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Hon. EditorDr. Anand N. WankhedeISSN0976-9277
DENTAL PROBEJOURNAL
DENTAL PROBEJOURNAL
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Dental Probe Journal Vol 17 (2) 2017
Executive Committee 2017
INDIAN DENTAL ASSOCIATION, NAGPUR BRANCH
PresidentDr. Manoj Chandak
44 Jeevan-Chhaya Building, New Ramdaspeth, Behind Hotel
Centre Pont, Nagpur- 10
Hon. SecretaryDr. Vaibhave Karemore66/11, Vastavya, VIP Road,Dharampeth, Nagpur - 10
Emil: [email protected]
Hon. EditorDr. Anand N. WankhedeOpp. Lok Vidhyalaya School,
Bachlor Road, Wardha - 442001Email : [email protected]
Editorial Committee
Editorial Committee
Editorial
President’s Message
Secretary’s Message
Debonding Techniques - A Review.
Anterior single Implant – Most demanding and challenging clinical case report.
Orthodontic Treatment Approach Towards Cleft Lip and Palate Cases A Review Article.
Dental Prob Journal Vol 17 (2) 2017
DR . MANOJ CHANDAK President
DR . VAIBHAV KAREMOREHon. Secretary
DR . KETAN GARG Treasurer
DR . TUSHAR SHRIRAOPresident Elect.
DR . SANDIP N. FULADI Imm Past President
DR . GIRISH BHUTADA1st Vice President
DR . KRISHNAKUMAR LAHOTI 2nd Vice President
DR. YOGESH S. INGOLEJoint Secretary
DR . SHRADDHA AGRAWALAsst. Secretary
DR. ANSHUL MAHAJANAsst. Treasurer
DR. POONAM HUDIYA Rep. to CDE
DR. VIVEK THOMBRERep to CDH
DR. ANAND WANKHEDE Hon. Editor (Dental Probe)
DR. MANGESH PHADNAIKEditor News Letter
DR. DEEPAK H. KAMDARRep. to IDA MSB
DR. ANIL Y. CHAUDHARI Rep. to IDA MSB
DR. ABHAY KOLTERep. to IDA MSB
DR. ZUBAIR QUAZI Rep. to IDA MSB
DR. JAYSHREE JOSHIRep. to IDA MSB
DR. ANKUR DHOOTRep. to IDA MSB
DR. SHARD KABRA Librarian
DR. MITUL MISHRA
EC Member
DR. GANESH BAJAJEC Member
DR. ANAND RATHI
EC Member
DR. ANURAG SHENDREEC Member
DR. PRAFUL SHUDDHALWAR
EC Member
DR. DEOKI KHATIEC Member
DR. ROHIT MUDEEC Member
Dr. Usha Radake
Dr. Ashok Pakhan
Dr. Manoj Chandak
Dr. Girish Bhutada
Dr. Abhay Kolte
Dr. Mangesh Padanaik
Dr. Sunita Kulkarni
Dr. Rakhi Chandak
Dr. Devendra Palve
Dr. Meenal Choudhary
Dr. Shweta Chandak
Dr. Pushpa Hazarey
Dr. Sindhu Ganvir
Dr. Vandana Gade
Dr. Abhay Datarkar
Dr. Chandrashekhar Bande
This views/ opinions express by the authors are entirely their own. The journal bears no responsibility, whatsoever about them. The readers are welcome to comment on the issues or subjects raised in the journal. No article/ write up in full or in part may be reproduced without the permission of the Hon. Editor. Any Legal issue/ matter subject to Nagpur Jurisdiction.
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Dental Probe Journal Vol 17 (2) 2017
EDITORIAL
It gives me immense pleasure to present theSecond issue of “Dental Probe ”. The aim of this scientific journal is to cultivate the culture of presenting scientific papers by the academicians and private clinician .
Dental probe brings a new research work and advances in dentistry which is mandatory for the growth and success of day to day dental practice. We are sure that the scientific articles published in Dental probe will be of immense help in updating the knowledge. We hope that this volume will bring the new scientific information to enhance the knowledge .
Journal
Your’s In IDA
Dr. Anand N. Wankhede
Hon. Editor,
IDA - Nagpur Branch
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Dental Probe Journal Vol 17 (2) 2017
President’s Message
I am happy to know that Journal of Dental Probe Journal has been providing members of IDA-Nagpur Branch, a unique platform for updating the scientific knowledge with advances in dentistry in past few years. New volume of Dental Probe Journal will help readers to explore new scientific knowledge through this volume. We are confident that our journal will devote to bring the new update and advances in dentistry from clinical aspect and academic point of view.
Your’s In IDA
Dr. Manoj Chandak
President,
IDA - Nagpur Branch
Dental probe journal is committed to continuously reporting new research finding and exploring new idea, methods in dentistry. IDA-Nagpur branch is to promote clinical excellence among its members. I am sure that our IDA-Nagpur branch members will get benefit from our journal.
Hon. Secretary’s Message
Your’s In IDA
Dr. Vaibhav Karemore
Hon. Secretary,
IDA - Nagpur Branch
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Dental Probe Journal Vol 17 (2) 2017
We, the undersigned, give an undertaking to our article entitled
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submitted for publication in the DENTAL PROBE JOURNAL 1. The article mentioned above has not been published or submitted to or accepted for publication in anyform, in any other journal. 2. I/We declare that I/We contributed significantly towards the research study i.e., (a) conception, designand/or analysis and interpretation of data and to (b) drafting the article or revising it critically for important intellectual content and on (c) final approval of the version to be published.
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5. The author(s) hereby represents and warrants that they are sole author(s) of the research work, that all authors have participated in and agree with the content and conclusions of the research work. Research work is original, and does not infringe upon any copyright, propriety and / or personal right of any third party and that no part of it nor any work based on substantially similar data has been submitted to another publication.
