Volume 7 Issue 4

ISSN: 2072-473X

Dental JournalEruptionof Oral LichenPlanus AfterInterferonTherapyfor HepatitisC Infection

Eruptionof Oral LichenPlanus AfterInterferonTherapyfor HepatitisC Infection



The Effect of TwoDisinfection Methods

on Surface Roughnessand Hardness of

Type III Dental Stone

The Effect of TwoDisinfection Methods

on Surface Roughnessand Hardness of

Type III Dental Stone

Yogafor Dental CareerLongevity




Cleft Lipand Palate:The MultidisciplinaryManagement

Cleft Lipand Palate:The MultidisciplinaryManagement

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Affiliation & DistributorsAffiliation & Distributors

Prof.RafiAljobory/IraqBDS, MSc, PhD Periodontics, President of the Iraqi Dental Association

Prof.AbdullahAl-Shammery/KSABDS, MS Restorative Dentistry / Rector, Riyadh Colleges of Dentistry & Pharmacy

Prof.MagidAminAhmed/EgyptOral & Maxillo-Facial Surgery / Vice President MSA UniversityDean, Faculty of Dentistry MSA University

Prof.JamalAqrabawi/JordanDDS, DSc, DMD Endodontics / Dental Faculty, University of Jordan

Prof.NabilBarakat/LebanonDDS, MSc, FICD Maxillo-Facial Surgery / President of LAO & EMAO

Prof.StephenCohen/USAMA, DDS, FICD, FACD, Diplomate, American Board of Endodontics

Prof.AzmiDarwazeh/JordanBDS, MSc, PhD Oral Pathology Oral Medicine / Former Dean, Faculty of Dentistry JUST / Examiner, Faculty of Dentistry RCS Ireland

Prof.MohamedSherineElattar/EgyptBDS, MSc, PhD Prosthodontics / Former Dean, Faculty of Dentistry, Pharos University / President of AOIA

Prof.FouadKadim/JordanBDS, MSc, PhD Conservative Dentistry / Vice Dean, Faculty of Dentistry, University of Jordan

Prof.HowardLieb/USADMD General Dentistry & Management Sciences / College of Dentistry, New York University

Prof.EdwardLynch/UKPhD (Lon), MA, BDentSc, TCD, FDSRCS (Ed), FADFE, FDSRCS (Lon)Head of Dental Education and Research Warwick University

Prof.LamisD.Rajab/JordanDDS, PhD, Pediatric Dentistry / Former Dean, Faculty of Dentistry, University of Jordan

Prof.IssamShaaban/SyriaBDS, PhD, Maxillo-Facial Surgery / Former Dean, Faculty of Dentistry Damascus University / President of Syrian OMFS Society

Prof.YousefTalic/KSABDS, MSc, DASO, FICOI, FICD, Consultant in Prosthodontics & Implantology, College of Dentistry, King Saud University

Prof.AbbasZaher/EgyptBDS, MS, PhD Orthodontics,Professor of Orthodontics / Vice-Dean, Alexandria University / Vice-President, World Federation of Orthodontists

Prof.CarinaMehannaZogheib/LebanonDDS, PhD Restorative and Esthetic Dentistry, FICDHead of Restorative and Esthetic Dentistry Department, Saint-Joseph University

Dr.NadimAbou-Jaoude/LebanonCES, DU, FICD Prosthodontics, Lecturer, Lebanese University / Clinical Associate, American University of Beirut

Dr.HasanenH.Al-Khafagy/UAEBDS, MSc, PhD Conservative Dentistry, Ajman University of Science & Technology

Dr.JaserAl-Maitah/JordanBDS, MSc Oral Surgery, Head of Dental Department, Jordanian Royal Medical Services

Dr.MaherAlmasri/UKDDS, MSc, PhD, FADFE, Director of Oral Surgery Courses, Bone Graft Modules Leader, Warwick University / President of the Syrian Section of IADR

Dr.AbdelsalamElaskary/EgyptBDS, FICOI, President of ASOI

Dr.YasinEl-Husban/JordanDDS, MSc Prosthodontics, Former Minister of HealthFormer Head of Dental Department & King Hussein Hospital

Dr.ZbysFedorowicz/BahrainDirector, The Bahrain Branch of the UK Cochrane Centre

Dr.WolfgangRichter/UKDDS, PhD, Restorative Dentistry, President of ESCD

Dr.MohammadSartawi/Jordan/UKBSc, BDS, MSc, FFDRCSI (OSOM)Senior Consultant Maxillo-Facial Surgeon

Founder&Editor-in-Charge

Dr. Issa S. Bader

DirectorDr. Mamoon A. Salhab

EditorialDirectorDr. Hassan A. Maghaireh

AssociateEditorsProf. Marco EspositoDr. Wesam A. Aleid

Assistant EditorsDr. Aveen K. Aljaff

Dr. Mohammad A. Abu KhalifehDr. Mohanad M. Ali Al-Janabi

MarketingDirectorSolange R. Sfeir

Art&DesignYazid M. Masa

Stephanie Moufarrej

SmileDentalJournalDecember 2012

Volume 7, Issue 4Quarterly Issued

Distributed Free of ChargeJordan: +962 7 96367954

Lebanon: +961 70 32 32 [email protected]

PrintedBy:Ad-Dustour Commercial Printing Press

Amman, Jordan

Mission StatementBridging the gap between advanced up-to-date peer-reviewed dental literature and the dental practitioners enabling them to do their jobs better- is our ultimate target.Besides, Smile provides readers with information regarding the available dental products, armamentarium, newsand proceedings of dental symposia, workshops and conferences.

Published by MENA Co. for Dental Services

Jordanian National LibraryRegistration # 3954/2008/P

ISSN 2072-473X

Editorial Review Board International Advisory Board

Paediatric Dentistry Dr.HaniAbudiakBDS, MFDS RCSFRCD, PhD

Dr.MajdAl-SalehBDS, DDS, MSc

Dr.GhadaKarienBDS, JDB

Dr.JumanaSabbariniBDS, MSc

Dr.LeemaYaghmourBDS, DUA, DUB

Prosthodontics

Dr.AhmadKutkutDDS, MS

Dr.LaylaAbu-NabaaBDS, MFD, RCS, PhD

Dr.YousefSadikMarafieBDS, MSD

Dr.ThamerM.TheebBDS, MSc

Prof.LouisHardanDDS, DEA, PhD

Restorative Dentistry

Dr.MaherM.AbdeljawadBDS, MDentSci

Dr.MohammadAl-RababahBDS, MFD RCSIre, MRD(Pros), RCSEd, JB(Cons) PhD

Dr.HakamMousaBDS, MSD

Periodontics Dr.ManalAzzehBDS, MSc

Dr.EdgardElChaarDDS, MS

Dr.MarwanQasemDDS, PG

Dr.HazemAl-AhmadBDS, MSc, FDSRCS

Maxillofacial Surgery

Dr.FaaizYaqubAl-HamadaniBDS, MSc

Dr.RaedAl-JalladBDS, MSc, FFDRCS, FDSRCS

Dr.HatemAl-RashdanBDS, MSc

Dr.KamisGaballahBDS, MSc, FDS RCS, PhD

Dr.AlanAl-QassabBDS, HDD (Ortho), MSc, MOMS RCPS(Glasg)

Dr.SuhailH.Al-AmadD.Clin.Dent (Melb), FRACDS-Oral Med, GradDip ForOdont (Melb), JMC

Oral Medicine

Orthodontics

Dr.EyasAbu-HijlehDDS, PhD

Dr.SamerSunnaBDS, MSc, M.Orth, RCS

Dr.FerasAbedAlJawadDDS, NBDE, MSc, PhD

Endodontics

Dr.MunaAl-AliBDS (Uni Jordan), MFDS (RCSI), DClinDent (Melbourne) Endodontics

Dr.HaniAlKadiBDS, Dip ODONT, MDS

Dr.MuayadAssafBDS, MSc

Dr.AliAbuNemehBDS, NDB, MSc

DisclaimerSmile Dental Journal makes every effort to report clinical information and manufacturers product news accurately, but cannot assume responsibility for the validity of product claims or typographical errors. Opinions or interpretations expressed by the authors are their own and do not necessarily reflect nor hold Smile team responsible for the validity of the content.

Affiliation & DistributorsAffiliation & Distributors

Editorial Policy Our objective is to publish a dental journal of consistent high quality and help to increase the exposure of literature written by dental professionals from our region at a global level. Literature review, original research, clinical case reports, case series, short communication, randomized clinical trials, and book reviews are among our scope of published

material, wheretheclinicalaspectofdentistryispresentedinascientificway,startingeacharticlewithanabstract,backedupbyreferencesinaccordancewiththeVancouvercitationstyle.

The journal encourages the submission of papers with a clinical approach, practicalormanagementoriented, besides papers that bridge the gap between dental research and clinical application.

Received manuscripts are first revised by the editor to check if it is appropriate for publishing in Smile and that it complies with the authors guidelines. The manuscript is then forwarded to two or more professional reviewers. Anonymity of both the author and reviewer is preserved (doubleblindedpeer-reviewprocess).

Our editorial policy which controls the quality of articles andassurestheiraccuracy,clarity,andsmoothreadability through high level enthusiast regional and international team of experts is our golden key for success.

Finally, we believe that a controlledcontent of advertisements could be informative and beneficial especially in dentistry, where the armamentarium and pharmaceuticals are a major and integral part of the dental science.

