Vol.6 No. 3 in This Issue

visual visual r 3 NO. 6 VOL. IN THIS ISSUE augmentation augmentation strategies at resolving horizontal alveolar ridge deficiencies prior to (staged approach), or simultaneous with dental implant placement? Bastian Wagne How How effective are different ridge adjacent adjacent implant restorations Johan Hartshorne Dean Dean Morton Planning for esthetics – Part II: See, recognize, realize: controlled activation technique Tactile with controlled memory files Immediate screw-retained CAD/CAM provisionalisation with an integrated digital approach Esthetics in the anterior maxilla: shade shade analysis and its realization into a ceramic crown Antonis Chaniotis Sepehr Sepehr Zarrine and Jerome Vaysse and Sofie AryanVelghe Eghbali a team-oriented approach Julian Julian Webber Shaping canals with confidence: GOLD single-file WaveOne reciprocating system William C Martin, Emma Lewis,

INTERNATIONAL DENTISTRY AFRICAN EDITION • VOL. 6 • NO. 3 • JUNE/JULY 2016 01052016_DEN_COV_4.5mmSpine_Layout 1 2016/05/25 8:19 AM Page 1 Page AM 8:19 2016/05/25 1 01052016_DEN_COV_4.5mmSpine_Layout 010516_DEN_IFC_Layout 1 2016/05/24 8:36 PM Page 1 ID-AE MayJune 2016_1-16_Layout 1 2016/05/25 8:20 AM Page 1 ID-AE MayJune 2016_1-16_Layout 1 2016/05/25 8:20 AM Page 2

Contents 6 June/July 2016 Volume 6 No. 3

6 Clinical Shaping canals with confidence: WaveOne GOLD single-file reciprocating system 18 Julian Webber 18 Clinical Planning for esthetics – Part II: adjacent implant restorations William C Martin, Emma Lewis, Dean Morton 30 Clinical How effective are different ridge augmentation strategies at resolving horizontal alveolar ridge deficiencies prior to (staged approach), or simultaneous with dental implant placement? Johan Hartshorne 50 42 Case Report See, recognize, realize: visual shade analysis and its realization into a ceramic crown Bastian Wagner 50 Clinical Tactile controlled activation technique with controlled memory files Antonis Chaniotis 60 Clinical Immediate screw-retained CAD/CAM provisionalisation with an integrated digital approach 60 Sepehr Zarrine and Jerome Vaysse 68 Case Report Esthetics in the anterior maxilla: a team-oriented approach Sofie Velghe, Aryan Eghbali

74 CPD Questionnaire 1 76 CPD Questionnaire 2 78 Products and News 80 Classifieds

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Vol. 6 No. 3, June/July 2016 ISSN 2226-1567

PUBLISHING EDITOR Ursula Jenkins EDITOR-IN-CHIEF Prof Dr Marco Ferrari ASSOCIATE EDITORS Prof Cecilia Goracci Prof Simone Grandini Prof Andre W van Zyl EDITORIAL REVIEW BOARD Prof Paul V Abbott Prof Antonio Apicella Prof Piero Balleri Dr Marius Bredell Prof Kurt-W Bütow Prof Ji-hua Chen Prof Ricardo Marins de Carvalho Prof Carel L Davidson Prof Massimo De Sanctis Dr Carlo Ercoli Prof Livio Gallottini Prof Roberto Giorgetti Dr Patrick J Henry Prof Dr Reinhard Hickel Dr Sascha A Jovanovic Prof Ivo Krejci Dr Gerard Kugel Prof Edward Lynch Prof Ian Meyers Prof Maria Fidela de Lima Navarro Prof Hien Ngo Prof Antonella Polimeni Prof Eric Reynolds Prof Jean-Francois Roulet Prof N Dorin Ruse Prof Andre P Saadoun Prof Errol Stein Prof Lawrence Stephen Prof Zrinka Tarle Prof Franklin R Tay Prof Manuel Toledano Dr Bernard Touati Prof Laurence Walsh Prof Fernando Zarone Dr Daniel Ziskind

DESIGN & LAYOUT C Designz PRINTED BY Paarl Media Paarl International Dentistry African Edition is published by Modern Dentistry Media CC, PO Box 76021 Wendywood 2144 South Africa Tel: +27 11 702-3195 Fax: +27 (0)86-568-1116 e-mail: [email protected] www.moderndentistrymedia.com

© COPYRIGHT. All rights reserved. No editorial matter published in International Dentistry SA may be reproduced in any form or language without the written permission of the publishers. While every effort is made to ensure accurate reproduction, the authors, publishers and their employees or agents shall not be held responsible or in any way liable for errors, omissions or inaccuracies in the publication whether arising from negligence or otherwise or for any consequence arising therefrom.

Published in association with ID-AE MayJune 2016_1-16_Layout 1 2016/05/25 8:20 AM Page 4

PRESS RELEASE

Taking treatment success to another level DENTSPLY Maillefer launches

April 2016, South Africa – DENTSPLY Maillefer, a Ballaigues (Jura)-based global leader in endodontics and state-of-the-art dental instruments for the treatment of root canals, has announced the launch of its new solution WAVEONE® GOLD. Building on the success of WAVEONE® launched in 2011, WAVEONE® GOLD offers a new standard in root canal shaping, using the latest generation of reciprocating technology. WAVEONE® GOLD is one of the pillars of DENTSPLY Maillefer’s “Choose your Endo Solution” concept. This comprehensive solution reinforces patient safety, as its Primary file is 50% more resistant to cyclic fatigue than the WAVEONE® Primary file. It also enables to cover a wider range of canal morphologies with the extra flexi bility and extended size range. Last but not least, the cutting efficiency has also been increased. DENTSPLY Maillefer has teamed up with the best endodontic professionals to develop WAVEONE® GOLD. Dr Sergio Kuttler (USA), Dr Willy Pertot (France), Dr Cliff Ruddle (USA) and Dr Julian Webber (UK) have contributed to the design of WAVEONE GOLD. A design that is particularly adapted to dentists looking for a greater confidence level when shaping the canals. Last but not least, WAVEONE® GOLD is part of the RestoDontics concept which brings together the aspects of endodontics and conservative dentistry. Various DENTSPLY divisions combine their innovative capabilities to enhance treatment success in this area. Whereas DENTSPLY Maillefer stands for state-of-the-art root canal treatment systems, DENTSPLY DETREY provide materials for the postendodontical restoration of the crown (e.g. SDR, ceram.x Sphere Tec).

CLINICAL

Shaping canals with confidence: WaveOne GOLD single-file reciprocating system

Julian Webber1

The mechanical and biological objectives of shaping root canals were beautifully 1 Dr Julian Webber has been a described by Herbert Schilder in 1974.1 As relevant today, in the era of automated practising endo dontist in London, canal preparation techniques, as they were in the days of hand preparation techniques, England for over 35 years. He these objectives provide the rationale for the designs, tapers and tip sizes of modern- was the first UK dentist to receive day endodontic instruments. Shaping the root canal facilitates 3-D irrigation and a master’s degree in endodontics cleaning of the root canal system of all pulp tissue, bacteria and their related by- from a university in the USA products.2 Importantly, shaping the root canal provides the resistance form and facilitates (Northwestern University, filling the root canal system.1,3 Chicago, IL) in 1978. He has lectured extensively and given many handson courses on From hand to rotary endodontics worldwide. When manually shaping canals with multiple sequences of stainless-steel files and He has published in numerous Gates–Glidden drills, root canal preparation techniques, old and new, have many peer-reviewed journals and deficiencies and iatrogenic problems, such as blocking, ledging, transportation and contributed numerous chapters to perforation, are common.4 The use of nickel-titanium (NiTi) files in continuous rotation endodontic texts. driven by a dedicated endodontic motor capable of speed and torque control maintains Dr Webber is a former President the original pathway of the canal while limiting the amount of apically extruded of the British Endo dontic Society debris.5,6 However, while the advantages of continuously rotating NiTi files are many, and American Dental Society of all commercially available file systems are influenced by cyclic fatigue and torque, London, a faculty member of the Pacific Endodontic Research especially in longer, narrower and more curved canals. Foundation in San Diego, CA, Cyclic fatigue, caused by the structural alteration and work hardening of the metal, Honorary Professor at the is induced by repeated tensile–compressive stress, especially when p reparing canals University of Belgrade in Serbia, exhibiting curvature.7 Torsional failure caused by using too much apical force occurs and an honorary member of the more frequently than flexural fatigue.8 Specifically, taper lock results when an excessive Ukrainian Medical and length of a file’s active portion binds in the canal during rotation. Undesirable taper Stomatological Academy. lock promotes torsional failure and file breakage. When the canal diameter is narrower He is a fellow of the International than the diameter of the rotating file, the latter has limited ability to progress deeper College of Dentists and an active into the canal, binds and then potentially unwinds and/or breaks.9 member of the American Association of Endodontists. He is the editor-in-chief of Endodontic From rotary to reciprocation Practice (UK) and a board While the majority of commercially available NiTi systems are mechanically driven in member of many prestigious continuous rotation, reciprocation—defined as any repetitive up and down or forward dental journals. and reverse movement—has been used to drive endodontic instruments since 1958. (Images courtesy of Prof. Sergio Early attempts at reciprocation utilised alternating, but equal, forward and reverse Kuttler) angles of either 90 degrees or, more recently, smaller angles of 30 degrees. As such