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Undertaking by the Author
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Dental Probe Journal Vol 17 (2) 2017
Abstract :
Debonding procedure is as important as
bonding for the overall success of the orthodontic
treatment. Debonding procedure in orthodontics
consist of removal of the attachments (brackets,
bondable tubes & buttons) and all the adhesive resin
from the teeth and restore the teeth surface as closely
as possible to its pre-treatment condition without
inducing iatrogenic damage. To obtain these
objectives a correct debonding technique is of
fundamental importance, else it may be unnecessarily
time consuming, painful to the patient and damaging
to the enamel.
Key Words - Debonding techniques, metal brackets,
ceramic brackets,enamel damage
Introduction :
The past 30 years have seen major changes in
the evolution of orthodontic materials. Due to
increased awareness, patients are not only demanding
high-quality orthodontic treatment, but they also want
the treatment to be minimally invasive, and more
comfortable with an esthetically pleasing final
outcome.
The demand for more esthetic appliance led to the
introduction of the direct bonding techniques and has
made banded attachments almost obsolete in present
day orthodontics. However, with the widespread use
of direct bonding materials, there have also been
concerns over how to remove the residual bonding
resin from the teeth surfaces most effectively without 1damaging the enamel .
Debonding procedure is as important as
bonding for the overall success of the orthodontic
treatment. In an attempt to increase the bond strength
of orthodontic appliances, we have neglected the fact
that these appliances have to be debonded at the end of
the treatment.Debonding procedure in orthodontics
consist of removal of the brackets, bondable tubes &
buttons and all the adhesive resin from the tooth and
restore the tooth surface as closely as possible to its
pre-treatment condition without inducing iatrogenic
damage. To obtain these objectives a correct
debonding technique is of fundamental importance,
else it may be unnecessarily time consuming and 1
painful to the patient and damaging to the enamel .
Many investigators have focused on the
debonding methods to determine the best technique
that would leave an ideal finish for the tooth surface
without damaging the tooth structure.
The debonding of orthodontic brackets is
commonly accomplished by mechanical means, but
the debonding technique should be varied according
to the bracket material and type.
Mechanical method is usually preferred for metal
DEBONDING TECHNIQUES - A REVIEW
Address for correspondences :Dr. Rizwan GilaniAssistant Professor, Department of Orthodontics, Sharad Pawar dental college, DMIMS(DU),Sawangi (M), Wardha.
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1) Dr. Rizwan Gilani2) Dr. Nikhil Mankar3) Dr. Pallavi Diagavane4) Dr. Priyanka Niranjane
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Dental Probe Journal Vol 17 (2) 20176
brackets but the use of mechanical debonding for
ceramic brackets carries the risk of bracket fracture
and the additional risk of injury to the doctor and/or
patient from flying bracket fragments. Patient
discomfort during removal of the brackets has not
been documented; however, empirical experience
suggests that "gentler" methods for bracket removal
are needed. Several techniques have been described
for debonding orthodontic brackets. These techniques
include: Mechanical, Thermal, Ultrasonic, Chemical,
and Laser debonding.
Mechanical Techniques :
A. Steel Brackets
Various designs of orthodontic pliers have been
designed for the purpose.
1. Debonding Pliers :
This is the most recommended technique in which the
chisel shaped beaks are placed as close to the base of
the bracket as possible and a peeling type force is
applied (fig.1).Because metal brackets are ductile,
this force is transmitted to the adhesive bond, 2
breaking it .
2. Lift-Off Debonding nstrument (LIOD) :
This is a design of pliers in which a tensile force is
placed on the adhesive bond through a wire loop
hooked over the bracket tie wings, pulling the wings
2,3
of the bracket directly away from the tooth surface
(fig2). This method distorts the brackets the least and 4,5is preferred if recycling is a consideration
3. Ligature Cutters :
Ligature cutters have been recommended by some
authors to debond brackets (fig.3) These work
perfectly well but can damage the beaks, which can 4,5.
detract from the original purpose
4. Weingart Pliers :
One of the methods for removing brackets is
to squeeze together the wings using weingart pliers
(fig.4). This transmits a shear force to the composite
adhesive and breaks the bond. In this technique
bracket wings often become distorted, altering the 5
slot dimension, making the bracket non reusable .
Fig. 1 Debonding plier
Fig.2 Lift off debonding instrument
Fig. 3 Ligature cutter
Fig.5 ETM 346 plier
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Dental Probe Journal Vol 17 (2) 2017 7
significantly weaker in the tensile mode.
Accordingly Unitek has introduced a new
debonding tool, called the debondingwrench which
applies a tensile force on the bracket while debonding.
The use of this debonding wrench has been shown to 4,5,6
produce less enamel damage .
Eelectrothermal Debonding :
Sheridan et al. developed an alternative to
conventional metal bracket removal, known as 7
electro-thermal debonding . It is the technique of
removing bonded brackets from enamel surfaces with
a cordless battery device that generates heat (fig.6).
This heat (in the range of 232ºC) is transferred to the
bracket by a blade that is placed in the bracket slot.
B. Ceramic Brackets :
The use of mechanical debonding for ceramic
brackets carries the risk of bracket fracture and the
additional risk of injury to doctor or patient from
flying fragments. The remaining bracket may also
have to be removed with a diamond bur, which is not
only time consuming and harmful to the enamel
surface but also injurious to pulp, if coolant is not
used. Generally, cutting brackets off with gradual
pressure from tips of twin beaked pliers close to the
bracket adhesive surface is not recommended as it 6could introduce horizontal enamel cracks .
In order to address the problem of enamel
fracture and cracks during debonding ceramic
brackets, various manufacturers have given their own
recommendations on debonding. GAC recommends
the use of the ETM 346 plier for removal of the Allure
brackets. (fig. 5). The Allure brackets are beveled on
the incisal and gingival edges for easy insertion of the
plier which is slowly squeezed to remove the bracket.
