.5 70.0 72.0 73.0 71.0 71.0 76.0 76.0 72.0 72.0 76.0 77.0 69.0 70.0 77.0 77.0 67.0 66.0 72.5 72.0 71.0 72.0 78.0 78.0 74.0 75.0 73.0 79.0 70.5 71.0 71.0 70.0 76.0 75.0 69.0 69.0 68.5 65.0 70.0 70.0 69.0 68.0 70.0 71.0 69.0 70.0 69.0 72.0 66.5 66.0 65.0 65.0

74.0 72.0 72.0 71.0 69.0 67.0 71.0 69.5 72.5 70.0 71.5 70.0 70.5 72.0 69.5 71.0 71.0 73.0 69.0 69.0 71.0 71.0 71.5 70.0 75.0 74.0 71.0 71.0 75.0 74.5 69.0 67.0 75.0 75.0 67.0 66.0 72.0 71.0 70.0 68.0 75.0 74.0 73.0 73.0 77.0 77.0 69.0 68.5 68.5 68.0 76.0 73.0 69.0 70.0 66.0 64.0 69.5 72.0 70.0 67.0 69.0 70.0 69.0 68.0 69.5 70.5 67.0 67.0 67.0 65.0

74.0 72.0 73.0 70.0 71.5 68.0 68.0 69.0 70.0 69.0 71.0 69.5 70.0 71.0 71.0 68.0 74.0 73.0 68.0 67.0 72.0 70.0 70.0 69.0 73.0 73.5 72.0 69.5 75.0 72.0 69.0 68.0 72.0 73.0 66.0 64.0 73.0 70.0 71.0 68.0 73.5 73.0 74.0 73.0 78.0 76.0 67.5 68.0 69.0 68.5 74.0 74.0 67.5 68.5 66.0 65.0 69.0 70.0 68.0 66.0 70.0 70.0 69.0 68.5 69.0 71.0 66.0 67.0 65.0 63.0

73.0 75.0 72.0 72.0 67.0 67.0 70.0 70.0 70.0 72.0 70.5 71.0 70.0 79.0 69.0 72.0 75.5 74.5 69.0 69.0 71.5 71.0 69.0 70.0 75.0 73.5 70.0 72.0 75.0 73.0 69.0 69.5 74.0 75.0 65.0 65.5 71.0 71.5 71.0 70.5 72.0 70.0 72.0 74.0 76.5 80.0 69.5 69.5 68.0 69.0 76.0 76.0 69.0 69.0 65.0 64.5 70.0 72.0 67.5 66.0 70.0 70.0 69.0 68.0 71.0 73.0 68.0 68.0 63.0 65.5

Gold Standard2nd measurement

Examiner A

Examiner B

Examiner C

Examiner D

Examiner E

Gold Standard1st measurement





0.0027). Table 3 shows the measurements of the fiveexaminers compared with the gold standard for bothmethods.

DiscussionThe diagnosis of perturbations in the MD is essential due to itstransient and preceding role of MD before the permanentdentition characterized by occlusion maturation.2 Diverse eventsoccur at this time, therefore prevention and interception of futuremalocclusions may be decisive. For this, it is possible to predictthe course of the development of the occlusion by using specificmethods for the analysis of MD since two or three millimetersof the real discrepancy may compromise the treatment plan.2

Based on the importance of choosing an accurate method ofmeasuring the difference between the leeway space in thedental arches and the space required for permanent teetheruption, different methods have been described in theliterature.2,3,4 Nevertheless, there is no consensus about whichis the most appropriate method; which one presents minimumsystematic error; and whether both can be performed withequal safety by the novice and the specialist.5,6,7 Furthermore,no article in the English literature has previously compared thesemethods.In the present study, the analysis of BW and BD, the most

used daily tools in the undergraduate clinic, revealed nostatistically significant difference between the two methods forthe specialist. The difference between the two methods was0.17mm which has no clinical relevance in relation toefficiency between the both methods. Thus, this concordancemay be attributed to the experience and skill of the orthodontist,due to high training and frequent use of these tools.However, the measurements from the BW method revealed

a statistically significant difference between twoundergraduate students in relation to the standard examiner.inexperience of the students in handling the brass wirecorrectly to get around the dental arch. Although the BW hasbeen considered by some authors as the most efficient andreliable method of measurement,5 there are differencesbetween the methods with regard to the ease of execution,an aspect that was evident in the present study. On the otherhand, the measurements with BD did not show a statisticallysignificant difference between the specialist and the students.These results are in concordance with the findings obtainedby other authors, indicating the high practicality andsimplicity of this method.7 Thus, the most convenient methodof learning the orthodontic process in the dental school mightbe the BD, due to easier handling by beginners.

No

1234567891011121314151617181920212223242526272829303132333435

Bow Divider

7473.75

6871.570.57271

70.7576

68.2572

71.757771767076

66.257271

73.7574.75

7970717669

66.7571

68.757169717165

Table 2 - Average of measures obtained by GoldStandard (real difference in millimeters). T-Student test(p = 0.82).

Brass Wire

747468

71.2570.75

7271

70.7576

68.7572

72.25777176

70.576

66.572.2571.2573.2574.75

7970

71.7576

69.2567.2571.56971

68.7571.5

71.7565.75

Difference

0-0.25

00.25-0.25

0000

-0.50

-0.5000

-0.50

-0.25-0.25-0.250.5000

-0.750

-0.25-0.5-0.5

-0.250

0.25-0.5

-0.75-0.75

Examiner

ABCDE

Bow Divider (p)

0.2440

0.7907

0.3224

0.1573

0.1067

Table 3 - Unpaired t-test difference of means of thegold standard and the examiners for bow divider andbrass wire methods.

Brass Wire (p)

0.8501

0.8946

0.0389

0.0027

0.3821





ConclusionAlthough previous studies on topic are scarce in the EnglishLiterature, we considered that using the BD method ofmeasuremnet is more accurate than the BW forundergraduate dental students. Thus, this method isrecommended for less trained professionals in order tominimize errors in performing space measurement inorthodontics. However, it should be emphasized that bothmethods are equivalent to evaluate the leeway space throughthe plaster models of patients in the MD when performed bytrained professionals.

Conflicts of interestThe authors declare no conflicts of interest.

There are no funding sources that supported the currentwork.

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Hamdan AM. Mixed dentition analysis in a Jordanianpopulation. Angle Orthod 2008;78:670-675.

2. Leal RC, Tanque IN, Gouveia SAS, Carmadella EG.Análise de modelos: uma revisão da literatura. Rev ClinOrtod Dental Press 2006;5:64-76.3. Moyers RE. Handbook of Orthodontics. Chicago: Year

Book, 1998. 4. Morrees CFA, Chada JM. Avaliable space for the

incisors during dental development- A growth study basedon physiologic age. Angle Orthod 1965;35:12-22.4. Mucha JN, Bolognese AM. Análise de modelos em

ortodontia. Rev Bras Odont 1985; 42:28-44. 5. Nance HM. The limitations of orthodontic treatment. I

– Mixed dentition diagnosis and treatkiuoment. Am J OrthodOral Surg 1947;33:177-23. 5. Hoette F, Thomazinho A. Espaço presente do arco

dental: análise crítica e comparativa. Ortodontia1977;11:38-48. 6. Machado LA. Evaluation of two techniques to measure

the available space in the mandibular dental arch using themethod error. Rev Odonto Cienc 2012;27:228-32.7. Vianna V, Amaral MT. Estudo comparativo entre dois

métodos de medição do espaço presente no arco dentáriopara a dentição mista. Rev SOB 2002;4:34-38.

Chart 2 - Bland-Altman plot of concordance analysis. 99.4% of agreement.




Biological width in the periodontic-restorative interrelationship

Shiehfung Tay1 and Nicola Di Vitale2

Restorative dentistry is considered successful only if the restorations are accompaniedby surrounding healthy periodontium. It is widely known that restorative proceduresinteract with or are influenced by periodontal tissues, thus creating a bidirectionalrelationship that must exist in harmony.As dental practitioners, we come across clinical cases where the biologic width is

violated or abnormally distributed. This affects the aesthetic and also periodontal health,which then influences the success of the restoration and the longevity of the restoredtooth. Increased aesthetic awareness among patients demands that the treatment weprovide must also have an acceptable, if not optimal, long term result following thedelivery of the prosthesis or completion of the crown lengthening surgery. To understand how this has an impact on the restorative and surgical treatment

planning, one has to have a comprehensive understanding of the core knowledge ofthe periodontium – specifically the dento-gingival interface (Figure 1). This inevitablybrings us to biologic width.

Biologic width: definition and calculationThe term biologic width was introduced by D Walter Cohen in 1962, defining it as‘the dimension of the soft tissue which is attached to the portion of the tooth coronal tothe crest of alveolar bone’. Histologically, it includes the junctional epithelium andconnective tissue attachment and it is synonymous to the sub-crevicular compartmentdescribed by Maynard and Wilson (1981). This supracrestal soft tissue attachmentforms a seal, protecting the underlying alveolar bone from any insult originating fromthe oral environment.The concept and clinical importance of biologic width cannot be emphasised enough

particularly if crown lengthening surgery or any other restorative procedure is planned.Although most studies reported average measurements that do not necessary apply inevery case, they however do establish a guidance upon which clinical decisions aremade (Sanavi et al, 1998).One of the few ways of calculating biologic width is through transgingival probing

(Table 1). This method, which is also known as bone sounding, is carried out underlocal anaesthesia with the use of a periodontal probe. Measurement can be influencedby many factors such angulation of the probing, precision of the probing instrumentsand distortion of the tissues during probing (Fu et al, 2010). In a recent systematic review, the biologic width distribution of the general population

ranged from 2.15mm to 2.30mm, although this showed intra- and inter-variability(Schmidt et al, 2013). Factors influencing this variability included: the type of tooth,

C L I N I C A L

1 Dr Shiehfung TaySenior Clinical Teaching Fellowand Research Associate, UCLEastman Dental Institute,London, UK. Private Practice, London, UK

2 Dr Nicola Di VitaleSenior Clinical TeachingFellow, UCL Eastman DentalInstitute, London, UK. Private Practice, London, UK

Biologic width (x) = Transgingival probing (y) – Sulcular depth (z)

Table 1: Calculating the biologic width


C L I N I C A L


study employed transgingival probing. Thick periodontium, which is normally found in posterior

teeth, shows a higher biologic width and this validly explainsthe difference of the values between anterior and posteriorteeth. The same study by Ghahroudi and co-workersconfirmed this finding.