14Maxillofacial

Cleft Lip and Palate: The Multidisciplinary ManagementBy Emad Hussein, John Van Aalst, Alev Aksoy, Libby Wilson, Khaled Abughazaleh, Nezar Watted 46

The Retention of Complete Crowns Prepared with Three Different Tapers and Luted with Four Different Cements

Effect of Working Length Measurement by Electronic Apex Locator or Radiography on the Adequacy of Final Working Length: A Randomized Clinical Trial

Microleakage in Class II Composite Resin Restorations: Total Bonding and Open Sandwich Technique

Research Summaries in Focus

08Debate in Focus

54 Flash News 50 Ask the Experts

Dental Materials

24 The Effect of Two Disinfection Methods on Surface Roughness and Hardness of Type III Dental StoneBy Suha Fadhil Dulaimi

30Oral Medicine

Eruption of Oral Lichen Planus After Interferon Therapy for Hepatitis C Infection: Case Report

By Wafa Al-Shamali, Mohamed El-Khalawany, Rasha Al-Shemmari, Saqer Al-Surayei

36 Yoga for Dental Career LongevityBy Tetyana Ratushnyak

Dentist Health

60 Two Minutes with

Bahrain:BahrainDentalSociety+973 17723767, [email protected]:AlexandriaOralImplantologyAssociation+203 5451277, www.aoiaegypt.comIran:ShayanSiminTebCo.+98 21 66380364/5, [email protected]+98 2188287794/5, [email protected]

Iraq:IraqiDentalAssociation+964 015379267, [email protected]+964 7504510315, [email protected]+964 7504544479, www.prohealthline.comEmiratesScientificBureau+964 771 0131978, www.prohealthline.com

Jordan:JordanianDentalAssociation(JDA)+962 6 5665520, [email protected](Pharmadent)+962 6 5605395, www.basamat.com

Kuwait:KuwaitDentalAssociation+965 5325094, www.kda.org.kwLebanon:LebaneseDentalAssociation+961 1 611555, www.lda.org.lbLebaneseDentalLaboratoryAssociation(OPDL)+961 5955 151, www.opdlb.comRichaDentalStore+961 5 452555, www.richadental.com

Oman:OmanDentalSociety+968 95769039, [email protected]:PalestinianAssociationofImplantDentistry(PADI)+970 2 2954545, www.implant.psQatar:QatarDentalSociety+974 4393144, www.qatardentalsociety.orgAliBinAliMedicalThei-partner+974 4867871 ext. 247, www.alibinali.com

SaudiArabia:SaudiDentalSociety+966 1 4677743, www.sds.org.saSudan:SudaneseDentalAssociation+249 83 779769, [email protected]:NajjarTradingEst.+963 (11) 2244140, [email protected]:NobleMedicalEquipment+971 4 3255046, [email protected].+971 6 554 0206, www.mamut-dental.com

| 4 | Smile Dental Journal | Volume 7, Issue 4 - 2012

On an ongoing basis, experts in dental health in various fields of dentistry keep on doing their researches and studies. They present their key research findings at international conferences and events around the globe.

Organizers of dental conferences in the Arab world quite often have a tendency to invite prolific world known international speakers in the field to enrich their conferences scientific programs giving the way to present the latest advancements and developments in different fields of dentistry. In addition to the distinguished speakers, dental conferences in the Arab world are being held in a very elegant atmosphere, usually in luxurious hotels as

the meeting ground of industrial leaders and professional practitioners. The professional practitioners are not only dentists from different specialties, but dental assistants and dental technicians surprisingly seem also to have a considerable portion of the specialty representation chart of various dental conferences. In a recent international dental conference in the Middle East, the specialty representation charting revealed only 47% of the participants were general dental practitioners, while 20% of the participants were dental assistants, 19% were dental technicians, and the rest were dental specialists in different fields. They all have enjoyed the high level of the scientific program and have had the opportunity to meet the top industrial players in the field.

No doubt that English is the dominant universal language of science, technology, and many other fields of human knowledge. And so it is, English is the main language used in dental conferences, dental research, and dental articles. However, the use of English as the de facto global language of science creates distinct challenges for those who are not native speakers of English or those who have limited knowledge of English. It is estimated that less than 15% of the worlds population speaks English, with just 5% being native speakers. This extraordinary imbalance emphasizes the importance of recognizing and alleviating the difficulties faced by nonnative speakers or those having limited command of English if we are to have a truly global understanding and world openness in our dental conferences.

In this regard, considering that I am writing in English at a dental journal styled in English, in spite of the fact that considerable amount of its readers come from the Arab world, I would like to emphasize on the point that as far as I am concerned Arabic is our beloved language and we should cherish it, live with it in weal and woe. Though in this I may be going at odds with many opinions, I know I would provoke none of our readers if I call for some Arabic inserts in Smile Dental Journal. Maybe an editorial, description of journal contents, some of the advertisements, and if possible the abstracts of certain articles to say the least. This hybridization of the Journals content between Arabic and English in my opinion will add to the glamour of Smile Dental Journal and bridge the gap between Smile Dental Journal and the Arabic speaking colleagues.

In conclusion, and back to the subject of this editorial, it is very important for the organizers of dental conferences in the Arab world to give extra attention to the subject of translation and simultaneous interpreting of conference lectures to and from the Arabic language. The type of language used in dental conference lectures is highly specialized, and thus the translators and interpreters hired in these conferences should have the specialized knowledge in different fields of dentistry in order to give translations that are linguistically correct, scientifically accurate, and terminologically consistent.

Dr. Amjad Khoury BDS, MA [email protected]

Dental Conferences in the Arab World & the English Language

January, 22 - 25 3rd International Dental Congress of the Faculty of Oral & Dental Medicine

Cairo, Egyptwww.dentistry.cu.edu.eg

February, 27 - 28 Oman International Dental Conference 2013

Muscat, Omanwww.omanidc.com/2013/

May, 1 - 4 LUSD 13th International Convention

Rac Hariri Campus, Beirut, Lebanon [email protected]

May, 17 - 18Iraqi Dental Reunion (IDR 2013)

Erbil, Iraq

March, 12 - 16 IDS 2013

Cologne, Germanywww.ids-cologne.de

January, 28 - 30 24th Saudi Dental Society International Dental Conference

Riyadh, KSAwww.sds.org.sa

April, 24 - 26 2nd IQDAC (International Quintessence Dental Arab Congress)

Riyadh, KSAwww.iqdac.org

April, 6 - 8 MedExpo Saudi Arabia

Jeddah, KSAwww.medexposaudi.com

April 11 - 1218th Irbid International Congress

Irbid, Jordan

February, 5 - 7 AEEDC 2013

Dubai, UAEwww.aeedc.com

April, 4 - 6 Dubai Implantarium

Dubai, UAEwww.dubaiimplantarium.com

May, 2 - 38th CAD/CAM

Dubai, UAEwww.cappmea.com/cadcam8/

May, 14 - 153rd International Dental Conference & Exhibition

Tripoli, Libya

August, 28 - 31FDI 2103

Istanbul, Turkeywww.fdiworldental.org

International Calendar

Smile Dental Journal | Volume 7, Issue 4 - 2012 | 5 |

For more dental events please visit www.smiledentaljournal.com or our page on Facebook


Smile MessageThe Battle Against CancerThe fight against cancer is one of the most challenging issues facing humankind today. According to the Surveillance, Epidemiology, and End Results (SEER) Program of the National Cancer Institute and Based on rates from 2007-2009, 41.24% of men and women born today will be diagnosed with cancer at some time during their lifetime.

This fight has never been easy; nevertheless we will always stand tall and try by all means to defeat this disease.

One of the leading organizations fighting cancer in the Middle East is the King Hussein Cancer Foundation (KHCF), the legal umbrella organization responsible for the King Hussein Cancer Center (KHCC). KHCF is a free-standing independent non-governmental not-for-profit institution founded in 1997 by a Royal Decree to combat cancer in Jordan and the Middle East region and is dedicated entirely to cancer care.

KHCF undertakes many fundraising activities to help support cancer patients and maintain KHCC as a comprehensive cancer care center of excellence and its life-saving work has gained the widespread support of many members of the community.

This upcoming spring, Mostafa Salameh, the first Jordanian to climb Mount Everest, is leading an expedition from the lowest point on Earth, the Dead Sea, to the highest point on Earth, Mount Everest base camp. The aim of this expedition, which is named From the Lowest Point to the Highest Point for Cancer, will be to raise funds to support the New King Hussein Cancer Center Expansion Project.

The expedition will begin with a symbolic walk along the shores of the Dead Sea, after which the team will visit the children receiving cancer treatment at KHCC and collect the childrens wish flags that will accompany the team on their journey. The team will then trek to the Mount Everest Base Camp at the end of March 2013.

During this journey, a team of prominent Jordanians will take part, including our colleague Dr. Samer Sunna. Dr. Sunna a consultant orthodontist at the Sunna Orthodontist Center was awarded in 2004 the Royal Jordan First Award for Excellence in Medicine and Dentistry and four years later was awarded Man of the Year in Dental Health by the American Bio Society. Dr. Sunna is also one of the pioneer supporters of Smile Dental Journal since its launch back in 2006 and a prominent member of our editorial board.

Miss Iman Al-Majali, an International Development Coordinator at KHCF and a news anchor at Jordan TVI, urged everyone in the community to support this historic initiative as it not only raises awareness about one of the most important causes we deal with on a daily basis but it will also support a much needed expansion project that will allow KHCC to absorb the increasing number of cancer patients seeking life-saving treatment and not turn them away due to lack of space.

Miss Al-Majali who works on various grants from international donors stated that the new KHCC expansion will be a state-of-the-art facility to complement the existing center. This project will consist of two new buildings three times the size of KHCCs current premises, thus increasing its capacity to absorb in-patients from 3,500 to over 7,000 per year and increase the number of outpatient visits from 100,000 to over 150,000 visits, as well as reduce the number of patients on the waiting lists.

We believe that the battle against cancer should be everybodys concern. Donations in the expeditions name can be made in person at the office of the KHCF, by calling (+962-6)554490, or by visiting the pledge page:www.cancerpledges.com/SelectPledge.aspx?P_ID=35

Dr. Issa Salem BaderFounder & Editor-in-Charge

Smile Dental Journal



ABSTRACT

This mini review is based on a Cochrane systematic review entitled Interventions for replacing missing teeth: management of soft tissues for dental implants published in The Cochrane Library.

