Journal of Specialist Dentistry Journal of Specialist ... · details of the next CPD seminar events organised by our ... Southwark Park Road, London • Ooi Dental ... Piezoelectric

Editorial Board

www.chiswellgreendental.co.uk Issue 9- October 2017 1

ContentsPiezo-surgery facilitated crown lengthening

surgery: a case report

- By Dr. Rajiv M Patel 2-3

Tissue is the issue. Part 1. Recession

defects – soft tissue loss around teeth

- By Dr. Dhru Shah 4-5

Digital Dentistry – It’s Here By Clinton Compaan 7

CPD courses / Lunch & Learn sessions 8

Dr Claudio PeruSpecialistEndodontist

Dr Luisa LucchesiSpecialistOrthodontist

Dr Rajiv PatelSpecialistPeriodontist

Dr Kostas IoannidisSpecialistEndodontist

Dr Zulaikha BurkiSpecialistProsthodontist

Dr Poonam KalsiSpecialistProsthodontist

Journal of Specialist DentistryDeveloping Dental Expertise

www.chiswellgreendental.co.uk

Journal of Specialist Dentistry

Editorial Board

Welcome to the JSDEditor, Dr Massimo Peru, BDS, MSc Endo

Following the success of the first edition, we are delighted to present two cutting edge clinical cases performed by two specialist dentists, andmembers of the JSD editorial panel, Dr Luisa Lucchesi and Dr ZulaikhaBurki.

We are also pleased to introduce our new sponsor, Wright Cottrell,leading suppliers of dental materials.

If you are interested in developing your knowledge and practical skills,details of the next CPD seminar events organised by our partners atChiswell Green Dental Centre can be found at page 4. The seminars arefree of charge and valid for two CPD hours.

Best wishes,Dr Massimo Peru

Contents

Dr Claudio PeruSpecialist Endodontist

Developing Dental Expertise

Dr Luisa LucchesiSpecialist Orthodontist

Dr Rajiv PatelSpecialist Periodontist

Dr Aneesha ShahSpecialist Oral Surgeon

Dr Kostas IoannidisSpecialist Endodontist

Dr Zulaikha BurkiSpecialist Prosthodontist

Dr. Zulaikha Burki20, Rennie Court,11 Upper Ground,London, SE1 9LP

Mob: 077890-72059Email: [email protected]

Nationality: BritishGDC no: 84508

OBJECTIVE:

I qualified as a dentist in 2002. After working in General Practice for 5 years, I successfully completed Masters in Clinical Dentistry in Prosthodontics with Distinction from Kings College London 2009-2013 based at Guys Hospital. I hold the Membership in Restorative Dentistry (MRD) from Royal College of Surgeons Edinburgh. I am a GDC registered Specialist in Fixed and Removable Prosthodontics. I am also a fully trained and certified provider for Inman Aligner orthodontic system.

I am looking to work in a progressive practice where I can offer high quality and ethical dentistry.

EXPERIENCE:

Currently working as a Specialist Prosthodontist in the Department of Restorative Dentistry at Guys and St. Thomas Foundation Trust. I am responsible for treatment planning and management of patients with complex restorative needs and those needing extensive implant treatment. Most of my patients suffer from Severe Hypodontia and the restorative phase of management involves reorganising occlusion, a combination of conservative adhesive dentistry, onlays, veneers and multiple implant restorations. I am actively involved in clinical research and postgraduate teaching at Guys Hospital.

Prosthodontist in private practice; Sterling House Dental Centre till Nov 2014. Treating patients referred from in-house and local general dental practices that require restorative management and implant treatment.

General Practice

Worked as a General Dental Practitioner in mixed practice for 5 years (2005-2009), treating cases from all dental disciplines. Working closely with patients to develop a comprehensive treatment plan, managing patients expectations and providing treatment to the highest standard.

