ISSUE 75 SEP20

The Maltese Dental Journal ISSN 2076-6181 ® DENTAL ASSOCIATION OF MALTA Variolink Esthetic The Professional Centre, Sliema Road, Gzira The esthetic luting composite Tel: 21 312888 Fax: 21 343002 Editorial Email: [email protected] By Dr David Muscat

Dear colleagues,

The Dental Profession has St Apollonia Celebration: implemented the Covid guidelines and we have braved the summer. It is rather unfair that we have been TheEarly Years excluded from the 50% reduction in electricity bills. By George E. Camilleri

In this issue I have asked a few Oral historical evidence attributes Golden Bay Hotel (Figs 3 & 4). Dental dentists to contribute articles as we the origin of the celebration of the students (Class 1957 and Class 1960), have not been able to organise many feast of St Apollonia (February 9th) to myself included, were invited. events this year. the outings organised by dentist Mr September 2020 – Issue 75 Anthony Ciappara (is-Sur Nin) for The event seems to have lapsed again On the 18th September 2020 the children from the orphanages. until 1966 when Mass was celebrated DAM arranged a free online at St Franics Church Valletta. International Congress with MOI The first documentary evidence of (Masters of Implantology, Goethe participation by dentaI surgeons I remember that the side altar of Sts University) for its paid-up members is from the Times of Malta which Cosmos and Damian was used and who wished to attend. stated that on Saturday February 7th a painting of St Apollonia put up. 1948 a number of dental surgeons In January 1975 I, as Dean of Dental The front cover is by the accomplished and dentists attended Mass in the Surgery, received a letter from Mr 3 artist Jacqui Agius, entitled ‘Aerial Hamrun Parish Church followed by Ciappara deploring that the custom View of Mdina’ from a photo taken lunch at the Riviera Hotel, Ghajn had been discontinued (Fig 5). The Dental Probe by her son, professional photographer Tuffieha. Two group photographs Michele Agius, brother of our probably dating to 1947 (Fig 1) and I forwarded the letter to the colleague Dr Andrea Agius. 1948 (Fig 2) were possibly related to Association who agreed to organise the St Apollonia event. the event. Mass was held at Best regards, University Chapel, Msida by Fr M. The activity as far as dentists were Jaccarini SJ followed by a reception David concerned seems to have died down hosted by Associated Products. Dr David Muscat B.D.S. (LON) until 1957 when members of the Amazingly simple Editor / Secretary, P.R.O. D.A.M. Association organised a lunch at the Continues on page 5. esthetics

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Figure 1: John J. Mercieca, Thomas Demajo, John Camilleri (back), John Bartolo (front), Edwin Galea, Figure 2: Registered Dentists – Back row L to R: John Camilleri, John Agius, Joseph Lapira, Anthony Ciappara (back), Carmelo Floridia, Egidio Lapira, Victor Salomone (back), Vincent Diacono (front), Anthony Ciappara, Carmelo Floridia. Sitting L to R: Bartolo John, Demajo Pascal, Anthony Demajo, Walter Bartolo, Joseph Lapira, Joseph J Mangion, Louis Caruana, Guido Caruana. Egidio Lapira, Caruana Louis, Bartolo Walter. Squatting: Diacono Vincent www.ivoclarvivadent.com Ivoclar Vivadent AG Advertisers are responsible for the claims they make in their ads and the opinion of the advertisers Bendererstr. 2 | 9494 Schaan | Liechtenstein | Tel. +423 235 35 35 | Fax +423 235 33 60 and editors of articles in the issue are not necessarily the opinion of the DAM. CHMLT/CHPLD/0003/15b (1) We’ll keep itgoing. them confidence. Your dentures gave Trademarks are owned by orlicensed to theGSKgroup ofcompanies. ©2018 GSKgroup of companies oritslicensor. their dentures. social activitiesbecausethey are conscious of than 1in3denture wearers admitto skipping with dentures. They may nottell you, butmore difficult for them to emotionallyadjust to living denture retention andtrapped food, makingit wearing patients canhave concerns around well-fitting dentures. However, your denture- you’ve given your patients speciallymadeand You canbeconfident intheknowledge that life Study. 2005;3.Munoz CA et al.JProsthodont. 2011;21(2):123-129; 4. Fernandez Petal.Poster presented at theIADR2011, Poster 1052. announcements/denture-wearers-embrace-new-smile-yet-avoid-popular-foods. Accessed September 2013; 2.GSKData onFile;CanadianQualityof References: 1.P&G News. Denture Wearers Embrace New SmileYet Avoid Popular Foods. http://news.pg.cpm/press-release/pg-corporate- †vs. noadhesive (p<0.0001) inwell-fitting dentures Corega adhesive reduces food entrapment vs. noadhesive use Ultra Fresh denture adhesive. with theirdentures by recommending Corega Maintain your patients’ confidence andsatisfaction from livinglife to thefullest. can holdyour patients back These everyday challenges and 55%experience denture movement. experience food trapping undertheirdentures Up to 29%skipeating outinpublic, *P<0.0001. dentures after subjectschewed andswallowed 32grams ofpeanuttest meal. Food entrapment was quantitatively measured by collecting andweighing residue from beneath the Subjects withwell madeandwell-fitting maxillaryandmandibulardentures completed thestudy. Randomised, blinded,3-way crossover study to evaluate denture adhesive useagainst noadhesive use. Weight of peanut particles recovered from beneath dentures (grams) 0.04 0.03 0.02 0.01 0 REQ NO: 1

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Floriana (Fig6). at Paceville, andadinnerattheHotelPhoenicia, new officesoftheFederationProfessionalBodies The followingyear (1980)Mass was heldatthe Casino Maltese. Onorati Chapel,Valletta followed byareceptionatthe University Chapel,Msidaandin1979theMassat and 1978theMassreceptionwere heldatthe This seemstohave hadthedesiredeffectandIn1977 half ofFebruary”. function about St. Apollonia’s Day annuallyin the first Association bymeansofareligiousandsocial commemoration oftheFoundationDay "He willberesponsibletoorgansethe made tothefunctionsanddutiesofSecretary: to theregulations“thatfollowingadditionbe Annual GeneralMeetingheproposedanamendment celebrated annuallybythe Association andatthe1976 Professor J.Mangionwas keenthatthefeastbe Continues frompage3. YearsTheEarly St Apollonia Celebration: John Mercieca, Beatrice Mangion, Herbert Messina Ferrante, Joann Camilleri, Thomas Demajo. Messina Ferrante, JoannCamilleri, Mangion, Herbert John Mercieca, Beatrice Dinner atHotelFig.6: Phoenicia. Lto (?), Ms Messina Ferrante, R: George Camilleri, Attard, MessinaFerrante, Carmen Sydney Joslin Herbert Joseph J.Mangion,Tony MsCiappara, JohnBonello. Squatting: camilleri, Ronald Delia, 4:Standing George Manara, Fig, Munroe, George Camilleri, Olivieri Lto R:Charles Galea. Demajo,Thomas Demajo, Mary Mrs 3:LtoFigure R: JosCiappara, Anthony Ciappara, JohnMercieca,

