Smile Dental Journal Volume 4 Issue 3

Dr. Layla Abu-Naba'aBDS, MFD, RCS, PhD ProsthodonticsDr. Hazem Al-AhmadBDS, MSc, FDSRCS Maxillo-Facial Surgery

Dr. Zaid Al-BitarBDS, MSc, MOrth, RCS Orthodontics Dr. Hatem Al-RashdanBDS, MSc, Jordanian Board of Maxillo-Facial SurgeryDr. Majd Al-SalehBDS, DDS, MSc Pediatric Dentistry Dr. Hisham Al-ShormanBDS, PhD PeriodontologyDr. Ahmad Al-TarawnehDDS, M.Clin.Dent, Jordanian Board of Orthodontics Dr. Hayder Al-WaeliBDS, MSc, Jordanian Board of PeriodontologyDr. Moeen Al-WeshahBDS, MSc, Jordanian Board of Endodontics Dr. Muayad AssafBDS, MSc Endodontics

Dr. Bader Eddin BorganBDS,MDS, MOrth, RCSEd Orthodontics

Dr. Manal AzzehBDS,MSc, Jordanian Board of Periodontology

Dr. Iyas DarweeshBDSDr. Moh'd HammoBDS, DESE Endodontics

Dr. William KhairallahDrCD, CESE Restorative & Esthetic Desntistry

Dr. Lama JarrahBDS,MSc, Jordanian Board of Orthodontics

Dr. Abeer MahmoudBDS, MSc Pediatric Dentistry

Dr. Ahmad KhraisBDS, MSc, Jordanian Board of Periodontology

Dr. Hakam MousaBDS, MSD Operative DentistryDr. Yanal NusairBDS, FDSRCS, PhD, FFDRCSI Oral & Maxillo-Facial SurgeryDr. Lina ObeidatBDS, Jordanian Board of Conservative Dentistry Dr. Jumana SabbariniBDS, MSc, Jordanian Board of Pediatric DentistryDr. Samer SunnaBDS, MSc, M.Orth, RCS OrthodonticsDr. Imad TamimiDMD, OMFS American DiplomateDr. Nora TleelDDS, MSD, Diplomate in the American Board ofPediatric DentistryDr. Leema YaghmourBDS, DUA, DUB Pediatric and Community DentistryDr. Nayef YounesBDS, MSc, Jordanian Board of Endodontics

Dr. Muna Al-AliBDS, MFDS

International Advisory BoardEditorial Review Board

Smile 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.

Bridging 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, news and proceedings of dental symposia, workshops and conferences.

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Smile Dental JournalSeptember 2009Volume 4, Issue 3Quarterly Issued

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Smile Dental Journal

Prof. Jamal Aqrabawi / JordanDDS, DSc, DMD EndodonticsDental Faculty, University of Jordan

Prof. Abdullah R. Al-Shammery / KSA BDS, MS Restorative DentistryDean, Riyadh College of Dentistry and Pharmacy Prof. Magid Amin Ahmed / EgyptOral and Maxillo-Facial SurgeryVice President MSA UniversityDean, Faculty of Dentistry MSA University

Prof. Azmi Darwazeh / JordanBDS, MSc, PhD Oral Pathology Oral MedicineFormer Dean, Faculty of Dentistry JUSTExaminer, Faculty of Dentistry RCS Ireland

Prof. Fouad Kadim / JordanBDS, MSc, PhD Conservative DentistryVice Dean, Faculty of Dentistry, University of Jordan

Prof. Issam Shaaban / SyriaBDS, PhD, Maxillo-Facial SurgeryFormer Dean, Faculty of Dentistry Damascus UniversityPresident of Syrian OMFS Society

Prof. Mohamed Sherine Elattar / EgyptBDS, MSc, PhD ProsthodonticsDean, Faculty of Dentistry, Pharos University, President of AOIA

Prof. Nabil J. Barakat / LebanonDDS, MSc, FICD Maxillo-Facial SurgeryPresident of LAO & EMAO

Dr. Jaser Al-Ma'itah / JordanBDS, MSc Oral SurgeryHead of Dental Dept., Jordanian Royal Medical Services

Dr. Nadim Abou-Jaoude / LebanonCES, DU, FICD ProsthodonticsLecturer, Lebanese UniversityClinical Associate, American University of Beirut

Dr. Yasin El-Husban / JordanDDS, MSc ProsthodonticsFormer Head of Dental Dept. & King Hussein Hospital

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Prof. Howard Lieb / USADMD General Dentistry & Management SciencesCollege of Dentistry, New York University Prof. Lamis D. Rajab / JordanDDS, PhD, Pediatric DentistryFormer Dean, Faculty of Dentistry, University of Jordan

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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, where the clinical aspect of

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08Dr. Mohammed Qasim Al Rifaiy

Patient’s Satisfaction With Removable Partial Dentures 50

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Function, Aesthetics and Biomimetics in the Interdisciplinary Treatment: Concerning a Clinical Case

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4 Smile Dental Journal Volume 4, Issue 3 - 2009

Editorial

A vaccine against 2009 H1N1 flu is being produced. The FDA announced on September 15th that it has approved four vaccines against the 2009 H1N1 influenza virus. Based on preliminary data from adults participating in multiple clinical studies, the 2009 H1N1 vaccines induce a robust immune response in healthy adults 8-10 days after a single dose, as occurs with the seasonal influenza vaccine.

At this time, there are few cases and few deaths reported in people older than 64 years old, which is unusual when compared with seasonal flu as this age group is considered a high risk condition. However, pregnancy and other previously recognized high risk medical conditions from seasonal influenza appear to be associated with increased risk of complications from this 2009 H1N1. These underlying conditions include asthma, diabetes, suppressed immune systems, heart disease, kidney disease, neuromuscular disorders and pregnancy.

People infected with seasonal and 2009 H1N1 flu may be able to infect others from 1 day before the symptoms appear to 5-7 days after. This can be longer in some people, especially children and people with weakened immune systems.

CDC recommends the use of the antiviral drugs Oseltamivir or Zanamivir this season. Antiviral drugs are medicines that fight against the flu by keeping flu viruses from reproducing in the body; they may also prevent serious flu complications.

Influenza virus is destroyed by heat (75-100°C). In addition, several chemical germicides, including chlorine, hydrogen peroxide, detergents, iodine-based antiseptics and alcohols are effective against human influenza viruses if used in proper concentration for a sufficient length of time.

Arthur A. Dugoni Pacific School of Dentistry Infection Control Committee released the following protocol for managing dental patients with confirmed or suspected respiratory infection in accordance with the United States Centers for Disease Control and Prevention’s (CDC) guidelines:Patients who present with acute respiratory symptoms consistent with infection (Fever, cough, fatigue, and sore throat) should be asked to delay all routine dental treatment until their current illness is resolved and the patient is symptom free. For patients who present with confirmed or suspected influenza A (H1N1) and require emergency dental care, the following precautions should be followed:* Limit treatment provided to the minimum necessary to reduce the patient’s pain or oral infection.* Instruct the patient to wear a surgical mask at all times when not actively receiving treatment.* Personnel treating the patient should wear a fitted surgical mask during patient treatment to prevent contact with contaminated aerosol.* Minimize the production of aerosols or cough-producing procedures to the minimum.

While routine and accurate cleaning and disinfection strategies are applied, and according to CDC, if a patient presents for routine treatment and has acute respiratory symptoms with or without fever and the dentist suspects the illness could be due to swine influenza (symptoms include fever, body aches, runny nose, sore throat, nausea, or vomiting or diarrhea), elective dental treatment should be deferred and the patient should be advised to contact their general health care provider. The health care provider will determine whether influenza testing or treatment is needed. If urgent dental care is required and swine influenza A (H1N1) has either been confirmed or is suspected, the care should be provided in a facility (e.g., hospital with dental care capabilities) that provides airborne infection isolation.

Staff experiencing influenza-like-illness (ILI) (fever with either cough or sore throat, muscle aches) should not report to work. Staff who have difficulty breathing or shortness of breath, or are believed to be severely ill, should seek immediate medical attention.

Influenza A viruses are found in many different animals, including ducks, chickens, pigs, whales and horses. According to Thacker and Janke pigs are unusual as they can be infected with influenza strains that usually infect three different species: pigs, birds and humans. This makes pigs a host where influenza viruses might exchange genes, producing new and dangerous strains. Because pigs are susceptible to avian, human and swine influenza viruses, they potentially may be infected with influenza viruses from different species at the same time. If this happens, it is possible for the genes of these viruses to mix and create a new virus. This type of major change in the influenza A viruses is known as antigenic shift. If this new virus causes illness in people and can be transmitted easily from person to person, an influenza pandemic can occur.

2009 H1N1 (referred to as “swine flu” early on) is a new influenza A virus subtype causing illness in people. This virus is spreading from person to person worldwide in much the same way that regular seasonal influenza viruses spread. On June 11, 2009, the World Health Organization (WHO) announced that the pandemic level of 2009 H1N1 flu had been raised to its highest level. According to the World Health Organization (WHO), a pandemic can start when three conditions have been met:1-Emergence of a disease new to a population 2-Agents infect humans, causing serious illness 3-Agents spread easily and sustainably among humans

Spanish Flu which had spread to become a world-wide pandemic on all continents in 1918, and eventually infected an estimated one third of the world’s population, killing about 50 million people, was identified as a subtype of H1N1 virus.

Spread of 2009 H1N1 virus is thought to occur in the same way that seasonal flu spreads. Flu viruses are spread mainly from person to person through coughing or sneezing. Sometimes people may become infected by touching a surface or an object with flu viruses on it and then touching their mouth or nose. Studies have shown that influenza virus can survive on environmental surfaces and can infect a person for 2 to 8 hours after being deposited on that surface. 2009 H1N1 viruses are not spread by food. You cannot get infected with novel HIN1 virus from eating pork or pork products.

The symptoms of 2009 H1N1 flu include fever (It’s important to note that not everyone with flu will have fever), cough, sore throat, runny nose, muscle aches, headache, chills and fatigue. A significant number of people who have been infected with this virus also have reported diarrhea and vomiting. While most people who have been sick have recovered without needing medical treatment, hospitalization and death from infection with this virus have occurred.

One thing that appears to be different from seasonal influenza is that adults older than 64 years do not appear to be at increased risk of 2009 H1N1 related complications. Centers for Disease Control and Prevention’s (CDC) laboratory studies have shown that no children and very few adults younger than 60 years old have existing antibody to 2009 H1N1 flu virus; however, about one-third of adults older than 60 may have antibodies against this virus.

Swine Flu: What should a Dentist Know

Dr. Issa Salem BaderEditor-In-ChargeSmile Dental Journal

Visit www.smile-mag.com or “Smile Dental Journal” page on facebook for updates

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ExpodentalRome, Italywww.expodental.it

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5Smile Dental Journal Volume 4, Issue 3 - 2009

Calendar of Events

Evaluation Of Some Of The Clinical Variables Affecting Patient’s Satisfaction With Removable Partial Dentures

AbstractPurpose: The purpose of the study was to examine the clinical variables such as age, gender, esthetic, comfort, speech and mastication on clinical acceptability and patient satisfaction associated with wearing removable partial dentures.

Materials and Methods: Sixty-six patients with 52 maxillary and 34 mandibular removable partial dentures (RPDs) were evaluated for satisfaction with their prostheses using visual analogue scales (VAS). The differences between two independent categories such as genders and dentures replacing mandibular or maxillary arches were tested for significance using Mann-whitney U-tests. Tests for significance of difference in the Kennedy classification consisting of four categories and opposing arch dentition with three categories were made by Krushkal – Wallis analysis of Variance tests. Spearman rank correlation coefficients between age of patients and retention / stability of RPDs and the VAS scores were determined to test positive or negative correlations.

Results: The difference between males and females for the mean scores for comfort was significant (p < 0.05). Aesthetics had a significant negative association with patients’ age. There were no significant differences between VAS scores and other clinical variables.

Conclusion: The difference between males and females for comfort was significantly different (p < 0.05). There was a significant negative association between aesthetic and age. The difference among other VAS scores and other clinical variables were not significant.

Key words: Prosthdontics, Removable partial denture, Visual Analogue Scale.

IntroductionRemovable partial dentures (RPDs) are one of the prosthetic treatment options for partially edentulous patients. Success of RPD treatment is often judged differently by dentists and patients. Dentists consider dentures to be successful when they meet certain technical standards whereas the patients evaluate their prostheses from the view point of their personal satisfaction.1,2 Patients’ satisfaction with RPDs seems to have multicausal factors.1 The risk of low patient’s acceptance has been associated with patients’ demographic variables including age, gender, previous denture experience and clinical variables such as pain, comfort, stability and design of dentures.2-7 According to Wakabayashi et al.4 and Frank et al.8-9, dissatisfaction with RPDs was higher in patients who had no prior experience with dentures. Other similar studies4,10 demonstrated that patients younger than 60 years and in poor health showed lower acceptance to RPDs. On the contrary, Knezovic et al.5 found no significant difference in patients’ assessment of the quality of their RPDs among age groups, previous denture experiences and type of opposing dentition.