Biologic width violationBiologic width violation could be seen in fractures (Figure 2)or caries extending to gingival or subgingival margins,inappropriately-finished restorations (Figure 3) such asoverhangs and overcontoured crown margins, restorativematerials such as excess cement, and orthodontic devices. Any factor that encourages plaque accumulation (Lang et

al, 1983; Silness, 1970) or impedes cleaning leads tobiologic width violation through inflammatory response (Table2). Overhangs harbour microflora that is consistent with thoseobserved in chronic periodontitis (Lang et al, 1983) andgreater loss of attachment has been reported at sitescorresponding to the overhang (Chen et al, 1987). In this article, we will be focusing mainly on restorative

margin placement and gingival retraction procedure.

Margin placementMargin placement generally falls into three types: supra-, sub-and equi- or paragingival. Whenever possible, supragingivalor equigingival placement is advocated to favour the

site, presence of restoration and periodontal status (forexample, presence of periodontal disease).According to Armitage et al (1977), inflammation allows

probes to descend further into the sulcus and possiblypenetrate the junctional epithelium as well as the connectivetissue compartment. The biologic width dimension can beaffected by periodontal disease, in both treated or non-treated cases (Schmidt et al, 2013). A reduction of biologic width was observed in the

presence of inflammation (Al-Rasheed et al, 2005),attachment loss (Gargiulo et al, 1961; Novak et al, 2008)and increased probing depth (Novak et al, 2008). It is vitalthat all tissues are inflammation-free before embarking on therestorative procedures.

Anterior versus posterior biologic widthThe next question of interest is probably: ‘Is there is adifference in the biologic width between anterior andposterior teeth?’ The answer is a resounding yes. Vacek et al (1994) reported that the mean values were

1.75mm, 1.97mm and 2.08 for anterior, premolar andmolar teeth respectively. However, Ghahroudi et al (2014)reported the values to be 1.46mm for anterior teeth and1.63mm for posterior teeth. The differences between these studies were thought to be

attributed to the techniques used. For example, the formerstudy used histomorphologic measurements while the latter

Figure 1: Bucco-lingual histologic specimen of healthy periodontium showing thecomponents of dento-gingival junction. Reproduced with kind permission from Dr MJ Novak et al (2008).

Enamel

Base of gingival sulcus

Junctional epithelium

Connective tissueattachment

Alveolar crest

Biologic width


Nevins and Skurow (1984) emphasised in their article thata safe distance of greater than or equal to 3mm from thealveolar crest to the crown margin should be allowed whenthe sulcus depth is considered to be 1mm (Figure 4). It is impossible for clinicians to detect exactly where the

sulcular epithelium ends and the junctional epithelium beginsand therefore any subgingival margin should be consideredas a compromise as more often than not it breaches thebiologic width zone.Sometimes, subgingival placement cannot be avoided and

clinicians may need to extend the margin subgingivally toobtain more retention during the crown preparation ornegotiate beyond caries and fracture line. It is also notunusual for clinicians to hide the margin of restorationsubgingivally, hoping to achieve an optimal aesthetic result.This could create a paradoxical result when, after a periodof time, the crown margin becomes visible following gingival

maintenance of periodontal health. Apart from better workingand visual fields, supragingival margin placement also offersadditional benefit such as ensuring that the preparation willbe kept on enamel structure (Harish et al, 2015). The interdental gingiva, a unique area composed of the

facial and lingual papillae as well as the col, is alwaysthicker than the facial or oro-gingivae. It is paramount toavoid the mistake of extending tooth preparation on allsurfaces to one circumferential depth as this will inevitablyviolate the soft tissue attachment interproximally (Nevins andSkurow, 1984).A systematic review by Akhlagi (2008) investigated the effect

of crown margin position on periodontal tissue condition. It wasconfirmed that those reviewed studies were in agreement thatsubgingival placement of crown margin increases gingivalinflammation although the depth of the crown margin extendinginto the intracrevicular crevice was not frequently reported.

TAY / D I V I TA L E


Figure 3a: Violation of biologic width viasubgingival placement of crowns on upperand lower incisors. Spontaneous gingivalbleeding can be observed.

Figure 3b: Radiographic assessmentrevealed that the crown margins wereinappropriately finished and were too closeto the alveolar crest.

Figure 2: Disto-palatal fracture at UL2extending subgingivally, causing localisedgingival overgrowth as a response to theirritation.

Figure 5: Splinted crowns at UR2-UR1 andUL1-UL2 with subgingivally placed margin.These teeth showed not only severe chronicinflammation and loss of attachment butwere also inaccessible to cleaning.

Figure 4: Crown lengthening surgery at UR1to re-establish the 3mm distance from thealveolar crest to crown margin.





Orthodontic extrusion is another technique for gainingclinical crown height by the means of orthodontic forcederuption in combination with a gingival fiberotomy asdescribed by Pontoriero et al (1987). This could be a viablealternative when crown lengthening surgery is unsuitable orcontraindicated. Crown lengthening surgery in a multi-rooted tooth can be

challenging even if this is in a non-aesthetic area. In apreliminary radiographic study by Dibart et al (2003), thecritical distance from the crown margin to the furcation wasassessed using radiographic measurements. Whenevercrown lengthening surgery was carried out, it was found that38.5% of those teeth developed furcation lesions after fiveyears of crown cementation. Their results suggested that aminimum of 4mm from the crown margin to furcation is aprerequisite whenever crown lengthening surgery is carriedout. Excessive bone removal that could result in exposing thefurcation area is contraindicated.

Retraction cord placementOne of the many ways of capturing the details of thesubgingivally placed margin during impression is throughgingival retraction. Development in dental materials saw oldtechniques such as copper bands phased out and replacedby cords impregnated with either 4% L-epinephrine or 25%aluminium chloride, foam or epoxy materials compound andelastic materials. However, it must be remembered that the currently used

cord technique can still cause trauma, leaving irreversibledamage to the local soft tissues. Minimally invasiveprocedures that avoid trauma inflicted by the use of cordscan be achieved by gingival retraction paste or gels such asExpasyl, which is universally accepted and widely used(Malbaker, 2010). According to Bennani et al (2012), thepressure generated by Expasyl is minimal and significantlylower compared to the cord system. However, it is becauseof this reduced mechanical pressure that many clinicians feelthat it does not expose the margins adequately.Duration, as well as the technique and material, is

important and should not be overlooked. In 1990,Goodacre and his team found that there was a directrelationship between the time that the gingival retractor cordremains inside the sulcus and possible gingival recession.They proposed that the junctional epithelium, which seals offthe dento-gingival junction, was damaged during theprocedure. In a dog study, Buttendorf et al (2015) showedthat significant gingival recession was observed whenretraction cord was left in situ for more than three minutes.

recession due to the biologic width violation.Any subgingival placement, if unavoidable, should be

confined to 0.5mm to avoid disruption of the junctionalepithelium and connective tissue apparatus during therestorative procedures. Adverse effects (Figures 5 and 6) such as gingival

inflammation, loss of attachment and bone resorption werenoted when restoration margins were placed too close to thebone (Newcomb, 1974; Tal et al, 1989; Gunay et al, 2000).Numerous studies have confirmed the importance of

respecting the biologic width. When violation of this biologicwidth is detected, there is a need to re-establish this zone toensure a harmonious periodontic-restorative interrelationship. If there is a need to extend the restorative margin

subgingivally beyond what is acceptable, or when re-establishment of the biologic width is required, thenincreasing the clinical crown structure by either crownlengthening surgery or orthodontic extrusion should beconsidered. This is aimed at exposing more tooth structurebefore proceeding with the final restoration.According to the American Academy of Periodontology’s

Glossary of Periodontal Terms, crown lengthening is: ‘Asurgical procedure designed to increase the extent ofsupragingival tooth structure, primarily for restorativepurposes, by apically positioning the gingival margins withor without the removal of supporting bone’. Crown lengthening surgery is performed to fulfil aesthetic

or functional requirement (Hempton and Dominici, 2010),or in some cases, both. Indication for this procedure includes the need to negotiate

beyond the subgingival caries or fracture and increase theretention form of a tooth. It can also be used for delayedpassive eruption where there is an excess of gingival display.