5 September 2020 – Issue 75 Issue – 2020 September The Dental Probe Dental The Camera Body

A BEGINNERS GUIDE TO The camera body houses the image sensor and processing units. The sensor detects photons of light and converts them into an electrical current which DENTAL PHOTOGRAPHY can be stored on our cameras as data. Image sensors are divided into pixels, these represent each unit of the sensor By Dr Josef Awad that can detect light. When relating to image quality, the number of pixels (megapixels) is of little importance I am a general dentist with special interest in cosmetic dentistry and when compared to the quality of pixels. occlusal rehabilitation. Pixel quality is more closely related to the size of each pixel on the For over 15 years I have been very passionate about photography, sensor. Larger pixels will yield a some of my work has been used to promote hotels, events, brands, wider range of colour and tonality. and magazines. Therefore a larger sensor will pick In this article I will give an overview of photographic equipment and up far more information than a discuss the fundamentals of exposure. Specific shooting techniques smaller sensor, even if the number Full Frame Sensor APSC Sensor Smartphone Sensor September 2020 – Issue 75 of megapixels are the same. (higher end dslr/mirrorless) (entry level dslr/mirrorless) will not be covered in this article and may be discussed in a followup. Smartphones are restricted to use small sensors due to space differentiating subtle differences in of lenses and equipment on the requirements. Manufacturers attempt colour and therefore they are not market. Other brands however to overcome these limitations using ideal for dental photography. are quickly catching up.

The Dental Probe EQUIPMENT advanced software techniques. Although smartphone images The camera systems of choice Both entry level and high end DSLR Camera Body 6 can sometimes look impressive today are Canon and Nikon. (or mirrorless) Camera systems are 7 Any camera that is capable of using

they are not very accurate at They support the largest variety very effective for dental photography. The Dental Probe interchangeable lenses (most commonly DSLR, or mirrorless systems), and has the ability to shoot in manual exposure. MACRO LENS should never be used for dental 3. To have good optical quality Lenses photography as they will create a have multiple glass elements inside Macro Lens When it comes to camera lenses distorted image that is not true to them that are used to focus light into The 100mm macro lens is ideal for

September 2020 – Issue 75 the selection can be vast and very life. Typically lenses above 50mm a sharp image. The lenses that tend most kinds of dental photography, daunting. Different lenses will provide show minimal distortion and can to have the best optical properties I would always recommend using a unique image outcome. Fortunately be used. The most commonly used are known as prime lenses. These are the same lens brand as your camera for dental photography our needs focal length for macro photography lenses that only have one focal length system as this will provide the are very specific and selecting the is 100mm. (eg: 100mm), in contrast to a zoom best autofocusing experience. right lens is very straight forward. lens which will have a range of focal 2. To be able to focus as close as length (eg: 18-125mm). The ideal properties of a lens to be possible to a subject (macro) An Macro Flash used in dental photography are: important built in property of a Continues on page 8. A ring flash is the most versatile 1. To create a true to life image with lens is its minimum focus distance. flash system for dental photography. as little distortion as possible Lenses For a lens to be considered Twinflash setups will produce are classified by their focal length, macro it should normally have a more aesthetically pleasing which is a measure of how strongly minimum focus distance results however are limited to a lens converges or diverges light. of 30cm or less. The anterior regions of the mouth. Focal length is measured in mm, smaller the distance this is normally marked on the the closer the lens exterior of each lens. The smaller the can approach the number the more wide angle the subject and the lens is considered while the larger more magnified the the number the more telephoto image. This can be (zoomed in). Wide angle lenses tend especially useful for to make close objects appear further taking small detail away and because of this they shots of single teeth, introduce distortion into the image. margins, texture and For this reason wide angle lenses so on. A BEGINNERS GUIDE TO DENTAL PHOTOGRAPHY

Continues from page 7. EXPOSURE Flash Exposure Compensation

Exposure determines how bright In the past a photographer would MACRO FLASH or dark an image will appear. The have to measure the mount of light different components of exposure are in a scene and set the brightness of The quality of an image is directly explained below: the flash manually. Today this can be related to the quality of light in APERTURE done automatically through a setting The Flash Exposure compensation the scene. The number of lighting 1. Shutter Speed known as TTL (through the lens). should be set to 0. options for dental photography 2. Aperture All camera lenses have an internal ring can be vast, however for the sake of 3. ISO with an adjustable diaphragm. The The camera will make an assumption of If a camera is consistently giving dark this article we will discuss 2 of the 4. White Balance size of the diaphragm is referred to as how much flash power is required by exposures it may be thinking that most commonly used systems. 5. Flash exposure compensation the aperture which is denoted with the assessing the brightness in the scene. there is more light in the scene than symbol f. there actually is. In this case we can Shutter speed ISO This is accurate most of the time move the exposure compensation up A camera sensor is normally hidden A smaller f number indicates a greater however if the camera becomes (right) 1 or 2 stops and try again. If September 2020 – Issue 75 behind a frame known as a shutter. In opening of the diaphragm while Iso is a property related to the image confused it may take incorrect an image is too brightly exposed, the order for light to enter the sensor the a larger f number will indicate a sensor within the camera. A sensor measurements, this will lead to an compensation can be moved down shutter must open and close to create a smaller opening. will normally operate as a setting image being too dark or too bright. (left) to darken the exposure. capture. The longer the period of time the known as a native ISO, this refers to shutter is open, the greater the amount of a clean signal that is sent from the light that will reach the sensor. camera sensor to the camera processor. RECOMMENDED SETTINGS The Dental Probe

Although slower shutter speeds Modern cameras allow us to amplify Full face image Full smile Close-up detail 8 1. Ring Flash will allow more light, they may also the signal from the sensor which 9

The rings flash is the most versatile increase motion blur. Shutter speed is increases its sensitivity to light. As Shutter speed 1/160s–1/200s 1/160s–1/200s 1/160s–1/200s The Dental Probe flash in dental photography. It has measured in seconds and is normally the ISO is increased the sensor will Aperture f10–16 f22 f22+ the quickest setup time and is useful denoted as a fraction, the smaller the pick up more light and the exposure for both anterior and posterior fraction the shorter the duration of will increase, this however results in a ISO 100 100 100 degradation of picture quality. shots. A ring flash tends to be more the exposure. A wider opening will allow more White balance Flash Flash Flash powerful than twin flashes which light to pass through the lens can be useful in situations where however it will also reduce the In order to maintain the highest Flash TTL mode TTL mode TTL mode