• St. James Road Dental Practice194a, Southwark Park Road, London

• Ooi Dental Practice 36, Brunel Road, London

Issue No2 - December 2015

Dr Simon MooreSpecialist Oral Surgeon

Page 2:Loss of a LowerIncisor in an adult. Case report Dr LuisaLucchesi

Chiswell Green Specialist Dental Centre

Page 3:MultidisciplinaryManagement OfSevere Hypodontia.Case report Dr Zulaikha Burki

Page 4:CPD courses/Lunch& Learn sessions/howto refer

Page

Welcome to the JSDEditor, Dr Massimo Peru BDS, MSc Endo

In this issue, Dr Rajiv Patel and Dr Dhru Shah discuss two interesting clinical cases on crown lengthening and soft tissue management in periodontics.Page 7 features an article by Clinton Compaan from Dental Dynamix regarding digital dentistry.If you are interested in developing your knowledge and practical skills, details of the new CPD seminar events organised by our partners at Chiswell Green Specialist Dental Centre can be found at page 8. The seminars are free of charge and valid for two CPD hours.You can also receive 1 hour verifiable CPD from our Journal of Specialist Dentistry by answering the questions on page 7 and emailing them to: [email protected]. We will then post you your certificate!

Best wishes, Dr Massimo Peru, Chief Editor

Dr Dhru ShahSpecialist Periodontist

Dr Vittorio FrancoSpecialistEndodontist



Piezo-surgery facilitated crown lengthening surgery: a case report.Dr. Rajiv M Patel, Specialist in Periodontics

Crown lengthening surgery aims to increase the amount of supragingival tooth tissue by resection of the adjacent soft and or hard tissues to enable otherwise unrestorable teeth to be restored by increasing the retention and resistance forms of the teeth.In the case of endodontically treated teeth, a post and crown restoration is far more likely to have a favourable long term outcome if a minimum 2 mm of supragingival dentine can be maintained circumferentially. This would allow the crown margins to finish on dentine and is known as the ferule effect. Retention of the crown would therefore not be solely reliant on the strength of the bond between the dentine and core material. Caries and previous restorations can however make it difficult to find the required amount of dentine. If the endodontic prognosis for the tooth is good, crown lengthening surgery may be considered to enable adequate restoration of the tooth and ultimately maximise the lifespan of the tooth. Excision of the surrounding gingival tissue alone to expose the desired amount of dentine is rarely sufficient; resection of the underlying alveolar crest must also be carried out. Thus, due consideration must be paid to the biologic width. The biologic width is said to represent the tissue attachment as measured from the apical extent of the gingival sulcus to the alveolar crest. It is comprised of approximately 1.5 mm of junctional epithelial attachment and 1 mm of connective tissue attachment. The measurement does not include the sulcus or probing depth. Therefore the biologic width can be measured clinically by subtracting the probing depth from the depth to the alveolar crest. The biologic width can then be used to determine how much bone removal is required (if required) to maintain healthy marginal periodontium. E.g. a biologic width of approximately 3 mm plus a pocket depth of 2 mm would require bone adjustment such that a distance of 5 mm was present from the new gingival margin position to the alveolar crest. In thin gingival tissues, encroachment of restoration margin on the biologic width may result in gingival recession. In thick tissues it may result in chronic inflammation. Removal of supporting alveolar bone (known as ostectomy) can be performed with a number of different instruments including bone chisels, rotary instruments and ultrasonic instruments. The following case report describes the use of

a Piezosurgery unit to facilitate crown lengthening surgery at a lower premolar tooth. Piezoelectric Bone Surgery is a process that utilizes piezoelectric vibrations in the application of cutting bone tissue. The process was developed by Tomaso Vercellotti. The special ultrasonic microvibrations of the Piezosurgery technique cut bone and nothing else. No soft tissue is damaged, which allows you to work with a precision that facilitates not only surgery, but reduces postoperative discomfort for patients.By adjusting the ultrasonic frequency of the device, it is possible to cut hard tissue while leaving soft tissue untouched by the process. The ultrasonic frequency is modulated from 10, 30, and 60 cycles/s (Hz) to 29 kHz. The low frequency enables cutting of mineralized structures, not soft tissue. Power can be adjusted from 2.8 to 16 W, with preset power settings for various types of bone density. The tip vibrates within a range of 60–200 µm, which allows clean cutting with precise incisions. Initial presentation:A 71 year old gentleman presented with a failed crown on the lower left second premolar tooth. Insufficient supragingival dentine remained to allow restorations following the removal of caries. The tooth subsequently required endodontic treatment and provision of a post.