Frank et al.8 reported that a majority of patients treated with RPDs, in private practices, were satisfied with their prostheses. However, even if the RPDs were constructed according to basic principles and concepts recommended by the Academy of Prosthodontics10, 10% of patients were dissatisfied.9 One study11 reported that the proportion of patients dissatisfied with their RPDs ranged from 3% to 4%. Thus, conflicting views existed on the influence of various clinical factors associated with the satisfaction or dissatisfaction with RPDs. Some of the clinical factors that are indirectly related to feeling of dissatisfaction with RPDs include age, sex, health, prior denture experience, esthetics and personality of patient. Dissatisfaction has also been reported to be associated with biomechanical factors of RPDs including retention / Stability, type ofopposing dentition, pain, and ability to chew and speak. This study examined seven aspects of

Dr. Mohammed Qasim Al RifaiyBDS, Cert (Prosth), MSc

Chairman of Prosthetic Dental Sciences DepartmentCollege of DentistryKing Saud University

[email protected]

Prosthodontics


clinical variables and evaluated them relative to the factors associated with dissatisfaction with removable partial denture treatment.

Materials and MethodsThe subjects were selected from patients who were treated at the Prosthodontic Department BLINDED. Maxillary and mandibular clasp retained cast partial dentures were made by the students under the supervision of one instructor. Patients with previous denture experience, pain in the remaining teeth, and who had recent extraction with incomplete healing and history of temporomandibular joint disorders were not included in the study.

Sixty-six subjects consisting of 38 males and 28 females with a mean age of 64.1 years participated in this study. Fifty-two maxillary and 34 mandibular RPDs were constructed by students supervised by one instructor (Table 1). The RPDs replacing partially edentulous arches were divided into four groups according to Kennedy classification (Class 1 through Class IV). Modification spaces and their numbers were not considered. The RPDs were further classified according to arch replacement as mandibular and maxillary RPDs. Opposing arch dentition were classified into three categories as natural teeth which included missing teeth replaced by fixed partial denture, RPD or complete denture. Complaints of pain due to over extension of denture base were relieved. The opposing dentitions were recontoured to develop occlusal harmony by recall appointments.

The patients were recalled after a period of one year for evaluation. The stability and retention of the RPDs were evaluated by one investigator using the index provided by Kapur12 modified by Wakabayashi et al.4 (Table 2). Each single prosthesis was evaluated by a sum score of retention and stability from 0 to 5 points by one investigator.

Patients were instructed to complete a questionnaire regarding name, age, gender and chronic diseases. In the other part of

the questionnaire, they were required to grade their RPDs depending on the level of satisfaction with regards to aesthetics, pain, comfort, speech ability, mastication ability and general satisfaction using a visual analogue scale (VAS).

The VAS scale consisted of a 100 mm line with the ends defining the grade of feeling between the phases. The left end of the line represented a satisfactory response and the right end of the line represented an unsatisfactory response. The patient registered his/her assessment with a pencil mark across the line at a point that corresponded to his/her subjective feelings. Satisfaction was then expressed as the distance in millimeters from the left end limit to the distance of pencil mark and represented as the VAS score. A low score represented a satisfactory feeling and a high score represented an unsatisfactory feeling.13,14 The scores for each RPD (maxillary and mandibular) were separately recorded by one investigator. The VAS was used in this study because it is easily understood and is sensitive.15,16 The authors have noted that Several other scales are available including behavior rating scale, verbal scale and combination scale.

The influence of clinical variables on the VAS scores was tested by the non-parametric Wilcoxon rank sum test. Kruskal-Wallis one-way ANOVA was used to establish the differences among the four Kennedy classification partial dentures and among the three different opposing arch dentitions. To establish positive or negative correlations between some of the clinical variables and the VAS scores, the Spearman rank correlation coefficient test was applied. The tests were conducted at 0.05 level of significance. The data were analyzed with statistical software SPSS version 11.0 (SPSS Inc.).

ResultsTable 3 presents the mean VAS scores for seven clinical variables. The highest mean score value recorded was for stability (46.0 mm) and lowest value was for pain (19.6 mm). A significant difference (p < 0.05) was recorded between males and females for comfort VAS scores (Table 3). There were no significant differences between males and females with other VAS scores. There was no significant difference in VAS rating for maxillary and mandibular dentures and dentition of opposing arches (Table 4). The differences for Kennedy classification were not significant for other VAS scores except for esthetics (Table 5). Patients were dissatisfied with Kennedy Class IV RPDs compared with other types of dentures (p < 0.05). The Spearman’s rank correlation coefficient between age and stability and VAS scores was presented in Table 6. With regards to esthetics, younger patients recorded significant negative correlation indicating that younger patients were less satisfied with Kennedy Class IV RPDs aesthetics compared with older patients (p < 0.05). Similarly, no significant negative association between stability of RPDs and VAS scores was observed.

DiscussionThis study evaluated the relative differences in VAS scores for some of the clinical variables. Patients treated with RPDs usually complain of pain. However, in this study, the mean VAS score for pain was the lowest compared to other clinical variables. The reason for this could be that all the patients who

(Table 1): Distribution of Age, Gender, Maxillary and Mandibular RPDs of Subjects in Study

52 / 34

Number of patients

22 / 1630 / 18

64.1 ± - 8.261.2 ± - 8.364.4 ± - 7.6

40 - 6646 -6440 - 66

662838

Age range (years)

Number of RPDs (Maxilla/Mandible)

Mean age range +/- SD

TotalFemaleMale

(Table 2): Scoring Index for Stability and Retention

0: No stability, denture base demonstrates extreme rocking on its supporting structures under pressure.1: Some stability. Denture base demonstrates moderate rocking on its supporting structure under pressure.2: Sufficient stability denture base demonstrates slight or no rocking on its supporting structure under pressure.

Stability

Retention

0: No retention. Denture displaces itself.1: Minimum retention. Denture offers slight resistance to vertical pull.2: Moderate retention. Denture offers moderate resistance to vertical pull.3: Good retention. Denture offers maximum resistance to vertical pull.


participated in this study were relieved of pain by adjusting their dentures during recall appointments and the patients were recalled for evaluation after a period of one year. The findings of this study supported the results of Wakabayashi et al.4 who investigated the association of clinical variables effects on satisfaction of patients to their prostheses.

In the literature, opinions vary among researchers as to which scales are more sensitive to expose a change in pain and discomfort. The different scales include visual analogue scale 13,14 numerical scale, verbal scales and combined scale.15,17 In this study, visual analogue scale was used because it has been reported to be superior to the other four behavior rating scales.4,16

Comfort indicates absence of any pain and acceptable feeling with the prosthesis. The VAS scores for comfort for females was approximately twice than that of males. The gender difference was statistically significant (p < 0.05). The finding was in accordance with the study of Wakabayashi et al.4 who also

found that the females showed higher mean value of VAS score than the males. The most commonly reported causes of dissatisfaction with RPDs were the lack of stability, fit and occlusion with opposing teeth. The VAS score for satisfaction although was higher for females compared with males, the difference was not statistically significant which compared favorably with the results of Wakbayashi et al.4 and Frank et al.9 All other clinical variables with the exception of comfort were not significant.

This study showed that aesthetics had significant (p < 0.05) negative association with younger patients wearing Kennedy Class IV RPDs (Table 5) which is in agreement with the results of Jepson et al.2 and Wakabayashi et al.4 On the other hand, Kenozovic et al.5 had results that seems to contradict. It is reasonable to assume that younger patients with replacement of anterior teeth by Kennedy Class IV RPDs would be more concerned with the colour and arrangement of teeth. The Kennedy classification I, II and III RPDs had no significant effect on any other VAS scores of the patients. Furthermore, the

(Table 3): Mean & Standard Deviation Values for VAS Score for Clinical Variables (millimeter)

Aesthetic GeneralStability Mastication SpeechComfortPain Satisfaction

Mean VAS

Score (SD) (+/- 4.0)(+/- 4.1)(+/- 3.4)(+/- 3.9)(+/- 3.0)(+/- 2.7)(+/-12.8)

41.741.628.446.035.619.635.4

(Table 4): Mean & Standard Deviation Values for VAS Scores in Millimeters for Maxillary, Mandibular RPDs and Gender

Aesthetics GeneralStability Mastication SpeechComfortPain Satisfaction

Maxilla (n=52)

38.3 (±-5.0)42.4 (±-5.2)31.4 (±-4.5)51.2 (±-4.9)32.7 (±-5.0)21.6 (±-5.7)40.4 (±-4.8)

45.7 (±-6.1)38.6 (±-5.1)25.6 (±-4.7)42.4 (±-6.1)36.1 (±-4.9)10.6 (±-4.1)34.2 (±- 6.0)

De

ntur

e A

rch

Mandible (n=34)

Male (n=38)

45.3 (±-4.8)41.8 (±-4.9)29.4 (±-4.1)47.1 (±-4.2)40.1 (±-4.3)19.5 (±-4.1)*39.1 (±-3.8)

38.0 (±-6.1)37.9 (±-5.8)24.8 (±-5.9)43.8(±-6.6)20.7 (±-5.9)10.6 (±-2.8)*32.4 (±-6.1)

Ge

nde

r

Female (n=28)

* Denotes significance difference between the clinical variables. The standard deviation numbers are in the brackets.

(Table 5): Mean & Standard Deviation Values for VAS Scores in Millimeters for Kennedy Class I, II, III and IV RPDs & Opposing Dental Arch Dentition

Aesthetics GeneralStability Mastication SpeechComfortPain Satisfaction

Class I (n=44)

36.4(±-7.1)42.3(±-8.1)26.7(±-5.1)48.6(±-6.9)25.9(±-4.6)19.4(±-4.3)20.0 (±-3.2) *

46.9(±-5.8)54.6(±-6.2)32.4(±-3.4)57.6(±-6.2)34.8(±-6.1)20.9 (±-5.0)44.6 (±/-4.9)*

Class II (n=21)

Class III (n=11)

68.7(±-21.4)51.3(±-9.4)37.0(±-12.9)56.8(±-7.3)63.6(±-22.3)29.6 (±-6.7)78.5(±-6.1) *

49.8(±-7.4)34.1(±-6.7)0.9(±-0.4)40.3(±-8.2)51.7 (±-21.9)5.1(±-3.9)57.6 (±-21.0) *

Class IV (n=10)

Kenn

ed

y C

lass

ific

atio

n

Natural (n=25)

40.1(±-8.)38.6(±-7.4)22.6(±-4.0)51.3(±-6.9)35.8(±-5.0)10.9(±-3.0)35.1 (±-4.1)

52.3(±-7.9)36.8(±-6.1)38.6(±-7.0)46.6(±-6.7)40.6(±-12.7)26.6(±-10.4)37.8(±-13.0)

Partial (n=51)

Complete (n=10) 37.6(±-10.1)42.6(±-6.8)26.1(±-8.0)26.7(±-8.0)20.0(±-9.4)23.9(±-12.9)47.2 (±-12.9)Op

po

sing

A

rch

De

ntiti

on

* Denotes significant difference between the different factors and brackets include standard deviation.

(Table 6): Spearman’s Rank Correlation Coefficient among some of the Variables and the VAS Scores

Aesthetics Stability Mastication SpeechComfortPain Satisfaction

Age

Retention & Stability

-0.297-0.147-0.079-0.06-0.162-0.039-0.304*

-0.173 -0.040 -0.106 -0.287 -0.101 -0.099 -0.234

* Denotes significant difference.

Prosthodontics


correlation coefficient between stability of RPDs recorded by the investigator and the VAS score was not statistically significant (Table 5). This study did not examine the correlations between the number of replaced teeth, different designs of major connectors and previous denture experience with their respective VAS scores. Further investigation of these clinical variables is needed.

ConclusionThe difference in the mean visual analogue (VAS) rating for comfort between males and females was statically significant. Aesthetics with Kennedy Class IV partial denture showed a negative association with the age of patients. There were no significant difference between VAS scores and other clinical variables examined.

References1. Van der Waas MAJ, Meeuwissen JH, Meeuwissen R, et al. Relationship between wearing a removable partial denture and satisfaction in the elderly. Community

Dent Oral Epidemiol. 1994; 22:315-8.2. Jepson NJA, Thompson JM, Steele JG. Influence of denture design on patient acceptance of partial dentures. Brit Dent J. 1995; 178:296-300.3. Elias AC, Sheiham A. The relationship between satisfaction with mouth and number

and position of teeth. J Oral Rehabil. 1998; 25:649-61.4. Wakabayashi N, Yatabe M, Ai M, et al. The influence of some demographic and clinical variables on psychosomatic traits of patients requesting replacement removable partial dentures. J Oral Rehabil. 1998; 25:507-12.