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Figure 1a: WaveOne GOLD file series, Small, Primary, Medium Figure 1b: WaveOne GOLD files have variable and reducing and Large. tapers, producing a more conservatively shaped canal compared with their WaveOne predecessor. none of these instruments ever complete a full rotation. Although these reciprocating systems offer an alternative to manual preparation, multiplefile sequences, apical transportation, reduced cutting efficiency, inward pressure and limited debris removal remain issues.5,10 However, with a novel reciprocating movement of unequal bidirectional angles that complete a full forward rotation of 360 degrees after four 90-degree cutting cycles of reciprocation, just one single file can start and fully complete the preparation of a canal to a perfect shape.11 A singlefile technique in conjunction with a novel reciprocating movement has been clearly shown to reduce both cyclic fatigue and torsional 12 failure, preventing broken instruments. Figure 2: The cross-section of WaveOne GOLD is a In 2008, the concept of the “single-file technique” was parallelogram with an 85-degree active cutting edge with adopted by DENTSPLY International as a project in alternate one and two point contact. collaboration with eight international clinicians to produce a more optimal, dedicated, safe, unique reciprocating single bacteria from root canal systems as efficiently as rotary file and to identify the most suitable unequal bidirectional systems.17 The shaping ability of reciprocating files is as angles with a motor system to generate this movement. The good as and in many cases better than rotary files.18 Finally, outcome was the launch of RECIPROC (VDW) in 2010 and it can be clearly stated that reciprocating files do not induce WaveOne (Dentsply Maillefer) in 2011. Both systems were dentine cracks.19 marketed as simple, efficient and predictable automated WaveOne and RECIPROC were designed as true single- methods to shape canals and embraced by many general use instruments that cannot be sterilised and re-used. The ISO dental practitioners looking to move into automated canal colour-coded ABS ring on the handle expands if sterilised shaping after years of unsuccessful attempts with manual and the file will not fit into its handpiece. Single use is based techniques and valued both in terms of time and cost savings. on sound scientific facts and common sense, as elimination WaveOne and RECIPROC file systems (reciprocating files) of repeated use decreases the possibility of fracture due to demonstrate considerably improved mechanical properties, both fatigue and torsional failure.20 The inability to superior to rotary files. While the cyclic fatigue properties of consistently clean and sterilise used instruments eliminates any RECIPROC are superior to WaveOne, the resistance to concerns about crosscontamination,21 and disposal after torsional failure of WaveOne is superior to RECIPROC.13,14 single-patient use eliminates the cost of disinfecting, cleaning Overall, reciprocating files are more resistant to fracture than and sterilising, reducing costs overall.22 However, it should are continuously rotating files,15 extrude less debris than do be understood and fully appreciated that a single conventional multiple-file rotary systems16 and eliminate reciprocating file performs the same task that would typically

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Figure 3a: WaveOne GOLD tip and profile. Figure 3b: WaveOne GOLD ogival tip design.

require three or more rotary NiTi files to accomplish. Logic mechanical properties of the file and give a new level of dictates that single use is by far the best solution to reducing confidence to the many clinicians still wary of automated the incidence of file breakage with all its ethical, emotional techniques for shaping canals. and malpractice ramifications. The result is the recent launch of WaveOne GOLD, a new generation of reciprocating files offering simplicity, safety and New developments single use in shaping canals. With today’s increased focus on minimally invasive endodontics23, the conclusions from the literature and taking Advanced metallurgy into account feedback from clinicians using WaveOne since WaveOne GOLD instruments are manufactured utilising a its introduction in 2011, four of the original opinion leaders new DENTSPLY proprietary thermal process, producing a involved in the initial development of the file, Drs Clifford super-elastic NiTi file. The gold process is a post- Ruddle (US), Sergio Kuttler (US), Wilhelm Pertot (France) and manufacturing procedure in which the ground NiTi files are Julian Webber (UK), worked in collaboration with the heat-treated and slowly cooled. From a technical perspective, research and development team at DENTSPLY in Ballaigues, the heat treatment modifies the transformation temperatures Switzerland, to further improve the cutting efficiency and (austenitic start and austenitic finish), and this has a positive

Figure 4: The WaveOne GOLD file engages 150 degrees CCW and 30 degrees CW, turning 360 degrees after three cycles of reciprocation.

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The various tip sizes and tapers afford the clinician the ability to clinically prepare a wider range of apical diameters and endodontic anatomy commonly encountered in daily practice.27 Canal preparations that have sufficiently tapered resistance form are ideal for irrigant exchange and removal of debris,28 thus promoting 3-D disinfection and filling of the root canal system. WaveOne GOLD has active cutting lengths of 16mm, shortened 11mm handles for improved posterior access and the same expanding ISO colour-coded ABS ring as WaveOne, maintaining the philosophy of single use. Figure 5: The new X-Smart iQ motor operated by the DENTSPLY Variable and reducing tapers ensure a more conservatively iOS app downloaded on to an iPad mini 2 is a full digital shaped canal with greater preservation of tooth structure at solution with a cordless Bluetooth 8:1 reducing handpiece. D16, the coronal extent of the preparation (Fig. 1b). While the concepts of “minimally invasive endodontics” lack effect on the instrument properties.24,25 While this process documented and meaningful studies,29 any shaping gives the file its distinctive gold finish, more importantly, it objective that removes less of the existing tooth structure while considerably improves its strength and flexibility far in excess optimising efficient 3-D irrigation and obturation is a positive of its predecessor. DENTSPLY internal testing has shown the step in an effort to preserve the integrity of the natural tooth. following: the cyclic fatigue resistance of WaveOne GOLD The cross-section of WaveOne GOLD is a parallelogram Primary is 50% greater than that of WaveOne Primary (which with two 85-degree cutting edges in contact with the canal itself was twice as great as most standard rotary file systems), wall, alternating with a patented DENTSPLY off-centred cross- and the flexibility of WaveOne GOLD Primary is 80% greater section where only one cutting edge is in contact with the than that of WaveOne Primary.26 canal wall (Fig. 2). Decreasing the contact area between the file and the canal wall reduces binding (taper lock) and, Design features in conjunction with a constant helical angle of 24 degrees There are four tip sizes in the WaveOne GOLD single- file along the active length of the instrument, ensures little or no reciprocating system: Small (20.07, yellow), Primary screwing in. The additional space around the instrument also (25.07, red), Medium (35.06, green) and Large (45.05, ensures additional space for improved debris removal. The white) (Fig. 1a), available in 21, 25 and 31mm lengths. tip of WaveOne GOLD (Figs. 3a & b) is ogival, roundly

Figure 6: Summary of the WaveOne GOLD shaping technique: 80% of cases start and finish with the Primary file. At completion of shaping, gauging with hand files or inspecting flutes for debris confirms whether either the Medium or the Large file is needed.

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tapered and semi-active, modified to reduce the mass of the centre of the tip and improve its penetration into any secured canal with a confirmed, smooth and reproducible glide path. Collectively, these design features result in a reciprocating movement that is very smooth, eliminating the need to push on the file, and thereby promoting safety and considerably improving cutting efficiency. This reduces shapin g time by a further 19% in canals when compared with WaveOne.26

Reciprocating movement Figure 7a: WaveOne GOLD procedural flow chart where a #10 hand file is able to establish length: confirm patency and verify WaveOne GOLD files are designed with a reverse cutting the glide path. ProGlider will expand any confirmed, verified helix, engage and cut dentine in a 150-degree counter- and reproducible glide path prior to the shaping procedure with clockwise (CCW) direction and then, before the instrument the Primary file. (Rx: radiograph; AL: apex locator; IRI: irrigate, has a chance to taper lock, disengages 30 degrees in a recapitulate and irrigate again). clockwise (CW) direction. The net file movement is a cutting cycle of 120 degrees and therefore after three cycles the file will have made a reverse rotation of 360 degrees (Fig. 4). The X-Smart iQ (Fig. 5) launched in conjunction with WaveOne GOLD is an endodontic motor and cordless 8:1 handpiece designed for reciprocation and continuous motion. The handpiece is Bluetooth controlled by a DENTSPLY Apple iOS iQ app downloaded on to an iPad mini 2 (Apple). As a complete digital solution, it is designed for all stages of the endodontic procedure, including patient management, file selection, torque control training and patient education. The X-Smart iQ also offers electronic apex locator functionality. Currently available DENTSPLY Figure 7b: WaveOne GOLD procedural flow chart for more reciprocating file motors and their respective handpieces, restrictive canals: use a #10 hand file in any region of the canal to create a glide path. ProGlider will expand any confirmed, the X-Smart Plus motor (Rest of the World) and Pro- Mark and verified and reproducible glide path. e3 Torque Control motors (North America), can be used without modification when using the complete range of WaveOne GOLD files. All reciprocating file motors are preprogrammed to produce the reverse bidirectional movement, but the CCW/CW angles, torque and speed settings cannot be altered. These motors can, of course, be used for continuous rotation when the clinician is able to adjust the speed and torque, as desired.

Shaping technique (Fig. 6) The WaveOne GOLD Primary (025.07) is always used first to initiate the shaping procedure. It will create optimal shape in approximately 80% of canals as a true single-file technique and is used in canals that have a confirmed, Figure 7c: WaveOne GOLD procedural flow chart when the smooth and reproducible glide path. An expanded glide Primary file does not progress: use the Small file in one or more path is a perfect set-up for the safe apical progression of passes to working length and then use the Primary file to any mechanically driven endo dontic file.30 working length to optimise the shape.

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Figure 8: A ProGlider progressing apically expands the glide Figure 9: WaveOne GOLD Primary progressing apically path. through the expanded glide path.

Figure 10: WaveOne GOLD Primary at full working length. Figure 11: WaveOne GOLD Primary loaded with debris, especially in the apical extent of the file, indicating that full shape has been achieved.

The WaveOne GOLD Small (020.07) file should be debris on the apical flutes, shaping continues with thought of as a bridge file, as the resulting shape is WaveOne GOLD Medium and/or WaveOne GOLD Large considered too small to allow disinfection and filling of the until the apical flutes are loaded. Apical gauging with ISO root canal system. When the Primary file will not passively #25 or 35 hand files, respectively, will also confirm whether advance through the glide path, which has been verified to the apical foramen diameter is larger and that a Medium length, the Small file is used to transition and expand the or Large file is required. shape. The Primary file is then re-utilised to reach the full WaveOne GOLD files are used in a brushing action to working length. Although a two-file sequence is the reduce resistance and more effectively instrument canals that exception, this method must be considered a safer and more exhibit irregular cross-sections. Brushing eliminates coronal efficient option compared with most other commercially interferences, creates lateral space, and promotes the available rotary shaping techniques. inward advancement of the file. Further, a brushing action After the Primary file reaches length, the flutes are reduces the contact between the file and dentine, mitigates inspected and if full of debris would indicate shaping is undesirable taper lock, and allows the instrument to run more finished. If the Primary file is loose at length with no dentinal freely. In order to avoid transportation, never brush at length.

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Figure 12: WaveOne GOLD obturating solutions with matching paper points, gutta-percha points and Thermafil.