Figure 1 & 2. Buccal and lingual views of the lower left second premolar tooth following completion of endodontic treatment and provision of a fibre post and composite core. Note the absence of any supragingival dentine buccally and interproximally. Minimal supragingival dentine remined lingually.Crown lengthening surgery was required before the tooth could be prepared for a crown. Sufficient keratinised tissue was present both buccally and lingually to allow a 2 mm resection. There was no medical contraindication to surgery.

The ultrasonic vibrations with irrigation produces a cavitiation effect. This helps to maintain a clear field of view. Additionally, cavitation helps to produce microbubbles, releasing oxygen which has a mild haemostatic effect. Following the completion of ostectomy, the exposed root was scaled with a curette to remove any remnants of periodontal ligament. This ensures that there is no chance of re-attachment and no ‘re-bound’ effect in the months after surgery. Flaps were sutured and primary closure achieved with 5/0 PTFE sutures.

Figure 11. Immediate post-operative occlusal view demonstrating primary closure.

Figure 12 & 13. Immediate post-operative view buccally and lingually. Note the increase in the amount of supragingival dentine.Sutures were removed one week after surgery. No post-operative complications were reported and the patient reported only minimal post-operative discomfort.

Figure 14 & 15. Comparative pre and post-operative views. Adequate supragingival dentine is now present to allow restoration. In this case, the use of a piezosurgery unit enabled the speedy and accurate removal of alveolar bone with no risk of damage to the buccal and lingual flaps. Consequently post-operative healing proceeded without complication and with minimal patient discomfort.

Crown lengthening surgery:

Figure 3 & 4. Buccal incision to remove 2 mm of tissue made with a scalpel blade. Incisions were made buccally and lingually to excise 2 mm of adjacent gingival tissue. The tissue was removed with a surgical curette. Full thickness buccal and lingual muco-periosteal flaps were reflected to allow access to the alveolar crest. A piezosurgery unit (Piezotome® Cube LED, Acteon) was used with sterile saline irrigation to carry out the ostectomy.

Figure 5 & 6. Piezotome® Cube and tips

Figure 7 & 8. Ball ended tip used to create a depth gauge of 2 mm in the alveolar crest. A depth gauge cut was made in the alveolar crest to a measurement of 2 mm corresponding to the amount of gingivae removal. This ensured that the biologic width could be maintained.

Figure 9 & 10. Ostectomy performed with the small ball ended tip. Note the good visibility.

Issue 9- October 2017 3

Figure 7 & 8. Ball ended tip used to create a depth gauge of 2 mm in the alveolar crest.

A depth gauge cut was made in the alveolar crest to a measurement of 2 mm corresponding to the amount of gingivae removal. This ensured that the biologic width could be maintained.










Many times we see patients with gingival recession and wonder what is the cause and the management for these items. In this article, I will aim to portray some thoughts behind this specific condition and management options. It is important to look out for these conditions in practice and be able to consider management options. The definition of gingival recession is “exposure of the root surface due to an apical shift in the position of the gingivae from the cemento enamel junction”Patients may present with a variety of complaints when gingival recession occurs. These could be:- Sensitivity due to the exposed root.- Aesthetic concerns. This could present in various ways with the patient presenting with complaints of a long tooth, a notch, a yellow (or darkened) margin of the tooth or black spaces between the teeth- Soreness or pain when brushing The most important part to consider is that some patients may have no complaints at all and may not even be aware of their recession. This is particularly noted in the lower anterior incisor regions. The biggest concern in these areas is that if this is not identified, the predisposing cause may cause the recession to progress to a level where treatment options may not be possible.In my personal experience, I have seen cases of recession around the lower incisor teeth that has resulted in significant attachment loss rendering the prognosis of these teeth as poor or uncertain.Therefore, as someone who is reading this article, may I suggest that you develop a keen eye for recession defects.Patients who have noticed severe recession defects are often concerned that the loss of tissue may lead to tooth loss and thus having a discussion about this is important. Understanding aetiology is important. There may be various causes for recession and a few of them are;