5. Knezovic ZD, Celebic A, Valentic-Peruzovic M, et al. A survey of treatment outcomes with removable partial dentures. J Oral Rehabil. 2003; 30:847-54.

6. Wostmann B, Budtz-Jorgensen E, Jepson N, et al. Indications for removable partial dentures: A literature review. Int J Prosthodont. 2005; 18:139-45.

7. Koyama S, Sasaki K, Kawata T, et al. Multivariate analysis of patient satisfaction factors affecting the usage of removable partial dentures. Int J Prosthodont. 2008; 21:499-500.

8. Frank RP, Milgrom P, Leroux BG, et al. Treatment outcomes with mandibular removable partial dentures: A population-based study of patient satisfaction. J

Prosthet Dent. 1998; 80:36-45.9. Frank RP, Brudvik JS, Leroux B, et al. Relationship between the standards of removable partial denture construction, clinical acceptability and patient satisfaction. J Prosthet Dent. 2000; 83:521-7.10. Academy of Prosthodontics. Principles, concepts and practice in Prosthodontics -

1994. J Prosthet Dent.1995; 73:73-94.11. Nyhlin J, Gunne J. Opinions of wearing habits among patients new to removable

partial dentures. An interview study. Swed Dent J. 1989;13:89-93.12. Kapur KK. A clinical evaluation of denture adhesives J Prosthet Dent 1967;18,550-555.13. Seymour RA, Simpson JM, Charlton JE, et al. An evaluation of length and end-phrase of visual analogue scales in dental pain. Pain 1985;21:177-85.14. Price DD, Harkins SW, Rafii A, Price C. A simultaneous comparison of fentanyl’s

analgesic effects on experimental and clinical pain. Pain1986;24:197-203.15. Magnusson T, List T, Helkimo M. Self-assessment of pain and discomfort in patients

with temporomandibular disorders: A comparison of five different scales with respect to their precision and sensitivity as well as their capacity to register memory of pain and discomfort. J Oral Rehabil. 1995;22:549-56.

16. Lamb DJ, Ellis B. Comparisons of patient self-assessment of complete mandibular denture security. Int J Prosthodont. 1996;9:309-19.

17. Harms-Ringdahl K, Carlsson AM, Ekholm J, et al. Pain assessment with different intensity scales in response to loading of joint structures. Pain 1986;27:401-11.

Accuracy of the Raypex-4 and PropexApex Locators in Detecting Horizontal andVertical Root Fractures: An In Vitro Study

AbstractUnforeseen root fractures during endodontic therapy are often difficult to diagnose and treat. Apex locators have been shown to be accurate in measuring the working lengths of root canals, and it was postulated whether they could also be used to determine the position of root fractures. This study was undertaken to assess the accuracy of two different apex locators in determining the position of fractures. Ninety six single rooted teeth were randomly divided into two groups. One group had simulated horizontal fractures cut into them and the other group had vertical fractures. All fractures were detected in both groups using both a Propex (third generation) and a Raypex-4 (fourth generation) apex locators. The actual lengths of the fractures were then measured under 2.5 times magnification, and the results subjected to statistical analysis. Both locators produced similar results and were found to be very accurate, with measurements that correlated closely to the actual lengths. Clinically, treatment options for root fractures vary depending on their location. Thus apex locators may be a valuable aid in not only determining the presence of a root fracture, but also its exact location, which will help the clinician decide on the most appropriate management.

Key words: Endodontics, Apex locator, Root fracture, Raypex-4, Propex.

IntroductionMany studies using apex locators to determine the working lengths in root canals, showed them to be very accurate and reliable.1-5 In most of these reports “Third generation apex locators” such as the Root ZX (Morita Crop, Tokyo, Japan) apex locator were used. These instruments are also termed “comparative impedance apex locators” as they are influenced by two alternating currents of differingfrequencies flowing through the tissue.6 Recently, a new apex locator, Bingo 1020 (also known as Raypex-4), (Forum Engineering Technologies, Rishon Lezion, Israel) has been introduced. The manufacturers claim this to be a fourth generation apex locator, in that it also uses two separate frequencies of 400 Hz and 8 KHz, but unlike the third generation locators, it uses only one frequency at a time. The use of a single frequency signal eliminates the need for filters that separate the different frequencies which helps prevent the noise inherent in such filters, and increases the measurement accuracy.7 In addition; these newer apex locators work in the presence of electrolytes, so there is no need to dry the canals before use.8 In use, a file is inserted onto the root canal and an electrical contact is made with the shank of the instrument. The device has a second electrode, which is placed in contact with the patient’s oral mucosa. A digital display or audible signal shows when the tip of the instrument reaches the apical foramen.8

A recent in vitro study compared the accuracy of a new fourth generation (Bingo 1020) locator with a third generation (Root ZX) locator when measuring canal lengths, and then evaluated these results against radiographic measurements. Both locators were equally accurate and reliable, and even though the measurements obtained using the Bingo 1020 were closer to the actual lengths than those obtained by the Root ZX, the differences were not statistically significant.9

One of the more perplexing problems in endodontic therapy is unforeseen horizontal or vertical fractures of the root canal wall, which are often difficult to diagnose and to treat. It has been postulated that apex locators could be used to determine the position of a fracture, if it communicateswith the periodontal membrane. However, until now only one study has been done to detect root fractures using an apex locator.10 The authors found that the locator could accurately determine horizontal fractures, but was unreliable in detecting vertical fractures.

ObjectivesThe aim of this study was to measure the positions of simulated horizontal and vertical fractures

Dr. Hani Al KadiBDS, Dip ODONT (ENDO), MDS (ENDO)

Private [email protected]

Prof. LM SykesHOD Department of Prosthodontics, Univ. of Limpopo

[email protected]

Dr. Z. VallyDepartment of Operative Dentistry, Univ. of Pretoria

[email protected]

Endodontics


using a third generation apex locator, Propex (J. Morita Corp, Tokyo, Japan) and a fourth generation apex locator, Raypex-4 (Forum Engineering Technologies, Rishon Lezion, Israel), and to compare these figures with each other and with the actual measurements of the fractures.

Materials and MethodsNinety six recently extracted, single rooted permanent human teeth were used in this study. Only teeth with sound roots and no evidence of root resorption or fractures were used. All of the teeth were placed in 10% formalin immediately after extraction. Access cavities were prepared and the working lengths were determined radiographically using a size 10 K-File (Dentsply, Tulsa, Okla). Teeth were numbered and randomly divided into two groups of 48 each. One group had simulated vertical fractures prepared (group V) and the other had horizontal fractures (group H), cut using a 0,2 mm thick diamond disc (Fig. 1). In group V, a cut was made vertically through the entire length of the root until the root canal was exposed, while in group H, the roots were incompletely cut horizontally until the root canal was exposed.

A Propex and a Raypex-4 apex locator were used in this study.A master plastic jaw in a phantom head model (Fig. 2) was used to hold the tooth specimens during the testing.11 The plasticanterior teeth were removed from their sockets, and the sockets were then enlarged with a bur until the human teeth could be adapted and easily fitted into them. The teeth were placed in the plastic jaw, and embedded with a layer of irreversible hydrocolloid (Blue-print, De Trey, Surrey, UK). Additional alginate was placed under the master model where the lip clip electrode of the apex locator was to be inserted. Four teeth were tested at the same time, and a new mix of alginate was used for every set.

All the fractures were detected in both groups using the Propex and the Raypex-4 apex locators, and all measurements were carried out by one operator to ensure standardization of the experimental technique. Eight teeth from each group were randomly re-tested to verify the accuracy and repeatability of the testing.

In group H, after the lengths of the simulated fractures had been recorded using both apex locators, the teeth were removedfrom the model, and the fractures were completed with the disc. The actual lengths were then measured using a size 10 K-File under 2.5 times magnification, using a radiographic viewer designed to eliminate extraneous light and magnify the image (Fig. 3). In group V, the lengths were determined up to the coronal end of the simulated fracture with the locators. They too were removed and the lengths of the fractures determined using a size 10 K-file under 2.5 times magnification.

Statistical AnalysisThe Pearson correlation co–efficient and regression analysis was used to determine the differences between all the test samples. Agreement between the two locators was measured by the Kappa statistic. Horizontal and vertical fractures were analyzed and compared to the actual values separately, and also with both sets of results combined. Closeness of the Raypex-4 and Propex measurements to the actual length was compared by the paired t-test, based on their deviations from the actual lengths. All

statistical procedures were conducted on SAS and p values ≤ 0,05 were considered significant.

ResultsIn both groups V and H, the mean values (mm), standard deviations, and minimum and maximum values were calculated for the Raypex-4 and Propex apex locators as well as for the actual measurements. The differences between Raypex-4 and Actual, Propex and Actual and Raypex-4 and Propex were then calculatedand used in the statistical analysis.

Results are shown in Tables 1 and 2 respectively. Table 3 shows the results obtained when both the V and H measurements were combined.

DiscussionApex locators are capable of accurate measurement and can determine the exact location of the apical foramen especiallyin cases where the outline of the canal on the pre-operative film is indistinct, or where the canal curves towards or away from the radiographic beam.8 They have also been used as an alternativeto working-length radiographs in cases where patients request to have a minimum number of radiographs taken, however an initial pre-operative film should still be used to obtain an estimatedfigure. Carrotte (2004)8 cautioned that there is a learning curve associated with the use of apex locators, thus the pre-operative radiograph is an essential guide as to whether the measurements are in accordance with the original radiographic estimated lengths. In this study, when comparing the two different apex locators,

(Figure 1) Radiographic viewer

(Figure 2) Phantom head used to hold plastic jaws

(Figure 3) Diamond discs (0,2 mm thick)


the operator found that both systems needed an initial practice period before repeatable accurate results could be obtained, however the Raypex was easier to use and detected the fracture lines more readily.

Azabat et al. (2004)10 found apex locators to be more accurate in determining horizontal than vertical fractures, however, in this study although both locators were slightly more accurate when measuring horizontal fractures, the differences were not significant statistically, and both locators were found to be very accurate in determining the actual position of all the fractures.

In this study, for the group H, both locators correlated very closely to the actual measurements with Raypex-4 being slightly more accurate than Propex, but not significantly so (p = 1.00 and p = 0.739 respectively). The difference between the two locators was also not statistically significant (p = 0.748). Group V showed similar results, with the Raypex-4 being slightly more accurate than the Propex (p = 0.369 and p = 0.339 respectively), but again, neither these nor the difference between the two, were statistically significant, and both were found to be extremely accurate. When both the H and the V figures were combined, similar results were seen with the Raypex-4 being marginally more accurate than the Propex (p = 0.438 and p = 0.405 respectively).

Clinically, it is more important to be able to diagnose the exact location of a fracture rather than its mere presence, as this can impact on the treatment options and eventual fate of the tooth. Contrary to popular belief, not all teeth with fractured roots need to be extracted. Rintaro et al. (2004)12 reported that when a root fracture is located very close to the gingiva, the chance of healing with calcified tissue is the poorest. However, in these cases as an alternative to extraction, the coronal fragments can be removed followed by orthodontic or surgical extrusion of the remaining root. This will allow for elevation of the fracture line above the epithelial attachment, and will bring the margins to a visible level, allowing for prosthetic restoration of the tooth. This is a more conservative treatment choice in young children compared to the prosthetic restorations that would be needed after an extraction.13 Thus, where root fractures are detected within the upper third of the root (± upper 4 mm), then forced eruption can be attempted to allow for restoration with physiologic gingival conditions, eliminating the need for surgical crown lengthening, marginal osteotomies or tooth extraction.14

Teeth diagnosed with fractures in the middle third of the root are usually unsaveable, although some authors have suggested that if these teeth are repositioned such that the displacement of the segments does not exceed 1mm, and then splinted for 4 weeks,

(Table 1): Values for the horizontal fractures (group H)

Variable Minimum p Value MaximumStd DevMean (mm)

Raypex-4

p < 0.000120.27.82.5813.0548

p < 0.0001207.92.6313.03

Propex

Actual

p = 1.00.30.20.11048

p < 0.0001207.92.6113.0348

Difference R: A

Difference P: A

p = 0.7481.72.70.58-0.0348

p = 0.7392.81.60.560.0348

Difference R: P

N

48

(Table 2): Values for the vertical fractures (group V)


Raypex-4

p < 0.000113.242.048.6148

p < 0.000113.14.22.048.73

Propex

Actual

p = 0.3690.4-0.30.180.0248

p < 0.0001134.32.038.7148

Difference R: A

Difference P: A

p = 0.2352.5-1.50.660.1148

p = 0.3391.3-2.30.66-0.0948

Difference R: P

N

48

(Table 3): Values for the combined vertical and horizontal fractures (groups V and H)


Raypex-4

p < 0.000120.243.2110.8396

p < 0.0001204.23.1810.88

Propex

Actual

p = 0.4380.4-0.30.140.0196

p < 0.0001204.33.1810.8796

Difference R: A

Difference P: A

p = 0.4932.5-2.70.620.0496

p = 0.4052.8-2.30.61-0.0396

Difference R: P

N

96

Endodontics


they may be salvaged. The repair process involves interposition of either hard tissue or periodontal ligament between the fragments,while the pulp may heal or undergo necrosis, in which case endodontic treatment would be required.15 Many different endodontic techniques have been proposed to determine which method will be the most successful in treatment of teeth with fractures in the middle or apical thirds of the root. One study found that root canal filling with GP of the coronal fragment only, with or without surgical removal of the apical fragment, can be successful in selected cases. Treatment of the root canal with calcium hydroxide followed by GP filling was recommended for root-fractured, non-vital teeth, and in those vital teeth where the fracture had caused pulpal exposure, partial pulpotomy of the exposed pulps showed similar results to those obtained following pulpotomies in root-unfractured teeth where pulp exposures had been similarly treated.16 Fractures involving the apical third of the root may also be saved by performing endodontics followed by an apicoectomy to remove the fractured segment.