The files are used with a gentle inward 'stroking' motion of activation with sonic and ultrasonic irrigation is now well short 2–3mm amplitude, to passively advance the file along accepted.31 Dynamic irrigation in the apical one-third of a smooth, reproducible glide path. highly curved canals has been shown to significantly improve Reduced shaping time with WaveOne GOLD means there disinfection.32 is more time available to focus on active irrigation methods. The stages of the shaping procedure can be summarised In order to enhance irrigation and improve effectiveness as follows (Figs. 7a–c): • Establish straight-line coronal and radicular access with emphasis on flaring, flattening and finishing the internal axial walls.32 Table 1: WaveOne GOLD tips. • In the presence of a viscous chelator, use a #10 hand file • Always initiate shaping procedures with WaveOne to verify a glide path to length. In more restrictive canals, GOLD Primary. use a #10 hand file in any region of the canal to create a glide path. • Irrigate abundantly and frequently with sodium hypochlorite after removing any given WaveOne GOLD • Expand this glide path to at least 0.15mm using either a file from a canal. manual or a dedicated mechanical file, such as the ProGlider or PathFile (DENTSPLY) (Fig. 8). • Remove the WaveOne GOLD file when it does not easily progress. Clean and inspect the cutting flutes for wear • Initiate the shaping procedure with the Primary file in the and/or distortion and then irrigate, recapitulate with a presence of sodium hypochlorite (Fig. 9). #10 hand file and re-irrigate. • Use gentle inward pressure and let the Primary file • Owing to the unique WaveOne GOLD post-manufacturing passively progress through any region of the canal that has process, the files may appear to be slightly curved. This is a confirmed glide path. After shaping 2–3mm of any not a defect and it is not necessary to straighten the file given canal, remove and clean the Primary file, irrigate, before use. Place the tip of the file in the canal entrance recapitulate with a #10 hand file and re-irrigate. and start the motor. The file will follow the glide path • Continue with the Primary file, in two to three passes, to conforming to the natural curvature. The advantage is that pre-enlarge the coronal two-thirds of the canal. a slightly curved file can be more easily placed into canals • In more restrictive canals, use a #10 hand file in the of posterior teeth where access is restricted. presence of a viscous chelator and negotiate to the

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13a 13b 13c

14a 14b 14c

Figure 13a–c & 14a–c: The series of pre- and post-op radiographs of tooth #26 demonstrates the ability of WaveOne GOLD to shape considerable curvatures in canals that are long, curved and narrow, following the apical anatomy. All canals were obturated with WVC.

15a 15b 15c

Figure 15a–c: The series of pre- and post-op radiographs of tooth #46 demonstrates the ability of WaveOne GOLD to shape considerable curvatures in canals that are long, curved and narrow, following the apical anatomy. All canals were obturated with WVC.

terminus of the canal. Gently work this file until it is remove the file to avoid over-enlarging the apical foramen. completely loose at length. Inspect the apical flutes; if they are loaded with dentinal • Establish working length, confirm patency and verify the debris, then the shape is finished (Fig. 11).* glide path. • If the Primary file does not progress, use the Small file • Expand this glide path to at least 0.15mm using a manual (020.07 yellow) in one or more passes to working length or mechanical glide path file. and then use the Primary file to working length to optimise the shape. • Carry the Primary file to the full working length (Fig. 10) in one or more passes. Upon reaching working length, • When the shape is confirmed, proceed with 3-D

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disinfection protocols. and torsional stress on the file during work. The fear of * If the Primary file is loose at length with no dentinal instrument breakage should be eliminated for many clinicians debris on the apical flutes, continue shaping with the by using WaveOne GOLD. Root canal preparation with Medium or Large file. WaveOne GOLD is very cost-effective, since 80% of cases can be completed with the single Primary instrument. Single Obturation solutions use eliminates the need to spend valuable time and Obturation of the root canal system is the final step of the unnecessary expense in sterilising procedures, with further endodontic procedure. The WaveOne GOLD system benefits in cost savings. Faster preparation time allows the includes matching paper points, guttapercha points and clinician to focus on the most important aspect of clinical Thermafil obturators (Fig. 12). The new nanotechnology- endodontics, disinfection, thus fulfilling the mechanical and engineered gutta-percha points with their extended heat flow biological objectives of shaping canals. are ideal for all warm vertical compaction (WVC) techniques WaveOne GOLD has set a new standard and shaping (Figs. 13a–c, 14a–c & 15a–c). WaveOne GOLD shapes canals with confidence is now a clinical reality for all. can also be effectively obturated with GuttaCore (DENTSPLY), the cross-linked gutta-percha core obturator. Editorial note: The author has a commercial interest in WaveOne and WaveOne GOLD file systems. Conclusion WaveOne GOLD is a safe, effic ient and simple system for A list of references is available from the publisher. preparing canals. Sophisticated metallurgy and design result in improved flexibility and cyclic fatigue life with less binding Reprinted with permission by Roots 1_2015

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Planning for esthetics – Part II: adjacent implant restorations

William C Martin,1 Emma Lewis,2 Dean Morton3

Predictable esthetic replacement of single missing teeth in the esthetic zone is made possible by a number of clinical factors. One important factor is related to the bone crests on the proximal surfaces of teeth adjacent to the edentulous space.1-5 In conjunction with the coronal anatomy and inter-coron al contact points, these bone crests directly influence the presence, morphology and predictability of the inter-dental papilla, and hence the quality of the esthetic outcome.6 Restoration of adjacent implants in the esthetic zone is made more challenging because the inter-implant space is characterized by an absence of these bone crests, resulting in a comparative deficit in vertical bone height when compared to natural teeth.7-11 When adjacent implants are placed, the deficiency in the inter-implant vertical bone height results in a consequent loss of support for the inter-implant papilla, and an esthetic compromise between dental implants (Figure 1). While more difficult to achieve, successful esthetic outcomes can be made possible in extended edentulous situations (Figures 2-3). In order to achieve these results it is important to understand that a cumulation of negative pretreatment factors can influence esthetic outcomes. As the number of “high risk” factors increase in a given clnical situation, the more difficult the challenge in achieving an esthetic result. The utilization of the Esthetic Risk Assessment analysis can be a key diagnostic aid in 1 DMD, MS, Associate Professor determining the potential for & Clinical Director, Center for an esthetic result (Table 1). Implant Den tistry, Department of This method takes into Oral and Maxillofacial Surgery, account various factors such University of Florida, College of as medical status and Dentistry, USA smoking habit of the patient, 2 DDS, Department of Oral and lip line, gingival biotype, Maxillo-Facial Surgery, width of the gap, bone level University of Florida, College of at adjacent teeth, restorative Figure 1: Various clinical dimensions of importance with adjacent implants in the esthetic zone. (a) horizontal Dentistry, Gainesvill status of neighboring teeth, dimensions: implant–root and implant-implant, (b) vertical 3 DDS, University of Florida soft tissue and bone dimension related to planned restorative mucosal margin, College of Dentistry, Center for anatomy, and the patient’s (c) distance from interproximal bone on adjacent teeth to Implant Dentistry, Gainesville, esthetic expectations. restorative contact point, (d) restorative contact points, (e) USA In extended edentulous inter-implant crest height to mucosal margin.

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Figure 2: Frontal view of extended edentulous space. (a) Figure 3: Occlusal view of extended edentulous space. (a) gingival margin position, (b) height of exisiting papillae. facial contours of soft tissue, (b) width of edentulous ridge.

situations, the potential for an esthetic result is reliant on meticulous planning, proper site enhancement procedures and detailed restoration-driven surgical and restorative procedures (as noted in Part I of this series). The evaluation of the proposed sites is restoration-specific and based upon the diagnostic wax-up, diagnostic casts and pre-treatment radiographs that will assist in identifying the presence of vertical ridge deficiencies and residual pathoses. Prior to pre-treatment radiographic evaluation, a diagnostic waxing which accurately identifies the proposed mucosal zenith (highest point of the free mucosal margin), and the desired coronal extension of the papillae is mandatory Figure 4: Diagnostic try-in with radio-opaque teeth for cone- (Figure 4). The wax-up relates the proposed implant margin beam computed tomography planning. to the oral tissues, and must recognize the emergence of the planned restorations from the tissues. Together, these employed to accurately map the osseous contour. The factors position the implant margin in the three dimensions. projection of the mucosal zenith will facilitate Because bone height (and ultimately papillary presence comprehensive assessment of soft tissues. The thickness and and morphology) is directly related to the position of this morphology of the mucosal tissues is significant as it margin, every effort should be made to plan for implant influences the position of the implant shoulder in both a positions as coronal as the mucosal architecture and apico-coronal and oro-facial position. The final position of emergence profile will allow. Radiographic evaluation of the implant shoulder will influence the inter-implant vertical the vertical and horizontal extension of the bone crests on heig ht of bone achievable around the implant as well as the teeth adjacent to and within the edentulous space dictate the initiation of the emergence profile of the should be undertaken to determine the need for abutment and restoration. Therefore, in the case of the augmentation procedures (Figures 5-6). bone-level implant design, it is critical to place the implant Examination of hard tissues should determine the facial- shoulder at a minimum of 3mm apical to the planned palatal dimension of the bone site, and relate t his to the mucosal margin. This will allow for optimum maintenance of proposed restorations. It should be noted that residual ridge inter-implant bone crests as well as allow for establishment anatomy is unreliable as an indicator of bone dimension, of idea l emergence profile contours of the abutment and and clinical procedures (e.g. sounding, CBCT’s) should be restoration. Surgical placement of the implants requires

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Table 1. Esthetic Risk Analysis – Ref. ITI Treatment Guide Volume I

careful attention to adjacent structures, particularly teeth. clinical information. The horizontal distance between Further, surgical templates can be fabricated using the implants and teeth should approximate 1.5mm.7 This radiographic information, facilitating effective transfer of dimension will help prevent significant resorption of the

Figure 5: Three dimensional view of site #8. Figure 6: Three dimensional view of site #9.

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Figure 7a: Occlusal view of the surgical template post-implant Figure 7b: Occlusal view of the final implant positions. placement.

Figure 8a: Unshaped transition zone immediately following Figure 8b: Provisional restoration exhibiting ideal contours removal of the healing abutments. to assist in shaping the transition zone and providing support for papillae formation.