A similar plier with an additional shield is
available to catch any splinters which may fly off
during debonding. 3MUnitek do not recommend the
use of conventional debonding tools with their
Transcend Series 2000 brackets. These brackets are
mechanically retained, and though strong in shear, are
Fig.4 Weingart plier
Fig.6 Electro-thermal debonding equipment.
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Dental Probe Journal Vol 17 (2) 2017
The heat deforms the bracket/adhesive interface and
the bracket may then be removed without distortion or
excessive forces being applied to the underlying
enamel8.
It has been reported that the mean increase in
pulpal temperature, when debonding metal brackets
with this method was 2.4 ºC. When cooling water
spray was used immediately after debracketing, the
mean increase was only 0.12ºC. These values are well 8-11within the biological limits .
Chemical Debonding :
A peppermint oil material has been marketed
previously as a debonding agent. Some authors have
assessed ex vivo the effects of peppermint oil
application on the debond behavior of ceramic
brackets compared with ethanol and acetone which
are recognized softening agents. One hour placement
in peppermint oil produced the lowest mean and
maximal debond forces (77 and 114 N, respectively.
Placement in peppermint oil produced the lowest
levels of retained resin. There was no evidence of
enamel fracture with any of the groups, but bracket 12
fracture remained a problem .
Ultrasonic Debonding :
Another technique describes the use of 2
Ultrasonic tips for debonding of brackets.(fig.7).
Bracket removal was initiated at the incisal portion of
the bracket, with the KJS tip, (KJC and KJS Dentsply
Int. York, Pa.).The straight chisel bevel directed 13
toward the bracket itself.
After placing the tip at either the gingival or
incisal edge, the ultrasonic unit was activated while
moving the tip in a mesial to distal direction. This
rapidly created a groove in the composite. On gaining
approximately a 0.5 to 1 mm "purchase point," a
rocking motion was then incorporated until bond
failure occurred. Alternating the use of the KJS with 13
the KJC tip facilitated bracket removal.
It was reported that although the incidence of
bond failure at the enamel-adhesive interface is high
when the ultrasonic technique is used, the likelihood
of enamel damage with this technique is relatively
minimal.
This is because the force levels required to
achieve bond failure are significantly reduced with
the ultrasonic tips compared with the force needed for
the conventional removal methods. Disadvantage of
ultrasonic method is the increased amount of time
required for debonding.
Laser Debonding :
The discovery of optic laser technology began
with the invention of ruby lasers in the early 1960s.
During the 1980s and early 1990s, introduction of
lasers into dentistry was approved by the USFDA.
Since the early 1990s, lasers have been used
experimentally for debonding ceramic bracket.
Mechanism of Laser debonding.
Laser energy can degrade the adhesive resin by 3
methods:
-Thermal softening
-Thermal ablation
-Photoablation.
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Fig. 7 Ultrasonic debonding
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Dental Probe Journal Vol 17 (2) 2017
Thermal softening occurs when the laser heats
the bonding agent until it softens. Clinically this
results in the bracket succumbing to gravity and
sliding off the tooth surface. It is a relatively slow
process, which means it can lead to a large rise in both
tooth and bracket temperature.
Thermal ablation occurs when heating is fast
enough to raise the temperature of the resin to its
vaporization range before debonding by thermal
softening occurs. This results in the bracket being
blown off the tooth surface.
Photoablation also results in the bracket being
blown off the surface of the tooth.
It occurs when very high energy laser light interacts
with the adhesive material and the energy level of the
bonds between the adhesive resin atoms rapidly raises
above their dissociation energy levels, resulting in
decomposition of the material.
It is suggested that mono-crystalline brackets
debonding takes place by ablation, while for
polycrystalline brackets it is due to thermal softening.
It is shown that with the aid of lasers, debonding force
is significantly reduced, when using a Bis GMA
adhesive resin.
Finishing Procedures After Debonding :
The removal of direct bonded attachments
and the finishing of underlying enamel has been an
acute clinical problem for the orthodontist. And a
proper finishing procedure is must for the overall
success of the treatment. It has been proved that
debonding pliers, scalers, and diamond finishing burs
should not be used to remove the remaining resin after
debonding because they cause deep gouges in the
enamel.
It isrecommended to use a 12-bladed tungsten
carbide bur (fig.12) at high speed with adequate air
cooling to remove the bulk resin and finishing the
14
14,15
14
14-18
19,20
residual resin and underlying enamel with graded
polishing discs or ceramiste wheels with light
pressure and adequate air cooling. The final
finishing should be done with water slurry of pumice
applied with a rubber cup.
Discussion:
As stated above, a correct debonding
technique is of utmost importance for the success of
the orthodontic treatment. Various authors have
recommended different techniques for debonding
brackets but none of the techniques offer totally
satisfactory results. Each technique has its own
advantage and disadvantage. Mechanical methods are
most commonly used as they can be easily done chair-
side and are less time consuming, but they involve
greater risk of enamel fracture.
Ceramic brackets are more difficult to debond
than metal brackets because; the inert composition of
the aluminium oxide ceramic brackets makes
chemical cohesion between the ceramic base and the
adhesive resin impossible. Therefore, a silane
coupling agent is used as a chemical mediator
between the adhesive resin and the bracket base. The
base of each bracket is thus coated with silica glass to
promote bonding with the silanol functional group of
the silane molecule. The adhesion between the resin
and the ceramic bracket bases has increased to a point
where the most common site of bond failure during
debonding has shifted from the bracket base-adhesive
interface to the enamel adhesive interface, a less
desirable site.
Also, during loading, stainless steel will
elongate approximately 20% of its original length
before failing, while sapphire will elongate less than
1% before failing. Therefore ceramics are more
likely to fracture than metals under the same
conditions during debonding. Clinically, this is seen
19
19,20
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Dental Probe Journal Vol 17 (2) 2017
most often at the tie wing area.
Electro thermal debonding offers a good
alternative to mechanical debonding but involves the
high cost of equipment and a greater risk of thermal
damage to pulp. Ultrasonic debonding though can be
done easily chair-side, is very time consuming and
can damage the scalar tips and enamel surface.