September 2020 – Issue 75 very high apertures are being used amount of area in focus known as the possible image quality the ISO should (f32). The ring flash can evenly light depth of field. This is a disadvantage be kept at the native ISO, for most up the scene however can make an in dental photography as using lower camera systems this is ISO 100. TROUBLE-SHOOTING image appear flat. f numbers will reduce the amount of teeth that appear sharp and in focus. Image too Dark Image is Blurry • Increase flash exposure • Use a flash On the other hand using very large compensation • Set the shutter speed between f numbers such as f32 will heavily • Reduce the f number 1/150 – 1/200 seconds reduce the amount of light entering • Move closer to the subject the lens. This leads to a greater amount Colour does not look natural of teeth being in focus however with Image too Bright • Set white balance to flash a deteriorated image quality, often • Decrease flash exposure While shooting dental photography leading to a very soft image. compensation our light source will normally come WHITE BALANCE • Increase the f number 2. Twin Flash from a flash. Most flash systems will One of the advantages of shooting • Move further away from the subject A twin flash is she setup of choice shoot a burst of light with a duration with a flash is that any limitation of This is an instruction that allows the for anterior aesthetic work. Twin that is between 1/300 and 1/1000 of light can be compensated by a higher camera to distinguish how warm or flashes create a softer beam of light a second. Since all the light that we flash power – most camera systems cool a certain image is. If the colour of especially when coupled with a are capturing will be coming from the will do this automatically. your photo appears too blue/yellow/ diffuser. This creates a realistic 3D flash any shutter speed that is slower green/purple, this is most likely an appearance and brings out more than this duration range will be In order to maintain the best balance issue of white balance. detail . A twin flash can be more sufficient to capture a sharp image. between image quality and depth of difficult to setup, and may require field I would recommend an aperture Since we are using direct flash other accessories like a flash trigger, My recommendation is a shutter speed between f16 for full face and f22+ for photography the white balance All information provided here is from my own personal experience. If any there is bracket and diffusers. between 1/100 and 1/200 of a second. intra oral shots. should always be set to flash. anything you wish to discuss please contact me on [email protected] long time or not come into effect Managing Loss of Inter- at all (Hemmings et al., 2000). Eliminate RCP-ICP horizontal slide Another method that can be used occlusal Space when to create space for our restorations involves reconstruction of the occlusion to the retruded contact position (R P). RCP is also a place Restoring the Anterior Bite registration our patients visit from time to time. in ICP (or MIP) Facebow and CR registration The vertical seating of the condyle Worn Dentition into centric relation can be used to 3. Reorganise the occlusion by (ICP) and create the necessary increase the vertical dimension for increasing the OVD with space by further occlusal reduction anterior teeth without increasing restorations in centric relation (CR) of the already worn teeth or the contracted length of the elevator By Dr Nicola McArdle BChD MFDS RCS MSc Aesthetic and Restorative dentistry (Manch) 4. Minimal prep vertical (arbitrary) their opposing dentition. muscles. When condyles are seated in 5. Facial Proportion CR, the mandible moves downward 6. Dahl concept Most materials require 1–2mm while the condyle moves upwards. of space so grinding these teeth This causes an increase in vertical Study casts accurately mounted in down can be very destructive dimension in the anterior dentition

centric relation (CR), are critical in and counterintuitive especially without a change in muscle length. September 2020 – Issue 75 Patients with worn dentitions walk assessing these spatial constraints when the surfaces have already through our practices on a daily basis, and treatment planning these been compromised by the In some patients, when casts are however they often walk out untreated rehabilitations. It is imperative that pathological wear itself. mounted in CR, the horizontal slide or only treated when their dentition before attempting to restore such from ICP to RCP could be around becomes severely compromised. cases, one would have mastered Occlusal reduction of these surfaces 2-4mm. This position of the mandible the skill of taking an accurate CR. may lead to a lack of axial height gives a definite physical stop to

The Dental Probe In the majority of these patients and thus insufficient retention work to accurately and if there is tooth surface loss (TSL) is followed Centic relation (CR) or retruded and resistance for conventional a reasonable vertical slide, there 10 axis position (RAP) being defined as extra-coronal restorations. is often sufficient space to restore 11 by dentoalveolar compensation Intervening early can avoid advanced wear and the need for full mouth rehabilitations

ensuring that occlusal contacts are the position of the condyles in their the worn dentition without the The Dental Probe maintained in order to sustain the most superior position in the fossa Surgical crown lengthening need of much tooth preparation. efficacy of their articulatory system. Most patients exhibiting significant restorative material proposed as well where the bone is braced, the position can be considered to achieve TSL are keen to improve their smile as aesthetics and phonetics (Mohindra is reproducible and the muscles more axial height, however Therefore, if a slide from ICP to RCP The resulting apparent lack of inter- and often ask for longer front teeth. and Bulman, 2002). Irrespective of most relaxed. Mounted models this procedure together with is present, the clinician needs to occlusal space can pose a challenge the material of choice, restorations must be verified against clinical the loss of coronal tissue can decide whether to restore the case to the restorative dentist, especially As teeth wear, some people lose their require between 1–2mm of space. records (Davies and Grey, 2001). present its own complications. in a conformative approach around