Figure 8c: Provisional restorations after four-weeks of Figure 8d: Occlusal view of the implant transition zones and function. ovate pontic formation after four-weeks of provisional use.

bone crests during healing. An inter-implant distance of required for the development of papillae. This is achieved 3mm has been advocated by Tarnow et.al. to reduce the by the placement of provisional restorations with liklihood of bone loss between implants (Figures. 7a-b).7 appropriate emergence and anatomy to shape the Submucosal tissue support f rom adjacent structures is also transition zone (area between the implant shoulder and

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Figure 9a: Customized impression coping generated from Figure 9b: Customized impression copings in place prior to the provisional restorations. the final impression.

Figure 10a: Prefabricated ZrO2 abutments and veneered Figure 10b: Final restorations prior to placement. copings.

mucosal margin). The provisional restorations (and Conclusion subsequent definitive restorations) should provide proximal Effective communication of the planned implant positions is contacts which extend to within 5–6mm of the inter-implant required if planning is to be translated into clinical success. bone and remaining bone crests if developed papillae are The use of surgical templates is required if this goal is to be to be viable in the long term (Figures 8a-d). Attention to routinely satisfied. Subsequent to accurate, three-dimensional detail is required through custom-impression procedures implant placement, provisional restorations are required to which transfer the contours of the subgingival region to the facilitate maturation of the connective and epithelial tissues dental technician for duplication in the final restorations prior to definitive restorations being fabricated. Effective (Figures 9a-b).12 planning and execution, in conjunction with the choice of Prior to the final impression, shade selection is performed appropriate implants, can lead to stability of the soft-tissue and photographed for communication with the laboratory. response and successful restoration of adjacent implants in Utilizing CAD/CAM technology, prefabricated ZrO2 the esthetic zone (Figures 11a-d). abutments (Ivoclar, Buffalo, NY) were utilized, followed by The authors would like to thank Mr. Mitchell Jim for the fabrication of ZrO2 copings (CAD/CAM by Straumann®) laboratory support and ceramics used on the patients whic h were then veneered with porcelain (VITA VM® 9, shown in Parts I and II of the Planning for Esthetics Series VITA Zahnfabrik, D-Bad Säckingen) (Figures 10a-b). highlighted in this publication.

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Figure 11a: One-year follow-up – frontal view. Figure 11b: One-year follow-up – occlusal view.

Figure 11c: One-year follow-up peri-apical radiograph. Figure 11d: One-year follow-up peri-apical radiograph.

References anterior maxilla: a review of the recent literature. Int J Oral 1. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Maxillofac Implants. 2004;19 Suppl:30-42. Tarnow DP, Malevez C. Clinical and radiographic 4. Degidi M, Nardi D, Piattelli A. Peri-implant tissue and evaluation of the papilla level adjacent to single-tooth dental radiographic bone levels in the immediately restored single- implants. A retrospectiv e study in the maxillary anterior tooth implant: a retrospective analysis. J Periodontol. 2008 region. J Periodontol. 2001 Oct;72(10):1364-71. Feb;79(2):252-9. 2. Kan JY, Rungcharassaeng K, Umezu K, Kois JC. 5. Lops D, Chiapasco M, Rossi A, Bressan E, Romeo E. Dimensions of peri-implant mucosa: an evaluation of Incidence of inter-proximal papilla between a tooth and an maxillary anterior single implants in humans. J Periodontol. adjacent immediate implant placed into a fresh extraction 2003 Apr;74(4):557-62. socket: 1-year prospective study. Clin Oral Implants Res. 3. Belser UC, Schmid B, Higginbottom F, Buser D. 2008 Nov;19(11):1135-40. Outcome analysis of implant restorations located in the 6. Tarnow DP. The effect of the distance from the contact

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point to the crest of bone on the presence or absence of the vertical and horizontal distances between adjacent implants interproximal dental papilla. J Periodontol 1992; 63 (12): and between a tooth and an implant on the incidence of 995-996. interproximal papilla. J Periodontol. 2004 7. Tarnow DP., Cho SC., Wallace SS. The effect of inter- Sep;75(9):1242-6. implant distance on the height of inter-implant bone crest. J 11. Degidi M, Novaes AB Jr, Nardi D, Piattelli Periodontiol 2000; 71 (4): 546-549. A.Outcome analysis of immediately placed, immediately 8. Cardaropoli G, Wennström JL, Lekholm U.Peri-implant restored implants in the esthetic area: the clinical relevance bone alterations in relation to inter-unit distances. A 3-year of different interimplant distances. J Periodontol. 2008 retrospective study. Clin Oral Implants Res. 2003 Jun;79(6):1 056-61. Aug;14(4):430-6. 12. Hinds, KF. Custom impression coping for an exact 9. Tarnow D, Elian N, Fletcher P, Froum S, Magner A, registration of the healed tissue in the esthetic implant Cho SC, Salama M, Salama H, Garber DA.Vertical restoration. Int. J Perio Rest Dent.1997 Dec;17(6):584-91. distance from the crest of bone to the height of the interproximal papilla between adjacent implants. J Dr William C Martin will be a keynote speaker at the Periodontol. 2003 Dec;74(12):1785-8. 2016 ITI National Congress, “Another Brick in the 10. Gastaldo JF, Cury PR, Sendyk WR.Effect of the Wall”, 16-17th July 2016, Pretoria.

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Khader Dolphin Coast D/L Design-A-Smile Ceramics Dental Design Studio PE D/L (CERAMILL) JOIN THE AESTHETIC REVOLUTION AESTHETIC THE JOIN TIUS RI ic Ceramics Cape Town Claremont Milnerton Umhlanga tEgcme083 541 2137 Mt Edgecombe Vryheid Durbanville Vermont Wetton Durbanville Bergvliet D/L Hartenbos Cape Town Ballito George George Gardens George Mill Park Claremont Durbanville Queensburgh Grosvenor Hout Bay Killarney (021) 910 9100 Gardens Pietermaritzburg Stanger Maputo Morningside Berea Bergvliet Hermanus l cc AMILL) Overport Port Alfred Port Durbanville Muizenberg Durbanville Claremont Morningside Cape Town Bellville Overport Scottsville Cape Town George Pietermaritzburg Somerset West Cape Town Somerset West Mill Park Geor Diep River Umdloti Swaziland Century City Century Bellville Knysna Parklands Cowies Hill Bellville Glencairn Claremont Durbanville Richards Bay Parow Melkbosstrand Durban North Pietermaritzburg Floreal Hermanus Parow Ballito Beacon Bay Somerset West Glen Ashley Sea Point Kenilworth Table View Gillitts Pinelands Stel Port Edward lenbosch Jeffreys Bay ge (032) 946 0792 (031) 202 1427 (031) 767 2481 (032) 586 0110 (00230) 698 7997 (021) 930 1488 (021) 939 1053 (034) 982 2739 (044) 873 6364 (044) 873 5862 (044) 873 3839 (021) 703 2034 (021) 919 7203 (044) 870 0352 (021) 919 0835 (021) 945 1635 (032) 552 7811 (031) 568 1247 (00258) 2148 6086 (044) 871 1996 (031) 207 2388 (044) 382 5418 (021) 462 4257 (021) 712 7747 (041) 374 3660 (041) 374 3660 (021) 712 8024 079 667 5634 (031) 207 3 (021) 556 2686 (021) 790 2992 (021) 511 1733 083 703 7816 (033) 394 8513 (021) 434 1368 (021) 782 0128 R ocks (044) 695 0445 (021) 822 8456 (028) 312 1820 (021) 671 5130 079 011 4680 (021) 712 0432 061 389 8899 (031) 467 9109 (046) 624 5111 (021) 761 0540 (021) 557 0707 (043) 748 3180 (021) 426 2803 (021) 465 2604 (021) 423 5680 (021) 975 6050 (021) 421 1220 (021) 976 8792 (021) 914 2555 (039) 311 2342 (042) 293 1069 (021) 975 1398 (021) 671 5070 (021) 425 5658 (031) 266 8410 (031) 201 0107 (022) 487 3283 (021) 843 3918 (021) 979 3456 (021) 788 7779 (021) 555 3547 ( 031) 312 2520 (035) 753 2807 (031) 572 2127 (031) 563 0227 (031) 464 6560 (021) 851 1560 (021) 855 2052 (021) 553 3462 (021) 851 2679 (031) 561 1920 (00268) 2404 4095 (033) 345 4313 (033) 345 3300 (033) 347 5106 (021) 975 7478 0860 456 123 260 Pro-Dent D/L Duodent D/L Johan White D/L Johan Havenga D/L Burmeister D/L Burmeister WINDHOEK / NAMIBIA Dr D.A. Kock JLC D/L Prosthetic Arts Dental LytteltonStudio PRETORIA &SURROUN Willie Fourie D/L Vildent D/L Theo Joose D/L Teck Ceramics D/L Techni-Dent D/L Tass D/L Specialised Dental Randburg Services Snap Dental Studio cc Cobus Weldent Lab. cc Uni-Pro C&B Studio Ergo Dent BK D/L Dura-Art D/L (CERAMILL) Dura-Art Sauer (CERAMILL) Dr Gert DNA D/L Dentcraft Laboratory cc Dentcraft Laboratory HT D/L Henrico Viljoen D/L Ehlers D/L Duradent Dimension D/L De Vos Dental Ceramics Deutsch D/L De Witts D/L DEuro D/L Crown D/L Creation D/L Compodent D/L Pretoria D/L Pietersburg D/L Park D/L Oral & Dental Hospital Smil Selwyn Grusd D/L Secunda D/L Schoenitz D/L (CEREC) Rustenburg D/L Rosebank D/Ceramics Roeloffze D/L Peers DL Pearly Whites D/L Monu-Dent G-Dent D/L Mel Laeveld D/L Labyrinth D/L Kruger Ceramic Studio KK D/L cc (CERAMILL) Keith Wilkie D/Ceramics John Mason D/Studio Image Dental Ceramics cc Gutsche D/L Chameleon D/L cc Ceramodent D/L Burchell D/L Biodontic D/L cc B-Dental Laboratory Atkinson D/Ceramics Andrew D/C Cornell cc Advance Ceramics GAUTENG &SURROUNDINGS Cent By Word of Mouth D/L Brütten Lab (CERAMILL) Brooklyn Dens D/L Bridge-Rite cc Bio-Ceramix Bendent D/L Apple D/L Anton De Wet D/L André D/L ABC D/L Com Castek D/L ORANGE FREE STATE Werner Retief D/L Vire Dent D/L R&J Dental Diotech Ceramics Deville Erasmus D/L Studio Dental Art Ceramics Denti-Art Charl Basson D/L Ceramica D/L Gauche D/L (CERAMILL) Fix-It D/L Erik Bergh D/L Henning du Plessis D/L Gauteng D/L Kara D/L K-Dent D/L cc Natural Design D/L R Medunsa Oral & Dental Hospital