Figure 6: Bone loss at the furcation entrance of LL6 as a result ofthe violation of the biologic width following amalgam restoration.



understand when it is possible to proceed with the finalimpression. Since the final restorative margin depends on theposition of the newly-created gingival margin, one needs towait for the tissues to mature and stabilise following the surgery. Although we routinely proceed to the final phase two

months after the surgery, studies have suggested that a longerwaiting period may be necessary – particularly in areaswhere aesthetics is a primary concern.Bragger et al (1992) studied the periodontal changes

during the healing phase after crown lengthening surgery.Although the majority of the patients showed stability at sixweeks to four months, 29% of the patients showed furtherrecession while 33% showed coronal displacement orgingival creeping attachment. Lanning et al (2003), Huynh (2007) and Shobha et al

(2010), in accordance to Bragger’s study, agreed that aminimum of six months after surgical crown lengthening isneeded for the tissue to stabilise further and the new biologicwidth to be re-established.

Conclusion In every restorative procedure, respecting the biologic widthor re-establishing the violated biologic width is a key factorin ensuring a predictable outcome. Any encroachment on the attachment apparatus can lead

Wound healing following crown lengthening surgeryThe outcome of clinical crown lengthening is achievedthrough surgically-induced recession. Predicting the finalposition of the new gingival margin can sometimes be elusive,as it can be influenced by the positioning of the flap duringthe surgery as well as the duration of the healing period.It is not uncommon to find that the new gingival margin

continues growing coronally in what is considered as‘creeping attachment’. This is also known as coronaldisplacement or rebound, and is found when the flap marginis positioned at the level of the osseous crest (Pontoreiro andCarnevale, 2001; Perez et al, 2007) during surgery. Thiswas more pronounced amongst those with a thick gingivalbiotype (Pontoreiro and Carnevale 2001).On the other hand, Deas et al (2004) noted that when the

flap margin is placed at a more coronal level of the newly-established osseous crest, less rebound of the supracrestal softtissue was observed. It is therefore important to avoid excessive soft tissue

resection but to allow primary closure during the flapadaption in this kind of surgery. Whenever an apicallyrepositioned flap is utilised, the biological width re-establishes itself at an apical level (Oakly et al, 1999).Another relevant aspect of the crown lengthening procedure

is the duration of wound healing. The clinician needs to



Table 2: Interaction of periodontium to the violation and correction of the biologic width.



therapy: a review. J Am Dent Assoc 141(6): 647-55Huynh G (2007). Surgical crown lengthening of the clinical crown: A

periodontal concept for reconstructive dentistry. J Periodontol 3: 193-201Lang NP, Kiel RA, Anderhalden K (1983). Clinical and microbiological

effects of subgingival restorations with overhanging or clinically perfectmargins. J Clin Periodontol 10: 563-578

Lanning SK, Waldrop TC, Gunsolley JC et al (2003). Surgical crownlengthening: evaluation of the biologic width. J Periodontol 74: 468-474

Malbaker AM (201). Gingival retraction—Techniques and materials:A review. Pak. Oral Dent J 30: 545–551

Maynard JG, Wilson RD (1979). Physiologic dimension of theperiodontium fundamental to successful restorative dentistry. J Periodontal50(4): 170-4

Nevins M, Skurow HM (1984). The intra-crevicular restorative margin,the biologic width, and the maintenance of the gingival margin. Int JPeriodontics Restorative Dent 4(3): 30-49

Newcomb GM (1974). The relationship between the location ofsubgingival crown margins and gingival inflammation. J Periodontol 45:151-4

Novak MJ, Albather HM, Close JM (2008). Redefining the biologicwidth in severe, generalized, chronic periodontitis: implications fortherapy. J Periodontol 79(10): 1864-9

Oakley E, Rhyu IC, Karatzas S, Gandini-Santiago L, Nevins M, CatonJ (1999). Formation of the biologic width following crown lengthening innonhuman primates. Int J Periodontics Restorative Dent 19(6): 529-541

Perez JR, Smuckler H, Nunn ME (2007). Clinical evaluation of thesupraosseous gingivae before and after crown lengthening. J Periodontol78(6): 1023-1030

Pontoriero R, Carnevale G (2001). Surgical crown lengthening: a 12-month clinical wound healing study. J Periodontol 72(7): 841-848Pontoriero R, Celenza F Jr, Ricci G, Carnevale G (1987). Rapid

extrusion with fiber resection: A combined orthodontic-periodontictreatment modality. Int J Periodontics Restorative Dent 7(5): 31-43

Rasouli Ghahroudi AA, Khorsand A, Yaghobee S, Haghighati F(2014). Is biologic width of anterior and posterior teeth similar? ActaMed Iran 52(9): 697-702

Sanavi F, Weisgold AS, Rose LF (1998). Biologic width and its relationto periodontal biotypes. J Esthet Dent 10(3): 157-63

Schmidt JC, Sahrmann P, Weiger R, Schmidlin PR, Walter C (2013).Biologic width dimensions- a systematic review. J Clin Periodontol 40(5):493-504

Shobha KS, Mahantesha, Seshan H, Mani R, Kranti K (2010). Clinicalevaluation of the biological width following surgical crown-lengtheningprocedure: A prospective study. J Ind Soc Periodontol 14(3): 160-167

Silness, J (1970). Periodontal conditions in patients treated with dentalbridges. 3. The relationship between the location of the crown marginand the periodontal condition. J Periodontal Res 5: 225-229

Tal H, Soldinger M, Dreiangel A, Pitaru S (1989). Periodontalresponse to long-term abuse of the gingival attachment by supracrestalamalgam restorations. J Clinical Periodontol 16: 654–659

Vacek J, Gher M, Assad D, Charles Richardson A, Giambarresi L(1994). The dimension of the human dentogingival junction. Int JPeriodontics Restorative Dent 14: 154-165

Reprinted with permission by Aesthetic Dentistry Today August 2016

to detrimental effects on the periodontium. Inflammation ofthe soft tissue leads to the loss of attachment and in somesusceptible individuals, this could potentially predispose themto periodontitis.As inter- and intravariability exists, the dimension of the

biologic width for each specific tooth and patient has to beassessed individually before any restorative procedure iscarried out. One must consider crown lengthening surgeryor orthodontic extrusion to correct the violated biologic widthand provide an acceptable biologic width that is compatiblewith periodontal health. If dimensions are found to beinsufficient, the most appropriate corrective procedure,whether surgical or orthodontic, can be undertaken forestablishment of sufficient width.

ReferencesAkhlaghi F. (2008). Effect of crown margin position on periodontal

tissue conditions. A systematic review and clinical interpretations (Masterdissertation). Retrieved from http://landalatandlakarna.se-/documents/Master%20studie.pdf

Al-Rasheed AA, Ghabban W, Zakour A (2005). Clinical biologicalwidth dimension around dentition of a selected Saudi population. PakOral & Dent J 25: 81-86

Armitage GC, Svanberg GK, Löe H (1977). Microscopic evaluationof clinical measurements of connective tissue attachment levels. J ClinPeriodontol 4(3): 173-90

Bennani V, Aarts JM, He LH (2012). A comparison of pressuregenerated by cordless gingival displacement techniques. J Prosthet Dent107(6): 388-92

Brägger U, Lauchenauer D, Lang NP (1992). Surgical lengthening ofthe clinical crown. J Clin Periodontol 19(1): 58-63

Buttendorf AR, Ferreira CF, Bianchini MA, Da Silva JE, Wicks RA(2015) Minimal Time for Gingival Retraction Cords to Achieve AccurateImpression: An In Vivo Study. J Dent Health Oral Disord Ther 1(3): 78

Deas DE, Moritz AJ, McDonnell HT, Powell CA, Mealey BL (2004).Osseous surgery for crown lengthening: a 6-month clinical study. JPeriodontol 75(9): 1288-1294

Dibart S, Capri D, Nunn ME, Van Dyke TE, Kachouh I (2003). Crownlengthening in mandibular molars. A 5 year retrospective radiographicanalysis. J Periodontol 74: 815-821

Fu JH, Yeh CY, Chan HL, Tatarakis N, Leong DJ, Wang HL (2010).Tissue biotype and its relation to the underlying bone morphology. JPeriodontol 81(4): 569-574

Gargiulo AW, Wentz FM, Orban B (1961). Dimensions and relationsof the dentogingival junction in humans. J Periodontol 32: 261-7

Goodacre CJ (1990). Gingival esthetics. J Prosthet Dent 64(1): 1-12Gunay H, Seeger A, Tschernitschek H, Geurtsen W (2000).

Placement of the preparation line and periodontal health--a prospective2-year clinical study. Int J Periodontics Restorative Dent 20: 171-81

Harish P, Joseph SA, Sirajuddin S, Gundapaneni V, Chungkham SA(2015). Iatrogenic Damage to the Periodontium Caused by FixedProsthodontic Treatment Procedures. The Open Dentistry Journal 9: 190-196

Hempton TJ, Dominici JT (2010). Contemporary crown-lengthening






Simplifying composite placement in theinterproximal zone

Douglas Terry1 and Mark Stankewitz2

IntroductionUnderstanding the importance of particle size and shape in the utilisation of newcomposite resin formulations with techniques to optimise the materials’ properties allowsthe clinician to attain predictable and pleasing aesthetic results.In the past, when utilising composite resin material to achieve a restorative result with

optimal physical and mechanical characteristics, it often required the use of acombination of hybrid and microfill. The hybrid provided the strength and sculptabilityand the microfill furnished the polish and durability of the restoration. Layering techniques were developed for use with smaller increments of composite

resin material to improve and optimise the depth of cure while reducing the effects ofshrinkage and stress forces during the polymerisation process (Tjan, Glancy, 1988;Kovarik, Ergle, 1993). Yet, when different restorative composites of varying refractiveindexes, shades and opacities were stratified, clinicians observed a ‘polychromaticeffect’ (Dietschi, 1995). However, by utilising an anatomic stratification with successivelayers of dentine, enamel and incisal composite, a more realistic depth of colour couldbe achieved, as well as surface and optical characteristics that mimic nature (Jefferies,1998; Donly, Browning, 1992).The improvements in the restorative quality and aesthetic result that have developed

from the inequities of these different composite resin systems (hybrid and microfill), inconjunction with the use of innovative placement techniques to optimise the materials’properties, have stimulated scientists, researchers, clinicians and manufacturers toexplore and develop new nanoparticle formulations of restorative biomaterials.Materials that are not only applied in relationship to the natural tissue anatomy, but thathave physical, mechanical, and optical properties similar to that of tooth structure.