Laser debonding is said to have no damaging
effect on pulp, but it involves high cost of equipment
and also the potential danger of laser irradiation to the
patient & the operator. The poly and mono-crystalline
brackets debond differently during laser
debonding.The different behaviours observed are, in
part, due to differences in the design (shape and
dimensions) of the two brackets, as well as in their
different microscopic structure. Though various
techniques have been described for debonding,
mechanical method still remains the preferred
method for both metal & ceramic brackets.
It should be done with proper debonding
instruments as prescribed by the manufacturers.
Proper finishing procedure should also be carried out
after debonding in order to achieve a satisfactory
finish at the end of the treatment and restore the tooth
surface to its pre-treatment condition. The finishing
procedure should include removal of residual
adhesive and restoration of the tooth structure to its
pre-treatment condition along with proper fluoride
therapy, teeth whitening, remineralisation and
restorative procedures for correcting the enamel tear
outs and white spot lesions that are commonly seen at
the end of the treatment.
Conclusion:
The concept of non-maleficence is embodied
by the phrase, "first, do no harm". Debonding
procedure if not done properly with correct technique
can cause iatrogenic harm to the patient involving
enamel loss and its complications. Further the
orthodontist also cannot reuse the distorted/ fractured
brackets caused by incorrect techniques. Hence a
proper debonding technique with proper finishing
procedure can be a cherryon the cake for a good
finished orthodontic case.
References:
1. Björn U. Zachrisson, Tamer Büyükyilmaz,
Bonding in orthodontics. Graber, Vanarsdall.
Orthodontics: Current Principles and Technique. 5th
Edition (Mosby) 2011. Page no. 749-756.
2. Oliver RG, Pal AD. Distortion of edgewise
orthodontic brackets associated with different
methods of debonding. AJODO, 1989, July, 96(1):
65-71.
3. Coley-Smith A, Rock WP. Distortion of metallic
orthodontic brackets after clinical use and debond by
two methods. BJO. 1999 Jun; 26(2):135-9.
4. Bishara SE, Trulove TS. Comparisons of different
debonding techniques for ceramic brackets: an in
vitro study. Part I. Background and methods. AJODO.
1990 Aug; 98(2):145-53.
5. Bishara SE, Olsen ME, Von Wald L. Evaluation of
debondingcharacteristic of a new collapsible ceramic
bracket. AJODO.1997 Nov; 112(5):552-9.
6. Diaz C, Swartz M. Debonding a new ceramic
bracket: a clinical study. JCO. 2004 Aug;38(8):442-5
7. John J. Sheridan, Glenn Brawley and Joe Hastings.
Electrothermaldebracketing Part II. An in vivo study.
AJODO. 1986 Feb: 89(2): 141-145.
8. Takla PM, Shivapuja PK. Pulpal response in electro
thermal debonding. AJODO. 1995 Dec; 108(6):
623-9.
9. Kearns HP, Sandham JA, Bryan Jones W,
Lagerstrom L. Electro thermal debonding of ceramic
brackets: an ex vivo study. BJO 1997 Aug;24(3):237-
42.
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Dental Probe Journal Vol 17 (2) 2017
10. Jost-Brinkmann PG, Radlanski RJ, Artun J, Loidl
H. Risk of pulp damage due to temperature increase
during thermodebonding of ceramic brackets.Eur J
Orthod. 1997 Dec; 19(6):623-8
11. SeemaLuthra, K Vighnesh, Nirmala Rao,
ValiathanAshima. Ceramic brackets and their
electrothermaldebonding-an in vivo evaluation.
TIBAO 1998 Vol 12, No.2. 47-49.
12. Larmour CJ, McCabe JF, Gordan PA. An ex-vivo
investigation into effect of chemical solvents on
debonds behavior of Ceramic orthodontic brackets.
BJO 1998 feb; 25 (1);(35-9).
13. Krell KV, Courey JM, Bishara SE. Orthodontic
bracket removal using conventional and ultrasonic
debonding techniques, enamel loss, and time
requirements AJODO. 1993 Mar; 103(3):258-66
14. Tocchio RM, Williams PT, Mayer FJ, Standing
KG. Laser debonding of ceramic orthodontic
brackets.AJODO. 1993 Feb; 103(2):155-62
15. Azzeh E, Feldon PJ. Laser debonding of ceramic
brackets: a comprehensive review. AJODO. 2003 Jan;
123(1):79-83
16. Obata A, Tsumura T, Niwa K, Ashizawa Y,
Deguchi T, Ito M. Super pulse CO2 laser for bracket
bonding and debonding.Eur J Orthod. 1999 Apr;
21(2):193-8.
17. Ma T, Marangoni RD, Flint W. In vitro
comparison of debonding force and intrapulpal
temperature changes during ceramic orthodontic
bracket removal using a carbon dioxide laser.
AJODO. 1997 Feb; 111(2):203-10.
18. KarlHeinzStrobl, Ted Bahns, Lee Wilham, Samir
E Bishara. Laser aided debonding of orthodontic
ceramic brackets. AJODO 1992, 101:152-8.
19. D. H. Retief, F.R. Denys. Finishing of enamel
surface after debonding orthodontic attachments.
Angle Ortho. Jan. 1979.
20. Hosein I, Sherriff M, Ireland AJ, Enamel loss
during bonding, debonding, and cleanup with use of a
self-etching primer. AJODO 2004 Dec; 126(6):717-
24.
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Abstract:
The replacement of teeth in the anterior region
of maxilla is most critical because esthetics,
phonetics, function, occlusal pattern, and patient
awareness blend to provide a very specific incisal
edge and contour position. Various treatment options
are available for the restoration of a single, maxillary
anterior missing tooth. When possible, the
independent implant and crown is the treatment of
choice. The single tooth implant is indicated to
improve the daily hygiene and decrease caries and
endodontic risks to the adjacent teeth.