September 2020 – Issue 75 when the TSL hasn’t occurred overbite and gradually develop an The only way we can gain that ICP, or in a reorganized manner across the whole dentition. edge to edge occlusal relationship space is by grinding down Orthodontics Sometimes when restoring worn by making an occlusal adjustment (from a class I to a class III occlusion). teeth or increasing the OVD. Orthodontic appliances are more upper anterior teeth, it can be that brings RCP and ICP the same When such cases are not intercepted at appropriate when other aspects of justified however to reduce the around RAP (Davies, 2004). an early stage, full mouth rehabilitations According to Gross et al, to gain If space is limited and not sufficient the occlusion need addressing such opposing lower anterior dentition. are often required in order to protect a noticeable improvement in to accommodate the adequate bulk as anterior crowding. Sufficient This is especially the case in elderly The occlusion is adjusted until the the remaining tooth structure with facial appearance, the OVD must for the restorative material of choice, inter-occlusal space can be created patients who could benefit from a vertical component is eliminated the aim of restoring function and be increased by at least 5mm. one must consider re-establishing by a combination of relative more even, flat occlusal plane. leaving just the horizontal component sometimes facial appearance. the patient’s vertical dimension or vertical and horizontal bodily so that the patient is permanently in With up to a 5mm increase in OVD, altering the opposing occlusion. movements and a change in the This would create a more harmonious RAP. This also eliminates the RCP to When planning these rehabilitations, the patient him/ herself would gain axial inclination of the dentition. anterior guidance which is less steep ICP slide making RCP and ICP the insufficient restorative space is the most an inner confidence boost but a Increasing OVD, requires and kinder to their articulatory same and allowing the condyles to common challenge we face on a regular lay observer would not perceive a reorganised occlusion Otherwise a localised bite-raising systems. Trimming the lower incisors move upwards and backwards in RAP. basis. Opening the vertical dimension the change (Gross et al., 2002). where RCP = ICP around RAP Dahl appliance can create the may also be the best alternative in ICP = RCP or RCP-ICP=0. of occlusion (OVD) is usually indicated necessary space required. Patients patients over the age of 65 given and sometimes mandatory. If patients decline an ortho-restorative Using mounted study casts, one can may decline an orthodontic that the Dahl effect may take a very Continues on page 12. approach, a restorative option that judge if the OVD can be maintained option however it is always The primary indications for would develop some overjet (OJ) or if it needs increasing, in which worth consulting our orthodontic changing the OVD are: and overbite (OB) can be proposed to case one must decide which of colleagues when considering all give the patient a better functioning the following concepts should be treatment options (Evans 1997). • harmonizing dentofacial aesthetics occlusion while improving their smile. considered in the treatment planning. Seating the condyle • providing adequate space for Maintaining existing VDO in CR maintains B but the restorative material In order to do so, adequate restorative 1. Orthodontics and conforming to ICP creates space for anterior • improving incisal and occlusal space is critical, and the specific 2. Maintaining existing VDO One approach is to conform to restorations where B = contracted length of the relationships (Calamita et al., 2019) amount depends upon the type of and conforming to ICP the existing intercuspal position elevator muscles 12 September 2020 – Issue 75 The Dental Probe (Nohl etal.,1997) aslongthe in compositeresin, metalorceramic first place.Restorations canbemade restored andrequiredchanging inthe restorations thatwere heavily in patientswithmultipleposterior only justifiedthistreatment ofchoice unaffected teethandtodate Ihave restorations beingplacedonmultiple However, thisstillresultsin when makingthecrown/onlaypreps. amount oftoothpreparationrequired tooth tissuelossbyminimisingthe articulator thatensurestheminimum estimate thatarbitrarypositiononthe planning withthedentaltechnicianto This involves arduoustreatment will require(Bishopetal1996). thickness thenewrestorations by approximatinghowmuchocclusal missing toothstructurepresentand observed bymeasuringtheamountof The amountofopeningcanbe satisfy bothaestheticsandfunction. least amountoftoothpreparationto of selectingtheOVDthatrequires reorganise theocclusionwithaim An alternative approachisto Minimal PrepVer 3. 2. 1. the vertical dimension(VD): We have 3optionswhenaltering Continues frompage11. Anterior W Space the whenRestoring Managing L length of the elevatormuscles. also increasethecontracted extra spacerequiredbutwould This wouldprovideyouwiththe the POICwithjointinCR. Build thenewVDmorethan length oftheelevator muscles. without increasingthecontracted can providetheextraspacerequired with thejointincentricrelation.This Build thenewVDlessthanPOIC initial contact(POIC). Build theVDatpointof tic al (Arbitrary) orn Dentition Premature contact inCRontooth 47 crowns which notonlycompromise need toprovide very bulky andlong achieve contact anteriorly,youwould In ordertoclosethisspaceand the upperandlower incisors! almost 1cm(9mm)ofspace between the vertical anteriorlyresulting in relays toathreefoldincreasein whatsoever onthemolars,this With notoothpreparation respectively i.e.3mmintotal. for theupperandlower restorations 1.5mm ofclearancewouldbeneeded rehabilitation isdoneusingzirconia, For instanceifafullmouth vertical openinganteriorly. the molarsresultsina3mm every 1mmincreasebetween Due tothegeometryofjaw, space fortheanteriorrestorations. for posteriorswhichinturncreates occlusal centralfossaeraisesthebite shallower cuspangles.Raisingthe on theocclusalsurfacesproviding central fossaeareraisedby1-1.5mm oss ofInter in CR articulated Models RCP of alecron carver Equilibration onmodels by means An increase in OVD isnot required inall these scenarios exclusively adhesive techniques. be subsequentlyrestoredeasily using support, theanteriorteethcan then opening. With astableposterior splint ismadeatthetentative correct A full-archmaxillaryormandibular posterior compositerestorations. OVD, implementingdirectlybonded compromised dentitionatanew of temporarilyrestoringtheworn additive rehabilitationwiththegoal a structuredapproachtofull-mouth preservation oftoothstructure.Itis outcomes whileensuringmaximum predictable aestheticandfunctional This techniqueachieves themost 2005 bytheUniversity ofGeneva. 3-STEP techniquedeveloped in clinicians areadoptingisthe An innovative approachmany preferred (Edelhoff&Sorensen,2002). and not‘nopreparation’isoften Hence why‘minimalpreparation’ aesthetics butmayalsoaffectspeech. Continues onpage 14. -occl

Anterior space gainedAnterior ICP usal

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splinted together to prevent drifting AGE in years Average TIME in months until the space required is attained. Managing Loss of Inter-occlusal • Stable inter-occlusal contacts 20–30 1.5 should be provided. 30–40 3 • The appliance should not impede Space when Restoring the the movement of the discluded teeth. 40–50 4–6 50–60 6–9 There are three types of Anterior Worn Dentition Dahl appliances: Table 1 Average time taken to get full contact (for space creation to occur) according to patient’s age 1. Traditional Dahl appliance 2. Prototypes Continues from page 12. 3. Adhesive bridgework Prototypes the dentition out of contact. This will This procedure in which the result in relative axial movement as Once the anterior contacts are re- The classic Dahl appliance provisional restorations act as a a result of alveolar compensation. established, the replacement of Bjorn’s first Dahl appliance was made Dahl appliance is common practice. the posterior provisional resin of Nickel Chromium and was in the When restoring the anterior worn Once the occlusal contacts reestablish, composites can commence. form of a removable partial chrome dentition, study casts are mounted and space is created, the prototype Facial thirds method Golden proportion Principle denture with a palatal bite platform. around RAP and a diagnostic wax can be replaced by a definitive Due to the presence of the provisional up is set at an increased vertical RBB of the cantilever type. posterior composites, the full-mouth Nowadays we tend to prefer the for the anterior worn dentition rehabilitation can be planned in a The Dahl Concept of direct composite restorations fixed version to ensure compliance. leaving the molars out occlusion. It is important that the temporary

quadrant-wise approach requiring Before the late 1990s, still perhaps either as fixed Dahl appliances or The fixed anterior bite plane can bridge is not a cantilever as September 2020 – Issue 75 fewer appointments and since the oblivious to the detrimental effects of as the definitive restorations. be cemented with glass ionomer It is recommended to equilibrate the this could result in rotation or contralateral part of the mouth such treatment on the pulp, TSL was cement and should have a purchase provisional restorations to verify that drifting of the abutment tooth and guarantees a stable occlusion, patients nearly always treated by excessive Any preparation for full coverage point for ease of cementation. they are in CR. Leaving the anterior prevent intrusion of the opposing feel comfortable throughout the crown preparation using a turbine extra-coronal restorations could result prototypes deliberately high will tooth (Briggs et al., 1993). treatment (Vailati and Belser, 2008). drill. In 1962, Declan John Anderson in deleterious affect on the pulp. It acts as an occlusal splint and allow the molars to overerupt in time. indicated that ‘occlusal changes some patients report that they It is also imperative to avoid