Vertical fractures are more difficult to diagnose. Patients may present with mild symptoms and it may appear as if the root canal treatment has not been successful. The diagnosis can be suspected when a radiograph shows bone loss extending all around a root, or a tooth, where the vertical fracture has led to bacterial contamination of the entire tooth surface.17 There has been no particular treatment established to preserve vertically fractured teeth. A recent study evaluated the long-term prognosis of intentional replantation of vertically fractured roots after they had been reconstructed with 4-META/MMA-TBB dentin-bonded resin. Results showed longevity of 88.5% at 12 months after replantation, 69.2% at 36 months and 59.3% at 60 months. All of the failures occurred in the premolars and molars, while those teeth where the fracture extended more than 2/3 of the way from the cervical towards the apical area had significantly shorter survival times than roots where the fractures were shorter. The authors concluded that replantation of vertically fractured roots reconstructed with dentin-bonded resins may be considered for incisors as an alternative to extraction, but cautioned that the long–term success was not optimal.18

Both of the apex locators tested in this study were not only able to detect the presence of root fractures, but were also able to determine their exact locations. They could prove to be of great value clinically in determining the treatment options for fractured teeth especially in cases where the fractures are impossible to detect on routine radiographs. However, there are some other factors to consider when using apex locators. Most of them perform better when used in wet canals as they rely on the presence of electrolytes to transmit the electrical signals. Errors may occur if the canals are too dry (in dry canals the Raypex-4 was more accurate than the Propex in this investigation), if there are large coronal restorations or metallic crowns that can cause a short circuit, if there is an open apex with a larger peri-radicular lesion, or if there is a perforation of the apex. These are usually apparent and then further measures will need to be taken.8

ConclusionBoth the third generation and the fourth generation apex locatorswere found to be equally accurate in determining the exact position of horizontal and vertical root fractures. The fourth

generation locator however did have advantages in that it was easier to use, performed better in wet and dry canals, and was slightly more accurate, although not significantly so. Either systems may be of value clinically in not only detecting the presence of a root fracture, but in determining its exact location, which can help the clinician decide on the best treatment option for that particular tooth.

References1. Kaufman AY, Fuss Z, Keila S, Waxenberg S. Reliability of Different Electronic Apex

Locators to Detect Root Perforations In Vitro. Int Endod J. 1997 Nov;30(6):403-7.2. Steffen H, Splieth CH, Behr K. Comparison of Measurements Obtained with Hand

Files or the Canal Leader Attached to Electronic Apex Locators: An In Vitro Study. Int Endod J. 1999; 32:103-7.

3. Fouad AF, Rivera EM, Kerll KV. Accuracy of the Endex with variations in canal irrigants and foramen size. J Endod. 1993 Feb;19(2):63-7.

4. Pratten DH, McDonald NJ. Comparison of Radiographic and Electronic Working Length. J Endod. 1996; 22:173-6.

5. Ounsi HF, Haddad G. In Vitro Evaluation of the Reliability of the Endex Electronic Apex Locator. J Endod. 1998; 24:120-2.

6. Ingle JI, Bakland LK. Endodontics. 5th ed. BC Decker Inc. 2002; 517-25.7. Bingo 1020 Apex Locator User Manual (Revised). Forum Engineering Rishon Lezion,

Israel Technologies Ltd. 1999; 5-7M.8. Carrotte P. Endodontics: Part 7. Preparing the root canal. Br Dent J. 2004 Nov

27;197(10):603-13.9. Kaufman AY, Keila S, Yoshpe M. Accuracy of a New Apex Locator: An In Vitro Study. Int

Endod J. 2002 Feb;35(2):186-92.10. Azabal M, Garcia-Otero D, De la Macorra JC. Accuracy of the Justy II Apex Locator

in Determining Working Length in Simulated Horizontal and Vertical Fractures. Int Endod J. 2004 Mar;37(3):174-7.

11. Tinaz AC, Alaçam T, Topuz Ö. A simple model to demonstrate the electronic apex locator. Int Endod J. 2002 Nov;35(11):940-5.

12. Rintaro T, Kiyotaka M, Minoru K. Conservative Treatment for Root Fracture Located Very Close to Gingiva. Dent Traumatol. 2005 Apr;21(2):111-4.

13. Koyuturk AE, Malkoc S. Orthodontic Extrusion of Subgingivally Fractured Incisor before Restoration. A Case Report: 3-Years Follow-Up. Dent Traumatol. 2005

Jun;21(3):174-8.14. Wehr C, Roth A, Gustav M, Diedrich P. Forced Eruption for Preservation of a Deeply

Fractured Molar. J Orofac Orthop. 2004 Jul;65(4):343-54.15. Andreasen JO, Andreasen FM, Mejare I, Cvek M. Healing of 400 Intra-Alveolar Root

Fractures. 2. Effect of Treatment Factors such as Treatment Delay, Repositioning, Splinting Type and Period and Antibiotics. Dent Traumatol. 2004 Aug;20(4):203-11.

16. Cvek M, Mejare I, Andreasen JO. Conservative Endodontic Treatment of Teeth Fractured in the Middle or Apical Part of the Root. Dent Traumatol. 2004 Oct;20(5):261-9.

17. Carrotte P. Endodontic problems. Br Dent J. 2005 Feb 12;198(3):127-33; quiz 174.18. Hayashi M, Kinomoto Y, Takeshige F, Ebisu S. Prognosis of Intentional Replantation

of Vertically Fractured Roots Reconstructed with dentin-bonded resin. J Endod. 2002 Feb;28(2):120-4.


Function, Aesthetics and Biomimetics in the Interdisciplinary Treatment: Concerning a Clinical Case

AbstractThe evolution of dentistry and dental specialties allowed for a clear improvement in the quality of treatment results for the patient’s complete oral rehabilitation, considering both functional and aesthetic aspects.

An adult patient’s aesthetic and functional rehabilitation present an even more difficult challengefor the dental professional, particularly in those situations where the treatment involves anintimate collaboration between different specialties, demanding a critical planning.

We will present a clinical case which involved an interdisciplinary approach, where the operative sequence and the multidisciplinary approach exerted in this case illustrates the importance of specialised knowledge and professional communication.

Key words: Aesthetics, Periodontics, Implantology, Orthodontics, Interdisciplinary approach.

IntroductionAn adult patient’s aesthetic and functional rehabilitation presents a challenge for the dentistry professional, particularly in those situations where the treatment involves an intimate collaboration between several specialties, demanding a critical planning. It is therefore important to define in what way aesthetic, periodontal, implantology and orthodontic specialists should connect in order to properly achieve the proposed goals.

As an example of an interdisciplinary treatment, we present a complex clinical case in an adult patient where periodontal, implantology, prthodontic and prosthodontic treatment were involved.

Case DescriptionA fifty-eight year old female patient consulted us to replace her missing teeth and to improve her smile’s appearance. This is a case of a patient with high expectations and a philosophical personality according to House’s classification.1

In medical terms, she was diagnosed as an ASA patient type 1,2 not presenting any associated pathology and not being under any kind of medication. She was non-smoker and had a moderately stressful life style.

Extra-orally, we can observe in figures 1 and 2 that the patient presents a facial type with normal patterns and a straight profile. It is also obvious in figure 1 that the patient presents a low smile line.

Dr. Faria Almeida RicardoDDS, MSc Periodontology

- Associate Professor, Faculty of Dentistry, Univ. of Oporto

[email protected]

Dr. Falcão Costa CarlosDDS, MSc Esthetic Dentistry

- Teacher at Fernando Pessoa Univ.

[email protected]

Dr. Pinho Monica DDS, MSc Orthodontics

- Teacher at Fernando Pessoa Univ.

[email protected]

Mr. Perez Lopez Javier Ceramist, Lugo

[email protected]

Dr. Afonso Pinhão Ferreira Orthodontics

- Full Professor, Faculty of Dentistry, Univ. of Oporto

[email protected]

(Figure 2) Initial lateral profile

(Figure 1) Initial anterior profile

Multidisciplinary


During intraoral examination we could observe the presence of posterior bite collapse with decreased occlusal vertical dimension resulting from the loss of posterior teeth number 14, 15, 24, 25, 26, 46 and 36, and from the mesioversion of teeth 47 and 37, as well as the extrusion of tooth 16 (Figs. 3-5). It was also possible to detect the presence of localized gingival recessions both in the upper and lower arches.

The intraoral examination also showed an increased overjet due to labial inclination of upper anterior segment with an increase of the horizontal overbite, which resulted in the absence of the anterior guide during protrusive movement. At the same time, we could observe the presence of a parafunction (bruxing habit), since there is a clear wear at the upper anterior teeth’s incisal edge (Fig. 6).

After examination of the upper anterior segment, gingival asymmetry was observed, especially at teeth 11 and 21, as well as presence of interincisal diastema that might have been caused by the labial movement of these teeth (Fig. 3) and/or the loss of teeth posteriorly. The upper anterior teeth present themselves with an inadequate height – width proportion and the incisors show a somewhat triangular shape.

The periodontal examination showed moderate generalized chronic periodontitis, with Plaque index values of 80% and Bleeding of 48% (Dicotomic Index). One can verify, as mentioned earlier, the presence of multiple areas of gingival recession. The microbiological analysis allowed to observe the presence of periodontal pathogens of endogenous character,3 therefore not presenting an increased risk in terms of response to the periodontal treatment.

In the initial radiographic examination, it was possible to confirm the presence of periodontal pathology, with a moderate radiographic horizontal bone loss except for tooth 27, which presents a circumferential defect. The detected bone loss is worsened due to the mal-positioning of some teeth (Fig. 7). We could also observe the clear buccalization of the antero-superior teeth in the lateral cephalometric projection (Fig. 8).

DiagnosisThe patient can be diagnosed with:- Moderate Generalized Chronic Periodontitis.- Bite Collapse Syndrome with buccal inclination of the anterosuperior teeth and presence of inter-incisive diastema.- Extrusion and mal-positioning of several teeth as well as posterior edentulism.- Bruxism.- Asymmetry of the anterior gingival margins and incorrect width-length ratio of anterior teeth.

Treatment OutcomeAfter the analysis of the presented case we can summarize our treatment plan as follows:

1- Treatment of the periodontal pathology.2- Alignment of the remaining molars and increase of the vertical dimension.3- Retrusion of upper incisors decreasing the horizontal overbite and reestablishment of an adequate anterior guide.

(Figure 3) Intra-oral 1



(Figure 6) Wear of incisal edges

(Figure 7) Panoramic view

(Figure 8) Lateral cephalometric view

(Figure 9) Pre-operative, upper right quadrant


4- Closure of the interincisal diastema and gingivoplasty.5- Reconstruction of the lost dental structure of the upper anterior segment.6- Replacement of the lost teeth.7- Treatment of the occlusal parafunction.

Treatment PlanHence our treatment plan consisted of the following, according to the sequence we have described:1- Initial or hygienic stage, with information and motivation for the interdisciplinary treatment as well as implementation of a basic periodontal treatment.2- Placement of osseointegrated implants in the sites of 14, 15, 24 and 25.3- Setting of provisional fixed partial prosthesis over implants on 14, 15, 24 and 25 for orthodontic anchorage.4- Bimaxillary orthodontic treatment with fixed appliances.5- Extrusion of tooth 47.6- Placement of implant in the area of 46.7- Placement of ceramic crown over implant in 46 and of implant-supported metaloceramics fixed partial prosthesis in the 14, 15 and 24, 25, 26.8- Rehabilitation of the anterosuperior sector with ceramic veneer.9- Placement of centric relation occlusal splint.

1- Initial or hygienic stage, with information and motivation for the interdisciplinary treatment as well as implementation of a basic periodontal treatmentThe goal of the periodontal treatment was to eliminate the opportunistic microorganisms that might impede, if not treated, any kind of interdisciplinary therapeutic approach.