This paper depicts the use of a two stage
implant for esthetic replacement of missing maxillary
left central incisor of in a patient simultaneous with
the use of bone graftingfor correction of minor
dehiscence in the alveolar ridge. A two-stage implant
surgery was done wherein the first surgery was for
implant insertion and the second surgery, several
months later was done for uncovering the implant and
attaching a prosthetic abutment.
Keywords: Anterior missing tooth, Dental implants,
Single tooth replacement, Single tooth implant
Introduction:
Dental implants have evolved into a
predictable procedure for the treatment of fully and
partially edentulous patients. The breakthrough in
oral rehabilitation was initiated by the discovery that
dental implants, made of commercially pure titanium,
which can achieve anchorage in the jaw bone with
direct bone-to-implant contact. This functional
ankylosis referred as Osseo integration was first
described by the two research groups of Branemark
and Schroeder. The mechanism of osseointegration 2
was well described by Davies . Osseointegration, as
first defined by Branemark, denotes at least some
direct contact of living bone with the surface of an
implant at the light microscopic level of
magnification. Branemark advocates complete
immobilization of the implant for 3 – 6 months before 3
placing it in function . The replacement of a single
missing tooth is a challenging and demanding clinical
endeavor. Not only must the crown conform to
contour, shade, and texture, but the gingiva must also
be in symmetry and harmony with the adjacent tissue.
From 1993 to the present, single tooth implants have
been shown to be the most predictable method of
tooth replacement. Multiple studies of at least five
years’ duration demonstrate a higher survival rate 4, 5than other methods of tooth replacement . When a
patient desires to avoid preparing adjacent teeth that
have no caries, restorations or both and to enhance
esthetics, a single tooth implant is the best solution.
The treatment of single missing tooth with implant
1
1) Dr. G. B. Bajaj
2) Dr. Y. Y. Mahale
Address for correspondences :Dr. Y. Y. MahalePost Graduate student, Department of Prosthodontics and Maxillofacial Prosthetics,Swargiya Dadasaheb Kalmegh Smruti Dental College& Hospital, Nagpur, India.
Anterior single Implant –
Most demanding and challenging clinical case report
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Dental Probe Journal Vol 17 (2) 201712
supported crown is a standard therapy, provided strict,
clearly defined indications are observed. These days,
single tooth replacement is one of the most common
procedures performed in implant dentistry and one of
the most common site is maxillary anterior arch3.
This paper depicts the use of implant for esthetic
replacement of missing maxillary left central incisor
of a patient.
Case Report:
A 19 year old male patient presented at the
Department of Prosthodontics with a chief complaint
of a missing tooth in the upper left anterior region.
Past history revealed that the tooth got fractured due
to contact sports 5 years back and subsequently the
root portion of the tooth was extracted by a local
dentist then. The patient reported no difficulties at the
time of extraction of the root portion of the fractured
tooth. His medical history was clear. On extra oral
examination, there were no abnormalities observed.
Intra oral examination showed that his oral cavity was
in good condition. Soft tissues were normal and other
hard tissues were sound. As per his chief complaint,
21 was missing (Fig. 1 & Fig. 2).
The neighbouring teeth were caries-free
without any signs of periodontal problems. Due to the
long interval of partial edentulism, substantial hard
and soft tissue loss had occurred and facial “hour
glass” concavity could be noted apical to the
edentulous region. Mesiodistal dimension of
theedentulous region was adequate. Width of the
edentulous ridge was adequate and tissue overlying
the ridge was firm and keratinized. Patient never used
removable partial denture before. Treatment
alternatives were discussed with the patient and
implant-supported restoration was agreed upon. The
pre-implant diagnosis and bone mapping indicated
the possibility for an implant with a diameter of 3.8
mm and length of 13 mm.implant with a gritblasted
and acid-etched surface was chosen.Alginate
impression made and cast was made by using dental
stone. Surgical stent was fabricated (fig 3).
The crestel incision was made to the palatal
aspect of the edentulous region and a sulcular incision
was carried on the proximal aspect of the adjacent
teeth; the papillae were reflected as part of the
mucoperiosteal facial flap (fig 4).
Fig. 1 Fig. 2
Fig. 4
Fig. 3
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Dental Probe Journal Vol 17 (2) 2017 13
Purchase hole to the depth of approximately 0.5 mm
was made with no. 6 round bur at the centre of crest
and 0.5 mm palatal to mid facial palatal dimension
then pilot drilling done (Fig. 5).
2 mm pilot drill was used to penetrate till the depth of
13 mm. Bone condensers were used in a sequential
manner before following each drilling protocol. After
the final drill of 3.8 mm diameter to the depth of 13
mm, implant was ratcheted into the osteotomy site
slowly until the top of the implant merged with the
crestel bone level (Fig. 6).
The implant was placed at the bone level to achieve
minimum sulcus depth. The bone grafting done on
defective buccal wall (fig 7). Site was primarily
closed by placing interrupted sutures (fig.8). Phase II
surgery was performed after 4½ months considering
the D3 bone density of the site. Healing was found to
be satisfactory with normal soft tissue contour. The
implant was uncovered and healing abutment was
placed (fig.9). After two weeks of the stage II surgery,
Fig. 5
Fig. 6
Fig. 7
Fig. 9
Fig. 8
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Dental Probe Journal Vol 17 (2) 201714
After making the impression, the permucosal
healing abutment was reinserted into the implant
body until the next restorative appointment. Later, the
transfer coping was removed, connected to implant
body analog, and reinserted into the impression. A
master cast was poured. An occlusal bite registration
was made in centric occlusion. The master cast was
mounted to the opposing arch with the bite
registration. We selected a 3.8 D, Straight abutment
with gingival height of 2 mm to have a crown margin
1 mm below the free gingival margin. The implant
abutment was modified for height and parallelism. A
full-contour wax-up and cut-down of 2 mm in the
regions of porcelain was made on metal coping. After
satisfactory metal try in, prosthesis was completed. In
the following appointment, the soft tissues were
healthy, the patient’s home care was found
satisfactory, and thus the restoration was cemented
(fig 13).