NanotechnologyNanotechnology, or molecular manufacturing, may provide the crucial information fordetermining how to best utilise the composite materials (Kirk et al, 1991). Byunderstanding how the actual size and shape of filler materials influences themechanical and physical properties of the material, the potential for improved adhesionand the clinical success of the restoration is increased. Composite resin with filler particle size that is dramatically smaller in size can be

dissolved in higher concentrations and polymerised into the resin system with moleculesthat can be designed to be compatible when coupled with a polymer, and provideunique characteristics (physical, mechanical, and optical). In addition, optimising the adhesion of restorative biomaterials to the mineralised

hard tissues of the tooth is a decisive factor for enhancing the mechanical strength,marginal adaptation and seal, while improving the reliability and longevity of theadhesive restoration. Currently, the particle size of many of the conventional compositesare so dissimilar to the structural sizes of the hydroxyapatite crystal, dental tubule andenamel rod, that there is a potential for compromises in adhesion between the

C L I N I C A L

1 Douglas A. Terry, DDSClinical Assistant Professor,Department of Restorative Dentistryand Biomaterials, University ofTexas Health Science Center DentalBranch, Houston, Texas, USA.Private Practice, Houston, Texas,USA. E-mail: [email protected] [email protected]

2 Mark L. Stankewitz DDS, CDT



C L I N I C A L

comparable shrinkage stress to conventional composites(Baroudi, Silikas, Watts, 2008; Cadenaro et al, 2009;Gallo et al, 2010).According to the manufacturers, this next generation

flowable resin formulation is purported to offer mechanical,physical and aesthetic properties similar or greater thanmany conventional hybrid composites (Yamase et al, 2010).The clinical attributes of the material include improvedadaptation to the internal cavity wall with easier insertionand manipulation, increased wear resistance and enhancedpolishability and retention of polish. They also show greaterelasticity and colour stability as well as a radiopacity similarto enamel.

macroscopic (40nm to 0.7um) restorative material and thenanoscopic (1 to 10 nanometers in size) tooth structure(Muselmann, 2003). However, nanotechnology has thepotential to improve this continuity between the tooth structureand the nanosized filler particle and provide a more stableand natural interface between the mineralised hard tissuesof the tooth and these advanced restorative biomaterials. A nano-hybrid flowable composite resin system (G-aenial

Universal Flo, GC America) may possess these improvedphysical, mechanical and optical properties. Theseproperties and the clinical behaviour of this biomaterialformulation is contingent upon its structure. This resin fillertechnology allows a higher filler loading because of the finefiller size, uniform shape and distribution of particles. Thisresin filler chemistry allows the particles to be situated veryclosely to each other and the reduced interparticle spacingand homogeneous dispersion of the particles in the resinmatrix increases the reinforcement and protects the matrix(Bayne, Taylor, Heymann, 1992; Turssi, Ferracane, Vogel,2005; Lim et al, 2002). In addition, the proprietary chemical treatment of the filler

particles allows proper wettability of the filler surface by themonomer and thus an improved dispersion and a stable andstronger bond between the filler and resin. Research studiesclearly indicate the significance that filler content andcoupling agents represent in determining characteristics suchas strength and wear resistance (Lim et al, 2002; Venhovenet al, 1996; Condon, Ferracane, 1997; Beatty et al,1998). Recent studies report that flowable composites have

Figure 1

Figure 2a Figure 2b Figure 2c


T E R R Y / S TA N K E W I T Z


Simplifying the application technique Adhesive procedures require properly integrating multipleinterrelated steps during the restorative process, whichincreases the potential for error. Restorative complicationsand compromised clinical results can occur from improperplacement of these adhesive materials. Although notscientifically proven, logic dictates that reducing thepossibility of error by simplifying the application of materialsshould improve the restorative result and the quality of therestoration.

The following clinical presentation describes a simplifiedtechnique utilising a next generation nanoparticle flowablecomposite resin (G-aenial, GC America) to restore theinterproximal zone.

Restoring the interproximal zoneRestoring the interproximal zone with composite resinrestorations using conventional hybrid composites has alwayspresented challenges. Improper placement of these viscouscomposite materials can result in gaps, voids and deficient

Figure 3a Figure 3b Figure 4a

Figure 4b Figure 5a Figure 5b





marginal seal at the restorative interface. However, byutilising a modified self-etch technique and a simplifiedplacement of a next generation flowable an ideal tooth-restorative interface can be achieved. The patient presents with interproximal caries on the mesialaspect of the mandibular left lateral incisor (Figure 1). Afterradiographic evaluation (Figure 2a), a shade comparisonwas performed prior to the restorative procedure (Figures 2band 2c). The dehydration of the tooth from water moleculesbeing depleted from the enamel rods can result in impropershade matching. Once anaesthesia had been administered to the patient,

the tooth was isolated with a dental dam to protect againstcontamination, using a modified technique. The techniqueinvolved the creation of an elongated hole that allowedplacement of the dental dam over the retainers to achieveadequate field control and protect against contamination(Croll, 1985; Liebenberg, 1994). The caries was removedwith a #2 high-speed round bur (#2 round bur, BrasselerUSA), which produces rounded line angles (Figures 3a and3b). The outline form was as conservative as possible withoutremoving healthy tooth structure unless dictated by caries.The axial line angles may vary in pulpal depth with thethickness of the enamel portion of the external walls and the

axial wall will be outwardly convex, following the normalexternal tooth contour and the DEJ, both inciso-gingivally andfacio-lingually (Sturdevant, 2002). To allow for a better resin adaptation, all internal line

angles were rounded and cavity walls made smooth.Sufficient retention for composite is achieved primarily bymicromechanical adhesion to the surrounding enamel andunderlying dentine and it is not necessary to produce anundercut in the preparation (Sturdevant, 2002). Acircumferential bevel is placed in enamel using a tapereddiamond bur (Figures 4a and 4b). An enamel bevel isindicated because it increases the surface area for end-onetching of the enamel rods for an increased etched surface,resulting in a stronger enamel to resin bond, which increasesthe retention of the restoration and reduces marginal leakageand discolouration (Sturdevant, 2002; Oilo, Jorgenson,1977; Lorton, Brady, 1981). Also, placement of acavosurface bevel improves the aesthetic integration ofrestorative material with the colours of the surrounding toothstructure (Sturdevant, 2002; Oilo, Jorgenson, 1977; Lorton,Brady, 1981; Sturdevant, 1995). However, the cavosurface is not bevelled if little or no

enamel is present or access is difficult for finishingprocedures. A gingival bevel is not recommended if the

Figure 6a Figure 6b Figure 6c




Figure 7

Figure 8a Figure 8b Figure 8c Figure 8d Figure 8e

preparation extends gingivally on to root structure or is ofpoor enamel quality. In addition, bevels are not placed onlingual surface margins that are in areas of centric contactor subjected to heavy occlusal forces, because compositehas a lower wear resistance than enamel for withstandingheavy occlusal forces (Sturdevant, 2002). Thus, bevellingshould be performed on class III preparations when there isadequate enamel present because it increases the potentialfor bonding, however it should not be placed on margins inthe occlusal contact zone. Bevelling increases the fracture resistance by increasing

the bulk of the restoration, increases the bonding surfacearea, and decreases microleakage and marginaldiscolouration (Welk, Laswell, 1976) by exposing theenamel rods for etching (Lorton, Brady, 1981; Craig,2001). The preparation was cleaned with a 2%chlorhexidine solution (Consepsis, Ultradent, South Jordan,UT), rinsed and lightly air-dried. A dead metal matrix was placed and secured in the

interproximal zone and a selective enamel etch procedure wasperformed. The prepared and unprepared enamel was etchedwith a 37.5% phosphoric acid gel (GEL Etchant, Kerr/Sybron,Orange, CA) for 15 seconds and rinsed for five seconds(Figures 5a and 5b). A self-etch adhesive (G-aenial Bond, GCAmerica) was placed on the enamel and dentine surfaces withan applicator tip for 10 seconds, air-dried for five secondsusing an A-dec warm air tooth dryer and light-cured for 10seconds (Figures 6a, 6b, 6c). The dead metal matrix wasreplaced with a mylar plastic strip in the interproximal zone toconfine and adapt the composite material to the tooth surface.The mylar strip produces a smooth surface (Chung, 1994)while maintaining the anatomical contour during thepolymerisation process (Figure 7). A bleach shaded flowable composite material (G-eanial

Universal Flo, GC America) was injected into the preparationand the syringe tip was slowly removed while extruding thematerial. The mylar strip was firmly adapted to an idealcontour and light cured for 40 seconds using a ramp mode(Figures 8a-8e). The material is thixotrophic; this property allows the

material to structurally breakdown so it flows through thesyringe tip when the material is stressed, then the hydrogenbonding restructures and it becomes more viscous (Craig,2001). Uno and Asmusen (1991) suggest that using aslower polymerisation causes an improved flow of moleculesin the material while decreasing the polymerisation shrinkagestress in the restoration. The mylar strip was removed and the interproximal region

was inspected for any residual composite resin tags oroverhangs. The excess residual resin was removed with asurgical blade (#12 BD Bard-Parker, BD Medical) (Figure 9).The proximal surfaces were cleaned and smoothed with aloose abrasive diamond polishing paste, which was carriedinto the interproximal region with finishing strips (Figures 10a,




Figure 9 Figure 10a Figure 10b

Figure 10c Figure 11

10b, 10c). The proximal surface was inspected foradequate contact with unwaxed floss prior to removing thedental dam (Figure 11). After the dam was removed, a definitive lustre and surface

reflectivity was accomplished with a goat-hair wheel anddiamond polishing paste using an intermittent staccato motion(Figure 12). This restorative procedure demonstrates theoptimal aesthetic results that can be achieved in theinterproximal zone through proper adhesive protocol and asimplified application of flowable composite resin (Figure 13).