Clinicians are under pressure to meet patients expectations to provide them with naturally looking teeth, and while dental implants are very predictable nowadays, the challenge has shifted to the peri-implant soft tissue level, shape, thickness and contour. Many soft tissue manipulation techniques including flap designs and placing dental implants flapless have been promoted by different clinicians, each group of them defending their technique and/or approach. On the other hand, clinicians area subjected to information overload, and evidence based answers are needed when ever they are faced with a clinical intervention question at their daily practice, rather than relying on opinion based information. This mini review aims to answer two main questions:1 Is flap elevation necessary in implant dentistry?2 What is the best flap design in implant dentistry? Relying on up-to-date random controlled trials.

KEYWORDS

Flapless, Flap design, Soft tissue management.

Flapless Implant Dentistry: Evidence Based DebateHassan Maghaireh, BDS, MFDS(Ed), MSc Implants

Department of Oral and Maxillofacial Surgery, School of Dentistry, The University of Manchester, Manchester, UKClarendon Dental Spa, Leeds, UK

INTRODUCTION

Traditionally, dental implant surgery starts with raising flap procedures for implant placement. However, in recent years there has been some interest in developing techniques that can provide function, advanced aesthetics, comfort and long lasting prognosis with as minimally invasive surgery as possible. To fulfil these requirements flapless surgery has been advocated by many clinicians. In return many flap design variations have strong proponents with surgeons claiming that a particular design offers improved implant success. However, there is frequently disagreement and this area is controversial.

Numerous techniques have been proposed to design flaps aiming to preserve or rebuild the interdental papillae, but it is still unclear which ones achieve the best results. This interesting subject is as important as the debate on various flap designs while placing dental implants.

HISTORYOFDENTALIMPLANTS

Dental implants started to be offered as an option to replace missing teeth in the mid-1960s, however, implants were being used in very small numbers. Typical designs were sub-periosteal frames, blade vents or trans-mandibular devices, none of which was properly documented clinically. In general, only poor clinical results had been recorded even though allegedly successful cases were occasionally presented at meetings by the few academic outcasts who used the devices. Per-Ingvar Brnemark placed his first clinical root form dental implant in 1965.1 In the following 5 years, his clinical results were also unacceptably poor, with success rates of about 50%. Brnemarks early results seemed

to confirm that foreign materials did not work in the oral cavity for a number of reasons including the risk of infection.2

During the 1970s clinical outcomes for patients with Brnemarks implants have clearly improved, not as a result of traditional controlled trial studies but in an empirical way with the simultaneous changing of a great number of parameters. Implants were made wider with some design changes, implant healing time was prolonged and changes were made to the surgical and prosthodontic routines. Brnemark published an experimental study which mentioned the term osseointegration,1 but it was till the late 1970s when he published a retrospective clinical study which further discussed and confirmed the concept of osseointegration of dental implants , which was described as direct structural and functional connection between living bone and implant surface.3

Since that time, the revolutionary concept of osseointegration is now considered highly predictable. Today the implant-supported dental restorations are among the most accepted treatment options for treating edentulous and partially edentulous patients

FlapDesign

The term flap been used to indicate a section of soft tissue that is outlined by a surgical incision, carries its own blood supply, allows surgical access to underlying tissues, can be replaced as required on its original position, maintained with sutures and is expected to heal.4


There are many advantages for the patient as well as for the surgeon, since the procedure is less time consuming, bleeding is minimal, implant placement is expedited, and there is no need to place and remove sutures. However, since flapless implant placement generally is a blind surgical technique, care must be taken when placing implants. Angulation of the implants affected by drilling is critical so as to avoid perforation of the cortical plates, both lingual and buccal, especially on the lingual side of

Implants are usually placed after soft tissue flap elevation to visualize better the bone sites where the implant(s) will be placed. Flap elevation ensures that some anatomical landmarks (e.g. foramina, lingual undercuts or maxillary sinuses) are clearly identified and protected. When the amount of available bone is limited, flap elevation will facilitate implant placement maximizing bony contact while minimizing the risk of bone fenestrations. However, flaps are associated with some degree of morbidity and discomfort, and require suturing. There are situations, where flap elevation may not be necessary since the amount of bone is more than adequate and the risk of complications is minimal. Under these circumstances, flapless implant placement may be indicated, but when placing implants with a flapless procedure the surgeon is working blindly and care must be taken to avoid any complications such as bone perforations. Guided surgery aided with customized surgical templates derived from CT scans can help clinicians to minimize the risk of perforation and incorrect implant alignment.5

When dental implants are placed after reflecting soft tissue flaps, there generally is some bone resorption. During the initial phase of healing, bone resorption of varying degrees almost always occurs in the crestal area of the alveolar bone.6 The extent of alveolar height reduction resulting from this resorption is related to the bone thickness at each specific site.7

When teeth are present, blood supply to the bone comes from three different sources: from the connective tissue above the periosteum, from the periodontal ligament, and from inside the bone. When a tooth is lost, blood supply from the periodontal ligament disappears, so that blood now only comes from soft tissue source through the connective tissue above the periosteum and from the bone. Cortical bone is poorly vascularised and has very few blood vessels running through it, in contrast to soft cancellous bone. When soft tissue flaps are reflected for implant placement, this will disturb the periosteal layer; hence, the blood supply from the soft tissue to the bone (supra-periosteal blood supply) is removed, thus leaving poorly vascularised cortical bone without a considerable part of its vascular supply, prompting bone resorption during the initial healing phase. Another major function of the periosteum which will be badly affected is the venous blood drainage, therefore after raising a surgical flap and disturbing the periosteum, the amount of resulting post operative oedema is usually considerable due to lack of proper drainage.

There is some swelling, pain, and discomfort associated with every surgical procedure. With a flapless approach, surgical trauma is minimal because the punch or circular cut is very small, usually 1mm wider than the implant to be placed, so that postoperative pain, swelling, and discomfort related to soft tissue trauma are greatly minimized.

(Case2) Astra Tech dental Implant placed at the upper right central incisor immediately with flap elevation, guided bone regeneration and soft tissue grafting and restored with porcelain fused to metal crown.

A

C

E

B

D

F

(Case1) Astra Tech dental Implant placed at the upper left central incisor flapless and restored 3 months afterwards with a CAD CAM Atlantis titanium abutment and porcelain fused to metal crown.

A

C

E

B

D

F

was sutured back in place. The rationale for this incision was to keep the incision line away from the implants, thereby possibly preventing infection.

In a retrospective study,9 it has been demonstrated that there was no difference in the implant success rates when implants were placed with a mid-crestal incision, however, they concluded that it was far more advantageous to use a mid-crestal incision since the swelling and the postoperative pain were greatly minimized.

THEEVIDENCEIsflapelevationnecessary?

Lindeboom et al. in their random controlled trail10 ompared flapless versus flap elevation to place at least 6 implants in fully edentulous maxillae. The flapless surgery procedure was performed using individually customised surgical templates fabricated with CAD/CAM technology planned with the Procera Software 3D Planning Program (Nobel Biocare AB, Goteborg, Sweden). In the flapless group, soft tissues were punched away and after implant installation, the punch wounds were sutured. Data were reported in the publication up to 1 month after implant placement, however, the authors provided data up to 6 months after loading. At baseline, the patients who were going to receive flapless surgery were less satisfied. There were no withdrawals or complications up to 6 months. Two implants were lost in the flapless group versus none in the flap elevation group but this difference was not statistically significant.

In another random controlled trial on flapless dental implant, Fortin et al.11 compared a flapless versus a conventional flap elevation procedure to place dental implants in partially or fully edentulous patients in a randomised controlled trial. The flapless surgery procedure was performed using an image-guided system (CAD Implant, Medfield, Ma, USA) based on a template. After a 6 day follow up, thirty patients were included in each group and it was reported that less patients subjected to the minimally invasive surgery experienced postoperative pain than those patients subjected to conventional flap elevation.

Cannizzaro et al.12, and compared a flapless versus a conventional flap elevation procedure to place dental implants in partially edentulous patients. Templates were used for both groups. The flapless surgery procedure was performed based on intra oral, panoramic or CT scan information. Implants that obtained a primary stability >45 Ncm (all but one) were functionally loaded the same day. Implants in the control group were placed after mid-crestal incision and flap elevation following the manufacturer instructions. Twenty patients were included in each group with no apparent baseline differences between the two groups. No withdrawals after 3 years. In one patient of the flapless group, a flap had to be elevated to properly evaluate the direction of the drill. No prosthesis or implant failed.

the mandibular anterior area. In a 10 year retrospective review,8 a 3% fenestration of the implants placed flapless was reported due to incorrect bur angulation. However, there should be no problem if the patient has been appropriately selected and an appropriate width of bone is available for implant placement.

From all the above, we can tell that whether to raise a flap or not while placing dental implants is a very controversial subject, and this is going to be the first question in our systematic review.

In connection to the above subject, another question which clinicians face is what the best flap design is. The surgical placement of dental implants has undergone changes since the beginning of placement of root-form implants. Initially, using the Brnemark protocol,1 an incision in the mucosa or the muco-buccal fold was made, and then a flap was reflected to expose the underlying bone. The implants were placed and the flap

(Case3) JD Evolution dental implant placed at lower right 2nd premolar flapless with minimal post operative bruising and swelling.

A

C

B

D

(Case4) White Zirconia dental implant placed at upper right lateral incisor area, with minimal post operative bruising and swelling.

A

C

E

B

D


placement of dental implants still needs to be assessed, especially for fully edentulous patients where it might be more difficult to correctly position the stent.