The Dental Probe Facial Proportion could be achieved without causing However, it is imperative to splint feel more comfortable in their Once they do come in contact, the high static and dynamic contacts Among the most commonly patient problems’ (Anderson, 1962). them together and to ensure that joints and muscles however prototypes can then be replaced that are on the pontic only. 14 accepted techniques to determine the they are hitting the palatal surface chewing can be hard and all with definitive restorations. Minimal 15 OVD, is that of facial proportions. Sadly this publication remained of the maxillary opposing teeth at 90 patients should be warned of preparation with just a finish line The contact should instead be on The Dental Probe Some clinicians regularly refer hidden in the archives for some degrees to prevent drifting. Once the this prior to its cementation. on the palatal aspects of the upper the retainer wing or shared between to the principle that the face is time until Bjorn Dahl proposed the Dahl effect has taken place they can worn anteriors is generally required. the natural teeth and pontic, as divided into three parts in the concept of creating space for the be separated and polished to ensure A bite plane which is 3mm thick should the guidance in excursions. horizontal plane and ideally these treatment of localised anterior tooth adequate hygiene and contacts. at front would result in the molars Personally I prefer lab made Minimal adjustment of the pontic and three parts should be equal. wear by separating the posterior to be out of contact by circa 1mm prototypes ensuring that the lower opposing teeth would achieve this. teeth with an anterior bite plane When applying the Dahl Concept: hence the upper molars would incisors are hitting the uppers at Throughout history a mathematical for 4-6 months (Dahl et al, 1975). • Models should be mounted in RAP erupt by 0.5mm and the lowers by a 90 degrees ramp. While waiting Continues on page 16. September 2020 – Issue 75 proportion known as the golden • A thickness of material should 0.5mm. The Dahl should stay in for the Dahl effect to take place, proportion, or phi which equates ‘Passive eruption (60%) of the be placed on the incisal/occlusal place until all canines and posterior one should monitor phonetics and to 1.618, has been used to measure posterior teeth and intrusion (40%) of aspect of those teeth where the teeth are holding shim stock. lip position. Lips tend to relax and and analyse facial aesthetic the anterior teeth, would allow the re- creation of inter-occlusal space speech can improve dramatically qualities in the population. establishment of the proper occlusion is necessary. There should be no The occlusion tends to re-establish during this prototype phase. while maintaining the anterior space’, mucosal-borne component. after about six months on average With recognition of this golden (Dahl and Krogstad). Anderson’s • The thickness of this material but it can take up to a period Adhesive bridgework proportion principle, these work viewed alongside with that placed should directly relate to the of 18-24 months (Table 1). If pre-operative assessment reveals relationships can be used to help of Bjorn Dahl, made a fundamental amount of interocclusal space that limited space available for the determine the lower facial height change in the way that we now treat is required. This will determine the The compliance with which a metal framework, resin-bonded and OVD. In 1928, Turner and Fox tooth wear (Poyser et al., 2005). increase in the OVD as measured removable appliance is worn bridges (RBB) can be bonded (Turner and Fox,1928) recommended at that particular site in the mouth. will greatly influence the speed high in occlusion at an increased Definitive RBB made on a model from an impression that the OVD should be determined The creation of inter-occlusal space • The occlusal bite platform should be at which the space is created vertical dimension and left to taken after the Dahl effect has taken place according to the external appearance significantly reduces the amount constructed to ensure that occlusal (Cousins et al., 1969), (Dahl and 'bed in’ until they achieve the of the face, with reference to the of tooth preparation required on forces are directed along the long Krogstad 1982), (Hemmings et al., ‘Dahl effect’ (Dahl and Krogstad, harmony between the lower third already compromised teeth. With the axis of the teeth. When restoring 2000) and (Redman et al., 2003) 1982). The patient should be pre- and the other thirds of the face. appearance and the predictability the worn upper anterior dentition, warned of occlusal changes and of bonding modern composites, ensure that the occlusal plane of the the possibility of the temporary In 1930, Willis developed the Willis nowadays we can also opt for palatal aspect of the Dahl appliance difficulty in speech and chewing. caliper to help determine if the provisional or direct composite hits the opposing lower incisors distance from the outer corner of the which can act as a fixed Dahl at 90 degrees forcing them down Treatment should ideally be held eye to the labial commissure was appliance (Wirsching, 2015). When their long access otherwise it may in two stages. The first phase is to equal to the distance from the base managing worn mandibular incisors lingualise these teeth. The lower provide a fixedfixed prototype RBB of the nose to the chin (Willis, 1930). one may consider the placement incisors should be temporarily A removable cobalt-chromium partial bite-raising appliance high in occlusion bringing the rest of Definitive RBB after bonding Dahl BL, Krogstad O, Karlsen K . Kois JC, Phillips KM. Occlusal vertical Poyser NJ, Porter RW, Briggs PF, Chana HS, An alternative treatment of cases dimension: alteration concerns. Kelleher MG. The Dahl Concept: past, present Managing Loss of Inter-occlusal with advanced localised attrition. J Compend Contin Educ Dent. 1997 and future. Br Dent J 2005; 198: 669−676. Oral Rehabil 1975; 2: 209–214. Dec;18(12):1169-74, 1176-7. Reshad M. Cascione D. Magne P. Space when Restoring the Davies S. Conformative, re-organized or agne P, Gallucci GO, Belser UC. Anatomic Diagnostic mock-ups as an objective unorganized?. Dent Update. 2004;31(6): crown width/length ratios of unworn and tool for predictable outcomes. 334-345. doi:10.12968/denu.2004.31.6.334 worn maxillary teeth in white subjects. Redman CDJ, Hemming KW, Good JA Anterior Worn Dentition Davies SJ, Gray RM. The examination J Prosthet Dent. 2003;89:453–61. . The survival and clinical performance and recording of the occlusion: why Poyser NJ, Porter RW, Briggs PF, Chana HS, of resin-based composite restorations and how. Br Dent J. 2001;191(6):291- Kelleher MG. The Dahl Concept: past, present used to treat localised anterior tooth 302. doi:10.1038/sj.bdj.4801169 and future. Br Dent J 2005; 198: 669−676. wear. Br Dent J 2003; 194: 566–572. Edelhoff & Sorensen (2002). Tooth Mohindra NK, Bulman JS. The effect of Turner C, Fox F. A securing additional Continues from page 15. The OVD should not be considered a Bataglion C, Ho a, TH, Matsumoto, W, structure removal associated with increasing vertical dimension of occlusion on record required in the construction of static reference, but rather a ‘dynamic Ruellas, CVO. Reestablishment of occlusion various preparations designs for anterior facial aesthetics. Br Dent J. 2002;192(3):164- artificial articulators. In: American concept providing the dentist with through overlay removable par al dentures: a teeth. J>Prosthet Dent; 87: 503-509. 168. doi:10.1038/sj.bdj.4801324 textbook of prosthetic dentistry, 1928. When not to use Dahl: an opportunity to improve facial case report. Braz Dent J. 2012;23(2):172-4. • Advanced /unstable perio beauty’ (Calamita et al., 2019). Evans RD . Orthodontics and the creation Moshaverinia A, Kar K, Aalam AA, Willis FM. Esthetics of full Bishop KA, Briggs PF, Kelleher MGD. of localised inter-occlusal space in cases Takanashi K, Kim JW, Chee WW. denture construction. J Am Dent • Worn posteriors Modern restorative management of • Heavily misaligned arches Finally, I wanted to share a list of of anterior tooth wear. Eur J Prosthodont A multidisciplinary approach for the Assoc 1930;17: 636– 642. advanced tooth-surface loss. Primary Rest Dent 1997; 5: 169–173. rehabilitation of a patient with an • Stepped occlusion internationally known educators Dental Care 1994; 1(1): 20–23. Vailati F, Belser UC. Full-mouth adhesive • Large ortho discrepancy who have highly influenced my Gurel G (2007). Porcelain laminate excessively worn den on: a clinical report. rehabilitation of a severely eroded • Anterior open bite restorative skills over the years: Bishop K, Bell M, Briggs P, Kelleher veneers: Minimal tooth prepration by J Prosthet Dent. 2014;111(4):259-63. dentition: the three-step technique. Part • Joint disease M . Restoration of a worn dentition design. Dent clin North Am; 51:419-43. Murray MC, Brunton PA, Osborne- 1. Eur J Esthet Dent. 2008;3(1):30-44. • Professor Paul Tipton (UK) using a double-veneer technique. Hemmings KW, Darbar UR, Vaughan Smith K, Wilson NHF . Canine risers: Vailati F, Belser UC. Full-mouth adhesive Conclusion • Stephen Davies (Manchester UK) Br Dent J 1996; 180: 26–29. S. Tooth wear treated with direct Indications and techniques for their use. Eur rehabilitation of a severely eroded dentition: The prevalence of TSL is on the • Stephen Phelan (USA) Briggs P, Dunne S, Bishop K. The single composite restorations at an increased J Prosthodont Rest Dent 2001; 9: 137–140. the three-step technique. Part 2. Eur J rise and the eventual failure of • John Kois (Seattle USA) unit, single retainer, cantilever resinbonded vertical dimension: results at 30 months. Nohl FS, King PA, Harley KE, Ibbetson Esthet Dent. 2008;3(2):128-146. restorations placed to manage this • Linda Greenwall (UK) bridge. Br Dent J 1996; 181(10): 373−379. The Dental Probe J Prosthet Dent 2000; 83: 287–293.a RJ. Retrospective survey of resin- problem is likely to be a significant • Professor Trevor Burke (UK) Wirsching E. Contemporary options for Calamita M, Coachman C, Sesma N, retained cast-metal palatal veneers for the issue in years to come. Planning Kois JC. The “Father” of optimum restoration of anterior teeth with composite. 16 Kois J. Occlusal vertical dimension: treatment of anterior palatal tooth wear. a rehabilitation for these patients centric relation. Compend Contin Educ Quintessence Int. 2015;46(6):457- treatment planning decisions and Quintessence Int. 1997;28(1):7-14. can be daunting for us clinicians, References Dent. 1997 Dec;18(12):1166-7. 463. doi:10.3290/j.qi.a33989 management considerations. Int J however if left untreated there can Anand S, Tripathi S, Chopra A, Esthet Dent. 2019;14(2):166-181. be cause for negligence such as Khaneja K, Agarwal S. Vertical and Cousins AJ, Brown WA, Harkness EM . An in cases of undiagnosed caries or horizontal proportions of the face and investigation into the effect of the maxillary periodontal disease and may equally their correlation to phi among Indians bite plane on the height of the lower incisor start subjecting us to litigation. in Moradabad population: A survey. J teeth. Dent Prac and Dent Record 1969: Indian Prosthodont Soc. 2015;15(2):125- September 2020 – Issue 75 As with all complex cases, more 130. doi: 10.4103/0972-4052.155033 Dahl BL, Krogstad O . The effect of a partial often than not, there is more than one bite raising splint on the occlusal face height. Anderson DJ. Tooth movement in solution. One must always evaluate An x-ray cephalometric study in human experimental malocclusion. Arch the OVD when diagnosing wear cases adults. Acta Odontol Scand 1982; 40: 17–24. and intervene before it is too late. Oral Biol 1962; 7: 7–16.