ConclusionThe continual development of new technology changes and,hopefully, improves, the practice of dentistry. Understandingthe importance of particle size and shape in the utilisation ofnew composite resin formulations with techniques to optimisethe materials’ properties allows the clinician to attainpredictable and pleasing aesthetic results. Although the long-term benefits of this material remain to be determined, theutilisation of an optimised nanoparticle flowable compositein the aforementioned patient demonstrated enhanced





Figure 12 Figure 13

sculptability, the polishability of a microfill, the strength of ahybrid, and the ability to simulate the optical properties ofthe natural tooth. Through continued advancement in clinicaland material research, refinements in formulations willcontinue to improve.

References1. Tjan AH. Glancy JF. Effects of four lubricants used during

incremental insertion of two types of visible light-activated composites.JProsthet Dent 1988;60(2):189-194.

2. Kovarik RE, Ergle JW. Fracture toughness of posterior compositeresins fabricated by incremental layering. J Prosthet Dent1993;69(6):557-560.

3. Dietschi, D. Free-hand composite resin restorations: a key toanterior aesthetics. Pract Periodontics Aesthet Dent 1995;7(7):15-25.

4. Jefferies SR. The art and science of abrasive finishing andpolishing in restorative dentistry. Dent Clin North Am1998;32(4):613-627.

5. Donly, KJ and Browning, R, “Class IV preparation design formicrofilled and macrofilled composite resin”, Pediatric Dentistry,January/February, 1992, 14:1; 34-36.

6. Kirk RE, Othmer DF, Kroschwitz J, Howe-Grant . Encyclopediaof Chemical technology. 4th ed. New York Wiley;1991:397.

7. Muselmann M. Composites make large difference in “small”medical, dental applications, Comp Tech; December 2003:24-27.

8. Bayne SC, Taylor DF, Heymann HO. Protection hypothesis forcomposite wear. Dent Mater 1992;8(5):305-9.

9. Turssi CP, Ferracane JL, Vogel K. Filler features and their effectson wear and degree of conversion of particulate dental resincomposites. Biomater 2005;4932-7.

10. Lim BS, Ferracane JL, Condon JR, Adey JD. Effect of filler fractionand filler surface treatment on wear of microfilled composites. DentMater 2002;18:1-11.

11. Venhoven BMA, de Gee Aj, Werner A, et al. Influence of fillerparameters on the mechanical coherence of dental restorative resincomposites. Biomater 1996;17(7):735-40.

12. Condon JR, Ferracane JL. In vitro wear of composite with variedcure, filler level, and filler treatment. J Dent Res 1997;76:1405-11.

13. Condon JR, Ferracane JL. Factors effecting dental compositewear in vitro. J Biomed Mater Res 1997;38:303-13.

14. Beatty MW, Swartz ML, Moore BK, et al. Effect of microfillerfraction and silane treatment on resin composite properties. J BiomedMater Res 1998;40:12-23.

15. Baroudi K, Silikas N, Watts DC. Edge -strength of flowableresin-composites. J Dent 2008; 36:63-8.

16. Cadenaro M, Marchesi G, Antoniolli F, et al. Flowability ofcomposites is no guarantee for contraction stress reduction. Dent Mater2009;25:649-54.

17. Gallo JR, Burgess JO, Ripps AH, et al. Three-year clinicalevaluation of two flowable composites. Quintessence Int2010;41:497-503.

18. Yamase M, Maseki T, Nitta T, et al. Mechanical properties ofvarious latest resin composite restoratives. J Dent Res 89(Spec IssA):abstract 464, 2010.

19. Croll TP. Alternative methods for use of the rubber dam. QuintInt 1985; 16:387-392.)

20. Liebenberg WH. General field isolation and the cementationof indirect restorations: Part 1. J Dent Assoc of South Afr 1994; 49(7):349-353.

21. Sturdevant CM. Class III, IV and V Direct Composite and othertooth-colored restorations. 4th St. Louis, MI: Mosby, In: The art andscience of operative dentistry, pp. 2002:490,491, 503-536.

22. Oilo G, Jorgenson KD. Effect of beveling on the occurrencesof fractures in enamel surrounding composite resin fillings. J Oral Rehab1977; 4: 305.

23. Lorton L, Brady J. Criteria for successful composite resinrestorations. Gen Dent 1981; 29(3): 234-236.

24. Sturdevant CM Dental Materials ed. 3rd In: The art and scienceof operative dentistry. St. Louis, MI: Mosby, 1995: 262.

25. Welk DA, Laswell HR. Rationale for designing cavitypreparations in light of current knowledge and technology. Dent ClinNorth AM 1976; 20(2): 231.

26. Craig RG. Restorative dental materials. ed 11. St. Louis, MI:Mosby, 2001.

27. Chung K. Effects of finishing and polishing procedures on thesurface texture of resin composites. Dent Mater 1994; 10: 325-330.

28. Uno S, Asmussen E. Marginal adaptation of a restorative resinpolymerized at reduced rate. Scand J Dent Res 1991;99(5): 440-445.




Pulp revascularisation in a traumatised andnecrotic tooth

Ricardo Machado,1 Gustavo Almeida,2 Thâmara Silva Santos,3 Brunna Presmini Barbosa,4

Guilherme Augusto Moreira5 and Alberto Porto Junior6

The greatest difficulties in carrying out root canal treatments in teeth with pulp necrosisand incomplete root formation lie in the limited efficiency of transoperative cleaningand in the great possibility of overfilling. This is mainly due to the divergence in theroot canal walls and lack of apical constriction (Thomson, Kahler, 2010; Forghani,Parisay, Maghsoudlou, 2013).

Successive changes of intracanal dressings using calcium hydroxide pastes areperformed to reduce the difficulties imposed by treating teeth with pulp necrosis andincomplete root formation, by boosting disinfection and inducing apexification (Silveiraet al, 2015). However, the major disadvantage of this therapeutic strategy is that theprocedure implies a long treatment period; hence, there is a real possibility of fractureand reinfection (Cvek, 1992; Andreasen, Farik, Munksgaard, 2002; Rosemberg,Murray, Namerow, 2007; Hawkins, Torabinejad, Retamozo, 2015; Valera et al,2015).

Mineral trioxide aggregate has been suggested as an alternative, to eliminate longtreatment periods (Pradhan et al, 2006; Raju, Yadav, Kumar, 2014; Badole et al,2015). However, both calcium hydroxide pastes and mineral trioxide aggregate arenormally used only to induce apexification. Neither is able to effectively induce rootformation and termination of dentine deposition on the side walls of the root canal(Valera et al, 2015; Pradhan et al, 2006; Raju, Yadav, Kumar, 2014; Badole et al,2015; Bose, Nummikoski, Hargreaves, 2009). Consequently, there has been a steadysearch for new alternatives.

Pulp revascularisation is a process by which the root canals of necrotic teeth withincomplete root formation are mostly disinfected using copious irrigation with anantibacterial solution and application of a combination of antibiotics, such asciprofloxacin, metronidazole, minocycline, and amoxicillin (Hoshino et al, 1996; Satoet al, 1996; Kahler et al, 2014), or calcium hydroxide pastes (Soares Ade et al, 2013;Nagata et al, 2014). In another visit, intracanal bleeding is stimulated to produce ablood clot to act as a matrix for the restoration of the vascular nerve bundle. Cervicalsealing is then performed (Iwaya, Ikawa, Kubota, 2001; Banchs, Trope, 2004; Chueh,Huang, 2006; Lovelave et al, 2011).

This article presents a case where pulp revascularisation was opted for instead ofinducing apexification, after a trauma in the upper right lateral incisor. The 12-monthfollow-up evidences the success of the treatment performed.

C L I N I C A L

1 Ricardo Machado is professorof multidisciplinary clinic I andII (endodontics) and supervisedstage in multidisciplinary clinicI (endodontics) at the School ofDentistry, ParanaenseUniversity – UNIPAR, FranciscoBeltrão, Paraná, Brazil.2 Gustavo Almeida is professorof endodontics at the BrazilianDental Association – ABO,Ilhéus, Bahia, Brazil.3 Thâmara Silva Santos isspecialist in endodontics at theBrazilian Dental Association –ABO, Ilhéus, Bahia, Brazil.4 Brunna Presmini Barbosa isan undergraduate student atthe School of Dentistry,Paranaense University –UNIPAR, Francisco Beltrão,Paraná, Brazil.5 Guilherme Augusto Moreira isan undergraduate student atthe School of Dentistry,Paranaense University –UNIPAR, Francisco Beltrão,Paraná, Brazil.6 Alberto Porto Junior isprofessor of endodontics at theBrazilian Dental Association –ABO, Ilhéus, Bahia, Brazil.