Whichisthemosteffectiveflapdesign/technique?

A randomised controlled trial by Hunt et al. in 199615 compared the vestibular incision with the crestal incision using a split-mouth design of fully and partially edentulous patients. Patients were examined at 1, 7, 14 and 30 days, as well as at abutment connection 4 to 6 months after. The authors reported no significant differences for pain and oedema. Furthermore, there were no statistically significant differences for biological complications (wound dehiscence) which occurred in two sites of the crestal and three sites of the vestibular incision. In another random controlled study, Heydenrijk et al.16 compared crestal versus vestibular incisions to place one-stage dental implants with five patients were included in each group. There were no statistically significant differences for prosthesis/im-plant failures and complications between the groups. However, it was reported that four patients from the crestal group and one from the vestibular group suffered from hyperplastic tissue covering the healing abutment after surgery.

Arnabat-Dominguez17 compared Erbium: YAG laser with flap elevation at implant exposure to connect abutments. Ten patients were included in each group, once more, no withdrawal or implant failures occurred up to 6 months after abutment connection. Patients treated with laser did not receive local anaesthesia, though two patients had to be anaesthetised during the procedure: one due to pain and one due to profuse bleeding (complication). Fewer patients treated with laser experienced postoperative pain than those treated with conventional flap elevation. In the article, it was also reported that patients of the laser group consumed significantly fewer analgesics and more interestingly, the prosthetic procedures could start earlier (after 7.3 days) than in patients of the conventional flap group (after 13.6 days).

CONCLUSION

There is evidence suggesting that flapless or mini-invasive procedures can cause less postoperative pain, oedema and consumption of analgesics than conventional flap elevation. Flapless surgery performed by skilful clinicians in properly selected cases can be as successful and complication-free as conventional flap elevation. However, there is still insufficient evidence regarding a potential increased risk of complications/failures using a flapless approach. Clinicians should select patients for flapless implant placement with a great deal of caution in relation to their own clinical skills and experience. The safety and efficacy of customized surgical templates created with the help of planning software on CT scans to facilitate placement of dental implants needs still to be assessed.

Five patients had complications in each group: transient disturbance of the alveolar inferior nerve (one patient), maxillary sinus membrane perforation (one patient), peri-implant mucositis (one patient) and perimplantitis (two patients) in the flapless group; and wound dehiscence (two patients), peri-implant mucositis (one patient) and perimplantitis (two patients) in the conventional flap group. Less patients subjected to a flapless procedure experienced postoperative pain than those patients subjected to conventional flap elevation. Canizzaro et al. reported that patients of the flapless group suffered significant less oedema and consumed less analgesics than those in the conventional flap group.

Cannizzaro et al.13 in a more recent study, compared flapless versus flap elevation implant placement in partially edentulous patients following a split-mouth design random controlled trial. All implants were placed with an insertion torque >48Ncm and were immediately functionally loaded. Forty patients were included and two prostheses and two implants failed in each group, all in different patients. Once more, there were no statistically significant differences for prosthesis/ implant failures or biological complications between the two groups. However, it is worth mentioning that one patient had one biological complication (peri-implantitis with purulent discharge) in the flapless group versus four complications in three patients (one intrasurgical haemorrhage, one intrasurgical fracture of the buccal bone plate, one case of peri-implant marginal bone loss exceeding 4mm and one patient experiencing pain on chewing) in the flap elevation group. Fewer patients subjected to a flapless procedure experienced postoperative pain than those subjected to flap elevation. An interesting finding was that there were no differences for peri-implant marginal bone levels between the flapless and the conventional flap groups. Thirty-one patients preferred the flapless intervention; three patients preferred flap elevation and six patients had no preference. This difference was statistically significant. In this study, it was also reported that patients of the flapless group suffered significantly less postoperative swelling and consumed less analgesics than those in the flap elevation group and that the flapless procedure was significantly shorter.

In a recent systematic review, Esposito et al.14 reported that there is limited weak evidence suggesting that flapless implant placement can cause less postoperative pain, oedema and consumption of analgesics than flap elevation. Flapless surgery performed by skilful clinicians in properly selected cases can be as successful and complication-free as conventional flap elevation. Further more, it was recommended that clinicians should select patients for flapless implant placement with a great deal of caution with respect to their own clinical skills and experience. One interesting finding at the same systematic review was that the safety and efficacy of customised surgical templates created with the help of planning software on CT scans to facilitate flapless


Very little well conducted studies were found on the best flap design for implant dentistry, although it is a major issue for every implant dentist, since the high number of complications may have occurred simply by chance. It would be prudent not to extrapolate any conclusions from any short term studies with few number of patients, not to mention case reports as larger random controlled multicentre trials are needed to answer this question. More research (properly designed and conducted randomised controlled trials) is needed to evaluate the potential risks/advantages of flapless procedures and the safety and efficacy of implant planning software based on CT scans.

REFERENCES1. Brnemark PI, Hansson BO, Adell R, Breine U, Lindstrm J, Halln

O, Ohman A. Osseointegrated implants in the treatment of the edentulous jaw. Experience from a 10-year period. Scand J Plast Reconstr Surg Suppl. 1977;16:1-132.

2. Albrektsson T. & Wennerberg A. Oral implant surfaces: Part 2-review focusing on clinical knowledge of different surfaces. International Journal of Prosthodontics. 2004;17:544-64.

3. Brnemark P, Breine U, Adell R, Hansson B, Lindstrom J, Ohlsson A. & Wennerberg. Intraosseous anchorage of dental prostheses. I. Experimental studies. Scand J Plast Reconstr Surg. 1969;3(1):81100.

4. Jephcott A. The surgical management of the oral soft tissue: 1. flap design. Dental updates. 2007;34:518-22.

5. Van Steenberghe D, Glauser R, Blomback U, Andersson M, Schutyser F & Pettersson A. A computed tomographic scan-derived customized surgical template and fixed prosthesis for flapless surgery and immediate loading of implants in fully edentulous maxillae: a prospective multicenter study. Clinical Implant Dentistry and Related Research. 2005; 7(1):S11120.

6. Ramfjord Sp & Costich Er . Healing after exposure of periosteum on the alveolar process. J Periodontol. 1968;38:199207.

7. Wood D, Hoag P, Donnenfeld O & Rosenfeld L. Alveolar crest reduction following full and partial thickness flaps. J Periodontol. 1972,42:1414.

8. Dominguez Campelo L & Dominguez Camara J. Flapless Implant Surgery:A 10-year Clinical Retrospective Analysis. int J Oral Maxillofac Implants. 2002;17:2716.

9. Sharf D & Tarnow D. Modified Roll Technique for localized alveolar ridge augmentation. Int J Periodontics Restorative Dent.1992;12:415-25.

10. Lindeboom JA, vanWijk AJ. A comparison of two implant techniques on patient-based outcome measures: a report of flapless vs. conventional flapped implant placement. Clin Oral Implants Res. 2010;21:366-70.

11. Fortin T, Bosson JL, Isidori M, Blanchet E. Effect of flapless surgery on pain experienced in implant placement using an image-guided system. Int J Oral Maxillofac Implants. 2006;21:298-304.

12. Cannizzaro G, Leone M, Consolo U, Ferri V, Esposito M. Immediate functional loading of implants placed with flapless surgery versus conventional implants in partially edentulous patients. A 3-year randomized controlled clinical trial. Int J Oral Maxillofac Implants. 2008;23:867-75.

13. Cannizzaro G, Felice P, Leone M, Checci V, Esposito M. Flap- less versus open flap implant surgery in partially edentulous patients subjected to immediate loading: 1-year results from a split-mouth randomised controlled trial. Eur J Oral Implantol. 2011;4:177-88.

14. Esposito M, Maghaireh H, Grusovin G, Ziounas I, Worthington H. Soft tissue management for dental implants: what are the most effective techniques? A Cochrane systematic review. Eur J Oral Implantol. 2012;5(3):22138

15. Hunt BW, Sandifer JB, Assad DA, Gher ME. Effect of flap design on healing and osseointegration of dental implants. Int J Periodontics Restorative Dent. 1996;16:582-93.

16. Heydenrijk K, Raghoebar GM, Batenburg RHK, Stegenga B. A comparison of labial and crestal incisions for the 1-stage placement of IMZ implants: a pilot study. J Oral Maxillofac Surg. 2000;58:1119-23.

17. Arnabat-Domnguez J, Espaa-Tost AJ, Berini-Ayts L, Gay- Escoda C. Erbium:YAG laser application in the second phase of implant surgery: a pilot study in 20 patients. Int J Oral Maxillofac Implants. 2003;18:104-12.


ABSTRACT

Patients with cleft lip and palate usually face a multitude of problems, esthetic compromise being the most noticeable, malocclusion, missing teeth, oronasal fistula, speech and hearing pathology are also present in most cleft patients; this necessitates a multidisciplinary treatment across various medical and dental specialties that extends from birth to adulthood but in separate stages. A protocol for the treatment of cleft patients should followed by the healthcare providers, and coordination amongst them is a major contributor to success in cleft treatment.

KEYWORDS

Cleft patients, Treatment protocol, Teamwork management.

Cleft Lip and Palate: The Multidisciplinary ManagementEmad Hussein - BDS, MSc, Associate ProfessorFormer chairman, Department of Orthodontics,

Faculty of Dentistry, Arab American University, Palestine - [email protected]

John Van Aalst - Associate ProfessorDirector, Pediatric/Craniofacial Plastic Surgery,

School of Medicine, University of North Carolina, USA - [email protected]

Alev Aksoy - Associate ProfessorSleyman Demirel University, Faculty of Dentistry

Department of Orthodontics, ISPARTA-TURKEY - [email protected]

Mahmoud Abu Mowais - ProfessorArab American University, Jenin, Palestine - [email protected]

Khaled AbughazalehDiplomate American Board Oral and Maxillofacial Surgery

Private Practice, Chicago, IL, Adjunct Assistant Professor Department Oral and Maxillofacial Surgery, University of KentuckyChicago, USA - [email protected]

Nezar Watted - ProfessorDepartment of Orthodontics, University of Wurzburg, Germany

[email protected]

INTRODUCTION

Cleft lip and/or palate are the most common craniofacial anomalies, occurring disproportionately across the world. Cleft anomalies affect several organs and functions within the human body, necessitating multidisciplinary treatment across various specialties.