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The Treasurer, Dr Noel Manche, ADDRESS: The Dental Association Of Malta, Federation Of Professional Associations, Sliema Road, Gzira. Essentials of Periodontal Plastic Surgery By Edward Sammut BChD MSc MClinDent MFDS MRD RCSEd FICD Specialist in Periodontics (UK) Private practice in Valletta

Right cells, right place, right time There is no way to get around the week. The procedure is highly face that the root surface is avascular predictable with very few failures In the article preceding this one, and does not offer any nutrition for observed. Free gingival grafts I discussed setting of goals with tissue placed on top of it. The larger work very well because the full the patient to correctly manage the surface area which we are trying area of the grafted tissue is placed expectations when treating recession. to cover, the bigger is the challenge on a periosteal bed and therefore of getting tissue to grow and indeed has a good chance of survival. If we decide to go ahead with some flourish on the root surface. form of mucogingival surgery, The grafted tissue is normally paler

The Dental Probe (otherwise known as periodontal The free gingival graft than the surrounding tissue and for plastic surgery) we need to be this reason, the procedure should 18 even more careful about what One of the most simple and effective not be the first choice in aesthetically we promise to the patient. Will periodontal procedures is the free important areas. The procedure we aim to: cover the root surface, gingival graft (or free mucosal graft) has been recently re-described with reduce hypersensitivity, smoothen (1). While it was originally intended some refinements to produce a the gingival contours, increase for use around natural teeth, it offers more aesthetic overall result (2). tissue thickness, increase sulcular an effective way to provide a width depth, remove fraenal attachments, of keratinised tissue around implants Pedicle Flaps provide keratinised tissue? or on an edentulous ridge for future implants to emerge through. There are several pedicle flap September 2020 – Issue 75 And if yes, how likely are we to designs, with the main ones being reach each of these individual A split thickness dissection is carried the lateral pedicle, the split papilla goals. Periodontal plastic surgery out at the recipient site, typically from and the coronally advanced flap. requires the operator to draw the mucogingival junction moving The overall principle is that pedicle on a “library” of procedures apically; to produce a periosteal bed. flaps work by mobilizing a piece documented in the literature and Fraenal attachments are automatically of tissue near to the receiving site apply the right techniques to removed in this process and there is so that it can be sutured over the the given biological situation. a local increase in the sulcus depth. receiving site while maintaining a good part of its original blood supply. While some situations are clear- An appropriately sized piece of cut and call for a well-described palatal mucosa is harvested by The pedicle is normally mobilized procedure to be used, sometimes it is sharp dissection and sutured onto through split thickness dissection, necessary to think out of the box, use the recipient bed. The main aims and the donor area is left covered knowledge of the biology, and create are to increase the keratinised with the remaining thickness, which a customised operation. In a broad tissue height and thickness on the can then re-epithelialize during sense, you need to put the right cells recipient area. Some root coverage healing. The recipient site must be in the right place at the right time – can sometimes be observed prepared – often the area needs to how you achieve that is up to you. even if there was no deliberate be de-epithelialised where there is aim to do so; this phenomenon existing tissue coverage, and where When planning any form of is known as coronal creep. root surface is to be covered, this periodontal plastic surgery which must be carefully debrided to remove will aim to cover root surface, one The donor site will heal by secondary plaque and any resin remnants. of the first questions I ask myself is: intention and is typically sore Where will it get a blood supply? and uncomfortable for about one Continues on page 20. Essentials of Periodontal Plastic Surgery