C L I N I C A L

In the second appointment, endodontic access wasperformed after anaesthesia (2% lidocaine and epinephrine1:80.000) and placement of the rubber dam, using1016HL and 3083 drills (Dentsply Maillefer). Only onecanal orifice was located. The working length wasdetermined by means of an electronic foramen locator(Elements Apex Locator, Sybronendo) and instrumentationwas performed according to the crown down technique,using K-files from the third series (Dentsply Maillefer). Irrigationwas performed using 2% chlorhexidine gel and 2.5ml ofsaline solution (Fórmula & Ação) at each change of files.Then, antibiotic paste consisting of ciprofloxacin (200mg)and metronidazole (500mg) was placed. A microhybridcomposite resin (Z100, 3M Espe) was used as a temporarysealing material.

Twenty-nine days later, after anaesthesia (2% lidocaine andepinephrine 1:80.000) and placement of the rubber dam,the microhybrid composite resin used as a temporary sealingmaterial and the antibiotic paste were removed with a1016HL drill (Dentsply Maillefer) and profuse irrigation wasperformed with saline solution and 2% chlorhexidine gel(Fórmula & Ação), respectively. The canal was dried withpaper points (Tanari) and bleeding was stimulated with a 30k-file (Dentsply Maillefer), eventually stabilising the clot at 3mmbelow the cementoenamel junction. Mineral trioxideaggregate (Angelus) was used as cervical barrier. A glassionomer cement (Ketac-Fil, 3M Espe) was used as a temporaryrestorative material (Figure 1b). The patient was then referredback to his clinician to perform the definitive restoration.

After a five-month follow-up, mobility and response topalpation and percussion tests were normal. Stabilisation ofthe periradicular disease was confirmed (Figure 1c), and thepatient no longer showed any symptoms. However, thetreated tooth still showed no sensitivity to thermal tests. After12 months, a radiographic exam showed a considerablethickening of the root side walls, completion of the rootformation and total healing of the periradicular disease. Aconsiderable absorption of mineral trioxide aggregate wasalso observed, suggesting the occupation of root canalspace by pulp tissue and dentine deposition (Figure 1d). Thetooth responded normally to cold sensitivity tests, indicatingthe success of the treatment performed.

Discussion Until recently, apexification has been the only alternative tomaintain teeth with pulp necrosis and incomplete rootformation. However, the major drawback of this therapeuticstrategy is that the procedure requires a long treatment periodwith successive changes of dressings of calcium hydroxidepastes; hence, there is a real possibility of fracture andreinfection (Cvek, 1992; Andreasen, Farik, Munksgaard,2002; Rosemberg, Murray, Namerow, 2007; Hawkins,Toabinejad, Retamozo, 2015; Valera et al, 2015). For this

Case report A 10-year-old male patient was seen at the EndodonticsSpecialization Course of the Brazilian Dental Association,Brazil, accompanied by his caregiver. The patient reportedthat he had suffered a dental injury in the anterior maxillaryregion about two years prior, but had only begun to feelpain, swelling and fistula in the region a few weeks beforethe visit. No relevant systemic diseases were reported. Theclinical examination included palpation exams, tooth mobilityanalysis, cold thermal tests (Endo Ice, Hygenic, Akron) andperiodontal probing in the incisors and canines of the region.All of these examinations and tests were within normal limits,except for the upper right lateral incisor, which did notrespond to thermal tests and showed grade II mobility.

Radiographic examination revealed the presence of apicalperiodontitis in the upper right lateral incisor, as well asincomplete root formation (Figure 1a). The diagnosis ofchronic periapical abscess was made by associating theinformation obtained from the clinical and radiographicexaminations.

In the first appointment, it was decided that only semi-rigidsplinting would be performed to stabilise dental mobility.Patient contact was lost, and the splinting was removed onlytwo months later.

Figure 1a: Initial radiograph. Figure 1b: MTA used as cervical barrier and GICused as a temporary restorative material.

Figure 1c: Five-month follow-up. Figure 1d: One-year follow-up


M A C H A D O E T A L


completion of the root formation in the case presented, incomparison with the cases mentioned above.

The case presented in this article confirms that pulprevascularisation is a viable alternative for the treatment ofteeth with pulp necrosis and incomplete root formation.However, considering the principles guiding evidence-baseddentistry, more longitudinal clinical studies, especially of aprospective nature, are needed to prove its effectiveness.

ConclusionsThe purpose of this article was to report a pulprevascularisation success story in a tooth with pulp necrosisand incomplete root formation. This procedure appears tobe a promising alternative to deal with this clinical situation.However, more research is needed to prove its effectiveness.

References Andreasen JO, Farik B, Munksgaard EC (2002) Long-term

calcium hydroxide as a root canal dressing may increase riskof root fracture. Dent Traumatol 18: 134-7

Badole GP, Warhadpande MM, Bahadure RN, Badole SG(2015) Nonsurgical endodontic treatment of permanentmaxillary incisors with immature apex and a large periapicallesion: a case report. Gen Dent 63: 58-60

Banchs F, Trope M (2004) Revascularization of immaturepermanent teeth with apical periodontitis: new treatmentprotocol? J Endod 30: 196-200

Bose R, Nummikoski P, Hargreaves K (2009) A retrospectiveevaluation of radiographic outcomes in immature teeth withnecrotic root canal systems treated with regenerative endodonticprocedures. J Endod 35: 1343-9

Chueh LH, Huang GTJ (2006) Immature teeth withperiradicular periodontitis or abscess undergoing apexogenesis:a paradigm shift. J Endod 32: 1205-8

Cooke A, Zaccone P, Raine T, Phillips JM, Dunne DW (2004)Infection and autoimmunity: are we winning the war, only to losethe peace? Trends Parasitol 20: 316-21

Cvek M (1992) Prognosis of luxated non-vital maxillaryincisors treated with calcium hydroxide and filled with gutta-percha: a retrospective clinical study. Endod Dent Traumat 8:45-55

Forghani M, Parisay I, Maghsoudlou A (2013) Apexogenesisand revascularization treatment procedures for two traumatizedimmature permanent maxillary incisors: a case report. RestorDent Endod 38: 178-91

Gomes-Filho JE, Aurélio KJ, Costa MM, Bernabé PF (2008)Comparison of the biocompatibility of different root canal

reason, mineral trioxide aggregate was suggested as analternative to eliminate long treatment periods (Pradhan et al,2006; Raju, Yadav, Kumar, 2014; Badole et al, 2015).However, neither treatment strategy is able to effectivelyinduce radicular dentine formation and dentine depositionon the side walls of the root canal (Bose, Nummikoski,Hargreaves, 2009).

The main objectives of pulp revascularisation are toreestablish the vascular nerve bundle and complete the rootformation process (Forghani, Parisay, Maghsoudlou, 2013;Saoud et al, 2014). Consequently, the respective clinicalactions are considerably different from those of apexification.

In the present case, chlorhexidine was used as an auxiliarychemical solution, because of its lower toxicity, comparedwith sodium hypochlorite (Gomes-Filho et al, 2008),considering the real possibility of extravasation of theirrigation solutions during treatment, due to lack of apicalconstriction. Recently published research has also usedsimilar protocols (Soares Ade et al, 2013; Nagata et al,2014).

The use of calcium hydroxide (Soares Ade et al, 2013;Nagata et al, 2014) and/or antibiotic pastes (Hoshino etal, 1996; Sato et al, 1996; Kahler et al, 2014) for pulprevascularisation is critical in cases of necrotic teeth withincomplete root formation. These pastes are responsible forthe disinfection process, considering that conventionalcleaning and shaping cannot be performed, owing to theanatomic features of these teeth. However, previous studieshave demonstrated the incidence of severe colour changesafter using minocycline (Kahler et al, 2014). Therefore,ciprofloxacin and metronidazole were the medications ofchoice for the present case.

The absence of pain symptoms, the disappearance ofpossible fistula, the continuation of root development and therestoration of sensitivity to thermal change are the key successfactors associated with pulp revascularisation (Kahler et al,2014). All of these characteristics were confirmed in thecase presented here, highlighted by complete rootdevelopment after 12 months. Iwaya et al (2001) andBanchs and Trope (2004) reported clinical cases of pulprevascularisation, where complete apical closure occurredonly after 30 and 24 months, respectively. Studies in differentmedical fields have shown that individuals can responddifferently to similar interventions, and that these responsesare strongly influenced by their systemic and immuneconditions (Cooke et al, 2004; Kosalaraksa et al, 2011).This could have been a crucial factor for the quicker



M A C H A D O E T A L


immature mandibular premolar with pulpal necrosis - a casereport. J Clin Diagn Res 8: 29-31

Rosemberg B, Murray PE, Namerow K (2007) The effect ofcalcium hydroxide root filling on dentin fracture strength. DentTraumatol 23: 26-9

Saoud TM, Zaazou A, Nabil A, Moussa S, Lin LM, Gibbs JL(2014) Clinical and radiographic outcomes of traumatized immaturepermanet necrotic teeth after revascularization/revitalization therapy.J Endod 40: 1946–52

Sato I, Ando-Kurihara N, Kota K, Iwaku M, Hoshino E (1996)Sterilization of infected root-canal dentine by topical applicationof a mixture of ciprofloxacin, metronidazole and minocycline insitu. Int Endod J 29: 118-24

Silveira CM, Sebrão CC, Vilanova LS, Sánchez-Ayala A(2015) Apexification of an immature permanent incisor with theuse of calcium hydroxide: 16-year follow-up of a case. CaseRep Dent 1-6