The patient was recalled after a month for
maintenance appointment. The soft tissue and hard
tissue surrounding the implant revealed stable
periimplant condition. Further he was recalled every
3 to 4 months for oral hygiene examination.
Fig. 10
Fig. 11
Fig. 12
Fig. 13
patient was recalled for the prosthetic procedure. On
removal of the healing abutment, gingival thickness
was found to be of 3 mm (fig 10). With a special tray,
implant level impression was made using additional
silicone (polyvinyl Siloxane) impression material (fig
11). For this procedure, a transfer coping was inserted
into the implant body and closed tray impression
technique was followed (fig 12).
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Dental Probe Journal Vol 17 (2) 2017 15
Discussion:
Implant dentistry has become successful
because of the biological properties of titanium.
Studies have advocated a 2-stage surgical protocol for
load-free and submerged healing to ensure
predictable osseointegration. It has been advocated
that after implant placement, surgical site should be
undisturbed for a period of 3-6 months, depending on
the bone quality, to allow uneventful wound healing,
thereby enhancing osseointegration between the
implant and bone. The rationale behind this approach
is that implant micromovement caused by functional
force around the bone-implant interface during
wound healing may induce fibrous tissue formation 6
rather than bone contact, leading to clinical failure . In
addition, primary closure of the implant after stage I
surgery has also been thought to prevent infection and 7, 8epithelial downgrowth . Branemark theorizes that
the implant must be protected and completely out of
function, as he envisions a healing phase up to 12
months in which new bone is formed close to
immobile, resting implant; remodeling phase of 3 to
18 months when the implant is exposed to masticatory
forces; and a steady state after 18 months, in which
there is a balance between the forces acting on the
implant and remodeling capacities of the anchoring 3bone . These days, loading implant right after
placement has gained popularity among clinicians.
Data from the current available literature suggest that
several factors may influence the results of immediate
implant loading. These could be divided into the
following four categories: surgery-, host-, implant-,
and occlusion-related factors. Primary implant
stability is a key factor to consider before attempting
immediate implant loading. Management of an
anterior missing tooth can pose a challenge to
practitioners. The alternative treatment options for
the restoration of a single, maxillary anterior missing
tooth include a fixed partial denture, a removable
partial prosthesis, and acid-etched resin-retained
prosthesis or an implant supported prosthesis.
T h e m o s t c o m m o n l y o b s e r v e d
contraindication for traditional fixed prosthesis is the
patient’s desire. But patients are more concerned
regarding the appearance of anterior teeth and wish to
keep adjacent teeth intact. Adequate case selection is
difficult and failures in performing have diminished
credibility amongst dentists, despite the conservative
nature of the technique
In clinical situations where adjacent teeth are
healthy, with acceptable esthetics and contour or in
the presence of diastema that the patient wishes to
maintain, or when the patient refuses the preparation
of adjacent teeth for the fabrication of three unit fixed
partial restoration, a single tooth implant is the best
solution. Studies have shown that single-tooth
implant restorations are a valid and lasting treatment
alternative to conventional prosthetic treatment. Jemt
et al reported one failure out of 70 single-tooth
implants inserted with 98.5% survival rate at 3 year.
Schimtt and Zarb reported no failures for 40 implants
placed in 32 patients. In 2002, Krennmair et al
reported 146 single-tooth implants, placed in 112
patients with cumulative implant survival rate of
97.3% at 7 years follow up. Implant retained single-
tooth replacements do save adjacent teeth from
treatment, but the operative procedure is extensive.
Predictable results have been reported when
clinicians adhere to the recommended protocol for
placement and reconstruction.
Conclusion:
The primary reason to suggest or perform a
treatment is often not related to the cost, time, or
difficulty to perform the procedure, but lays in the best
possible long-term solution for each individual
patient. The single tooth implant is indicated to
improve the daily hygiene and decrease caries and
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Dental Probe Journal Vol 17 (2) 201716
endodontic risks to adjacent teeth. Replacement of
missing maxillary left central incisor with dental
implant resulted in successful implant angulation and
stable periimplant condition.
References:
1. Buser D, Mericske-Stern R, Bernard J P, Behneke
A, Behneke N, Hirt H P et al, Long-term evaluation of
nonsubmerged ITI implants. Part 1: 8-year life table
analysis of a prospective multi-center study with 2359
implants. Clin Oral Implants Res. 1997; 8:161-72.
2. Davies J E. Mechanisms of endosseous integration.
Int J Prosthodont. 1998; 11:391-401. Misch C M.
Contemporary implants dentistry. 2nd ed. St. Louis:
Mosby; 1999.
3. Schmitt A, Zarb G A. The longitudinal clinical
effectiveness of osseointegrated dental implants for
single-tooth replacement. Int J Prosthodont. 1993;
6:197-202.
4. Henry P J, Laney W R, Jemt T, Harris D, Krogh P H,
Polizzi G, et al. Osseointegrated implants for single-
tooth replacement: A prospective 5-year multicenter
study. Int J Oral Maxillofac Implants. 1996; 11:450-5.
5.Adell R, Lekholm U, Rockler B, Brånemark P I. A
15-year study of osseointegrated implants in the
treatment of the edentulous jaw. Int J Oral Surg. 1981;
10:387-416.
6. Brånemark P I, Hansson B O, Adell R, Breine U,
Lindström J, Hallén O, et al. Osseointegrated
implants in the treatment of the edentulous jaw.
Experience from a 10-year period.
7.Scand J PlastReconstrSurg Suppl.1977;16:1-132.
Branemark P I, Zarb G, Albrektsson T. Tissue-
integrated prosthesis: Osseointegration in clinical
dentistry. Chicago: Quintessence; 19858.Gapski R,
Wang H L, Mascarenhas P, Lang N P. Critical review
of immediate implant loading. Clin Oral Implants
Res. 2003; 14:515-27.