1. Bacterial plaque can be a possible cause. Bacterial plaque and inflammation can lead to tissue loss (periodontitis) which can eventually result in recession. Similarly, treatment of periodontitis can also lead to recession.In these kind of cases, the recession normally involves interproximal tissue as well.2. Inappropriate tooth brushing can result in recession.This may be accompanied by various predisposing factors. In this case it is important to identify the cause and deal with the aetiology as part of the management3. Restorative factors can result in recession. Many times I have seen cervical lesions (at times being caused due to toothbrush trauma) being restored with restorations. The lack of marginal integrity of these restorations, allows inflammation and further recession to occur.4. Partial denture clasps may cause trauma in certain cases5. Lip or tongue piercings have also been reported to be associated with recession defectsWhen one has predisposing factors, these can make the recession occur faster. Some of these are:- A bulbous root (very often seen around upper canine teeth)- Buccally placed tooth- Lack of attached gingivae (this is often seen around lower incisors)- Presence of a fraenum (this is often seen around lower incisors as well)- A very shallow vestibule or buccal fold- Presence of a thin gingival biotypeThese factors may impede good oral hygiene or in the presence of aetiological factors initiate recession.

Tissue is the issue. Part 1.Recession defects – soft tissue loss around teethDr. Dhru Shah, Specialist in Periodontics


Classification of recessionThere are various classification systems used. The most common one is the Miller’s classification system. This looks at how extensive the recession defect is beyond the mucogingival junction and how much interproximal tissue loss has occurred. Miller’s ClassificationClass I – the recession does not extend beyond the mucogingival junction and the interproximal tissue is intactClass II – the recession extends beyond the mucogingival junction and the interproximal tissue is intactClass III – the recession does not extend beyond the mucogingival junction but there is interproximal tissue lossClass IV – is a total attachment lossIn this classification, if the recession is Class I and Class II, then complete root coverage is possible. However if the recession is class III or IV, then complete root coverage may not be possible.Therefore when a recession defect is noticed, the management plan must be considered. It is always important to address the aetiology first e.g if a patient has a history of traumatic tooth brushing, then this must be addressed.Then one must consider all the parameters to decide on the soft tissue procedure to consider. Some questions to ask are:1. What is the purpose of the procedure?2. What is the available tissue?3. What is the tissue biotype?4. Where is the recession defect?5. Is complete coverage possible if the purpose is root coverage?6. What is the patient’s main concernIn this case, the aim was not root coverage. The aim was to augment keratinised tissue in the shallow sulcus to enable better oral hygiene.If we consider the above information, the interproximal tissue loss is noted and therefore root coverage was not predictable. The patient’s main concern was not aesthetic but a healthy periodontium and thus a free gingival graft was considered.

In this next case – again of a lower anterior tooth, the patient was concerned about the recession from an aesthetic viewpoint. In addition, there was attachment loss past the mucogingival junction but the interproximal tissue was intact. Thus a root coverage procedure was done.

Considering the size of the defect, two separate connective tissue grafts were obtained.The aim of this article, is not to show each procedure but to give an overview of recession defects and the main things to look out for in order to manage or refer the case early.I hope this has been a useful overview.

Pre-operative view

Post-operative view

Pre-operative view

Post-operative view

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Issue 3 - March 2016 7

Digital Dentistry – It’s Here!

By Clinton CompaanDental Dynamix


“Digital dentistry” is a phrase that we read or hear more and more about but what does it all mean?

Most significantly, what does it mean for my patients and secondly how could my team and I benefit from moving into this digital world..?

Firstly, I strongly believe that this new digital world dramatically improves the overall experience felt by the patient. Patient satisfaction is one of the highest priorities of many private practices across the country but how do I increase patient satisfaction over and above treatment care? Many believe the secret is by increase your patient’s involvement, through better communication of their oral health, treatment options and outcomes. Patients want to be more involved and now they can, though experiencing their own treatment process via chair side, single visit CADCAM (PlanMill 30S) or the use of a 3D impression scanning camera (Planmeca Emerald) or a chair side smile design software makeover (Romexis Smile design), 3D x-rays (ProMax CBCT), 3D face photo (ProFace) are just some of the options now available to the modern dental practice, that can significantly increase and enhance your patients overall experience.