.C. D/L e Design D/L ville View D/L ury D/L pudent D/L Fourie D/L Wierdapark Lyttleton Weltevreden Park Klerksdorp Midrand Arcadia Polokwane Cullinan Faerie Glen Rietfontein Vanderbijlpark Florida North Centurion Centurion Magalieskruin Arcadia Klerksdorp Midrand Kempton Park Eden Glen Welkom Nelspruit Windhoek Windhoek Eastleigh Villieria Potchefstroom Bordeaux Arcadia Phalaborwa Erasmusrand Walvis Bay Klerksdorp Benoni Secunda Rivonia Clydesdale Bedfordview Sandton Moreleta Park Nylstroom Moreleta Park Centurion Klein Windhoek Darrenwood Garsfontein Roodepoort Booysens Pietersburg Rustenburg Welkom Roodepoort Windhoek Norwood Polokwane

Krugersdorp Bethlehem Benoni Vereeniging Wierdapark Hazelwood Newlands Boksburg Melville Moreleta Park Springs Fairland Jeppestown Brooklyn Woodhill Centurion Westdene Moreleta Park Wierdapark Hazelwood Potgietersrus Randpark Ridge Halfway Gardens Randpark Ridge Sandton Randburg Birchleigh Windhoek Pretoria Nelspruit Garsfontein Die Wilgers Midrand Randburg Krugersdorp Eloffsdal Silverlakes Si Lonehill East Brooklyn Sandton DI NGS aly ukeek(012) 346 4944 Baileys Muckleneuk Medunsa lver lakes (011) 849 7091 (011) 425 6011 (011) 803 7730

(057) 355 2350 (012) 664 5714 (012) 333 2184 (011) 362 6845 (057) 357 6528 (012) 342 8551 (012) 303 9098 (011) 726 7291 (012) 344 3755 (012) 344 3755 (012) 346 7521 078 802 1822 (011) 805 1979 (011) 021 2689 (017) 634 6488 (011) 706 7702 (011) 728 9412 082 904 0920 (011) (012) 460 0031 (012) 732 0487 (011) 433 3148 (011) 609 4560 (011) 894 4301 (013) 752 2529 (013) 752 3073 (011) 789 6383 (012) 751 6191 (012) 998 2120 (012) 521 4948 082 776 5737 (058) 303 4307 (051) 447 3777 (011) 673 3010 (011) 886 5355 081 445 0865 (011) 483 0606 (012) 653 3203 (012) 655 0685 (014) 717 1717 (012) 654 0091 (012) 654 1347 (00264) 64 40 0916 (00264) 61 21 7695 (00264) 61 22 9281 (018) 468 8457 (00264) 61 23 9899 (018) 462 3094 (014) 597 0094 (011) 789 4272 (011) 468 6767 (011) 524 0455 (015) 298 8811 082 404 3814 (012) 809 3948 (012) 809 1499 (012) 331 5674 (00264) 64 20 5118 (012) 346 5631 (011) 958 1586 (011) 679 5348 (015) 295 7684 (011) 624 1020 (012) 993 2248 (012) 460 8910 (012) 998 2356 (012) 653 3058 (011) 953 2444 (016) 423 6598 (012) 991 3404 (012) 653 1064 071 353 2205 (012) 656 0382 (011) 516 0321 (011) 954 3741 (015) 781 1268 (012) 753 1104 (011) 888 4975 086 044 7776 (015) 491 6877 (012) 347 3728 (011) 472 0240 (011) 975 2980 (018) 290 7447 (012) 993 1652 (012) 997 0652 (012) 993 5557 (012) 543 2897 (012) 993 3083

(00264) 61 22 5380 (011) 791 0081 (011) 794 1664 (011) 475 5135 (011) 805 5708 (016) 933 2806 082 602 6694 678 2977 ID-AE MayJune 2016_17-32_Layout 1 2016/05/25 8:25 AM Page 13

Verification Ask your laboratory

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CLINICAL

How effective are different ridge augmentation strategies at resolving horizontal alveolar ridge deficiencies prior to (staged approach), or simultaneous with dental implant placement?

Johan Hartshorne1

A critical appraisal of a systematic review: I. Sanz-Sánchez, A Ortiz-Vigón, I. Sanz-Martin, E. Figuero, M. Sanz. Effectiveness of lateral bone augmentation on the alveolar crest dimension: A Systematic review an d meta-analysis.

Journal of Dental Research, September 2015; 94 (9 Suppl): 128S-142S First published on July 27, 2015. doi:10.1177/0022034515594780 Origin of research – Section of Graduate Periodontology, University Complutense, Madrid, Spain

Summary Systematic review conclusion: Lateral ridge augmentation procedures are effective in treating deficient alveolar ridges prior or simultaneously to the placement of dental implants. For the simultaneou s approach, the combination of bone replacement grafts and barrier membranes was associated with superior outcomes. For the staged approach, the combination of bone blocks, particulate grafts, and barrier membranes provided the best outcomes. The morbidity and postoperative complications associated with the staged approach should not be underestimated. Both treatment strategies led to high survival and success rates (>95%) for the implants placed on the regenerated sites.

Critical appraisal conclusion Different ridge augmentation strategies resulted in statistically significant defect height and width reductions in the simultaneous approach and achieved significant bone width gains in the staged approach. Follow-up was too short (median = 6 months) to establish the long-term efficacy. The results suggest that for the simultaneous approach, the combination of bone replacement grafts with barrier membranes presented with better outcomes. For the staged approach, bone blocks combined with particulate graft material and bio absorbable membranes showed better bone width gains. However, 1 Johan Hartshorne B.Sc., increased morbidity and postoperative complications was observed with the latter B.Ch.D., M.Ch.D, M.P.A. Ph.D. intervention. The most frequent advers e events reported for both the simultaneous and (Stell), FFPH.RCP (UK), staged approach were membrane and/or graft exposure. Non-exposed grafts Visiting Professor, Department of presented with better bone width gains compared to exposed grafts. Overall, the lack Periodontics and Oral Medicine, of good quality randomized controlled trials, variability in research methodology University of Pretoria, Pretoria, South Africa. amongst individual studies, and risk of bias factors resulted in poor quality of evidence therefore potentially reducing the validity of the results. Therefore, any clinical decisions E-mail: regarding superiority or inferiority of ridge augmentation strategies or biomaterials [email protected] should be interpreted with caution.

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Implications for clinical practice: and in good general health requiring the placement of 1 Knowledge and understanding of grafting materials and implant in sites presenting ridge deficiencies. surgical techniques play a critical role in the predictable and The primary outcomes measured were the changes between successful management of simple and complex alveolar baseline and the reentry 3 to 9 months later in the alveolar defects to facilitate dental implant therapy. Ridge ridge width and height dimensional changes in the augmentation procedures should always follow a simultaneous approach, and the width dimension of the ridge prosthetically driven treatment plan to allow placement of the in the staged approach. Two reviewers independently and implant in the correct 3D position. The anatomy of the defect in duplicate assessed the quality and risk of bias of the has to be assessed not only in relation to the type of included RCTs and CCTs, following the Cochrane resorption (horizontal, vertical or combined), or to the size Collaboration recommendations2 and the Newcastle-Ottawa of the defect (volume of lost bone), but also in relation to the scale for the cohort studies. 3 neighborin g teeth. Use of CBCT scanners for assessment of Appropriate statistical testing and analysis was conducted the bone volume and pretreatment planning allows clinicians to establish heterogeneity and average estimate of treatment to anticipate more confidently whether a simultaneous or effect. The data on the primary and secondary outcomes staged approach should be taken. Primary wound closure is were pooled and described with weighted mean differences fundamental for the successful outcome of alveolar ridge (WMDs) and 95% confidence intervals (CIs) using the augmentation. The primary objectives include containing random effects model. graft materials, optimizing blood supply to the surgical site, and preventing bacterial contamination and mechanical Main results irritation of the augmented site. Adequate soft tissue From the 40 selected studies, 21 investigated the conditions must be present and good surgical techniques simultaneous approach (2 CCTs, 9 RCTs, and 10 case should be applied to ensure successful and predictable series), seventeen (17), the staged approach (3 CCTs, 3 primary soft tissue coverage of the augmented site. Clinicians RCTs, and 11 case series), and two (2), the ridge expansion should always opt for a treatment strategy that is least procedure (2 case series). This systematic review pooled invasive and least risk of surgical and postoperative data of 1,242 patients at baseline, with a total of 1,881 complications. implants placed. The mean follow-up period was of 21.48 months, with a minimum of 4 months. When stratified by Clinical question treatment group, 783 patients were treated with the In situations with horizontal alveolar ridge deficiencies, how simultaneous approach (755 completed the follow-up), 373 effective are different regenerative surgical interventions at patients with the staged approach (364 completed the increasing the width of the alveolar ridge and resolving crest follow-up). deficiencies? Primary outcome: defect width reduction with Review methodology simultaneous approach The systematic review and meta-analysis was conducted by The maximum defect width reduction was obtained fore th following the PRISMA (Preferred Reporting Items for combination of particulate xenograft + BMP + bio Systematic Reviews and Meta-analyses) guidelines.1 The absorbable membrane (WMD = − 5.69 mm; 95% CI: – electronic databases of the National Library of Medicine 6.68, –4.69; P < 0.001). The GBR procedure combining (MEDLINE Pubmed) and Cochrane Central Register of particulate xenograft + bio absorbable membrane was the Controlled Trials were searched for human clinical trials on most frequently used procedure (n = 7), demonstrating a lateral ridge augmentation (simultaneous or staged significant reduction in the defect width (WMD = − 3.28 approach) published until December 2014. Only mm; 95% CI: –3.72, –2.82; P < 0.001). randomized controlled clinical trials (RCTs), controlled clinical From eight RCT’s or CCT’s included the met a-analysis only trials (CCTs), and prospective case series with a minimum 1 found a statistical significant difference between test and sample size of 10 patients and a minimum follow-up time of control, showing a higher reduction in alveolar bone width 6 months were eligible. Participants had to be >18 years when using a particulate synthetic graft with a collagen bio

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absorbable membrane as compared with the use of the barrier membranes was associated with superior outcomes. same graft with a crosslink bio absorbable collagen For the staged approach, the combination of bone blocks, membrane (WMD = 1.00 mm; 95% CI: 0.58, 1.41; P < particulate grafts, and barrier membranes provided the best 0.001). The intervention combining bone replacement grafts outcomes. The morbidity and postoperative complications with barrier membranes was associated with superior associated with the staged approach should not be outcomes. underestimated.