Continues from page 18. suture line directly overlying Tunnel CT graft procedures Alternatively the lack of sulcular References 10. Zucchelli G, De Sanctis M. Treatment of the root surface to be covered depth could contribute to poor multiple recession-type defects in patients and many operators will use an If you want to cause as little damage plaque control and development 1. Sullivan HC, Atkins JH. Free autogenous with esthetic demands. J Periodontol. 2000 All pedicle flap procedures can interpositional CT graft beneath it. as possible to the blood supply of the of peri-implant disease (14). A gingival grafts. III. Utilization of grafts Sep;71(9):1506-14. be modified by the use of an flap, then you should avoid performing common-sense viewpoint would in the treatment of gingival recessions. interpositionalfree connective tissue The coronally advanced flap is a any incision at all! With this in mind, uphold the utility of immobile Periodontics 1968;6:152-160. 11. Zucchelli G, Amore C, Sforza NM, (CT) graft (3). Dense submucosal versatile operation. It was originally the tunnel procedure aims to further keratinized tissue around the implant Montebugnoli L, De Sanctis M. Bilaminar connective tissue from the palate is designed for single defects where there diminish blood supply interruption but at the same time some studies 2. Cortellini P, Tonetti M, Prato GP. techniques for the treatment of recession- harvested and placed between the was availability of keratinised tissue by leaving out the principal coronal show no differences in bone loss The partly epithelialized free gingival type defects. A comparative clinical study. J September 2020 – Issue 75 pedicle flap and the recipient bed, apical to the defect which could be incision normally used to define a flap. around implants emerging through graft (pe-fgg) at lower incisors. A pilot Clin Periodontol. 2003 Oct;30(10):862-70. which may include root surface (4). moved to cover the root surface (8). keratinized or non-keratinised study with implications for alignment Instead, microsurgical blades and tissue provided that the patient is of the mucogingival junction. J Clin 12. De Sanctis M, Baldini N, Goracci C, The main objective of interpositional First, a new gingival margin is instruments are used via a careful able to keep the surface clean (15). Periodontol. 2012 Jul;39(7):674-80. Zucchelli G. Coronally advanced flap connective tissue (CT) grafting surgically defined and a flap raised incision in the gingival crevices associated with a connective tissue graft is to increase the thickness of the from this point apically. The papillae and possibly also through a single With this in mind, it can be tricky 3. Langer B, Langer L. Subepithelial for the treatment of multiple recession The Dental Probe tissue, thereby altering the biotype. are then de-epithelialised and the vertical incision well away from to decide on whether or not to connective graft technique for root defects in mandibular posterior teeth. Int J Thicker tissue is associated with flap mobilized coronally through the gingival margin (13). intervene in specific cases. Some coverage. J Periodontol1985;56:715-720. Periodontics Restorative Dent. 2011 Nov- 20 improved root coverage success the use of a periosteal release. The operators will place free gingival Dec;31(6):623-30. 21

(5). In addition to this, because the flap is then sutured into place. If This is usually used for multiple defects, grafts on edentulous ridges to 4. Harris RJ. A comparison of two The Dental Probe epithelial type is governed by the no keratinized tissue was available typically the lower anterior teeth. The augment the keratinized tissue even techniques for obtaining a connective 13. Allen AL. Use of the supraperiosteal underlying connective tissue, palatal apical to the defect, the procedure buccal tissue can thus be lifted away before the implants are placed. tissue graft from the palate. Int J envelope in soft tissue grafting for root connective tissue placed underneath could be used too, provided that an from the periosteal bed without cutting Periodontics Restorative Dent. 1997 coverage. I. Rationale and technique. mucosa will encourage the overlying interpositional CT graft was applied (9). through the papillae at any point. In sites where aesthetics are at a Jun;17(3):260-71. Int J Periodontics Restorative mucosa to become keratinsed. premium, tissue augmentation Dent1994;14:216-227. Zucchelli and De Sanctis described The procedure is quite delicate with connective tissue grafts at the 5. Hwang D, Wang HL. Flap thickness