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Dental Probe Journal Vol 17 (2) 2017 17
Abstract -
Management of the cleft lip and/or cleft palate
(CL/CP) patient is a process that starts in infancy and
continues on into adulthood. Problems encountered in
the CL/CP patient are complex and therefore best
managed through a team of experts.Apart from
Psychosocial problems, Feeding problems and
Speech defects are also frequently encountered. As
the advancement in providing basic care has
increased, the quality of life for these patients has also
increased. Improvement in esthetics can provide
patients with CL/CP high self esteem. Maxillary
Protraction and palatal expansion are the common
treatment modalities used by Orthodontists during
growth period to decrease the chances of future facial
orthognathic surgeries.
Keywords- Cleft lip and Palate, Maxillary
Protraction, Expansion, Circum-maxillary sutures,
Appliances.
Towards Cleft Lip and Palate Cases - A Review ArticleOrthodontic Treatment Approach
1) Dr. Chinmay H. Khandait
2) Dr. (Mrs.) Sunita S. Shrivastav
3) Dr. Vikas Pakhre
4) Dr. Krishna Sharma
5) Dr. Arihant Golcha
Clefts involving the lip or/and palate or
isolated cleft of palate are a significant congenital
anomaly, requiring a complex long term treatment
and having lifelong implication for those individuals
unfortunate enough to be affected. They represent a
complex phenotype and reflect a breakdown in the
normal mechanisms involved during the early
embryological development of face. Incidence of
cleft lip and palate varies according to the
geographical location, ethnicity and socio-economic
status. In Caucasian population it ranges from 1:800 1to 1:1000 , where as in Indian population it ranges
2from 1:500- 1:800 . Clinical manifestation of these
defects ranges from the isolated cleft of lip to
complete bilateral cleft of lip, palate and alveolus.
Broadly speaking, about 70 percent of cleft cases are
non-syndromic, occuring as an isolated condition
unassociated with any other recognizable anomaly
and 30 percent are syndromic which are associated
with deficits or structural abnormalities occuring 1outside the region of cleft .
Cleft lip and palate (CLP) may have
undesirable esthetic and functional consequences for
the affected cases. Many studies, including both
unoperated and operated cleft cases, have suggested
that some facial deviation are directly caused by the
primary anomaly, whereas others may be caused by
Address for correspondences :Dr. Chinmay H. KhandaitPost Graduate Student, Dept. of Orthodontics, Sharad Pawar Dental College, Sawangi (Meghe)Email- [email protected] 9096264924
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Dental Probe Journal Vol 17 (2) 201718
the surgical intervention and the subsequent 3
dysplastic and compensatory growth of facial bones .
The resultant surgical scar leads to retardation of
growth of the maxilla 3-dimensionally, leading to a
Class III malocclusion due to hypoplastic maxilla
with a relatively normal mandible (Fig.1).
Fig.1-Patient with cleft lip and palate
The treatment of cleft cases requires a team
work and a role of each speciality occurs at various 4
stages of patient’s life . The role of Orthodontist
occurs from time to time. The correct prediction and
interception of maxillary growth helps a cleft child 5grow almost normally . In infancy role of orthodontist
is to make the cleft segment symmetrical facilitating
its surgical repair using PNAM where ever indicated.
During late mixed dentition the role of
Orthodontist is profound. The concern of
Orthodontist is to identify maxillary deficiency and
give appropriate treatment
so as to reduce severity of developmental
malformation and also to reduce the need for
Orthognathic surgery in future. The goal of
Orthodontic treatment is to correct maxilla in three
dimensions. Transversely it can be corrected by
giving Rapid Maxillary Expansion appliances
(RMEs) like Hass, HYRAX, Miniexpandersetc
(Fig.2);Sagittally the correction for hypoplastic
maxilla can be achieved by using protraction
headgears and facemask. (Fig.3)
Fig.3- Protraction Facemask
The protraction of maxilla is achieved by exerting a
stimulating force directed downwards and forwards 6-7
at 30o to occlusal plane which has a favorable effect
on stimulating sagittal growth of maxilla. The force
due to protraction headgear exerts stresses in various
circum-maxillary sutures which includes
P t e r y g o m a x i l l a r y, Z y g o m a t i c o f r o n t a l ,
Zygomaticomaxillary, Zygomaticotemporal,
Nasomaxillary, Transverse maxillary, Frontonasal,
Internasal and Frontomaxillary sutures and may
experience various degree of resistance as cranial
base is the stronger bone. Any residual stresses at
these circum-maxillary sutures are the main reason
for relapse. Protraction in normal cases can be
performed till the patency of sutures occurs. In Class
III cases along with deficient maxilla by using rapid
maxillary expansion and facemask, it has been
Fig.2- Modified Haas and Hyrax type expanders.
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Dental Probe Journal Vol 17 (2) 2017 19
advised that the timing to protract the maxilla was 8
between ages 6 to 8years . Eric Liousuggested to
protract the maxilla as late as possible so that the
adverse effects of delayed mandibular growth that
occurs later could be minimal. He stated the optimal
timing therefore was right before the fusion of
circum-maxillary sutures and it was at the cervical
vertebrate stage 2 (CVMI 2). It coincided along with
the beginning of puberty i.e. around the ages of 11-13 8
years in girls and ages of 13-15years in boys. As per
the findings of Shibasaki et al there may be delayed
skeletal growth in cleft cases as compared to the 9normally growing class III cases . Therefore fusion of
circum-maxillary sutures may occur at much older
age in cleft patients. Probably maxillary protraction
done at older age may also yield a good result and
benefit those cleft individuals who missed this mode
of intervention at earlier age.