Soares Ade J, Lins FF, Nagata JY, Gomes BP, Zaia AA, FerrazCC, de Almeida JF, de Souza–Filho FJ (2013) Pulprevascularization after root canal decontamination with calciumhydroxide and 2% chlorexidine gel. J Endod 39: 417-20

Thomson A, Kahler B (2010) Regenerative endodontics-biologically-based treatment for immature permanent teeth: acase report and review of the literature. Aust Dent J 55: 446-52

Valera MC, Albuquerque MT, Yamasaki MC, Vassallo FN,da Silva DA, Nagata JY (2015) Fracture resistance ofweakened bovine teeth after long-term use of calcium hydroxide.Dent Traumatol 31: 385-9

Reprinted with permission by ENDODONTIC PRACTICEDecember 2016

irrigants. J Appl Oral Sci 16: 137-44Hawkins JJ, Torabinejad M, Retamozo B (2015) Effect of three

calcium hydroxide formulations on fracture resistance of dentinover time. Dent Traumatol 31: 380-4

Hoshino E, Kurihara-Ando N, Sato I, Uematsu H, Sato M, KotaK, Iwaku M (1996) In-vitro antibacterial susceptibility of bacteriataken from infected root dentine to a mixture of ciprofloxacin,metronidazole and minocycline. Int Endod J 29: 125-30

Iwaya SI, Ikawa M, Kubota M (2001) Revascularization ofan immature permanent tooth with apical periodontitis and sinustract. Dent Traumatol 17: 185-7

Kahler B, Mistry S, Moule A, Ringsmuth AK, Case P, ThomsonA, Holcombe T (2014) Revascularization outcomes: a prospectiveanalysis of 16 consecutive cases. J Endod 40: 333-8

Kosalaraksa P, Srirompotong U, Newman RW, LumbiganonP, Wood JM (2011) Serological response to trivalent inctiveinfluenza vaccine in HIV-infected children with differentimmunologic status. Vaccine 29: 3055-60

Lovelace TW, Henry MA, Hargreaves KM, Diogenes A(2011) Evaluation of the delivery of mesenchymal stem cells intothe root canal space of necrotic immature teeth after clinicalregenerative endodontic procedure. J Endod 37: 133-8

Nagata JY, Gomes BP, Rocha Lima TF, Murakami LS, de FariaDE, Campos GR, de Souza-Filho FJ, Soares Ade J (2014)Traumatized immature teeth treated with 2 protocols of pulprevascularization. J Endod 40: 606-12

Pradhan DP, Chawla HS, Gauba K, Goyal A (2006)Comparative evaluation of endodontic management of teeth withunformed apices with mineral trioxide aggregate and calciumhydroxide. J Dent Child 73: 79-85

Raju SM, Yadav SS, Kumar SRM (2014) Revascularization of




Making sense of mouth ulceration: Skin disordersCrispian Scully1 The clinical appearance of an oral ulcer on its own is rarely diagnostic. In the light of

multiple causes, some systematic way of dealing with ulceration is needed, such as mysystem of splitting causes into:

• Systemic • Malignancy• Local • Aphthae• Drugs.

This article discusses the last of the systemic causes – skin disorders.

Skin disorders• Pemphigus• Pemphigoid• Dermatitis herpetiformis• Linear IgA disease• Epidermolysis bullosa• Erythema multiforme.

Vesiculobullous diseases Vesiculobullous diseases are potentially life changing; for example, pemphigus is lifethreatening. Any ulceration, especially multiple, lasting more than three weeks musttherefore be regarded with suspicion.

This article covers the more important vesiculobullous diseases, which arecharacterised by the formation of blisters (vesicles/bullae) within (intraepithelial) orbeneath (subepithelial) the epithelium.

PemphigusPemphigus is the term for a group of rare autoimmune disorders; with antibodiesdirected mainly against epithelial intercellular ‘cement’ that helps keratinocytes adhereto each other (in desmosomes and termed desmoglein [DSG]).

Seen mainly in middle-aged and older people, and with a female predisposition,the common variant – pemphigus vulgaris (PV) – has a strong genetic background, andis prevalent in Ashkenazi Jews, Asians (India, Malays, Chinese, Japanese) andMediterranean peoples.

HLA-DRB1*0402 or HLA-DQB1*0503 are found in more than 95% of PV patients. Pemphigus is usually idiopathic but sometimes implicated are:

• Pesticides (organophosphates)• Malignancy• Pharmaceuticals• Hormones• Infections/immunisations• Gastronomy• UV light• Stress.

Triggers occasionally include:• Drugs (thiols, phenols or non-thiol, non-phenols)• Foods (black pepper, garlic, leek, onion, pepper, red chilli, red wine, tea)• Radiation• Surgery.

C L I N I C A L

1 Professor Crispian Scully CBEFMedSci DSc FDS MD isprofessor emeritus at UCL,London, King James IVprofessor at the Royal Collegeof Surgeons, Edinburgh,Harley Street DiagnosticCentre, 16 Devonshire Streetand 19 Wimpole Street,London.


C L I N I C A L


• Autoantibody removal– Immunoadsorption– Plasmapheresis.

Oral lesions may be helped also by use of:• Topical corticosteroids (fluocinolone acetonide or clobetasol)• Intralesional steroids• Topical tacrolimus.

Pemphigus variants Paraneoplastic pemphigus is the most important otherpemphigus variant, seen usually in the sixth decade.

Associated with anti-plakin (plectin, desmoplakin I,desmoplakin II, bullous pemphigoid antigen I,envoplakin, and periplakin) antibodies plus DSG-1 andDSG-3, it often causes oral ulceration on the lips andtongue, along with palmar/plantar bullous lesions.

The prognosis is poor with a mortality of approximately90% because of the presence of lymphoproliferativedisorders such as:

• Non-Hodgkin’s lymphoma• Castleman’s disease• Chronic lymphoid leukaemia• Adenocarcinomas, Kaposi and other sarcomas• Bronchiolitis obliterans.

Immune-mediated subepithelial bullous diseases Immune-mediated subepithelial bullous diseases (IMSEBD) isa group of blistering diseases, less dangerous than PV, inwhich autoantibodies to various components of thehemidesmosomes that link keratinocytes to the epithelialbasement membrane zone (EBMZ) cause subepithelialvesiculation and blistering of squamous epithelia.

Often in the past these IMSEBD have all been calledpemphigoid but it is now recognised that other disorderscan cause a similar clinical picture. Even pemphigoid hasseveral variants.

Pemphigoid Pemphigoid is an autoimmune disorder that affects skinand/or mucosae associated with HLA-DQB1*0301. It mayaffect one or several sites, and oral lesions predominate inmucous membrane pemphigoid (MMP) subtypes.

MMP is uncommon, with a female predisposition and seenin the fifth to sixth decade of life. Rarely, it is drug-induced. MMP affects mainly oral, ocular, nasal, nasopharyngeal,anogenital, laryngeal, and oesophageal mucosae. Sub-setsof patients with MMP have autoantibodies targeting antigensof the EBMZ, such as epiligrin and integrins. These maydiffer, depending on sites mainly involved:

• Oral MMP: α-6 integrin

Activation of HLA class II restricted, desmoglein-specificCD4 T effector lymphocytes drives autoreactive B-cell activityand autoantibody production and the ST18 gene regulatesapoptosis and inflammation.

Pemphigus affects stratified squamous epithelia of skin andmalpighian mucous membranes.

Pemphigus vulgaris manifests with skin blistering andmucosal lesions and, if left untreated, has a high mortality.Oral lesions are invariable and seen early. They includeblisters that rupture to erosions as well as persistent ulcers.

Lesions are seen mainly where there is trauma andNikolsky’s sign is positive – pressure on the blister causes itto spread. Irregular red erosions seen early on have a whitishsurround due to necrotic epithelium (Figure 1) but there is afibrinous slough on older erosions.

People with PV have an increased incidence of otherautoimmune disorders themselves (especially myastheniagravis, Basedow disease, rheumatoid arthritis, systemic lupuserythematosus) and in their blood relatives (type 1 diabetes,autoimmune thyroid disease, less commonly PV).

Diagnosis is confirmed by histopathology, mainly. Biopsyis essential and shows acantholysis. Immunostaining by directimmunofluorescence (DIF) microscopy shows a net-likeappearance of deposited IgG and C3. Indirectimmunofluorescence (IIF) microscopy shows pemphigusantibodies.

Depending upon involvement of eyes, larynx, skin, andgenitalia, appropriate referral to physicians is essential. Management is by using:

• Systemic immunosuppression • Corticosteroids • Alternates

– Azathioprine– Dapsone– Intravenous immunoglobulins– Rituximab

Figure 1: Pemphigus


Dermatitis herpetiformisDermatitis herpetiformis is an IMSEBD in which autoantibodiesagainst epithelial transglutaminase cause an itchy rash onextensor surfaces, along with gluten sensitive enteropathy andoral blisters or desquamative gingivitis. Lesional biopsy ondirect immunofluorescence shows granular deposits of IgA atbasement membrane zone (BMZ).

Linear IgA disease Linear IgA disease (LAD) or chronic bullous disease ofchildhood is an IMSEBD similar to dermatitis herpetiformisbut antibodies are against ladinin in the EBMZ, with linearIgA deposition.

ReferencesGandolfo S, Scully C, Carrozzo M (2006) Oral medicine.