Primary outcome: bone width gain with staged approach The authors declared that no funding was provided for the The greatest bone width gain was reported for the elaboration of this study nor was there potential con flict of combination of particulate xenograft + autologous bone + interest with respect to the authorship and/or publication bio absorbable membrane (WMD = 5.68 mm; 95% CI: of this review. 5.00, 6.35; P < 0.001). The lateral bone augmentation procedure using an autologous bone block alone was the Commentary most frequently used (n = 6) demonstrating a significant Background and importance width gain (WMD = 4.25 mm; 95% CI: 4.04, 4.47; P < A basic requirement for a successful and predictable 0.001). treatment outcome with dental implant therapy is the In RCTs and CCTs, 4 studies used autologous bone blocks presence of adequate bone volume to support the required as control group and were compared with different test number and distribution of osseointegrated implants in their treatments (autologous particulate + non-bio absorbable correct three-dimensional position.4 When bone volume is membrane; autologous block + particulate xenograft; deficient due to ridge atrophy, dento-alveolar trauma (i.e. autologous block + non-bio absorbable membrane; traumatic extractions) or pathosis, implant therapy may not autologous block + particulate xenograft + bio absorbable be possible unless the alveolar ridge is augmented membrane). The meta-analysis demonstrated better results, sufficiently. A horizontal ridge augmentation with the staged although statistically non-significant with autologous bone approach enables the placement of a dental implant at a blocks (WMD = − 0.27 mm; 95% CI : –1.16, 0.61; P < subsequent intervention. An alveolar ridge augmentation 0.545). procedure with simultaneous implant placement is usually used to augm ent smaller bone defects or to cover exposed Secondary outcomes: survival and success rates and threads in dehiscence or fenestration type defects. Staged adverse effects or simultaneous ridge augmentation procedures are well Both simultaneous and staged treatment strategies led to high documented, well accepted and considered predictable and survival and success rates (>95%) for the implants placed on widely performed with different guided bone regeneration the regenerated sites. (GBR) techniques with varying outcomes around the word.5,6 The most frequent adverse events reported for either the The GBR technique refers to the use of barrier membranes simultaneous or staged approach were membrane and/or (resorbable or non-resorbable) in the treatment of alveolar graft exposure. The need of regrafting was reported in 7 ridge defects.5 Barrier membranes are placed for various stu dies and ranged from 0% to 23.5%. For the simultaneous reasons, namely its separating effect (to separate the bone approach, non-exposed membrane cases demonstrated a graft from the overlying soft tissues allowing the grafted site significant higher reduction in vertical bone (WMD = 1.01 to be populated with new blood vessels and osteogenic mm; 95% CI: –0.38, 1.64; P < 0.002). The staged cells; to stabilize the blood coagulum and any particulate approach also showed a significant higher bone width gain grafting materials underneath; and to protects the graft from in the non-exposed cases (WMD = 3.10 mm; 95% CI: sharp edges of bone blocks and other biomaterials 2.58, 3.61; P < 0.001). potentially leading to dehiscences.5 Membranes are also used for creating and maintaining space. In such cases non- Conclusion resorbable membranes or resorbable collagen membranes, Lateral ridge augmentation procedures are effective in in combination with tenting pins or screws to support or treating deficient alveolar ridges prior to or simultaneously secure the membrane, are used to prevent collapse of the with the placement of dental implants. For the simultaneous membrane into the defect. The natural matrix for bone approach, the combination of bone replacement grafts and healing is the fibrin of the blood clot.5 Any implanted material

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that promotes bone healing is defined as a bone graft.7 partially edentulous or edentulous, anterior or posterior, Ideally a grafting material must be: osteoconductive (allow maxilla or mandibular). Anterior and posterior parts of the or direct new bone to form within the material structure); maxilla and mandibula have different bone qualities; hence osteoinductive (provide recruitment and /or differentiation they have different regenerative capacities.8 Furthermore, the factors for bone forming cells; and osteogenic (provide length of the defect may affect the degree of vascularization induced or inducible bone forming cells). Different bone to the augmented site.8 The high variability in terms of the grafting materials and techniques are available, depending interventions for ridge augmentation and the different on the indication and intended resorption period, to combinations of bone replacement grafts and barrier guarantee the stability and reorganisation of the augmented membranes used resulted in reduced number of studies within area. In general, augmentation materials are classified as: each subgroup thus making it very difficult to allow for autologous (autogenous/ harvested from the same patient), adequate statistical analysis. allogenic (homologous/derived from the other humans), xenogenic (heterologous/ derived from animal species) and Quality and bias alloplastic bone substitute (synthetic). Ridge augmentation The individual studies were generally of a poor quality serves three primary objectives. Firstly, to restore function by presenting with a high risk of bias for most of the criteria. creating volume of vital bone that will accommodate a dental Combining studies of poor quality and overly biased data implant in its ideal 3D position. Secondly, to promote with thos e that were more rigorously conducted may not be aesthethics by giving the associated soft tissues the bony useful and can lead to worse estimates of the underlying truth support needed for an aesthetic appearance and stability of or a false sense of precision around the truth, thus the restoration. Thirdly, to ensure a predictable long-term compromising the reliability of the data. prognosis of the implant by creating sufficient bone volume coronally around the neck of the implant, ensuring a tight Study design soft-tissue protective seal.5 The influence of study design on the magnitude of the This meta-analysis is the first study to evaluate the relative outcome of the average treatment effect may have a negative effectiveness of different ridge augmentation strategies on the effect on the reliability of the results presented. The results dimensional changes in the alveolar bone prior to (staged), from th e case series studies were superior when compared or simultaneous with implant placement. to that of the RCT’s. Including such studies in a meta-analysis may lead to overestimation of the average treatment effect. Are the results valid? An important consideration and limitation is that the The research methodology used for the meta-analysis was interventions were not tested head on in a comparative well conducted, therefore the results presented are analysis thus compromising the magnitude of the effect. considered valid within reason. However, the validity of the meta-analysis and reliability of Number of studies and sample size the evidence presented depends heavily on the validity of Inadequate number of studies in the subgroup analysis may the individual studies and is only as reliable as the research also result in inability to examine heterogeneity reliably. This methods used in each of the primary studies. In other words, combined with small sample sizes may affect the reliability conducting a meta-analysis does not overcome problems that of average estimations of the treatment effect. were inherent in the design and execution of the primary studies. The primary studies presented with several important Lacking important data and clinical significance limitations that could affect the reliability of evidence Individual studies were lacking data on important long-term presented. outcomes such as aesthetic outcome and soft tissue and bone stability, as well as patient reported ou tcomes and costs. Heterogeneity The CI for the WMD of the pooled data as well as for The individual studies are characterized by diverse study subgroups does not include 0 therefor showing a statistically designs and variations in methodological quality (outcomes significant difference. However a statistically significant measured, standardization of measurement criteria, and finding by itself can have very little to do with clinical practice follow-up times), interventions and biomaterials used, and and has no direct relation to clinical significance9 types of alveolar bone defects studi ed (simple or complex, Judgements about clinical significance should take into

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consideration how the benefits and adverse events of an Adverse events intervention are valued by the patient. These parameters For both the simultaneous as well as the staged approach, were not adequately reported on in the individual studies.9 the most frequently reported adverse event was membrane and/or graft exposure. Strengths Significant higher bone width gains (WMD = 3.10mm; 95% On the positive side, the meta-analysis has important CI: 2.58, 3.61) and defect height reduction (WMD = 1.01 strengths that may contribute towards supporting the validity mm; 95% CI: -0.38, 1.64) were achieved in non-exposed of the data. The width of CI’s in the reported data of compared to exposed cases. The need for regrafting was individual studies was small, thus indicating precision of the reported in 7 studies and ranged fr om 0% to 23,5% average estimate of the treatment effect. Furthermore, the results of the combined data, as well as RCT plus CCT’s How are the results of this review applicable in clinical separately, consistently showed a positive average estimate practice? of treatment effect thus lending support to the effectiveness Are these interventions feasible? of the interventions. The simultaneous approach can be recommended in Overall, the lack of good quality comparative trials, situations with small or single tooth or self-containing bone heterogeneity and variability in research methodology defects (dehiscence or fenestration defects). A staged amongst individual studies, and risk of bias factors resulted approach is preferred whenever a bone defect does not in poor quality of evidence the refore potentially reducing the allow correct placement of an implant in the correct 3D validity of the results. Any clinical decisions regarding position, where there is a large defect that requires an superiority or inferiority of interventions or biomaterials should augmentation beyond the existing bony envelope, or if the be interpreted with caution. bone defect has a vertical component exceeding 1-2 mm.5 Adequate soft tissue conditions should always be present to What are the key findings? ensure successful and predictable coverage of the graft. Effectiveness Several bone grafting materials and membranes are The meta-analysis showed that different ridge augmentation available to choose from depending on the specific situation strategies resulted in statistically significant defect height and and defect. Autogenous bone remains the gold standard due width reductions (baseline vs. final) in the simultaneous to its biocompatibility, osteogenic, osteoconductive, approach and achieved significant bone width gains in the osteoinductive properties. Use of membranes is important staged approach for the interventions and combinations of especially when using particulate bone grafting substitutes. biomaterials used. The results suggest that for the Using growth factors (i.e. BMP) may lead to improved simultaneous approach, the combination of bone outcomes. Resorbable membranes are easier to use and will replacement grafts with barrier membranes presented with offer the least complications. better outcomes. For the staged approach, bone blocks Non-resorbable membranes generally offer the best width combined with particulate graft material and bio absorbable gains provided that soft tissue healing achieved and membranes showed better bone width gains. However, maintained during graft maturation6 however, non-resorbable increased morbidity and postoperative complications was membranes are known to involve high rates of complications. observed with the latter intervention. Premature exposure of a non-resorbable membrane may necessitate its removal along with the graft and the implant.6 Success and implant survival rates The success of bone augmentation is usually dependent on The success rates of simultaneous and staged ridge primary wound closure. Soft tissue dehiscence’s can interfere augmentation procedures were high, ranging from 73.3% with the healing of block grafts, thus promoting resorption to 100%. (19 studies did not report success rates) The short- and complete loss of the graft.5 To avoid such undesirable term implant survival rate likewise was also high ranging from adverse outcomes, it is mandatory to use surgical techniques 78,2% to 100%. (5 studies did not report on the implant that will guarantee primary soft tissue closure over survival rate). The median follow-up period was 6 months (7 augmentation sites. Factors that may increase the risk of studies reported no follow-up). wound exposure include: the width of keratinized mucosa;