This article gives a brief comprehensive overview of cleft lip and palate, including the embryology and etiology of cleft formation, the incidence of clefting, and the contemporary multidisciplinary treatment approach of cleft lip and palate.

Embryology of cleft formation

The critical period for proper intrauterine development of the face is between the fifth and seventh weeks of gestation, with the sixth week being the most important. During this time, the morphodifferentiation and orientation of the unpaired frontonasal process, which includes the medial and lateral nasal processes, occur simultaneously with progressive medial migration and growth of the paired maxillary processes (Fig. 1).1

The palate is formed in two stages: In the first stage, the primary median palatal triangle is formed, derived from the merging of the two mesial processes originated from the median frontonasal process. This is completed by the eighth intrauterine week. In the second stage, shelf-like outgrowths known as lateral palatine processes, derived from the maxillary processes, grow horizontally above the tongue to form the secondary palate.

(Fig. 1) Formation of lip and primary palate

Libby Wilson - MD, Program DirectorCraniofacial/Cleft Palate Program at Orthopaedic Hospital, Los Angeles, USA - [email protected]


Additionally, adult patients with cleft anomalies may also suffer from marital problems. These and other scenarios all require psychosocial support for the cleft patient as well as his/her family.5

By improving a childs social skills, educational pursuit, both the child and his/her parents may be able to overcome the issues that stem from the childs physical appearance.5

Other associated abnormalities include oronasal fistula, speech and hearing pathology, malocclusion, which is always present in cleft lip and palate patients. Anterior and posterior crossbites due to anteroposterior and transverse deficiency of the maxilla, rotation of the incisors due to muscle pull, lateral incisors at the cleft site are frequently missing and supernumerary teeth may be present at the non-cleft side. Carious teeth and periodontal inflammation are often present due to dental neglect (Figs. 3-5).6,7

The merging or fusion of these processes is completed by the twelfth intrauterine week (Fig. 2).

Any insult to the fusion process between the fifth and seventh intrauterine weeks leads to the formation of clefts. This may lead to irritation of the nasal septum, causing repeated respiratory tract and middle ear infections. Additionally, the tongue may be postured in the cleft space during swallowing, which may further widen the cleft space.

Etiology of cleft Lip and Palate

The etiology of cleft remains unclear. It is presumed to be multifactorial, with various contributing environmental and genetic factors.2

Toxin exposure during the antenatal period is more likely to be present in developing countries due to poor sanitation, inadequate infrastructure, and political instability. For many of the same reasons, metabolic disorders and malnutrition are also more likely tobe an issue for pregnant women in developing countries. Genetic factors and consanguinity are also major potential risk factors for birth defects.3

Problems Associated With Clefts

Patients with cleft lip and palate usually face a multitude of problems, esthetic compromise being the most noticeable.

The esthetic obstacle in children with cleft lip and palate may often lead to various types of psychosocial distress. For example, patients may feel that there is a stigma attached to their appearance. They often perceive themselves as unattractive, which may influence their psychological behavior and lead to problems with communication.4

Esthetic issues can also limit a childs life prospects. Some affected children may not attend school regularly, due to teasing, bullying, speech difficulty, and hearing problems.6

(Fig. 2) Formation of secondary palate

(Fig. 3) Skeletal and Dentoalveolar irregularities associate with cleft lip and palate

(Fig. 4) Oronasal fistula associated with cleft palate

(Fig. 5) Repaired oronasal fistula during alveolar bone graft


TREATMENT TIMING & PROTOCOL The First Closure: Lip

The first procedure that cleft patients receive is surgical closure of the lip. Following the rule of 10s, a patient admitted for lip closure should be 10 weeks of age, weigh at least 10 pounds, have a hemoglobin 10mg/100ml, and have aWBC count


The central incisor is usually distolabially rotated and inclined due to muscular pull (Fig.14). Care should be taken while leveling this incisor and other teeth, so as not to push the roots of these teeth into the cleft space. Following a successful graft placement, it is preferable to keep the incisor roots invested in bone at the pre-grafting stage while the correct tooth angulation is achieved at least 2 months after grafting (Figs.15,16).7

Treatment Principles in the Mixed Dentition Stage

The main objective during the mixed dentition stage is to prepare the cleft patient for a bone graft. The collapsed (overlapped) alveolar segments may be impeded in theirgrowth. It is important that these segments be unlocked by expansion during the early stages of development when growth is most rapid. Orthodontic expansion of collapsed buccal segments will also facilitate the push-back of the premaxilla to restore a favorable arch form, which was initially interrupted by the lack of alveolar bone continuity on the cleft side.

Expansion is carried out successfully by a quadhelix expansion appliance (Fig. 11), giving the surgeon a more favorable surgical field to perform the bone graft.Expansion devices should be used for at least four months after the bone graft, as freshly grafted bone is unable to maintain the expansion (Fig. 12).7

Crowding is usually present on the non-cleft side in unilateral cleft patients, and should also be relieved during the mixed dentition stage. At the crowding site, serial extractions can sometimes be carried out to provide space for eruption of the canine, while lateral incisors are usually missing at the cleft side. Supernumerary teeth should be extracted during the bone graft surgery and primary teeth adjacent to cleft should be extracted at least two months prior to surgery (Fig. 13).10

(Fig. 13) Post orthodontic expansion of collapsed buccal segments

(Fig. 12) Collapsed buccal segments in unilateral cleft palate patient before expansion

(Fig. 11) A quadhelix expansion appliance

(Fig. 15) Corrected position of the central incisor

(Fig. 16) A successful bone graft placement appearing by a periapical X-ray

(Fig. 14) The central incisor is usually distolabially rotated and inclined in a cleft palate patient


Bone Graft at the Cleft Side

Bone grafting has several advantages. It is performed to support the long-term expansion of the dental arch, maintaining arch continuity and form while also providing bone for the passage of the erupting canine through the graft.6

A bone graft will also support the teeth adjacent to the cleft site, ensuring orthodontic movement of these teeth without periodontally compromising them. The bone graft will also improve facial esthetics by providing support to the base of the nose, which is lacking due to the cleft space (Figs. 17-19).

The bone graft is usually taken from the cancellous bone of the iliac crest. Other donor sites that provide cancellous bone include the mandibular symphysis and the skull.

Timing of alveolar bone graft relates to tooth development and is carried out between the ages of 6-9 years, using the stage of root formation of the maxillary canine as a guide for the proper timing for bone graft is better than just following chronological age, when one third of the canine is formed viewed by a periapical x-ray is the best time to consider bone graft. . This may lead to spontaneous canine eruption through the graft and healthy gingiva surrounding the graft, with normal bone height.6, 9

Orthopedic Mid Face Growth Enhancement

Maxillary hypoplasia is a well-known feature of cleft lip and palate patients. It may be due to scarring from the surgical repair of the cleft lip and/or palate, which may cause lip tightness and palatal scarring that restricts the growth of the maxilla. Studies by Ross et al. showed that untreated cleft patients exhibited normal maxillary growth, further supporting this hypothesis.

Orthopedics applies interrupted forces which can aid maxillary sutures. However, the success of maxillary orthopedic advancement remains limited due to the tightness of the lip and palatal scarring. The decision to use a face mask or to undergo orthognathic surgery should be made early during treatment planning for patients with mild to moderate skeletal discrepancies (Fig. 20).11,12

Orthognathic surgery

Cleft patients will usually have jaw disharmony at the end of their facial growth period, manifested by mid-face deficiency. Growth of the maxilla is impaired in sagittal,transverse and vertical dimensions, evident in the form of anterior and posterior cross bites. Mandibular over-closure is also apparent due to maxillary deficiency in the vertical dimension.

Orthognathic surgery is required in about 25% of adult cleft patients according to the severity of skeletal features. The most commonly affected jaw in cleft patients is the upper jaw. Thus, in most cases,

(Fig. 17) Alveolar bone exposed at cleft side

(Fig. 18) Cancellous bone packed into cleft

(Fig. 19) Incisor roots invested in bone at the pregrafting stage while the correct tooth angulation can be achieved after successful graft placement

(Fig. 20) Orthopedic treatment using a facemask


Orthodontic preparation for the orthognathic surgery aims to correct dental compensation due to the skeletal discrepancy. Other goals of pre-surgical orthodontics include arch coordination and removal of any occlusal prematurity.

Relapse in the upper jaw position is possible due to the scar tissue resulting from the upper lip and palate repair. Distraction osteogenisis enables the gradual advancement of the hypoplastic maxilla with corticotomy cuts that will allow expansion of the scar tissue (Figs. 21,22). This decreases the possibility of relapse and allows for a longer-term correction over orthognathic surgery.

Distraction ostegenesis has recently benefited from major advances in instrumentation, especially regarding the materials used to create instruments and the creation ofbidirectional instruments. This has improved results and further decreased the need for more orthognathic surgery.12

SUMMARY

Patients with cleft lip and palate require a team approach for their treatment, comprised of several specialists. This multidisciplinary care starts from birth and continues into adulthood, and coordination amongst specialists is a major contributor to success in cleft treatment.