Secondly, how can my team and I benefit from taking this next step? This technology is design to be easy to use, time and cost effective, as well as reducing storage of paper and stone models, etc. Digital technology greatly improves diagnoses by displaying a greater amount of information. For example; overlaying 3D x-rays, 3D quadrant scans and 3D face photos all in one image, saved and displayed in one software package.

I’m excited to be part of this new Digital Connected World of Dentistry. At Dental Dynamix, we have always strived to bring the very latest technology to forward thinking practices, across the country, with a reputation of the highest levels of customer service and support, together with competitive prices.

Talk to us today, if you would like Dental Dynamix to connect you with your dream digital dental clinic.

“Innovation distinguishes between a leader and a follower.” Steve Jobs

CPD QuestionsAll questions relate to articles in this issue of the JSD by completing the answers you can earn I hour verifiable CPD.1). For endodontically treated teeth, what is the minimum supragingival dentine for a post and crown to have a favourable long term outcome? A. 2 mm B. 1.5 mm C. 1 mm2). What is an Ostectomy? A. Removal of a failed implant B. Removal of impacted teeth C. Removal of supporting alveolar bone3). When gingival recession occurs which is not a patient complaint? A. Aesthetic concerns B. Increased overbite C. Soreness or pain when brushing 4). Which is the description of Miller’s Classification Class III? A. The recession does not extend beyond the mucogingival junction but there is interproximal tissue loss B. The recession does not extend beyond the mucogingival junction and the interproximal tissue is intact C. The recession extends beyond the mucogingival junction and the interproximal tissue is intactPlease email your answers to: [email protected] o your name o GDC number o Postal addressWe will then post your certificate


By Clinton Compaan









By Clinton Compaan










Upcoming CPD EventsAs part of Chiswell Green Dental Centre‘s committal to dental excellence we periodically organise eveningseminars on different dental related subjects. These seminars are free of charge and valid for two CPD hours. To register for your place please contact our reception team on 01727 800 372 or email [email protected] Registration with refreshments starts at 6.15pm and the course begins at 7pm.

The next available seminars will be:

Lunch & LearnBook a “Lunch & Learn” session. We can visit you or you are welcome to bring your team to us. Let us show you the practice and give you a quick overview of the different treatment options available to your patients. We will provide a light lunch with refreshments. Just let us know how many members of your team will attend and each person will receive training worth 1 CPD hour. A certificate will be issued.

If you would like to participate in these sessions please email [email protected] or call us on 01727 800 372 for more information.


Tuesday 17th October 2017 - Dr Jashme Patel - Oral Surgery - Update on Mandibular Third Molars

Tuesday 14th November 2017 - Dr Dhru Shah - Periodontics - Tissue is the Issue, an Interactive case discussion

Wednesday 13th December 2017 - Dr Luisa Lucchesi - Orthodontics - Local Factors in the Aetiology of Malocclusion

Private referral formPractice and referring dentist detailsReferring practice ............................................................ Referring dentist details:Practice address ............................................................................................................................................................................................................................................Patient detailsPatient’s name ................................................................. Male/female ..................................................Patient’s address .............................................................. Date of birth .................................................Town/City....................................Post code: ................... Home telephone ................................................................................................................................. Mobile ..........................................................

Treatment required:Orthodontics Endodontics BiopsyImplants + Restorations Endodontics + Crown Crown LengtheningImplants placement only Prosthodontics Opinion onlyPeriodontics Oral Surgery Other Treatment (please specify below)

Reason for referral/provisional diagnosis ..........................................................................................................Treatment carried out to date .........................................................................................................................Medical and dental history .............................................................................................................................................

.....................................................................................................................................................................................

Documents

Journal of Specialist Dentistry Journal of Specialist ... · details of the next CPD seminar events organised by our ... Southwark Park Road, London • Ooi Dental ... Piezoelectric