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flap thickness; flap tension; vestibular depth; type and size = 3.90mm). of the bony defect; and materials used.10 Both treatment approaches demonstrated high survival and Lastly, there should be no reason for a clinician to withhold success rates (>95%) when implants were placed in these from their patients useful procedures of bone augmentation regenerated sites. merely because they personally lack the skills to conduct The evidence presented by this meta-analysis supports the these procedures on there own. It is better to refer a patient use different bone replacement grafts, the use of barrier than to accept a compromise that may be limiting to the membranes and application of the biological principles of restorative outcome.5 guided bone regeneration (GBR) with ridge augmentation techniques. The relative effectiveness of different ridge Can I apply the results in my practice? augmentation strategies is very relevant to clinical practice. The therapeutic effectiveness of ridge augmentation and However, due to the poor quality of the individual studies, implant therapy may be affected by risk factors and the evidence could be compromised. Therefore, any limitations such as, smoking, systemic conditions, dental clinical decisions regarding superiority or inferiority of ridge status, the extent and location of the bone defect, anatomical augmentation strategies or biomaterials should be limitations, patient preferences, budget constraints and interpreted with caution. An important finding in this meta- reluctance to undergo major surgical procedures or analysis is that for both the simultaneous as well as the acceptance of bone substitutes.5 Clinicians should give staged approach, membrane and/or graft exposure was careful consideration to these issues before deciding whether the most frequently reported adverse event. More to incorporate a particular piece of research evidence into importantly, significant higher bone width gains and defect clinical practice. Use of CBCT scanners for pretreatment height reduction were achieved in non-exposed compared planning allows clinicians to anticipate more confidently to exposed cases. This highlights the importance of ensuring whether a simultaneous or staged approach should be taken. proper treatment planning, appropriate surgical technique and application of biomaterials to ensure proper wound Do benefits outweigh the potential harms and costs? closure. It is important to consider the burden to patients, such as donor Well-designed RCT’s are needed to determine the long- site morbidity in hard and soft tissue grafting, and to pay term efficacy of different ridge augmentation strategies, with attention to appropriate indications and correct choice and specific focus on bone and soft tissue stability. These studies use of grafting materials to avoid overtreatment.11 To reduce should also incorporate the use of adjunctive therapies such morbidity and complications and reduce costs it is always best as platelet rich fibrin into ridge augmentation strategies to to select a treatment strategy that will offer the least amount of establish their effect on promoting healing and minimizing surgical invasiveness. The simultaneous approach is less soft tissue dehiscence complications. Patient reported burdensome, costly and time-consuming compared to the outcome measurements and aesthetic outcomes were seldom staged approach. In both approaches there is potential risk reported. Greater focus should be place on these outcomes of membrane or graft exposure, graft shrinkage or partial in future studies. resorption. However with the simultaneous approach, postoperative wound infection or wound dehiscence may Disclosure and Disclaimer result in surface exposure of an implant and loss of the bone Dr Johan Hartshorne is trained in clinical epidemiology, graft. This adverse event may turn out untreatable and require biostatistics, research methodology and critical appraisal of a second intervention for implant removal.5 research evidence. This critical appraisal is not intended to, and do not, express, imply or summarize stan dards of care, Clinical resolution but rather provide a concise reference point for dentists to The meta-analysis showed that different ridge augmentation aid in understanding and applying research evidence from strategies were effective at gaining alveolar bone width in referenced early view or pre-published articles in top ranking both the simultaneous and staged approach, although width scientific publications and to facilitate clinically sound gains were slightly higher for the simultaneous approach decisions as guided by their clinical judgement and by (WMD = 4.28mm) compared the staged approach (WMD patient needs.

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References Berlin. 2014. 1. Moher D, Liberati A, Tetzlaff J, Altman DG, Prisma 6. Cordaro L. Literature review in: Ridge augmentation Group. Preferred Reporting Items for Systematic Reviews and procedures in implant patients. ITI Treatment Guide Vol. 7. Meta-Analyses: The PRISMA Statement. Ann Int Med 2009; Pp. 9-11. Quintessence Publishing Co, Ltd. Berlin. 2014. 151:264-9, W64. 7. Bauer TW, Muschler GF. Bone graft materials. An 2. Hig gins JP, Green S. 2011. Cochrane handbook for overview of the basic science. Clin Orthop Relat Res. 2000; systematic reviews of interventions version 5.1.0. Oxford 371:10-27. (UK): Cochrane Collaboration. 8. Behnia H, Homayoun S, Qaranizade K, Morad G, 3. Wells GA, Shea B, O’Connell D, Peterson J, Welch V, Khojasteh A. Multidisciplinary reconstruction of a Losos M, et al. The Newcastle– Ottawa Scale (NOS) for palatomaxillary defect with non-vascularized fibula bone assessing the quality of non-randomized studies in meta- graft and distraction osteogenesis. J Craniofac Surg. 2013; analyses. 2011. Ottawa Hospital Research Institute. 24(2):e186-90. Available from: 9. Akobeng AK. Principles of evidence-based medicine. http://www.ohri.ca/programs/clinical_epidemiology/oxf Arch Dis Child 2005: 90:837-840. ord.asp. Accessed on 16 June 2015. 10. Chan Y-C, Chang P-C, Fu J-H, Wang H-L, Chan H-L. 4. Chen S, Buser D, Wismeijer D. Preface in: Ridge Surgical Site Assessment for Soft Tissue Management in augmentation procedures in implant patients. ITI Treatment Ridge Augmentation Procedures Int J Periodontics Restorative Guide Vol. 7. Quintessence Publishing Co, Ltd. Berlin. Dent 2015; 35: e73–e81. doi: 10.11607/prd.2097 2014. 11. Masaki C, Nakamoto T, Mukaibo T, Kondo T, Kondo 5. Terheyden H, Cordaro L. Introduction in: Ridge Y, Hosokawa R. Strategies for alveolar ridge reconstruction augmentation procedures in implant patients. ITI Treatment and preservation for implant therapy J Prosthodon Res. Guide Vol. 7. pp. 1-2. Quintessence Publishing Co, Ltd. 2015; 59: 220-228

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CASE REPORT

See, recognize, realize: visual shade analysis and its realization into a ceramic crown

Bastian Wagner1

The wide variety of ceramic materials available today, allows the dental technician to reproduce the natural, dynamic light qualities present in natural dentition. Recognizing and reali zing these visual characteristics, however, is a challenge which can only be mastered with a great deal of patience and knowledge.

Each individual patient case requires the full attention of all involved – patient, dentist, dental technician – to the finer details in this complex piece of work. It is the dental technician’s job to produce a durable prosthetic restoration, which with its functional, biological and esthetic characteristics, is adapted to suit the individual requirements and specifications of the patient. The advancement in technologies and materials within the last few years has dramatically changed the work of dental technicians. We are, however, still often faced with a huge challenge: to recreate nature’s perfection and provide oral harmony. In particular, consistency and discipline are needed to fabricate anterior teeth. In order to produce an esthetic restoration, the dental technician must recognize the correlation between the tooth shape, surface structure and function and the effects of phonetics and colour. These factors form the foundation. With a passion for the work involved and the necessary sensitivity and specialized knowledge, a lifelike appearance can be successfully imitated. At times this can be a laborious task and require a great deal of patience and sometimes it takes quite a few attempts to achieve the desired results. In order to realize a harmonious and esthetic smile in the end result, good communication between the patient and dental technician is essential. The patient’s expectations must be clearly understood by all parties and their wishes transposed as a team. This article concentrates on shade selection and shade reproduction using the veneering ceramic IPS e.max® Ceram. The fabrication of an anterior tooth is shown on the basis of a patient case.

The visual properties of natural teeth Three shade characteristics must be taken into account when determining the shade: the colour (Hue), the brightness (Value) and the colour intensity (Chroma). The colour itself is the most obvious part of a shade. The brightness is a definition of how light or dark a colour is. The colour intensity describes the purity of a colour. The highest attention should be paid to the brightness. If the value of a restoration is not ideally matched to the rest of the dentition, then even the slightest deviation can be detected within normal speaking distance by the person standing opposite.2 In general, it is very important to understand the three visual properties and use the chosen ceramic system to adapt to each situation individually.