ACKNOWLEDGMENTS

The Authors thank Sonya Patel and Hala Borno from the medical school at The University of North Carolina for their participation to the editing of this article

REFERENCES1. Moore KL. The Developing Human: Clinically Oriented

Embryology. Philadelphia, PA: Saunders, 1977.2. Malcolm C, Johnston P. Embryogenesis of cleft lip and palate, In:

McCarty JG, editor. Plastic Surgery, vol 4. Cleft Lip and Palate and Craniofacial Anomalies. Saunders, Philadelphia, PA, 1990:2532.

3. Persaud TVN, Chudley AE, Skalko BG. Basic Concepts in Teratology. New York: Alan R. Liss, 1985.

4. Marcusson A. Adult patients with treated complete cleft lip and palate. Methodological and clinical studies. Swed Dent J Suppl 2001;145:1 57.

5. Mars M, Sell D, Habel A (2008) Management of cleft lip and palate in the developing world. GBR, Chichester.

6. Peter D. Waite and Daniel E. Waite, Bone Grafting for the Alveolar Cleft Defect Seminars in Orthodontics, Vol 2, No 3 (September), 1996:192-6.

7. Christos C. Vlachos. Orthodontic Treatment for the Cleft Palate Patient Seminars in Orthodontics, Vol 2, No 3 (September), 1996:197-204.

8. Black PW, Scheflan M. Bilateral cleft lip repair: putting it all together. Ann Plast Surg. 1984;12:118127 23.

9. Samuel Berkowitz, A Comparison of Treatment Results in Complete Bilateral Cleft Lip and Palate Using a Conservative Approach Versus Millard-Latham PSOT Procedure Seminars in Orthodontics, Vol 2, No 3 (September), 1996:169-18.

10. Carla A. Evans, Orthodontic treatment for patients with clefts Clin Plastic Surg 31 (2004;27190.

11. Rygh P, Tindlund R. Orthopedic expansion and protraction of the maxilla in cleft palate patientsa new treatment rationale. Cleft Palate J 1982;19:104-112.

12. Graber L , Vanarsdall R, Vig K. Orthodontics Current principles and Techniques, 5th edition, Elsevier. 2011;965-89.

the orthognathic procedure performed involves the advancement of the upper jaw (Le Fort I) rather than setting the mandible back. When the reverse overjet is severe, a two-jaw surgery may be required, impacting breathing and esthetics (Figs. 21-24).7

The proper timing of orthognathic surgery is when facial growth has ended. A hand and wrist radiograph can help determine the end of facial bone growth.

(Fig. 21) Cephalometric X-ray for adult cleft patient before surgery

(Fig. 23) Lateral facial view of a cleft patient before orthognathic surgery

(Fig. 22) Surgical advancement of the upper jaw (Le Fort I) for the same patient in Figure 21

(Fig. 24) Lateral facial view of the same cleft patient in Figure 23 after maxillaryadvancement and mandibular set back


ABSTRACT

Dental stone casts are often heavily contaminated with microorganisms from saliva and blood. The aim of this study is to evaluate the surface properties (roughness and hardness) of dental stone type III subjected to two different disinfection methods.

Materials & Methods: Thirty specimens of type III dental stone were prepared and divided into three groups: control group (10 specimens without disinfection), Sodium hypochlorite group (10 specimens immersed in 0.525% NaOCl for 10 min), and microwave group (10 specimens subjected to microwave irradiation at 650 watt for 10 min). Surface roughness was tested by two dimensional profilometrer and Shore D hardness test was carried out.

Results: dental stone specimens immersed in 0.525% NaOCl for 10 min resulted in surface roughness and hardness values comparable to control group P values (0.657, 0.591 respectively) using Student t-test. While microwave irradiation at 650 watt for 10 min produces smoother casts (mean 0.816) with reduced hardness (mean 68.8).

Conclusion: Disinfection of type III stone casts with immersion in 0.525% NaOCl for 10 min did not affect surface roughness and hardness, while microwave irradiation at 650 watt for 10 min result in smoother surface with reduced hardness.

KEYWORDS

Disinfection, Microwave irradiation, Dental stone, Sodium hypochlorite.

The Effect of Two Disinfection Methods on Surface Roughness and Hardness of Type III Dental Stone

Suha Fadhil Dulaimi BDS, Msc. Conservative Dentistry Lecturer, Dental Technologies Department, College of Health & Medical Technologies, Foundation of

Technical Education, Ministry of Higher Education & Scientific Research, Baghdad Iraq [email protected]

INTRODUCTION

Controlling the risk of bacteriological and viral transmission from the dental clinic to the dental laboratory and vice versa has been of interest to staff at dental clinics and dental laboratories for several years.1 Dental prosthesis, appliances, impressions and casts are heavily contaminated with micro-organisms from saliva and blood.2

Recommendations exist for the use of safety measures, as well as for the disinfection techniques required after impression making.3,4 Because of difficulties associated with impression disinfection and sterilization an alternative method would be cast sterilization or even disinfection.5 Another indication for cast sterilization or disinfection, when laboratory has no assurance that an appropriate disinfection protocol was followed.6 Also disinfection of impression materials hinders possible cross-contamination only at the time the cast is poured. Because prosthesis are tried in the patients mouth, they must be regarded as the major vehicle for cross contamination.7,8

Sodium hypochlorite is one of the worlds oldest and most widely used disinfectants, it is effective against HIV and hepatitis virus.9 Many researchers recommended using sodium hypochlorite for impression and cast disinfection.10 Microwave energy has been suggested for drying and disinfection of gypsum cast and authors found that it is effective for sterilization of casts after

24hrs and does not affect strength of cast,11 but the effect of microwave energy or chemical disinfection on physical properties has not thoroughly examined.

The purpose of this study is to evaluate the surface properties (roughness, hardness) of dental stone Type III subjected to microwave energy or chemical disinfection with sodium hypochlorite.

MATERIALS&METHODS

In this study Type III dental stone (Geastone Type III Zeus Seri Loc. Tamburino 58036 Roccastrada GR Italy) was evaluated. Thirty specimens were prepared from mixing dental stone Type III with distilled water according to manufacturer instructions (powder/water ratio 100gm/30ml). The recommended powder was added to the water in a rubber bowel and mixed by hand to a smooth consistency. Mixed dental stone were poured down the side of 7cm diameter and 1cm thickness mold, which was vibrated using vibrator (Bego, Germany) during filling to draw out air bubbles from the mixture and reduce porosity. Then all specimens were stored in air at room temperature range of 232C for 1hr., after that all specimens were removed from the mold and left to dry for 24hrs at room temperature.


difference among groups P


(Table6) P- value = 0.591, no significant difference in comparison with control, while microwave irradiation group showed highly significant difference in comparison with control and NaOCl group P


irradiation on disinfection, dimensional accuracy, and surface porosity of dental casts. Mustansiriyah Dental Journal. 2011;8(2):177-87.

23. Luebke RJ, Chan KC. Effect of microwave oven drying on surface hardness of dental gypsum products. The Journal of Prosthetic Dentistry. 1985;54(3):431-5.

As conclusion, disinfection of dental stone casts with immersion in 0.525% sodium hypochlorite for 10 min resulted in surface roughness and hardness values comparable to that of control group. However disinfection with microwave irradiation at 650 watt for 10 min leads to smoother casts with reduced hardness.

REFERENCES1. Sofou A, Larsen T, wall B, Fiehn N-E. In vitro study of

transmission of bacteria from contaminated metal models to stone models via impressions. Clin Oral Invest. 2002;6:166-70.

2. Verran J, Kossar S, McCord JF. Microbiological study of selected risk areas in dental technology laboratories. Journal of Dentistry. 1996;24:77-80.

3. Taylor RL, Wright PS, Maryan C. Disinfection procedures: their effect on the dimensional accuracy and surface quality of irreversible hydrocolloid impression materials and gypsum casts. Dental Materials. 2002;18:103-10.

4. Rentzia A, Coleman DC, ODnnell MJ, Dowling AH, OSullivan M. Disinfection procedures: their efficacy and effect on dimensional accuracy and surface quality of an irreversible hydrocolloid impression material. Journal of Dentistry. 2011;39:133-40.

5. Tarik EM, Al-Ameer SS. The effect of storage time and disinfection method on the activity of some dental stone disinfectants. Journal of Baghdad Dentistry College. 2005;17(3):8-12.

6. Anusavice KJ. PHILLIPS Science of Dental Materials. Tenth edition W.B. Saunders company Philadelphia Pennsylvania USA. 1996:208.

7. Berg E, Nielsen , Skaug N. Highlevel microwave disinfection of dental gypsum casts. International Journal of Prosthodontics. 2005;18(6):520-5.

8. Berg E, Nielsen , Skaug N. Efficacy of high level microwave disinfection of dental gypsum casts: the effects of number and weight of casts. International Journal of Prosthodontics. 2007;20(5):463-4.

9. Schwartz RS, Hensly DH, Bradley DV. Immersion disinfection of irreversible hydrocolloid impressions in PH-adjusted sodium hypochlorite Part 1: microbiology. Journal of Prosthodontics. 1996;9(3):217-22.

10. Ivanovski S, Savage NW, Brockhurst PJ, Bird PS. Disinfection of dental stone casts : antimicrobial effects and physical property alterations. Dental Materials. 1995;11:19-23.

11. Hassan RH. The effect of microwave disinfection on tensile strength of dental gypsum. Al- Rafidain Dental Journal. 2008;8(2):213-8.

12. Rohrer MD, Bluard RA. Microwave sterilization. Journal of American Dental Association. 1985;110(2):194-8.

13. Abdelaziz KM, Hassan AM, Hodges JS. Reproducibility of sterilized rubber impressions. Brazilian Dental Journal. 2004;15(3):209-13.

14. Hersek N, Canay , Aka K, ifti Y. Tensile strength of type IV dental stones dried in a microwave oven. The Journal of Prosthetic Dentistry. 2002;87(5):499-502.

15. Abdleaziz KM, Combe EC, Hodges JS. The effect of disinfectants on the properties of dental gypsum, Part 2: surface properties. Journal of Prosthodontics. 2002;11(4):234-40.