The face mask was first used in the treatment of
patients with maxillary deficiency and Class III 3malocclusion by Delaire et al in 1972 . Berkowitz
used a modified Delaire type of facemask which had a
padded chin cup and forehead rest for treating
maxillary retrusion among young patients with cleft 3
lip and palate . He claimed that this appliance was
very successful without causing severe sore spots on
the chin and forehead. He stated that the maxillary
protraction forces did not change the direction of
mandibular growth but increased the midfacial height
and caused downward and backward rotation of the
mandible which is the reason that makes the maxillary
retrusion appear less evident.
There are studies in literature where the
attempts to improve the results and increase the
success rate in maxillary protraction were
undertaken. The clinical trials included use of RME 10
using HYRAX along with maxillary protraction
appliances or using Alt-RAMEC along with 11-12
maxillary protraction appliances in Class III cases
due to deficient maxilla with varied degree of success.
Eric Liou stated that the protocol of alternate rapid
maxillary expansions and constrictions (Alt-
RAMEC) was effective in loosening the circum-
maxillary sutures which resulted in increasing
protraction effect on maxilla. He also stated that the
Alt-RAMEC could be effectively used in non-cleft 12
Class III as well as cleft cases . Both HYRAX and fan
type expander could be used effectively. The key was
the protocol of Alt-RAMEC rather than the types of
expander. Protocol consisted of alternate period of
7mm of weekly expansion and 7mm of weekly
constriction (daily 1mm activation) and was carried
upto seven weeks. This resulted in loosening of
circum-maxillary sutures and facilitated the
maxillary protraction. The expansion forces were
distributed not only in the maxilla but also extended
into the circum-maxillary structures. Alt-RAMEC
protocol opened the circum-maxillary sutures and
showed an extreme orthopaedic effect in patients with
cleft lip and palate which in later by various other
researchers was found to be a similar to be temporary
effect and no different from routine protraction with 8,13
expansion using RME .
The various appliances used for RME included
HYRAX, Hass, Bonded RME, Miniexpanders etc.
One of the appliance which has a unique feature is the
Fig.4- NiTi Expander
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Dental Probe Journal Vol 17 (2) 201720
NiTiexpander(Fig.4) which is a flexible modification
of Quad helix and is known to exert a very light force 14-15
as is required in cleft cases . Another unique feature
is of NiTi expander is that it is a RME appliance in
cleft cases and mixed dentition cases and a slow
expander in adult cases. So maxillary expansion done
with use of NiTi expander may be beneficial for the
successful protraction of hypoplastic maxilla in cleft
cases.
Conclussion-
Maxillary expansion and Protraction is one of
the interceptive procedure undertaken by
Orthodontist during early mixed dentition and/or
adolescence during whichthe patency of sutures have
not been established and the expansion and
protraction procedures canbring about more
favourable skeletal than dental changes.Its depends
on how the Orthodontist utilise the window of
opportunity and plan a treatment accordingly so that
to avoid the future chances of Orthognathic surgery in
Cleft lip and palate patients.
References-1) MartynT.Couborne. The complex genetics of cleft
lip and palate. Eur J Orthod. 2004; 26: 7–162) Shrinivas Reddy, Rajgopal Reddy, E. Bronkhorst,
R. Prasad, A.Ettema, Heramann S, S.Berge.
Incidence of cleft lip and palate in state of Andhra
Pradesh, South India.2010,43:2,184-89 3) MontianManosudprasit, Tasanee Wangsri-
mongkol, PoonsakPisek ,Bowornsilp Chowchuen
MD, ThanatpiyaSomsuk . Growth Modification in
Unilateral Cleft Lip and Palate Patients with Face
Mask. J Med Assoc Thai 2012; 954) Alexander cash. Orthodontic Treatment in the
Management of Cleft Lip and Palate. Front Oral Biol.
Basel, Karger, 2012; 16,111–1235) Subtenly,Rochester Orthodontic Treatment of
Cleft Lip and Palate, Birth to Adulthood. The Angle
Orthodontist: October 1966;36: 273-2926) AhmetKeles, Ebru C¸ etinkayaTokmak;
NejatErverdi, Ravindra Nanda. Effect of Varying the
Force Direction on Maxillary Orthopedic Protraction.
Angle Orthod 2002;72,387–396.7) ArunachalamSivakumar, AshimaValiathan.
Maxillary Protraction Therapy. 2009;43: 40-478) ERIC LiouR Dental Press OrtodonOrtop Facial 27
Maringá, 2009; 14: p. 27-379) Y.Shibaski, R.Ross. Facial growth in children with
isolated cleft palate. Americal cleft palate association,
Chicago,April 196710) Hyung S. Yu, Hyoung S. Baik , Sang J. Sung , Kee
D. Kim and Young S. Cho (2007) Three-
dimensional finite-element analysis of maxillary
protraction with and without rapid palatal expansion
.European Journal of Orthodontics 2007;29,
118–12511) Eric Jein-WeinLiou, Wen-Ching Tsai presented A
New Protocol for Maxillary Protraction in Cleft
Patients: Repetitive Weekly Protocol of Alternate
Rapid Maxillary Expansions and Constriction.Cleft
Palate–Craniofacial Journal. 2005;42(2):121-12712) Stephen L-K Yen, Protocols for Late Maxillary
Protraction in Cleft Lip and Palate Patients at
Childrens Hospital Los Angeles. SeminOrthod. 2011;
17(2): 138–14813) Bilge H. Canturka; MevlutCelikogl. Comparison
of the effects of face mask treatment started
simultaneously and after the completion of the
alternate rapid maxillary expansion and constriction
procedure. Angle Orthodontist 2015; 85 ,284-291.14) ParthasarathyraamRaju, P Bhattacharya, Ankur
Gupta, JaishreeGarg, DK Agarwal Maxillary
expansion by nickel titanium palatal expander in cleft
palate patient JNTR univ health sci 2014;3,51-5415) Rahul Paul, TapasyaKapoor, VarunMalhotra,
Krishna Nayak ,Shruti Bhatt. Efficacy of NiTi palatal
expanders. Journal of IOS 2011,45(4):243-250
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