Elsevier Churchill Livingstone (Edinburgh and London). ISBN 13:29780443100376

Scully C, Almeida ODP, Bagan J, Diz PD, Mosqueda A(2010) Oral medicine and pathology at a glance. Wiley-Blackwell (Oxford) ISBN 978-1-4051-9985-8

Scully C, Flint S, Bagan JV, Porter SR, Moos K (2010) Oraland maxillofacial diseases. Informa Healthcare (London andNew York). ISBN-13: 9780415414944

Scully C, Bagan JV, Carrozzo M, Flaitz C, Gandolfo S (2012)Pocketbook of oral disease. Elsevier, London. ISBN 978-0-702-04649-0

Scully C (2013) Oral and maxillofacial medicine. 3rd edition.Churchill Livingstone (Edinburgh). ISBN 9780702049484

Scully C (2012) Aide memoires in oral diagnosis: mnemonicsand acronyms (the Scully system). Journal of Investigative andClinical Dentistry 3(4): 262-3

Scully C (2013) RULE for cancer diagnosis. British DentalJournal 215: 265-6

Reprinted with permission by Private Dentistry July 2014

• Ocular MMP: β-4 integrin.MMP with oral lesions affects mainly the gingiva, soft and

hard palate as well as buccal mucosae.MMP is a common cause of:

• Desquamative gingivitis – erythematous, ulcerated,tender gingiva, patchy distribution (Figure 2)

• Erosions, arising from vesicles that burst within severaldays, causing persistent ulcers or erosions covered withyellowish slough and surrounding erythema (Figure 3).Blood-filled blisters are sometimes seen.

Diagnosis is from a positive Nikolsky sign (ie, pressure on ablister causes it to spread). However, this is non-specific,therefore the following are also necessary:

• Biopsy – oral (not ocular) mucosal biopsy• Immunostaining; shows linearly deposited IgG, IgA, or

C3 at EBMZ. Management may be with:

• Topical corticosteroids (fluocinolone acetonide orclobetasol)

• Intralesional steroids• Topical tacrolimus • Systemic immunosuppressants in advanced cases

(corticosteroid or alternates – azathioprine, dapsone,high dose IV Ig, rituximab).

Appropriate referral to physicians (depending uponinvolvement of eyes, larynx, skin, and genitalia), and needfor systemic immunosuppression (severe or widespreaddisease) may be necessary.

Patients with apparently exclusive oral involvement may laterdevelop ocular lesions. There is a higher relative cancer riskin MMP patients with autoantibodies to epiligrin/laminin-332but a lower than expected relative cancer risk in patients with:

• Exclusive oral mucosal disease (autoantibodies to α-6integrin)

• Exclusive ocular mucosal disease (autoantibodies to β-4 integrin).

S C U L LY


Figure 3: Erosions in pemphigoidFigure 2: Pemphigoid causing desquamative gingivitis




P R O D U C T S

All products available from: HENRY SCHEIN HALAS • Tel: 1300 65 88 22 • www.henryschein.com.au

Exclusive to Henry Schein Halas. The Gemini 810 +980 diode laser is dentistry’s first dual-wavelength softtissue diode laser featuring 20 watts of peak super-pulsedpower and a stunning, fully transparent electroluminescentdisplay. No matter the procedure, the innovative Geminilaser makes it faster, smoother, and more efficient.• Dual wavelength technology combines the optimal

melanin absorption of the 810nm wavelength and theoptimal water absorption of the 980nm wavelength

ULTRADENT GEMINI SOFT TISSUE LASER

GC Initial LiSi Press is a new highstrength lithium disilicate ingotwith HDM (High DensityMicronization) technology. Thisnew material from GC attributesthese benefits to their new HDMtechnology. It utilizes equallydispersed lithium disilicate micro-crystals to fill the entire glassmatrix, rather than usingtraditional larger size crystals that do not take full advantage of theentire matrix structure. As a result, GC Initial LiSi Press combines theultimate combination of strength and aesthetics making it suitable forall different types of dental restorations. Most importantly, thistechnology allows the product to be stable without distortion and dropin value, even after multiple firings. GC Initial LiSi Press is alsoperfectly optimized to be used with the already proven GC Initial LiSiveneering ceramic and GC Initial Lustre Paste NF.

• Tip illumination • Sleek, innovative design features transparent

electroluminescent display • Simple user interface and 19 preset procedures • Wireless foot pedal and battery operation allow for

convenient movement from operatory to operatory • Autoclavable handpiece for simple sterilization

between procedures

Isolite’s Mouthpiece has been specifically designed and engineeredaround the anatomy and morphology of the mouth to accommodateevery patient, from children to the elderly. It is constructed out of apolymeric material that is softer than gingival tissue for patient comfort,and it has excellent optical qualities. Its safety advantages andease-of-use will boost your practice's efficiency, results, and patientsatisfaction. Compatible with the full line of Isolite's products, theMouthpiece is the heart of our system.

Available in sizes Pedo, Small, Medium, Medium DV and Large. Now available in Extra Small.

ISOLITE ISOLITE MOUTHPIECES –

NOW AVAILABLE IN EXTRA SMALL!

GCINITIAL LiSi PRESS

• Made with xylitol and 1.23% fluoride • Features an optimal formulation of abrasive and adhesive

properties designed for minimal splatter and great stain removal! • Six delicious, gluten-free, kid-friendly flavours • Available in coarse medium five grit• Individual Flavours or an Assortment pack• Box of 100 cups of prophy paste and a special autoclavable

Zooby Prophy Paste Animal Gripper with a wide base, whichallows the clinician to hold the paste cup with ease.

Fun Zooby flavours TURTLE MELON, GATOR GUM, CHOCOLATECHOW, HAPPY HIPPO CAKE, GROWLIN' GRRRAPE, SPEARMINTSAFARI

YOUNGZOOBY PROPHY PASTE

Case collaboration Dr Ricky Canizaresand Mr Bill Marais – USA

CAD/CAM Solutions. High performance – made brilliantBRILLIANT Crios reinforced composite bloc combines all theadvantages of an innovative submicron hybrid composite materialwith those of a CAD/CAM fabrication process for reliable, aestheticand fast restorations without a separate firing process. • Two sizes, two translucencies and13 shades offer a broad range

for daily use in the dental practice.• Suitable for anterior teeth as well as posterior teeth and single-tooth

restorations, such as inlays, onlays, veneers and crowns. • Due to the shock absorbing effects, BRILLIANT Crios is

recommended for restorations for bruxism patients or implant-supported crowns.

COLTENE BRILLIANT CRIOS



P R O D U C T S


All products available from: HENRY SCHEIN HALAS • Tel: 1300 65 88 22 • www.henryschein.com.au

Daniel Wismeijer; Stephen Chen; and Daniel Buser (editors)People now live longer and have higherexpectations for health and quality oflife than they did in previousgenerations, and demographic shiftshave occurred in recent decadesleaving more older people thanyounger. These shifts have brought newdemands to implant dentistry andpractitioners, who now see elderlypatients routinely in practice. Because of their age, these patientsare subject to certain limitations and often require special dentalcare, especially patients in ailing condition. This volume addressesthe situation and needs of the elderly patient, from systemicchanges and physical and mental limitations to considerations ofquality of life. Twelve clinical cases demonstrate solutions forvarious clinical situations, including treatment of an Alzheimerpatient, rehabilitation of a patient with osteoarthritis, treatmentsequencing for full-arch removable dental prostheses, flaplessguided surgery for bar-supported overdentures, and minimallyinvasive treatment of a patient in her 90s with severe peri-implantitis, among others.Q-5120827 312 pp; 500 illus

Articaine hydrochloride 4% with adrenaline 1:200,000

Indicated for local anaesthesia for simple dental procedures inadults, adolescents and children 4 years of age and older.

What you can expect from a high quality anesthetic brand likeSeptanest:

• Less acidic pH at release

• Highest level of sterility assurance

• Blister packed to reduce risk of cross contamination

• 100% latex-free

• Approval by over 70 health authorities worldwide

• Highest guarantee of quality

Note: For surgical procedures where more haemostasis is needed,Septanest 4% with 1:100,000 adrenaline should be used.

SEPTODONT SEPTANEST 4%

(with 1:200,000 adrenaline)

QUINTESSENCE ITI TREATMENT GUIDE, VOL 9

IMPLANT THERAPY IN THE GERIATRIC PATIENT

ONE COAT 7 UNIVERSAL is a light-cured, one component bondingagent used with self-etching, selectively etching or total etchtechnique for adhesive restoration techniques.

One bond for all application techniques• Exceptional bonding values on enamel and dentine • Excellent marginal seal • Minimised postoperative sensitivity

Effortless bonding to materials such as gold, titanium, ceramics,zirconium oxide and composite entirely without additional primer orsilane.A new ergonomic bottle with optimised dropper deliversprecise, clean dispensing without continued flow with up to 300applications Also available in a practical single dose for hygienicsingle use applications. Easy, all round efficient performance in yourdaily practice routine.

COLTENEONE COAT 7 UNIVERSAL

Kuraray Noritake introduces the new series KATANA™ ZirconiaUltra Translucent Multi-Layered (UTML) and Super Translucent Multi-Layered (STML) discs offering highly aesthetic zirconia for indirect,milled restorations. With one of the highest zirconia translucencylevels in the market and a natural colour gradient, KATANA™brings an unsurpassed aesthetic appearance to all your prosthetics.KATANA™ Zirconia Ultra Translucent Multi-Layered (UTML) discsare optimal for anterior crowns, veneers, inlays/onlays andposterior single crowns, where maximum translucency & highaesthetics are demanded. KATANA™ Zirconia Super TranslucentMulti-Layered (STML) discs are ideal for producing up to 3 unitposterior bridges with a well-balanced combination of chromaticand gradational translucency, reproducing natural enamel anddentine effects.

KURARY NORITAKEKATANA™ ZIRCONIA UTML

& STML DISCS


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