16. Abdulla MA. Surface detail, compressive strength, and dimensional accuracy of gypsum casts after repeated immersion in hypochlorite solution. The Journal of Prosthetic Dentistry. 2006;95(6):462-8.

17. Craig RG. Restorative dental materials. 10th edition Mosby St. Louis Missouri USA.1997:334-44.

18. Hasan RH, Mohammad K. The effects of drying techniques on the compressive strength of gypsum products. Al-Rafidain Dental Journal. 2005;5(1):63-8.

19. Tuncer N, Tufekioglu HB, Calikkocaoglu S.. Invetigation on the compressive strength of several gypsum products dried by microwave oven with different programs. The Journal of Prosthetic Dentistry. 1993;69:(3)333-9.

20. Luebke RJ, Schneider RL. Microwave oven drying of artificial stone. The Journal of Prosthetic Dentistry. 1985;53:(2)261-5.

21. Kumar RN, Karthik KS, Maller SV. Infection control in Prosthodontics. Journal of Indian Academy of Dental Specialist. 2010;1(2):22-4.

22. Abass MS, Mahmood MA, Khalaf BS. Effect of microwave


ABSTRACT

Background:The association between oral lichen planus (LP) and hepatitis C virus infection (HCV) has been discussed in several papers worldwide. The exact pathogenesis of oral LP in HCV-positive patients is still uncertain. There are several studies, which highlight the role of alpha-interferon (INF) being used for treatment of HCV- positive patients, resulting in eruption or exacerbation of oral LP.

Casedescription:We present a case of erosive LP limited to oral cavity in a 44-year-old Egyptian man with chronic HCV infection who was treated with INF and ribavirin. Despite an extended period of treatment, there was no significant effect on the viral activity (viral load). Interestingly, following five months of termination of anti-hepatitis therapy, there was recurrence of oral LP lesions which was confirmed histopathologically. His condition improved dramatically by Protopic cream 0.1%.

Conclusion:Altered immunogenicity of HCV appears to be the likely explanation, hence understanding the importance of follow-up of the patient post anti-hepatitis C therapy.

KEYWORDS

Oral lichen planus, Hepatitis C infection, Alfa-interferon.

Eruption of Oral Lichen Planus After Interferon Therapy for Hepatitis C Infection: Case Report

Wafa Ali Al-Shamali - BDS, MFDS-RCSI, FRCD (C)Specialist in Oral Medicine and Pathology, Farwaniya Dental Specialty Center - Kuwait

[email protected]

Mohamed Ahmed El-Khalawany - MD, ICDPSpecialist, Farwaniya Hospital- Dermatological Department - Kuwait

Rasha Matter Al-Shemmari - MD, MRCGP (INT)Specialist Family Medicine, Dasman Center - Kuwait

Saqer Abdulrahman Al-Surayei - MD, FRCP Gastro-CanadaSenior specialist, Farwaniya Hospital, Department of Gastroenterology - Kuwait

INTRODUCTIONOral lichen planus (LP) is a relatively common chronic inflammatory condition that affects the oral mucous membrane with variable clinical traits. Since the first description of oral LP associated with hepatitis C infection was reported in 1991,1 there have been several reports suggesting the association between HCV infection and oral LP.2 Many studies have showed higher prevalence (1.6-20%) of oral LP in HCV-positive patients.2-7 In contrast, some researchers found weak or no correlation between chronic HCV infection and LP.8-11

A region-based correlation between HCV infection and LP has been described by some researchers worldwide.12 However, the possible etiopathogenic mechanism that links the two diseases remains unclear. Immunogenic dysregulation of host infected with HCV, reaction to anti-hepatitis medications particularly alpha-interferon or viral infection are considered to be the current acceptable etiopathogenic factors causing oral LP.12-13

The clinical and histological features of oral LP associated with hepatitis C infection subjects are no different from the control patients. Although, erosive form of oral LP is common clinical phenotype noted in seropositive hepatitis C individuals, the management of oral LP in patients with or without hepatitis remains the same. CASEREPORT

A 44-year-old Egyptian male was referred from dermatology department at Farwaniya hospital to oral medicine clinic, who presented with painful and swollen ulcerated lower lip on March 2010. On examination, there was apparent swollen lower lip with central erosive areas oozing fresh blood from the eroded surfaces on light palpation, and there were white fine and coarse lace-like mucosal changes abutting the eroded lesions (Fig.1). Also, there was bilateral lymphadenopathy with mobile, tender lymph nodes palpable in the submandibular triangular region.


lesions were seen on the rest of oral cavity mucosa. The clinical presentation of the lip and oral cavity lesions were consistent with LP.

On reviewing his medical history, he had been diagnosed with hepatitis due to HCV infection (genotype 4) in 2008 for which he received combined therapy of pegylated interferon-alpha (180mcg SC, weekly for 48 weeks) and ribavirin (1000mg PO daily for 48 weeks).

The patient reported an oral soreness and burning sensation after one month of the anti-hepatitis therapy inception for the first time. The exact diagnosis of oral lesion and subsequent therapy provided by dermatology department had not been known to us. Nevertheless, oral condition was quiescent through the period of the therapy. The oral symptoms reappeared five months following discontinuation of anti-hepatitis therapy with increased severity resulting in severe pain, difficulty in eating, swallowing and speaking. In addition, he noticed progressive swelling of the lower lip with bleeding ulcers over the next 6 weeks.

Besides his known medical condition, he is on insulin to manage his diabetes (type II). Furthermore, he is not a cigarette smoker and he does not drink alcohol. An incision biopsy of lower lip lesion revealed interface dermatitis confirming our clinical provisional diagnosis. Microscopically, the specimen exhibited ortho-keratosis with prominent granular layer, intense band-like lymphohistiocytic infiltrate with plasma cell predominance and hydropic degeneration of basal cell layer with scattered Civatte bodies. (Figs4-6)

The patient was treated with protopic cream 0.1% three-four times daily for 2 weeks. The lower lip status improved dramatically. (Fig.7)

Intra-oral examination revealed bilateral white and red lesions on posterior part of the buccal mucosa. These lesions had striking reticular pattern (reminiscent of LP) centered on erythematous mucosal areas. The lesion on right buccal mucosa was found rubbing against heavily restored molar tooth with amalgam (Figs2,3). No other

(Fig.4) reveals interface dermatitis (Hematoxylin and eosin stain at lower magnification 4X plain)

(Fig.1) shows a swollen lower lip with central erosive and hemorrhagic areas

(Figs2-3) Exhibit lichenoid changes reticular pattern on right (A) and left (B) buccal mucosae

A

B


DISCUSSION

Among viruses, human herpes viruses, human papilloma virus and hepatitis viruses have been linked with oral LP, albeit on the basis of equivocal data.12

There have been several studies, which suggest an association between LP and HCV infection.3-7 In a recent review the pooled data from all studies revealed a statically significant difference in the population of HCV seropositive subjects among LP patients when compared with the controls.

Interestingly, geographic heterogeneity seems to play an important role in this LP-HCV association. As indicated by studies from the Mediterranean basin showing a significant association whereas studies from Northern Europe did not present any such association. Furthermore, in studies from countries with high prevalence such as Egypt, negative or insignificant association between HCV infection and oral LP has been reported.12,14 The discrepancy may be explained by genetic differences among the population studies and this may possibly be the reason for development of LP in our patient.

The exact etiopathogenesis of oral LP in HCV-positive individual is still uncertain. Nonetheless, eruption of oral LP in our case could have resulted from a lichenoid reaction to the medication used in the treatment of hepatitis C, particularly alpha-interferon. This hypothesis (i.e. drug reaction) was plausible in some studies.15-20 Most of these case reports demonstrate the aggravating effect of the interferon rather than causative effect for the development of oral LP in patient with HCV infection. Besides, in our case, reappearance of severe erosive oral LP while not receiving INF therapy, suggests that it may not have played a significant role in its pathogenesis. Nonetheless, this may be viewed as it having more aggravating rather than causal effect. Therefore, it would be a good practice to screen the oral cavity of HCV-positive patients prior to initiating antiviral therapy. So, the possible eruption of oral LP can be anticipated and managed appropriately especially in those with quiescent LP.

Besides INF therapy, other confounding factors appeared to have contributed to the possible initiation or aggravating already present of oral LP in our case, such as presence of amalgam on right mandibular molar and chronic rubbing of buccal mucosa. Unfortunately, we are not aware of the intra-oral examination findings of the patient prior to anti-hepatitis treatment.

Also, there is plethora of literature suggesting role of immune dysregulation in the pathogenesis of oral LP involving the cell-mediated immunity. However, viral factors, such as genotypes of HCV and HCV-RNA levels, are less important pathogenic cause.12

(Fig.5) Reveal hydropic degeneration with intense lympho-histoicytic infiltrates. (Hematoxylin and eosin stain at higher magnification 20X)

(Fig.6) Shows prominent Civatte body (*)

(Fig.7) shows dramatic improvement of lower lip lesion after two weeks of topical tacrolimus use


5. Sanchez-Perez J, De Castro M, Buezo GF, Fernandez-Herrera J, Borque MJ, Garcia-Diez A. Lichen planus and hepatitis C virus: prevalence and clinical presentation of patients with lichen planus and hepatitis C virus infection. Br J Dermatol. 1996;134(4):715-9.

6. Thais Dias Tavares Guerreiro, Marilia Moura Machado, Thais Helena Proenca de Freites. Association between lichen planus and hepatitis C virus infection: a prospective study with 66 patients of the dermatology department of the hospital Santa Casa de Misericordia de Sao Paulo. An Bras Dermatol. 2005;80(5):475-80.

7. Nima Mahboobi, Farzaneh Aga-Hosseini, Kamran Bagheri Lankarani. Hepatitis C virus and lichen planus: the real association. Hepat Mon. 2010;10(3):161-4.