The initial or hygienic stage aims to eliminate the etiologic cause of the periodontal disease; eliminating all the bacterial deposits, as well as the plaque retaining factors. During this stage, we proceeded with the patient’s motivation, instructing her on oral hygiene techniques.

Therefore, in theory, with the basic periodontal treatment we should get:- A reduction of the Bleeding Index to values equal or inferior to 25%.- A total elimination of gingival pockets with probing depth of over 5 mm.- Reduction of the furcation lesions.- The elimination of pain since the only pain that the patient had was due to periodontal problems.- Starting to achieve the patient’s functional and aesthetic satisfaction.

At the same time, we must have the ability to effectively control the risk factors associated with chronic periodontal disease, such as bacterial plaque, tobacco and uncontrolled diabetes.4 In this particular case, the need to improve the used oral hygiene techniques was to promote a better plaque control. From the above mentioned risk factors, bacterial plaque was the only one initially present. In terms of active treatment, we proceeded with the root planing in the sites with probing depth of over 3 mm. Forty-five days after the basic stage’s completion, we proceeded to the re-evaluation of the performed treatment.

(Figure 10)Implants placement in positions 14 & 15 with

immediate sinus lifting

(Figure 11)Post-operative photo of

implants in positions 14 & 15 after suturing

(Figure 12)Incision for upper left

quadrant

(Figure 13) Flap reflection

(Figure 14)Sinus lifting

(Figure 15)Bio-Oss application

(Figure 16)Suturing

Multidisciplinary


Re-evaluation aimed to assess the results of the established treatment and to plan the need for additional periodontal treatment (surgical, for example) or supporting periodontal treatment. In the analyzed clinical case, and considering the good results obtained (plaque index values and bleeding inferior to 20%) with the initial treatment it was possible to move the patient to a supporting periodontal treatment program. The periodicity of the appointments relative to the program is dependent on the present risk factors, on the degree of initial bone loss presented and on the treatment’s complexity to be executed in interdisciplinary terms. For this patient periodontal supporting appointments with a 2-month periodicity5 were prescribed.

2- Placement of osseointegrated implants in positions 14, 15, 24 and 25Considering the edentulous spaces and bearing in mind the orthodontic movement to be performed it was decided to proceed with the placement of osseointegrated implants in the position of teeth 14, 15, 24 and 25 in the maxilla and tooth 46 in the mandible. The decision was made in order to maintain teeth 27 and 47 as orthodontic anchorage and to re-evaluate their status after orthodontic treatment ends.

For both sides in the maxilla, the need to perform sinuselevation was verified, although on the right side such procedure was performed at the same time of the implant placement,6 as there was over 6 mm of residual bone (Figs. 9-11),7 but on the left side, the necessity to perform a previous elevation of the maxillary sinus floor arose as we did not have sufficient alveolar bone to achieve primary stability, and afterwards (6 months) we proceeded with the placement of the implants (Figs. 12-16).8

3- Setting of provisional fixed partial prosthesis over implants 14, 15, 24 and 25 for orthodontic anchorageAfter the implants’ osseointegration period (6 months), we proceeded with a casting and record registration for the fabrication of a fixed partial prosthesis, screwed in metal-acrylic, allowing, on one hand, the re-establishment of a suitable vertical dimension and on the other hand, an additional anchorage during the execution of the orthodontic treatment.

4- Bimaxillary orthodontic treatment with fixed appliancesThe orthodontic treatment began with the alignment of mandibular teeth (Fig. 17). In a later stage, already with a steel rectangular arch, of a bigger gauge, the verticalization of tooth 47 was initiated, resorting to an open spring of nickel-titanium. After tooth 47 verticalization, the alignment of maxillary teeth was initiated (Fig. 18).

This arch being leveled and aligned, we proceeded with the recoil of the anterosuperior sector, with steel contraction arches and resorting to the anchorage provided by the implants previously placed in teeth positions 14, 15, 24 and 25 (Fig. 19). The canine neutroclusion was achieved and improved in an initial stage through the use of triangular rubber bands placed bilaterally (Fig. 20).

(Figure 17) Alignment of mandibular teeth

(Figure 18) Initiation of maxillary teeth alignment

(Figure 19) Stainless steel contraction arches

(Figure 22) Implant placement in the position of tooth 46

Depth

GM

GM

Depth

Tooth #

123 312 113 122121111122 111 432

17 16 1112131415 21 22 23 262524 27

233 543223221321222223322 323

Depth

GM

GM

Depth

Tooth #

459 211 232 211122132112 132 213

47 46 4142434445 31 32 33 363534 37

388 223213111121123111221 213

122 211212

122122222

(Figure 21) Periodontal chart: tooth # 47 had mobility grade II

(Figure 20) Triangular rubber bands placed bilaterally


5- Extraction of tooth 47As previously anticipated, tooth 47 extraction was decided due to its periodontal bad condition (Fig. 21).

6- Placement of implant in the position of 46Besides the implant at the site of tooth 46 and since tooth 47 extraction was performed, the possibility of also placing an implant at the site of this last tooth was taken into consideration. Nevertheless, the bone availability was limited and it would imply the use of guided bone regeneration technique which was not accepted by the patient at this stage of the treatment. The risk that might exist from tooth 17 extrusion was not confirmed due to the centric relation splint foreseen for the end of the treatment (Fig. 22).

7- Placement of ceramic crown over implant in 46 and of implant-supported metaloceramics fixed partial prosthesis in the 14, 15 and 24, 25, 26Right after the bimaxillary fixed orthodontic appliances removal (that were used for 18 months), as well as after the osseointegration period of the implants placed in the mandibular arch, we proceeded with the definitive impressions using an elastomeric material, as well as to the collection of intermaxillary registrations which allowed the elaboration of structures built in metal-ceramics, which were cemented over prefabricated intermediate abutments. As for the second quadrant, we decided for an implant-supported structure design over implants in positions 24 and 25 and a cantilevered pontic at the level of tooth 26 (Fig. 23).

8- Rehabilitation of the anterosuperior sector with ceramic feldspar veneersAfter the removal of the fixed appliances we also proceeded with the anterosuperior segment rehabilitation. In order to do so, we performed a previous waxing up, in order to be able to visualize the intended final result. This wax up also made possible the attainment of an in-mouth “Mock-up ” , as well as it functioned as a guide during all the dental preparation process, creation of temporary restorations and the execution of ceramic feldspar veneers (Fig. 24).

The dental preparation based on the previous wax up insured a thickness of approximately 0,5 mm in buccal and 2 mm in the incisal 1/3 in order to assure a suitable thickness for the feldspar ceramic. The vestibular and palatal finish line was a deep chamfer to assure an easier positioning of the definitive restorations and to promote a higher marginal integrity after the definitive cementation (Figs. 25, 26).

In these areas in which the preparation included the exposure of dentin, we recommend the use of an immediate dentinal sealing technique by applying phosphoric acid and a dentinal adhesive (of fourth or fifth generation) on areas of exposed dentin, where after a first cycle of 20 seconds curing an oxygen inhibitor (glycerine gel) was applied in order to perform a second cycle of curing, assuring a total sealing of the exposed dentinal tubules. We also intended, by doing this, to increase final adhesion values during the cementation of the ceramic feldspar veneers.

After the dental preparation, we proceeded with the definitive casting as well as with the intermaxillary registrations, determining the vertical dimension of the occlusion to be used.

(Figure 24)Waxing up of the antero-

superior segment

(Figure 26)Deep chamfer

vestibular & palatal finish line

(Figure 25)Preparation of the upper

anterior teeth

(Figure 29)Centric relation occlusal

splint

(Figure 28)Extra-oral view

(Figure 27) Final cementation of ceramic feldspar

veneers

(Figure 23)Fabrication of fixed partial dentures.

Tooth # 26 replaced as a cantileverd

pontic

Multidisciplinary


The cementation technique included the acid conditioning of both enamel and dentin with phosphoric acid and of the interior surface of the veneers with hydrofloric acid. We proceeded with the silanization of the interior surface of the veneers, placed an adhesive of fourth generation on the restorations and on teeth without curing, used a photo-curable micro-hybrid resin cement and performed the final cementation (Figs. 27, 28).

9- Placement of centric relation occlusal splintDespite the thought that the incisal and canine guides’ re-establishment will solve the parafunction problem, we decided to produce an occlusal splint that will allow, on one hand, to reduce the parafunctional habits’ effects and that will simultaneously allow it to function as a retainer for the orthodontic treatment performed at the maxilla (Figs. 29, 30).

DiscussionAfter the clinical case treatment, the main discussion topics are:1- no placement of implant at the site of tooth 26, 2- the possible extraction of tooth 27 and the extraction of tooth 47.

As to what concerns tooth 26, no implant was placed because the initial planning foresaw the extraction of tooth 27, which would make the implants location to be at 24, 25 and 27. However, and since the tooth was maintained as a result of the periodontal treatment, a cantilever was made supported on the 24 and 25 implants. Obviously, and once the case was finished, we could claim that it might have been preferable to place them at the sites of the 24 and 26. Nevertheless, the performed treatment did not present any kind of problem as far as the long term predictability is concerned.

Relatively, tooth 47 had to be extracted due to periodontal causes. The ideal would have been to also place an implant at that level. However, as above mentioned, the bone availability was limited and it would imply the use of guided bone regeneration technique, not accepted by the patient at this stage of the treatment. The risk that might derive from tooth 17 extrusion was not confirmed due to the centric relation splint foreseen for the end of the treatment.

ConclusionThe evolution of dentistry and dental specialties allowed for a clear improvement in the quality of treatment results for the patient’s complete oral rehabilitation, considering both functional and aesthetic aspects. Naturally, the excellence of the results demands an interdisciplinary approach, consolidated in a close collaboration between the different protagonists where the patient’s motivation and availability is pivotal. The therapeutic planning, the operative sequence and the pluridisciplinarity exerted in this case illustrate the importance of specialised knowledge and professional communication.

(Figure 33) Pos-operative lateral cephalometry

(Figure 31) Post-operative anterior view

References1. House MM. Full denture technique. In: Conley FJ, Dunn AL, Quesnell AJ, Rogers RM,

editors. Classic prosthodontic articles: a collector’s item. Vol III. pp 2-24. Chicago: American College of Prosthodontists, 1978.

2. Keats, AS. The ASA classification of physical status--a recapitulation. Anesthesiology. 1978 Oct;49(4):233-6.

3. van Winkelhoff AJ, Rams TE, Slots J. Systemic antibiotic therapy in periodontics. Periodontol 2000. 1996 Feb;10:45-78.4. Kinane DF, Peterson M, Stathopoulou PG. Environmental and other modifying factors of the periodontal diseases. Periodontol 2000. 2006;40:107-19. 5. Boyd RL, Leggott PJ, Quinn RS, Eakle WS, Chambers D. Periodontal implications of

orthodontic treatment in adults with reduced or normal periodontal tissues versus those of adolescents. Am J Orthod Dentofacial Orthop. 1989 Sep;96(3):191-8

6. Summers RB. A new concept in maxillary implant surgery: the osteotome technique. Compendium. 1994 Feb;15(2):152, 154-6, 158 passim; quiz 162.

7. Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the Sinus Consensus Conference of 1996. Int J Oral Maxillofac Implants. 1998;13 Suppl:11-45.8. Tatum H Jr. Maxillary and sinus implant reconstructions. Dent Clin North Am. 1986

Apr;30(2):207-29.

(Figure 32) Post-operative lateral view

(Figure 30) Splinting of lower anterior teeth


Mobile: +962 7 96999310e-mail: [email protected]

Tooth Movement With Vacuum Formed Retainer: A Case Report

AbstractNowadays, the adult patients demand for aesthetic alternatives other than casual orthodontic treatment is increasing. The current case report introduces a technique of correcting a minor crowding of maxillary incisors in an adult patient using a combination of thermoplastic retainer and bonded composite buttons as force delivering appliance. Treatment plan, protocol, progress and post retention pictures are presented throughout this article.

Key words: Aesthetic alternatives, Thermoplastic retainer, Bonded composite buttons.

IntroductionAdult patients are getting more interested in orthodontic treatment nowadays. This interest increased the demand for aesthetic alternatives to conventional fixed stainless-steel appliances. Lingual fixed appliances, ceramic brackets and removable appliances are the aesthetic alternative offered by the profession.1 Although the removable appliances cannot offer the wide range of movements such as the fixed appliances, in minor crowding cases such as post treatment relapse, removable appliances can produce equally good results as the fixed appliance when tipping movements are required. Removable appliances have the advantage of saving chair-side time.2

In 1945 Kesling introduced the tooth positioner appliance as a finishing device to achieve minor tooth movements.3 Major movements can be accomplished with a series of positioners, by changing the teeth on the setup slightly as treatment progresses. Align Technology developed an “invisible” method of orthodontic treatment (Invisalign) that uses a series of computer-generated, clear removable appliances.4,5 Raintree Essix has developed a technique using aligners formed on plaster models and can create tooth movement up to 2-3 mm.