September 2020 – Issue 75 In the lateral pedicle flap (6), thick a modification of the coronally and should really be attempted same time as implant placement as a predictor of root coverage: a 14. The Significance of Keratinized Mucosa on tissue overlying a tooth is moved to an advanced flap in 2000 (10), enabling only after one has some experience has been frequently suggested, systematic review. J Periodontol. 2006 Implant Health: A Systematic Review. Lin adjacent tooth. A typical application it to be used to cover multiple performing other types of but the reason for doing this is Oct;77(10):1625-34. GH, Chan HL, Wang HL.J Periodontol. of this procedure is to move thick adjacent recession defects. periodontal plastic surgery. more to do with bulking out the 2013 Mar 1. [Epub ahead of print] keratinized tissue overlying an tissue than with having keratinized 6. Wilderman, M and Wentz, F. Repair of a upper first premolar to cover the In this operation, surgically defined An interpositional CT graft can be tissue around the implant (16). dentogingival defect with a pedicle flap. J 15. Wennström JL, Derks J. Is there a need for canine root where this is prominent papillae are raised split thickness, threaded beneath this tunnel to increase Periodontol 1964(35): 218 keratinized mucosa around implants to and has suffered some recession. followed by full thickness dissection the tissue thickness and cover the root In a situation where an implant is maintain health and tissue stability? Clin Oral By extending the flap distally, the to the mucogingival junction and split surface. The CT graft may end up emerging through healthy mucosa, it 7. Harris RJ. The connective tissue and Implants Res. 2012 Oct; 23 Suppl 6:136-46. operator can control where the exposed thickness periosteal release – giving rise being exposed buccally as the papillary could be argued that a free gingival partial thickness double pedicle graft: split thickness area will be left after to the aide-memoire “split-full-split”. tissue is long and narrow, as defined graft should be done as a preventative a predictable method of obtaining 16. Hsu YT, Shieh CH, Wang HL.Using soft the operation, ideally choosing the by the original morphology around the measure to reduce the risk of peri- root coverage. J Periodontol. 1992 tissue graft to prevent mid-facial mucosal tooth where the buccal tissue is at its No relieving incisions are used to recession. This does not appear to be a implant disease developing. Finally, May;63(5):477-86. recession following immediate implant thickest and therefore most able to heal minimize interference with lateral problem as it will readily epithelialize. some will advocate free gingival placement. J Int AcadPeriodontol. 2012 predictably without further recession. blood supply. Interestingly the grafts or connective tissue grafts as 8. Restrepo OJ. Coronally repositioned flap: Jul;14(3):76-82. authors found that in situations were Soft Tissue Procedures one of the steps in the management report of four cases.J Periodontol. 1973 The split papilla flap (7) is basically there was no keratinized tissue and around Implants of peri-implant disease (17). Sep;44(9):564-7. 17. Schwarz F, Sahm N, Becker J.Combined two lateral pedicles, one taken interpositional CT grafts were not used, surgical therapy of advanced peri- from each side of a recession defect, the area seemed to keratinize by itself. The importance of keratinized tissue Clearly much of this has a weak 9. Bouchard P, Etienne D, Ouhayoun implantitis lesions with concomitant soft which are sutured together (“zipped Notwithstanding this finding they still around the transmucosal part of dental evidence base and until such time JP, Nilvéus R. Subepithelial connective tissue volume augmentation. A case series. up”). Apical to the recession defect, recommend the use of interpositional implants is the subject of some debate. as better evidence being available, tissue grafts in the treatment of gingival Clin Oral Implants Res. 2013 Jan 27. doi: tissue is removed by means of a CT grafts to increase tissue thickness Those who suggest it is important cite we must treat each case on its recessions. A comparative study of 10.1111/clr.12103. [Epub ahead of print] V-shaped incision, which can be used and maximize root coverage outcome poor seal of non-keratinised tissue, own merits and carefully discuss 2 procedures. J Periodontol. 1994 to remove fraenal attachments. where the tissue is thin or where there microbial ingress and subsequent with the patient, the evidence on Oct;65(10):929-36. Usually this design results in the is no keratinized tissue (11, 12). inflammation and bone loss. which we suggest treatment. Continues on page 22. Essentials of Periodontal

Plastic Surgery Continues from page 21.

CASE 1 CASE 2

A 45-year-old female professional presented with recession Composite restorations had been placed in cervical areas Removal of the composite restoration to present tissues with Lower incisors with Miller type III (some loss of papilla height) Split thickness dissection just above the periosteum showing Harvest of an epithelial and CT graft from the palate. which was causing aesthetic concern and sensitivity of the of maxillary canines to alleviate sensitivity. Some keratinised root surface after surgical coverage. recession. There is near-absence of keratinised tissue on the very thin alveolar bone around the teeth.

teeth. The cause was an incorrect brushing technique and the tissue was available apical to all recession defects. buccal aspect of the teeth and the tissues are extremely September 2020 – Issue 75 patient received detailed instructions on atraumatic plaque thin. The sulcus is shallow as a result and there is a fraenal removal which included the use of an electric toothbrush with attachment on the midline that is more coronal than the a pressure sensor. receded gingival margin. The Dental Probe

22 23 The Dental Probe

Initial incision defines the new papillary architecture. The The surgical papillae are dissected split thickness from the Small CT grafts harvested from the palate are sutured using Graft suture to height of the recession defect defines the height of papilla to underlying base and the residual papillae are de-epithelialised resorbable sling sutures to the exposed root surfaces of 11 recipient bed leave out of the surgical papillae. to provide a nutrient bed for the surgically defined and 13. papillary tips. The flap is then raised full thickness up to the mucogingival junction and then split thickness more apically to provide coronal mobility for tension-free closure. September 2020 – Issue 75

Immediate post- op. Note no Graft near sutures apically the carboard to prevent lip template used pull from lifting to define the graft off the harvest. recipient bed.

The flap is displaced coronally, held in place using continuous Ten days postoperative sutures are removed. Three months postoperative root coverage is satisfactory sling sutures then each papilla is closed with a single however the tissues still need time to turn over to eliminate the interrupted suture. Slings are arranged mesially and the single local unevenness. suture is placed distally for optimal aesthetics.

Five years postoperative review. Healthy marginal conditions Extraoral view of the same completed case, also showing the Three months post-operative showing good graft adhesion, increase in Five-year post-operative showing maturation of graft in recipient bed and stable with aesthetics and tissue contours satisfactory to clinician result from the treatment of the left side. keratinised width and thickness, increased sulcular depth, which aids satisfactory attachment around the teeth. and the patient’s aesthetic aspirations. self-performed plaque control. Continues from page 24. Essentials of Periodontal CAN WE MAKE ENDO SIMPLE? By Maria Lessani BDS (B’HAM), MFDS RCPS (GLAS),M CLIN DENT (EASTMAN), MRD RCS (EDIN) Specialist in Endodontics Plastic Surgery Continues from page 23.

CASE 3

A general dentist noted initial recession on tooth 31 in this Lateral views show the adaptation of the thin gingivae around the thin alveolar housings of the incisors. Such tissue arrangements 28-year-old female patient. Although the recession was are extremely prone to progression of recession. minimal, the soft tissues were paper thin and the roots of the

teeth could be seen through the tissues. September 2020 – Issue 75 The Dental Probe

24 25

Periapical radiograph confirms Access through a midline fraenectomy incision and careful Tunnels to the left and right extent to the mesial aspect of the lower canines bilaterally. The The Dental Probe that interdental bone levels sharp dissection just supra-periosteal. Additional access probe, lifted coronally, shows the displaceable tissues and the extent of the incision. are consistent with health or a through the gingival margins. minimal amount of horizontal bone loss. September 2020 – Issue 75

Graft harvest from the palate of sufficient length to augment Sutures are a combination of 5/0 polyglactin resorbable Five months post-operative photo shows buccal gingival the tissues from mesial 33 to mesial 43. This is attached to a and 6/0 polyvidylene monofilament non-resorbable. The tissues of a thickness consistent with health. Coverage of the suture and then threaded through the tunnel created. peripheral sutures (below the mesial of both canines) are (minimal) recession on 31 has been achieved. holding the graft tissue at its extremities. Crossed sling sutures hold the graft and marginal tissues coronally at the lateral incisor sites and mattress sutures hold the graft around the midline. The fraenectomy incision is closed with the resorbable suture and some exposed connective tissue is visible in the middle of the incision.

Volumetric thickening of the tissues around the lower incisors in previously concave areas. Continues on page 26. CAN WE MAKE ENDO SIMPLE?

Continues from page 25. September 2020 – Issue 75 The Dental Probe

26 27 The Dental Probe September 2020 – Issue 75

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28 29 The Dental Probe September 2020 – Issue 75

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