8. Simon C, Tucker and Ian H. Coulson. Lichen planus is not associated with hepatitis C virus infection in patients from North West England. Acta Derm Venereol. 1999;79:378-9.

9. Karin Soares Goncalves Cunha, Angela Correa Manso, Abel Silveira Cardoso, Jacqueline Bittencourt Althoff Paixao, Henrique Sergio M. Coelho, Sandra Regina Torres, and Rio de Janeiro. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:330-3.

10. Yu Zhou, Lu Jiang, Jie Liu, Xin Zeng, Qian-ming Chen. The prevalence of hepatitis C virus infection in oral lichen planus in an ethnic Chinese cohort of 232 patients. Int J Oral Sci. 2010;2(2):90-7.

11. Del Olmo JA, Pascual I, Bagan V, Serra MA, Escudero A, Rodriguez F, Rodrigo JM. Prevalence of hepatitis C virus in patients with lichen planus of the oral cavity and chronic liver disease. Eur J Oral Sci. 2000;108(5):378-2.

12. Giovanni Lodi, Crispian Scully, Marco Carrozzoo, Mark Griffiths, Philip B. Sugerman, and Kobkan Thongprasom. Current controversies in oral lichen planus: report of an international consensus meeting. Part1. Viral infections and etiopathogenesis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:40-51.

13. A. A. Al Robaee and A. A. Al Zolibani, et al. Oral lichen planus and hepatitis C virus: is there real association? Acta Dermatoven APA. 2005;15(No1):14-9.

14. G. Lodi, M. Giuliani, A. Majorana, A. Sardella, C. Bez, F. Demarosi, A. Carrassi, et al. Lichen planus and hepatitis C virus: a multicentre study of patients with oral lesions and a systematic review. British journal of drematology. 2004;151(6):1172-81.

15. Nagao Y, Sata M, Ide T, Suzuki H, Tanikawa K, Itoh K, Kameyama T. Development and exacerbation of oral lichen planus during and after interferon therapy for hepatitis C. Eur J Clin Invest. 1996;26(12):1171-4.

16. Nagao Y, Kawaguchi T, Ide T, Kumashiro R, Sata M. Exacerbation of oral erosive lichen planus by combination of interferon and ribavirin therapy for chronic hepatitis C. Int J Mol Med. 2005;15(2):237-41.

17. Grossmann Sde M, Teixeira R, de Aguiar MC, do Carmo MA. Exacerbation of lichen planus lesions during treatment of chronic hepatitis C with pegylated interferon and ribavirin. Eur J Gastroenterol Hepatol. 2008;20(7):702-6.

18. Barreca T, Corsini G, Franceschini R, Gambini C, Garibaldi A, Rolandi E. Lichen planus induced by interferon-alpha-2a therapy for chronic active hepatitis C. Eur J Gastroenterol Hepatol. 1995;7(4):367-8.

19. Protzer U, Ochsendorf FR, Leopolder-OchsendorfA, Holtermuller KH. Exacerbation of lichen planus during interferon alfa-2a therapy for chronic active hepatitis C. Gastroenterology. 1993;104(3):903-5.

Why oral mucosa is most frequently affected is still unknown. Several experimental studies conducted proposing a theory of compartmentalization of mucosa that still does not give a clear explanation to this phenomenon.21,22

In HCV seropositive subjects, erosive oral LP is commonly prevalent lesion.23,24 Mega et al.25 noted three types of OLP. He found lymphocytic inflammation deeply infiltrating lamina propria in OLP associated with a HCV infection and that could be associated with the erosive trait, as noted in our case.

Management of HCV associated oral LP lesion is no different from oral LP in HCV-negative subjects. Since there is no cure different therapies are aimed primarily to ameliorate the signs and symptoms of oral LP. Although corticosteroids have been the mainstay of management, other immunosuppressant and immunomodulatory agents have also contributed significantly towards treatment of the disease.12,26-28 A comparative systemic review of 28 randomised controlled clinical trials of therapy for symptomatic oral LP has concluded that there is insufficient evidence to support the effectiveness of any specific treatment as being superior.26,29 A plausible therapeutic approach should be guided by severity of the patients condition. In our case, tacrolimus cream (0.1%) was prescribed and used three to four times daily for 2 weeks. Some studies recommend use of tacrolimus as second line of treatment especially in reluctant lesion. We preferred to use it due to severity of the lesion, which is found to be effective in other studies.12,26 In order to prevent a flare up of the condition, we avoided use of systemic immunosuppressant therapy.

Up to the time of writing this case report, his oral condition is fairly controlled with topical steroids in addition to tacrolimus. Due to chronicity of LP, relapses of his oral condition did occur but with lesser frequency and severity. The potential for malignant transformation of OLP is still controversial. The frequency ranges from 0.4% to 6.25% with the highest rates in the erythematous and erosive lesions.30-32 Follow up is mandatory not only to control his oral LP but also to detect early malignant transformation. REFERENCES

1. Mokni M, Rybojad M, Puppin D. Lichen planus and hepatitis C virus. J Am Acad Dermatol. 1991;24(5 Pt 1):792.

2. Nita Chainani-Wu, Francina Lozada-Nur, Norah Terrault. Hepatitis C virus and Lichen planus: a review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004; 98(2):171-83.

3. LC Figueiredo, F Carrilho, HF De Andrade, DA Miglian. Oral Diseases. 2002;8(1):42- 6.

4. Ghaderi R, Makhmalbaf Z. Shiraz E-Medical Journal. 2007;8(2):72-9.


20. Areias J, Velho GC, Cerqueira R, Barbedo C, Amaral B, Sanches M, Massa A, Saraiva AM. Lichen planus and chronic hepatitis C: exacerbation of the lichen planus under interferon-alpha-2a therapy. Eur J Gastroenterol Hepatol. 1996;8(8);825-8.

21. Carrozzo M, Quadri R, Latorre P, Pentenero M, Paganin S, Bertolsso G. Molecular evidence that the hepatitis C virus replicates in the oral mucosa. J Hepatol. 2002;37:364-9.

22. Pilli M, Penna A, zerbini A, Vescovi P, Manfredi M, Negro F. Oral lichen planus pathogenesis: a role for the HCV-specific cellular immune response. Hepatology. 2002;36:1446-52.

23. Carrozzo M, Grandolfo S, Carbone N, Colombatto P, Broccoletti R, Garzino-Demo P, Ghisetti V. J Oral Pathol Med. 1996;25(10):527-33.

24. Michele D, Mignogna MD, Lucio Lo Russo, et al. Oral lichen planus: different clinical features in HCV-positive and HCV-negative patients. Int J Dermatol. 2000;39(2):134-9.

25. Mega H, Jiang W, Takagi M. Immunohistochemical study of oral lichen planus associated with hepatitis C virus infection, oral lichenoid contact sensitivity reaction and idiopathic oral lichen planus. Oral diseases. 2006;7(5):296-305.

26. Thongprasom K, Carrozzo M, FurnessS, Lodi G. Intervension for treating oral lichen planus. Cochrane Database of Systemic Reviews 2011, Issue 7.

27. N Lavanya, P Jayanthi, Umadevi K Rao, K Ranganathan. Oral lichen planus: An update on pathogenesis and treatment. J Oral Maxillofac Pathol. 2011;15:127-32.

28. Mahnaz Sahebjamee, Fatemeh Arbabi-Kalati. Management of oral lichen planus. Archives of Iranian Medicine. 2005;8(4):52-6.

29. Analia Veitz Keenan and Debra Ferraiolo. Insufficient evidence for effectiveness of any treatment for oral lichen planus. Evidence-based dentistry. 2011;12:85-6.

30. Giovanni Lodi, Crispian Scully, Marco Carrozzoo, Mark Griffiths, Philip B. Sugerman, and Kobkan Thongprasom. Current controversies in oral lichen planus: report of an international consensus meeting. Part1. Viral infections and etiopathogenesis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;100:164-78.

31. Atessa Pakfetrat, Abbas Javadzadeh-Bolouri, Samira Basir-Shabestari, Farnaz Falaki. Oral lichen planus: A retrospective study of 420 Iranian patients. Med Oral Patol Oral Cir Bucal. 2009;14(7):E315-8.

32. Marija Bokor-Bratic, Ivana Picuric. The prevalence of precancerous oral lesions. Oral lichen planus. Archive of oncology. 2001;9(2):107-9.


ABSTRACT

Dental professionals are always at high risk for musculoskeletal disorders and mental stress due to the nature of their work. This article will discuss work related injuries among dentists and will introduce Yoga Techniques to prevent and recover from these injuries; specifically designed postures will be described to practice in-office time between appointments, as well as breathing techniques and relaxation.

Aim: To introduce Yoga practice to Dental Professionals and discuss techniques that are able to prevent and treat common injuries at work. To aquante dental professionals with Meditation, Pranayama (breathing) & Relaxation techniques for their own and their patients benefit.

Conclusion: Several studies and tests have shown great improvement implementing Yoga practice into daily life among dental practitioners with different work related health issues. Physical Yoga practice improved postures and strength of the musculoskeletal system, mental relaxation and meditation helps to reduce work related stress and breathing techniques helped to calm and focus the mind. Better health better productivity at work and a better, longer life.

KEYWORDS

Dentist, Work-related injury, Musculoskeletal Disorder (MSD), Yoga, Stretching.

Yoga for Dental Career LongevityTetyana Ratushnyak

Certified full time Yoga Teacher and Fitness Class Instructor Amman - Jordan / Shenzhen China [email protected]

INTRODUCTION

Being a dentist for a while, how often have you noticed headaches, back and neck pain, or stiffness in your arms? How many colleagues have complained of serious spine injuries or joint pain? Working full day, without brakes, trying to accept

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