According to Sheridan, the first law of biomechanics states that in order to get tooth movement space, force and time are required. The space is created by Interproximal Reduction (IPR) with stainless steel strips or slow- speed discs and burs, or by Air- Rotor Stripping using high-speed burs. The force is applied by means of bumps formed at specific sites in the aligners using either Essix Divoter or the Hilliard Precision Thermoplier. In addition, windows should be cut with fine burs creating the space into which the teeth will move. The appliance should be worn full-time except while eating. The expected tooth movement is approximately 1mm per month.6-9

Aim of this ArticleThrough this case report, we are presenting an alternative for correcting minor crowding using the concept of the aligners relying on a thermoplastic splint associated with composite buttons.

Case PresentationA female patient (20 years old) presented to the Lebanese University complaining of crowding of her maxillary left central and lateral incisors. Her extraoral examination showed proper horizontal and vertical proportions but her upper lip is short, her profile is straight and her smile is not consonant with the lower lip (Fig. 1).

The intraoral examination shows weak Class I molar and canine on both sides. The overjet equals 3 mm and the overbite is 35%. The mandibular midline is on and the maxillary midline is deviated by 0.5 mm to the right relative to facial midline (Fig. 2).

The cephalometric analysis shows the presense of a prognatic maxilla and a normodivergent pattern, retroclined maxillary incisors and proclined mandibular incisors. The panoramic showed normal anatomic structures, missing maxillary third molars and multiple restorations. The frontal cephalogram showed symmetry and normal transverse relationship (Fig. 3).

Dr. Marc RahmeDCD, DESSO, MSc

Private practice of Orthodontics Beirut-Lebanon

[email protected]

Dr. Bilal KoleilatDCD, MSc

Assistant Professor & Director of Postgraduate Program inOrthodontics, Faculty of Dentistry Lebanese University

[email protected]

Orthodontics


(Figure 2) Intra-oral photographs

(Figure 4) Photographs showing arch length deficiency

(Figure 3) Frontal and lateral cephalograms with measurements and panoramic radiograph

SN=77 (70mm)SN/H=10 (8)SNA=82 (82)SNB=76 (80)ANB=6 (2)Retrognathic mandible I/NA=10(22) -1 (4mm)I/SN=95 (104)I/PP=105 (110)Retroclined maxillary incisors

i/NB=31 (25)i/NB=6 (4mm)i/Apo=25 (22)i/Apo=2 (2mm)i/MP=100 (90)Proclined mandibular incisors

PP/MP=24 (27)PP/H=0 (0)MP/SN=33 (32)MP/H=24 (25)Normodivergent patten

(Figure 1) Anterior and lateral extra-oral views


Treatment optionsTwo treatment options were offered for the patient:

1st option: Full maxillary and mandibular fixed appliances for the purpose of aligning and leveling and uprighting the mandibular right second molar.

2nd option: Correct the crowding on the maxillary incisors using a removable thermoplastic splint with composite buttons on the palatal side of the maxillary left central incisor and on the buccal side of the maxillary left lateral incisor.

Treatment protocolThe patient opted for the second option. An alginateimpression was first taken and sent to the laboratory, one week after we received the thermoplastic retainer. The next step was to plan the movements in order to accurately bond the composite buttons on the teeth and then create windows through which the teeth will move. The windows were exactly equal in size to the moving tooth; the thermoplastic retainer was hard so no risk of breakage or bad retention was presented. The clinical examination showed that the maxillary left central incisor was rotated mesio-palataly and the left lateral incisor was tipped bucally (Fig. 4). In order to correct the misalignment of the incisors, space, force and time are needed.6 The space required was 1.5 mm. Enamel stripping using abrasive strips were performed to acquire the space needed. The enamel of the distal side of the central and

(Figure 5)Composite button

bonded on the palatal aspect of the central

incisor and on the middle third of the

buccal aspect of the lateral incisor

(Figure 6)Two windows created in the thermoplastic splint

using scissors

(Figure 7)After 4 months

of treatment, complete

alignment was attained

(Figure 8)Grinding of maxillary

incisors edges

(Figure 9)Nine months

following treatment The results were stable and the alignment was

perfect

Orthodontics


both proximal sides of the lateral incisor has been stripped. The stripping was done sequentially: about 0.5 mm in each appointment. The force was planned in order to rotate the central incisor mesio buccaly and push the lateral incisor palatally. A composite button was bonded on the distal part of the palatal aspect of the central incisor and on the middle third of the buccal aspect of the lateral incisor. The composite buttons were about 1mm thick (Fig. 5). To clear the way for the teeth to be moved, two windows were created in the thermoplastic splint using scissors. The first window was palatal to the lateral incisor and the second was buccal to the central incisor (Fig. 6). The patient was instructed to wear the splint 24 hours and only remove it during eating and brushing.

Treatment results The patient was compliant wearing her appliance and was warned that the seating will improve over time. Alignment progressed gradually. At each appointment, stripping was performed and composite buttons were added, in order to create pressure at the location needed. After 4 months of treatment, complete alignment was attained (Fig. 7).

Aesthetical grinding of the edges of the incisors was done (Fig. 8). For retaining the results, a new thermoplastic splint was delivered to the patient. The patient was instructed to wear it 24 hours per day.

Nine months following treatment the patient presented for new records. The results were stable, the alignment was perfect (Fig. 9).

DiscussionThe option of treatment presented throughout this case report offered many advantages for the patient than the fixed bimaxillary appliances. First the treatment was aesthetic and less cumbersome, second the treatment time was less and third the cost of treatment was much more less and in terms of stability the post retention records showed a great stability 9 months following treatment.

ConclusionThe previous case report offered a simple, aesthetic and inexpensive alternative to fixed appliances. Fixed appliances are often a frustrating option to adult patients complaining of minor crowding.

References1- Miller RJ, Derakhshan M. The Invisalign system: case report of a patient with deep

bite, upper incisor flaring, and severe curve of Spee. Semin Orthod. 2002;8(1):43–50.2- Grossman W, Moss JP. Removable appliance therapy. JPO J Pract Orthod. 1968

Jan;2(1):28-36.3- Kesling, H.D. The philosophy of the Tooth Positioning Appliance. Am. J. Orthod. 1945;

31:297-304.4- Warunek SP, Sorensen SE, Cunat JJ, Green LJ. Physical and mechanical properties

of elastomers in orthodontic positioners. Am J Orthod Dentofacial Orthop. 1989 May;95(5):388-400.

5- Wong BH. Invisalign A to Z. Am J Orthod Dentofacial Orthop. 2002 May;121(5):540-1.6- Sheridan JJ, LeDoux W, McMinn R. Essix appliances: minor tooth movement with

divots and windows. J Clin Orthod. 1994;28:659-663.7- Spranley T. Minor tooth movement. Woman dentist journal. 2005 Oct;3(9):39-428- Sheridan JJ, Hilliard K, Armbruster P. Essix Appliance Technology: Applications, Fabrication and Rationale. GAC International. 2003;19-55.9- Rinchuse DJ, Rinchuse DJ. Active tooth movement with Essix-based appliances. J Clin

Orthod. 1997 Feb;31(2):109-12.

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The Innovative Approach to the Treatment of Total Edentulism and Advanced Alveolar Atrophy

AbstractThis article describes the surgical preparation and prosthodontic treatment of total edentulism and advanced bone atrophy followed by alveolar reconstruction with tibial autografts and the insertion of Anthofit implant-supported removable prosthesis on telescopic crowns and a zirconium framework (with the use of CAD/CAM technique and galvanoplasty).

Key words: Alveolar atrophy, Implantation, Tibia bone grafting, Galvanoplasty, Telescopic prothesis, Zirconium dioxide.

IntroductionAccording to statistics, 20% of Russia’s population under age 60 suffer from total edentulism.1 The quality of life of totally edentulous patients is significantly decreased. Edentulism inflicts a severe psychological injury on patients, and for many of them is associated with the loss of self-esteem because of embarrassment and discomfort. Edentulism results in pronounced esthetic disturbances: the height of the facial lower third decreases, occusal relations are compromised, the labial muscle tone decreases, the lips become narrower, and the face looks senile and unhappy. TMJ disorders and speech disturbances develop or exacerbate.2

Traditionally, patients with total edentualism have been treated with removable prosthesis. In 2003-2006 the percentage of cases treated with removable prosthesis, compared to other treatment modalities, was as high as 50 to 70% in the Moscow region, according to the Moscow regional dental clinic.1 However, the performance of complete removable prosthesis has fallen short of desired; for example, virtually every prosthesis required repair and adjustments after 1 year of service, and the average longevity was less than 3 years.1 Removable prostheses further promote jaw bone atrophy and worsen the anatomical conditions. Traditional mandibular prostheses get often dislodged when buccal and hyoid-glossal muscles contract, therefore the teeth tend to be placed not in anatomically favorable position, but in neutral zones to stabilize the prosthesis. As bone atrophy advances, the height of the facial lower third decreases, and traditional removable prostheses serve, to increasingly larger extent, to maintain facial contours, thus they become bulkier and, as a consequence, less functional, less stable, and less retentive.2

In recent decades, implant-supported prosthodontic restorations have proven to be a reliable, predictable, and effective treatment modality.2,3 Over the last 10 to 15 years, the survival rate for implants and implant-supported restorations has reached as high as 96 to 98%.2 Being inserted in jaw bone, the implant prevents bone atrophy and serves as a reliable abutment for a prosthesis. With the use of implant-supported prostheses, teeth can be set as required to fulfill esthetic and speech considerations. Implant-supported prostheses not only restore facial contours, but also provide stability, reproducible centric relation, excellent retention and masticatory efficiency. Masticatory proprioception doubles, and bite force increases by 85%. Speech improves, and clicking sounds typical for a traditional removable prosthesis user disappear.2

Thus, implant-supported prostheses in patients with total edentualism have indisputable advantages over traditional removable prostheses. However, edentulism is associated with advanced bone atrophy, which counteract implant insertion without surgical preparation, which, in turn, can be very extensive.3 To perform alveolar reconstruction prior to implant insertion, many grafting techniques have been suggested (for example, tibial grafts, calvarium grafts, iliac grafts).3

A fixed prosthesis has clear advantages (in terms of psychology and convenience of use). However, with advanced alveolar atrophy associated with total edentualism and the development of false ‘senile’ prognathism, fixed prosthesis has a number of disadvantages, such as lack of buccal and labial soft tissue support, speech disturbances, implant care difficulties, the development of frontal cantilever, poor load distribution, and long unaesthetic crowns.2

Dr. Evgeny ZhdanovDDS, PhD

Founder & Owner of Domodent Dental Clinic

[email protected]

Dr. Alexey KhvatovDDS, prosthodontist

Private practice, Domodent Dental Clinic

Ilia KorogodinDental Technician

Private practice

Implantology


Implant-supported removable prosthesis possess a few advantages, but in general patients like these prostheses less than fixed ones. In many respects, this is associated with the prosthesis mobility in the oral cavity.

This article presents an innovative approach to the fabrication of esthetic, comfortable, hygienic and light removable prostheses on telescopic crowns and zirconium frameworks and galvanic caps. With good retention, simple care and maintenance, and the precise fit of the components,4 a patient feels this prosthesis as fixed one.

Case StudyA 56 year-old male patient presented himself at our clinic on the 31st of January, 2008. The patient was a non-smoker and medically fit. In the maxilla, 3 remaining teeth exhibited mobility (grade III) and were extracted. In the mandible, both canines were preserved. In the maxilla, the alveolar process had division C and D atrophy (according to 1985 Misch & Judy classification). In the mandible, division B atrophy was observed. Jaw relationship in the sagital plane was classified as pseudo-class III malocclusion. The alveolar arch shape was flat (Figs. 1, 2).

After physical/lab examinations, preliminary wax-up and computerized exam, the tooth roots were extracted and 8 Anthofit implants were inserted in the mandible to seat a fixed ceramic-to-metal prosthesis. During the implant insertion, Kazanjian Vestibuloplasty was performed in the anterior mandible. (The prosthesis was fabricated 4 months later (Fig. 17)).

To perform implant insertion in the maxilla, alveolar reconstruction with tibial cortical grafts (in the form of bone blocks and chips) and bilateral sinus-lifts with Bio-Oss grains were performed. The bone augmentation was performed only in perspective insertion sites, which reduced the extent of the surgery and the amount of grafted bone. For augmentation, the vestibular approach with elements of tunnel technique was used. The recipient and donor sites healed with primary intention (Figs. 3-5).

In the maxilla, 6 implants were inserted to seat a dental prosthesis on telescopic crowns. Due to the flat shape of the alveolar arch, anterior implants were inserted in the positions of missing canines. During implants insertion, the repaired bone had good vascularization and no signs of resorption (Fig. 6). Repaired bone morphology stained with hematoxylin-eosin showed that grafted bone tissue was viable; it contained viable osteoblasts and osteocytes. At the periphery of the grafted bone young bone rods were being formed (Fig. 7). 4 mm Anthofit implants with internal octagonal connection were inserted in positions 13, 15, 23, 25 and 5 mm in positions 17 and 27 five months after grafting (Fig. 8). On tibial X-rays 6 months later complete bone repair was noted (Figs. 9,10).

The implant exposure was performed 4 months later using free palatal epithelial flap split in the shape of mesh, consequently, implant abutments were surrounded with dense attached keratinized gingiva (Fig. 11). Four weeks after the uncovery surgery, prosthodontic part of the treatment in the maxilla began.

(Figure 1) Pre-operative frontal view

(Figure 2) Pre-operative intra-oral view

(Figure 3) Tibial autogenous graft

(Figure 4) Collected bone from the donor site

(Figure 5) Bone graft fixation at the recipient site

(Figure 6) Good bone vascularization and no sign of resorbtion

(Figure 7) Viable osteoblasts & osteocytes and young bone rods at the periphery of the grafted bone


For the provisional prosthesis, interim abutments (implant carriers) with external hexagonal connections were used. The fabricated removable prosthesis was adapted to the inserted abutments. Due to provisional restoration, the patient received fixed interim prosthesis soon after the uncovery (Fig. 12). During the fabrication of final prosthesis, the patient was rehabilitated prosthodontically.

For the final restoration, straight “Tin-plus” abutments with a collar height of 1 mm were used. To select abutments, orthopedic platform switch technique was used. The abutments were machined in a surveyor. Zirconium frameworks for the implant abutments were fabricated and machined with a dental turbine in the surveyor with an angle of 2° (Fig. 13).

In “AGC Micro Weiland” machine, galvanic caps for zirconium frameworks were fabricated (Fig. 14). A tertiary framework

(Figure 9)Tibial X-ray immediately

after bone grafting

(Figure 13)Implant abutments

(Figure 14)Galvanic caps for

zirconium framework

(Figure 12)Provisional prosthesis

(Figure 11)Implants surrounded by dense attached keratinized gingiva

(Figure 10)6 months after grafting: complete bone repair

was observed

(Figure 15) Tertiary framework fixed to galvanic caps

(Figure 16) Final prosthesis

(Figure 17) Occlusal view of lower arch

(Figure 18) Final extra-oral view

(Figure 19) Post-operative panoramic view

(Figure 8)Implant insertion

5 months after grafting

Implantology


made of chromium-cobalt-based alloy was fabricated to place on the galvanic caps. The zirconium frameworks were cemented on the implant abutments with “Fuji+” cement. The tertiary framework was fixed to the galvanic caps with “Nimetic Cem” 3M Espe (Fig. 15). The centric relation was determined. The restoration was checked in the oral cavity. Then, the final prosthesis was fixed (Figs. 16-19).

Conclusions and DiscussionThe treatment of total edentualism is a medical and social problem that is expected to remain in the future due to the increase in life expectancy. Prosthodontic treatment of the elderly patient with traditional removable restorations doesn’t allow us to restore completely the functions of the stomatognatic system and results in a significant compromise in patients’ quality of life. The prosthodontic treatment of edentulous patients is more effective, but is complicated by a number of factors, where advanced bone atrophy and changes in oral mucosa associated with edentulism are the most important. For this reason, further development and refinement of bone reconstruction and soft tissue management are very topical. Very promising, in our view, is the use of tibial cortical grafts to perform alveolar reconstruction. The use of tibial grafts has some advantages over other techniques in that it permits a greater amount of grafted tissue, has lower morbidity, uses less invasive surgical technique, is performed in an out-patient setting, permits a bone repair of good quality and complete and quick donor site restoration of bone tissue.

When fabricating implant-supported prostheses in general and removable prostheses in particular, it is vital that the dense gingival tissue be placed around the implants. “The masticatory mucosa” (as the keratinized gingiva is sometimes referred to) protects the osseointegration zone and prevents inflammatory complications. The dense keratinized gingiva is capable of self-cleaning, which is very important to patients with limited hygienic skills in older age groups.

In spite of psychological advantages and convenience of use, an implant-supported fixed prosthesis to treat total edentulism or/and advanced bone atrophy has a number of disadvantages. The first disadvantage is the complicated hygiene. Both self care and professional care are prerequisites for long term function of an implant-supported prosthesis. Sometimes it is extremely difficult for patients, especially the elderly, to clean a fixed prosthetic restoration on all sides. However, the possibility to remove and clean the restoration and gain access to implant abutments to clean them is the primary prevention of mucositis and peri-implantitis and, consequently, implants loss as a result of inflammatory complications. The above described prosthesis construction combines the advantages of a fixed prosthesis; due to a very precise fit, the patient feels the prosthesis as a bridge or his own teeth. At the same time, the patient can take it out and provide hygienic care for the prosthesis and implants. The second disadvantage of fixed implant prosthesis, such as FP-3 (fixed prosthesis which replace crown, part of the root & part of the gingiva) according to Misch classification,2 is speech disturbance. Too long tooth crowns and loose contact between a framework and the palate impede the pronunciation of sibilants and some vowels. In contrast, a removable prosthesis on telescopic crowns closely

fits to the palate and doesn’t cause such problems. To fabricate an implant-supported fixed prosthesis, 8 to 10 implants are required. A prosthesis on telescopic crowns can function, at least, on 4 implants in the presence of other favorable factors.4 Fewer implants reduce treatment costs and the extent of bone reconstruction.

Removable telescopic prostheses are as good as ceramic-to-metal prosthesis. In addition, they are significantly lighter than ceramic-to-metal prosthesis, whose framework often weighs more than 40 g (in either arch) in such clinical situations. They are also lighter than a screw-retained metal-plastic hybrid prosthesis whose metal framework is by far bulkier and heavier than a tertiary framework of a removable prosthesis on telescopic crowns.

The important advantage of this prosthesis is the possibility to repair as well as the possibility to splint teeth and implants (taking into account prosthesis biomechanics), which permits the preservation of proprioceptive sensibility of natural teeth, which, in turn, protects the prosthesis from overloading.4 In the described clinical case, we managed to retain two opposing natural teeth in the mandible. In addition, change in jaw position in the sagital plane inevitably occurs in total edentualism, and the so called senile prognathism precludes the fabrication of a fixed prosthodontic restoration.

CAD-CAM technology to fabricate a primary prosthesis framework and galvanic caps by means of galvanoplasty provides the high precision of the component fit. Passive glue fixation in the oral cavity sets off possible inaccuracies of the tertiary prosthesis framework. A galvanic cap and zirconium framework machined by a special cutter in a water-cooled dental turbine ideally fit each other and provide smooth and unimpeded movement of the cap on a primary framework during insertion and removal of the prosthesis. Due to passive fixation of the tertiary prosthesis bone tissue around the implants doesn’t experience strains that can occur after fixation of the traditional metal-cast framework that splints several implants.

Thus, the innovative approach to surgical preparation and prosthodontic treatment of patients with total edentulism allows us to perform oral rehabilitation of patients with such a condition in shorter terms and in out-patient setting and fabricate implant-supported removable prosthesis on telescopic crowns made with CAD/CAM technology and with reliable prosthesis fixation, ease, high esthetic qualities and convenience of use.

* This article was presented in France during the 1st International Anthogyr Leader’s Meeting in Sallanches on 5,6 February 2009.

References1. The dental aid to the Moscow region population. Statistical data for 2007. Ministry for

health care of the Moscow Region. The Moscow regional board of stomatologists and oral surgeons. Moscow 2008. pp:72-78.

2. Misch C. Dental Implant Prosthetics. St. Louis: Elsevier MOSBY, 2005.3. Khoury F, Antoun H, Missika P. Bone Augmentation in Oral Implantology. UK: Quintessence publ, 2007. 4. Weigl P, Trimpou G, Lee J-H, Krenz E, Arnold R. Inoovatives Behandlungsprotokol zur

Herstellung von Galvano-Konusprothesen. ANHANG Stand: Juni 2005.


Elegant styling with titanium finish, long-life LED illumination, superior reliability, reduced noise and light weight are just a few of the various new features offered by the new THERA®L 40SE high-speed Turbine.The handpiece incorporate special integral-structure high-precision ceramic ball bearings which, together with the perfectly balanced rotor, makes the turbine with unmatched high reliability and quietness.

Once coupled to the new GYROFLEX®LED rapid Coupling, the turbine can immediately get advantage of the new LED source which allows 25000-LUX daylight quality illumination of the operating area and produces a superior and perfectly uniform light pattern.

The innovative LED technology integrated in the rapid coupling produces a level of brightness never seenbefore! The emitted white light also helps reducing colour distortion with respect to halogen light.The new special GYROFLEX®LED rapid Coupling can be used on its own to immediately add LED illumination feature to any dental Turbine with fiber-optics and Multiflex® connection.

TeKne presents THERA®L 40SE Turbine + GYROFLEX®LED Coupling

nano-sized filler particles contribute to the XP Enamel’s excellent polishability and translucency, while the reinforcing filler allows for maximum strength and durability.

Syringe and unit-dose dispensing options are available and complete kits are offered.

REFLEXIONS™ Universal Aesthetic Composite SystemREFLEXIONS is a simplified universal nano-technology composite system. The system consists of Low-Shrinking XLS Dentin and Highly Polishable translucent, refractive XP Enamel shades. REFLEXIONS composites are engineered as a biomimetic approach to the replacement of lost dentin and enamel substrates. With only 8 shades, REFLEXIONS utilizes a shade system that simplifies the technique to match the most common VITA® shades.

The REFLEXIONS system of composites includes XLS Dentin shades which are light-cured,low-shrinking nanohybrid composites. This nanohybrid formulation is the perfect dentin replacement material offering opaque chromatic characteristics of natural teeth. The low-shrink properties minimize shrinkage stress and post-operative sensitivity. REFLEXIONS XP Enamel composites are highly reinforced nanofil composites. The

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Indicator of wear on endo hand instruments

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At the same time, we have developed a new ergonomic handle, featuring : - An improved grip-bean-shape;- A larger diameter at the back end, for an easier, more comfortable and safer pull;- Improved control of feather-touch rotation – balanced force.

Stainless Steel instruments availability:- Set of 6 instruments, individual sizes- Assortment : ISO 15 to 40- Length in mm : 25 (21/31 is also available)

SafetyMemoGrip (SMG) &

The SafetyMemoDisc (SMD) system, originally on FKG RaCe rotary NiTi instruments, is a success.FKG Dentaire applied the same concept to stainless steel hand files which is called SafetyMemoGrip (SMG).

The information on the number of uses/sterilisations is recorded all along the file life.Practitioners will scratch one or more petals off after each use – depending on the effort on the blade and the canal curvature.The remaining petals indicate how many more times the instrument can be used.

SafetyMemoGrip at the backof the new handle

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Flash News

“Big Kids” Braces The NEW 3M™ Unitek™ Clarity™ SL Self-Ligating Appliance with Lowers system is launched

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Dubai, UAE, August 2009 - In recent years, braces have taken on a sort of a chic feel.True, not many people would commit to braces purely as a fashion statement. The real purpose of orthodontics is to correct problems with the teeth and jaw such as underbites or overbites, and crowded or gappy teeth.For some, it’s a cosmetic fix; for others, ignoring the issue could potentially lead to more serious medical problems.What is surprising is that more adults are seeing orthodontics as an option. It is evident why 3M Unitek

is excited about its newest Orthodontics product. The truly advanced aesthetic - almost invisible – braces system.Clarity™ SL Self-Ligating Brackets for the upper teeth have been available since 2007, and now 3M™ Unitek™ is in the midst of the worldwide launch of its ceramic brackets for the lower arch. The complete system for both upper and lower arches is called the 3M™ Unitek™ Clarity™ Self-Ligating Appliance System.

The ceramic upper arch and lower arch complete the aesthetic self-ligating system.Now, people who didn’t have the opportunities for orthodontics when they were young and have been unhappy with the way their teeth look, and people seeking treatment prior to having veneers or other work done if their teeth are worn down, can look at another option.

Dima Zein, Business Leader of 3M™Unitek™ in Middle East says, “Those patients that rejected orthodontic treatment for aesthetic reasons in the past can now reconsider thanks to the new techniques like the Incognito™ Lingual System and the ceramic 3M™ Unitek™ Clarity™ Self-Ligating Appliance”.

Clarity™ SL Appliances are made from high-tech ceramic with smooth, rounded edges for a comfortable fit.Clarity™ SL braces are translucent, so they are less visible than metal braces. And they are the coolest looking braces you’ll find anywhere. Without ligatures to stain or hold food particles, they’re easier to keep clean.

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W&H Easy-to-dismantle surgical instruments with LED and generator - now even more innovative

The new W&H surgical instruments with LED and generator produce perfect light and can easily be dismantled and re-assembled.

Perfect light, independently generated.Operate by daylight quality light and with a self-sufficient light source: W&H surgical instruments with LEDs make this possible and generate perfect white light all by themselves. As soon as the straight or contra-angle handpiece is started up, the integrated generator starts to independently produce the required electricity and supplies the LEDs on the easy-to-dismantle S-11 LED G and WS-75 LED G with energy. Excellent lighting conditions facilitate thorough diagnoses and perfect treatment results.

Innovative performance characteristics.The impressive features of the W&H easy-to-dismantle surgical instruments include, in particular, the perfect daylight-quality LED light and its illumination of the entire treatment area with a light intensity of up to 31,000 Lux. As a result it puts conventional halogen light firmly in the shade. Additional advantages of W&H surgical instruments include compatibility with ISO couplings, an independent power supply and the possibility of sterilizing up to 135°C and thermo washer disinfecting both the straight and contra-angle handpiece.Get the new standard for yourself: perfect light, comprehensive compatibility, precision, ergonomics and total hygiene.


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anthogyr

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tioLogic© dental implants– the logical evolution

Flexibility and reliabilityIt is essential that a modern implant system provides the operator with an optimal combination of high flexibility, easy handling, an efficient technique and maximum safety and reliability. Particularly in the case of surgical instruments, it is essential that the operator can rely fully on the system during the surgical procedure. The surgical components should be suitable for use with any indication, even with difficult cases, and should be manufactured to a high quality. The design of the tioLogic© implant system from Dentaurum Implants is based on more than 18 years’ experience and on close collaboration with experts.

www.anthogyr.com

The company ANTHOGYR, created more than 60 years ago, in 1947, benefits from a very strong experience and worldwide reputation, through its wide range of dental instruments and implants such as:

ANTHOGYR Bone Collector ASPEO: The Aspeo bone collector is to be attached on the dental’s chair suction system and allows the harvesting of bone fragments during implant site preparation.AXIOM®: new implant system features a unique conical abutment connection for a significant and intuitive connection. With its sub-crestal positioning, AXIOM provides a better aesthetic management of restorations.ANTHOFIT®: with its internal octagon connection, this implant is easy to use in mouth, flexible and adapts over time. Available in straight or tapered shape with a BCP body treatment, it is recommended for juxta-crestal positions. The neck surface treatment helps to promote attachment to bone at this level.MONT BLANC CONTRA ANGLES®: the new range delivers at last all the features you expected! The new technological achievements allow easier access and better visibility in mouth. Full range for general dentistry, i.e 5:1, 1:5 and 1:1, and implantology 1:20, with or without light.IMPLANTEO®: this brushless motor has been designed to complete any implant and surgical procedures.TORQ CONTROL®: the manual dynamometrical declutching wrench Torq Control allows very precise tight locking of the prosthetic parts on implants. With its adjusting knob, it allows 7 tightening torque values from 10 to 35 N.cm. Once the desired torque is reached, the tightening is automatically stopped.

Experience acquired in the cold disinfectant and steriliser fields for medical-surgical devices has allowed Zhermack to develop a newly improved, widely effective range for dental clinics and laboratories.

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The whole Zhermack products range respect the most restrictive European norms regarding disinfectants and sterilisers. Their CE marking further ensures their conformity with Directive 93/42/CEE on medical devices.

Thanks to careful research protocols, Zhermack products offer an ideal efficiency-time ratio by fully respecting the operator and the environment.

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Proprietary heat treatment and cryogenic processing ensure that the superior edge retention and wear characteristics of EverEdge Technology will last the entire life of the instrument. It’s not a superficial coating – EverEdge Technology scalers can be sharpened again and again for your best instrument value.

Technology ScalersEverEdge Technology is unlike anything you’ve experienced before in a scaler. We’ve applied state-of-the-art technology in metallurgy, heat treatment and cryogenics to create a superior stainless steel alloy for scalers and curettes that stay sharper 50% longer than any instrument you’ve used. That means less frequent sharpening, less hand fatigue, and greater comfort throughout the day.

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TOOLS TO KEEP SMILING

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BioEDEN, an International, Britain based, Bio-Technology company, launched its activity in Amman, Jordan on the 28th of July 2009, in an elegant ceremony held at the British ambassador’s residency.

BioEDEN is the 1st company in the world to isolate mesenchymal stem cells from deciduous teeth which multiply rapidly and differentiate into many different cell types; these cells can then be introduced to damaged tissues to treat debilitating conditions. Some scientists say that stem cells may be used to cure conditions such as Alzheimer’s, Parkinson’s, diabetes and some cancers. There may also be cosmetic benefits as the cells isolated from teeth may be able to be used to grow new teeth.

Through the partnership with BioInsure, their local agent in Jordan, people can have the chance to offer their children what might be their only hope in the future to treat major diseases. When a child’s primary tooth is shed, it is stored in fresh milk, packed and then sent to BioEDEN’s laboratories.

Stem cells collected from primary teeth are a viable and ethical alternative for embryonic stem cells and they grow faster and have more potential to differentiate into other cell types than adult stem cells.

BioEDENlaunched its activity in Amman

Recent Study Participants are WOWed by the sensitivity free whitening that comes with Sapphire Professional Chairside Whitening!Unbelievable brilliance and healthSapphire Professional Whitening allows you to achieve dramatic results quickly. When used with the Sapphire Supreme Light1, the system is proven to whiten smiles up to 7 shades in only 30 minutes. Sapphire Professional Whitening also gives you the flexibility to whiten smiles without light activation. Beyond beautifying smiles you can also protect them from demineralization and caries, thanks to the integrated fluoride. With the Sapphire Supreme Light you can also say goodbye to complicated patient setup. Unlike other lights, it does not expose your patients to harmful UV rays and thus does not require protective sunscreen or face masks.

Easy maintenance for lasting resultsNot only can you create bright, white smiles with Sapphire Professional Whitening, but also included in the kit is everything you need to maintain that radiance. Sapphire After Care is a complete maintenance kit with Sapphire Take Home Whitening. Sapphire combines the speed of in office whitening with the longevity available with home whitening Zero sensitivity.With Sapphire Professional Whitening, you can bid farewell to sensitivity - the most common patient complaint about whitening. Not even a pre-treatment Aspirin is needed when you use this breakthrough chairside formula.

MILLENNIUMNot Just Any Sterilizer

Millennium B+ is Mocom’s revolutionary step forward in the field of type-B steam sterilizers. It represents an ideal point of reference in terms of safety, performance and flexibility.

Millennium B+ is a technologically advanced sterilizer which is also extremely easy to use. Thanks to its high number of configuration options and to the corresponding patented devices, it can satisfy any sterilization requirement, and ensures the highest performance in every situation.

It is equipped by microprocessor controlled electronics, an advanced sterilization process self-evaluation system (“Process Evaluation System”, as defined by EN 13060), an instant steam generation system, an integrated printer, a robot controlled locking system, a widescreen liquid crystal display which allows the clear visualisation of all the necessary information in real time and a wide range of programs specifically developed for a suitable treatment of the various materials.

“Millennium” is today a complete line of autoclaves, including four models: Millennium B+, Millennium B, Millennium B2 and Millennium Bmicro.

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MM-GP PointsFor a perfect match with the Revo-S root canal preparation system, MICRO-MEGA has just launched the MM-GP Points 0.06 taper gutta percha points.Advantages:- Radio-opaque.- Optimal biocompatibility.- Easy to place.- High plasticity and very flexible to mould perfectly to canal walls without bending.- Colored top for quick and easy ISO number identification.

0.06 special taper gutta percha points

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Flash News


- 0.06 special taper ideal for use following continuously rotating canal preparations (ideally Revo-S).- Cadmium-free fabrication using high quality raw materials.- Shape that adapts to cold, hot and thermo mechanical condensation techniques.- 29 mm in length, 60 points (n° 20-25-30-35-40-45).

Turnstraße 31 · 75228 Ispringen · Germany · Phone + 49 72 31 / 803-0 · Fax + 49 72 31 / 803-295www.dentaurum-implants.de · E-Mail: [email protected]

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tioLogic© implantology course, incl. 2 surgical live-operations December 11-13, 2009 – CDC, Ispringen, Germany For further informations please contact: [email protected]

Area Manager Middle East:Mahmoud LutfiTel: +962 6 5656404Mobile: +962 7 95536867Email: [email protected]

Area Manager Middle East:Mahmoud Lutfi

Tel: +962 6 5656404Mobile: +962 7 95536867Email: [email protected]

Aptica Plus Bthe faster B class autoclave specially designed for your handpieces sterilization.

Domina Plus Bdesigned for a safe, reliable and rapid sterilization of all your instruments.

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CAPP Tel: +971 4 3616174; Fax: +971 4 3686883; Mob: +971 50 2793711; [email protected]/aesthetic www.cappmea.com/awards2009

Dr Julian Caplan, UKBritish Academy of Cosmetic Dentistry"Back tooth solutions – Cerec is the answer""Anterior Cerecs – discover their beauty"

Prof. Wolfgang Richter, AustriaPresident of ESCD"Excellence in Esthetic Dentistry Using Adhesive Direct Composite Restorations"

Dr. Luca Dalloca, Italy"Veneers and Porcelain Crowns – how to make them look natural and real" Dr. med. dent. Daniel Rothamel, Germany"Guided bone and tissue regeneration: success factors and treatment concepts"

Dr. Philippe Tardieu, France"New Opportunities in Computer Guided Aesthetic Reconstructions"

Dr. Nael Abouhassan, UAE"Entice your patient with Clear Aligners"

Dr. M. Qureshi, Pakistan"The New Frontier in the Reconstruction of the Atrophic Maxillae"

Prof. Vintzen, Austria“Orofacial Esthetics – Interdisciplinary Aspects in Esthetic Dentistry”

Dr. Donald J. Ferguson, Dr. Baltensperger, Dr. Richard R. Lebeda, Switzerland"Maximizing Dento-Facial Esthetics Using Surgical-Orthodontic Techniques"

Dr. Joseph Muhammad, UAE"Multidisciplinary Management of Dentofacial Deformity: Achieving Optimum Results Through a Team Approach"

Dr. Ninette Banday, UAE“Hollywood Smile”

Dr. Kakino, France“The face harmony and some post-orthodonties smiles”

Dr.Reza Nokookar, Iran“Surgical procedures in partially edentulous patients”

Dr. Hani A. Salam, Canada"An Overview of Minimally-Invasive Facial Rejuvenation Techniques for the Lips"

Dr. Christian Makary, Lebanon"Hard and soft tissue management: The key for perfect esthetics"

Prof. Abbas Zaher, Egypt“Orthodontic �nishing contributing to ultimate esthetics”

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On the 18th of April 1955, Mohammed Sherine Ibrahim El-Attar was born

in Alexandria, the Pearl of the Mediterranean, grew up there, and got his

first and second dental degrees from Alexandria University. In 1982 he

flew to Pittsburgh, USA where he got his Master degree of Dental Science

in Prosthodontics. Back to Egypt, he got his Doctor’s Degree in Prostho-

dontics from the University of Alexandria in 1986.

We know Professor El-Attar for being a great instructor and lecturer since

1978….

We know him as a renowned speaker and chairman present in almost

every major congress or dental event in our region….

We know him as a leader implantologist since 1984 when he got his fellowship of the

International Congress of Oral Implantologists held in Munich, Germany, and as the chairman of Alexandria

Oral Implantology Association (AOIA) since 1996….

We know him for being such a beloved husband and caring father….

For Smile team, we know him as the spiritual father, strong supporter and intimate friend…

Now… We know him as the Dean of the Faculty of Dentistry, Pharos University…

Your strong personality, professionalism, great experience and wonderful sense of humor are your armors

against the difficult challenges and major responsibilities such an important position has.

CongratulationsProfessor Sherine

Professor Mohammed Sherine El-Attar

Recognition

S I M P L I F Y I N G D E N T A L M O T I O N

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KOS Four ways to successR

KOS A implants are available as pre-angulated implants with a 15 or 25 degree angulation between implant and abutment. This allows equipping the regions anterior to the maxillary sinus as well asplacement in the (edentulous) front area

KOS B implants provide a bendable neck. The neck is bent right after insertion. KOS B implants are suitable for circular bridges and if multiple implants are placed and splinted

KOS EB: this reverse cone type features both the aesthetic neck (4.8mm width) and a reverse cone which allows overcoming differences in the direction of insertion up to 20 degrees

All KOS & KOS A (and BCS) implants may be equipped with “angulation adapters”. Thos adapters are cemented or glued onto the original implant head and help to overcome differences in the directionof insertion of 15 or 25 degrees. Implant analogues for these adapters are available The KOS concept allows the implantologist to treat virtually all cases without bone augmentations, atremendous advantage compared to tradition two-piece systems requiring more width of bone

KOS Implants – 4 ways to create angulations in one-piece-implantsR

Smile Dental Journal Volume 4 Issue 3

Documents

Transcript of Smile Dental Journal Volume 4 Issue 3