The principles of shade selection For shade selection a shade guide is used, which presents the 1 Bastian Wagner following colour tones: Dental Practice Dr Markus Regensburger A = orange B = yellow/orange Effnerstrasse 39a C = grey/orange D = brown/orange 81925 Munich Germany The shade should be selected at the start of the restorative treatment so that it is not [email protected] affected by a dehydrated natural tooth structure. In order to select the hue, value and

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Figure 1: Individual shade samples for the ceramic range IPS e.max Ceram.

chroma, individually fabricated shade samples in the relevant further details. In general, digital photography is a unique ceramic assortment can be useful (Fig. 1). The ceramic communication tool for the entire treatment team and it should materials are designed in such a way that the complex shades be firmly established within the treatment process.1 When and characteristics of natural teeth can be better distinguished. taking photographs, the following procedure must be The colour of the gingiva or other surrounding influences can observed. The shade sample and the natural tooth must both affect the shade selection. For example, the background be parallel to the sensor level on the camera and receive the colour during shade selection can change the perception of same amount of light exposure as the camera flash. The shade the colour intensity and the colour tone. In order to avoid any information in the photograph and the anatomical and misinterpretation it is advisable to cover the dark oral cavity morphological characterization can then be analyzed on the with a grey card. Another method is to use a gingiva coloured screen. In order to avoid falsified information on the screen, it holder (Gumy, Shofu, Germany) for each individual shade should be calibrated perfectly. If a grey card is used whilst sample in order to provide simultaneous and successive photographing, differing camera values can be corrected contrast effects. The samples are surrounded by a colour using white balance with the image-editing program (e.g. which imitates their natural envir onment. The Gumy gingival Adobe Photoshop Lightroom). Information is not lost or mask is available in four different colours. When a shade is distorted. When the photos are converted in the image-editing selected, the sample is then placed into the Gumy so that it program into black and white pictures, the surface texture and can be checked with the gingiva. For basic shade difference in brightness is clearly visible. To better identify determination it is advisable to take a photo of three different internal characterization, the contrast control can be adjusted shade samples on one photo. This provides a comparison. to “maximum” and the highlight function to “minimum”. This One sample should represent the brightness of the tooth to be will show all details clearly. The collected information is prepared; the second should have a lower value and the third converted into a shade diagram, which is synchronized with a slightly higher value. Furthermore, during the preoperative the ceramic material to be used, and a layering concept is shade determination, important information on the selection created. The following case shows one possible procedure of a suitable material should also be considered. for realizing the determined tooth shade.

Photographic documentation of the shade selection Patient case In an addition to the shade selection, photo documentation This patient case with the reconstruction of tooth 11 shows is essential. A photographic shade comparison of the natural clearly how the determined shade can be reproduced. The tooth colour and the corresponding shade tabs provides preoperative shade analysis shows that the adjacent tooth 21

Figure 2: Reconstruction of tooth 11. Shade determination at the Figure 3: Shade determination with gingiva coloured holder for beginning. the shade samples.

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Figure 4: Shade determination of the internal structures. Figure 5: Selection of the individual opal materials using self- fabricated shade samples.

has a very high degree of brightness in the cervical area and The structure was lightly covered in a wash bake with MM in the body (Figs 2 and 3). The natural tooth exhibited light and then fired (Fig. 7). During the firs t dentin bake, the opalescent/ transparent areas on the ridges and in the incisal framework was evenly covered with dentin B1 and MM light. region. The mamelon structure had a high value and a slightly The area towards the ridge which had a high degree of value yellowish chroma (Figs 4 and 5). The basic shade selected was imitated using Deep Dentin B1 and MM light to a ratio was BL 3. Various methods can be used to increase the of 4:1 (Fig. 8). The tooth shape was then completed using brightness of the IPS e.max Ceram ceramic. In this case, due Dentin BL 3 (Fig. 9). Cutting back the incisal area and the to the high degree of value, the brightness of the dentin B1 edges made space for the Effect materials. Before the actual ceramic material was increased with the highly fluorescent build-up, in order to create the mamelon structure, the material MM light ceramic material from the IPS e.max range. The MM light was mixed with Essence Lemon and White until the framework material used was an MO1 press ingot (Fig. 6). ideal mixing ratio had been found and then a firing sample

Figure 6: The crown framework IPS e.max Figure 7: Wash bake and characterisation Press (MO1 ingot) before the wash bake. with MM light before firing.

Figure 8: The crown framework was built up Figure 9: Completion of the internal structure with Dentin B1 and MM light and Deep Dentin with Dentin BL 3. and MM light (ratio 4:1) was built-up towards the edges.

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Figure 10: Application of the mamelon structure with a mixture Figure 11: Completion of the incisal plate with Opal materials. of MM light and Essence materials.

Figure 12: Results after the first bake. Figure 13: Checking the surface structure.

Figure 14: The finished piece of work after the glaze firing. Figure 15: The finished restoration of tooth 11 in situ.

was fabricated. The exactly mixed ratio was then applied to essential. Even though the material prerequisites for the incisal plate (Fig. 10) and the edges were built up with reproducing lifelike restorations are available, each dental OE 1. The incisal plateau was completed by alternately technician is responsible for developing their own skills and layering OE 2 and OE 3 (Fig. 11). Finally, the halo-effect was capabilities. The challenge of recreating a shade will always imitated from the incisal edge to the proximal area and the be unique for each different patient case. crown was then fired (Fig. 12). The second bake included In autumn 2015, Ivoclar Vivadent introduced the IPS e.max slight shape corrections. To achieve a natural appearance the Ceram Power Dentin and Incisal layering ceramics which ceramic surface was given structure and then fixed with a feature a high brightness value. These materials are ideal for glaze bake (Figs 13 to 15). use on less reflective translucent substructures. In cases such as the one presented in this article, in which a high degree of Conclusion brightness is required, the Power materials can also be used The diverse spectrum of a modern ceramic range gives the on opaque frameworks to realize the desired results with little technician the ability to reproduce a variety of dynamic light effort. features. Recognizing and realizing the tooth shade is and Literature available from the editors on request always will be a huge challenge. This is why the intensive study of chromatics and of your own ceramic assortment is Reprinted with permission by Reflect 1_2016

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CLINICAL

Tactile controlled activation technique with controlled memory files

Antonis Chaniotis1

The ultimate biologic objective of endodontic therapy is the prevention of periradicular disease and the promotion of healing when disease is already established. Arguably, mechanical instrumentation and chemical disinfection of the root canal system are considered the foundational principles for the successful accomplishment of these objectives (Schilder, 1974). Although these principles cannot be co nsidered separately, canal preparation is the essential phase that will determine the efficacy of all subsequent procedures (Peters, 2004). Traditionally for gutta percha fillings, root canal shaping should satisfy specific design objectives: • The shape of the main root canal should resemble a continuously tapering funnel from the orifice to the apex • The cross-sectional diameter of the main canals should be narrower at every point apically • Canal preparation should follow the shape of the original root canal • The original position of the apical foramen should be preserved • The apical opening should retain its original dimensions as much as possible (Schilder, 1 Dr Antonis Chaniotis graduated 1974; Hulsmann, Peters, Dummer, 2005). from the School of Dentistry, The biological objectives of root canal instrumentation consist of: the confinement of University of Athens, Greece, in instrumenta tion to the limits of the roots themselves; the avoidance of extruding necrotic 1998. In 2003, he completed debris into the periradicular tissues; the removal of all organic tissue from the main the three-year postgraduate canals as well as from the lateral extent of the root canal system; and the creation of programme in endodontics at sufficient space to allow irrigation and medication by simultaneously preserving enough the School of Dentistry, circumferential dentine for the tooth to function (Hulsmann, Peters , Dummer, 2005). University of Athens. He is a Achieving these objectives in straight canals is considered a simple and clinical instructor affiliated with straightforward procedure with all instrumentation systems available today. The problems the undergraduate and of biomechanical instrumentation arise when the internal anatomy of human teeth is postgraduate programmes in the endodontics department at the severely curved or even bifurcated and anastomotic (Figure 1). dental school, and owns a In such teeth, the accepted basic endodontic techniques and instrumentation protocols private practice in Athens limited might be challenging to follow. to microscopic endodontics since The aim of this article is to describe the application of tactile controlled activation 2003. He has been clinical (TCA) technique with controlled memory files for the safer and more predictable fellow of dentistry at the instrumentation of severely curved and challenging canals. University of Warwick since 2012. Dr Chaniotis has The challenge of curved canal management published articles in local and The internal anatomy of human teeth can be extremely complicated. Based on canal international journals and he has curvature, Nagy et al (1995) classified root canals into four categories: straight or I-form lectured at more than 40 local (28% of the root canals), apically curved or J-form (23% of the root canals), entirely curved and international congresses. In or C-form (33% of the root canals) and multicurved or S-form canals (16% of the root canals). 2010, he joined the Roots Forum and became well known for his Schafer et al (2002) found that 84% of the human root canals studied were curved and clinical skills through his 17.5% of them presented a second curvature and were classified as S-shaped root canals. microscope-enhanced From all curved canals studied, 75% had a curvature of less than 27o, 10% had a curvature endodontic video case with an angle between 27o and 35o and 15% had severe curvature of more than 35o. management series. Traditionally, root canal curvatures were assessed by using the Schneider angle of

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Figure 1: Complex root and root canal anatomical challenges in endodontics.

curvature concept (Schneider, 1971). According to Schneider into three categories: small radius (r≤4mm), intermediate (1971), root canals presenting an angle of 5o or less could radius (r>4 and r≤8mm) and large radius (r>8mm). The be classified as straight canals, root canals presenting an smaller the radius of a curvature is, the more abrupt it angle between 10o and 20o as moderate curved canals, becomes. and root canals presenting a curve greater than 25o as All these attempts to describe the parameters of root severely curved canals. canal curvature had one common denominator, the Many decades later, Pruett et al (1997) reported that two preoperative risk assessment for transportation and curved root canals might have the same Weine angle of unexpected instrument separation. curvature, but totally different abruptness of curvature. In order to define the abruptness of curvature they introduced the The risks of canal transportation and instrument concept of the radius of curvature. The radius of curvature is separation the radius of a circle passing through the curved part of the According to the glossary of endodontic terms (American canal. The number of cycles before failure for rotary Association of Endodontists, 2012), transportation is defined endodontic instruments significantly decreased as the radius as the removal of the canal wall structure on the outside curve of curvature decreased an d the angle of curvature increased. in the apical half of the canal due to the tendency of the files Further attempts to describe mathematically and to restore themselves to their original linear shape. For stainless unambiguously root canal curvatures in two-dimensional steel hand files and conventional nickel titanium hand or radiographs introduced parameters such as the length of the engine-driven files, the restoring force of a given instrument is curved part of the canal (Schäfer et al, 2002) and the location directly related to its size and taper. The bigger the size or of the curve as defined by curvature height and distance taper of a given file is, the bigger the restoring force becomes (Günday, Sazak, Garip, 2005). due to the increase of the metal mass of the instrument. Estrela et al (2008) described a method to determine eth If root canals were constructed precisely on the dimensions radius of root canal curvatures using CBCT images analysed of our instruments, then transportation wouldn’t be a problem by specific software. Radius of canal curvatures was classified and our instruments would be well constrained inside the root

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instruments to create adequate apical preparations and on the selection of the appropriate delivery techniques (Boutsioukis et al, 2010). Achieving adequate apical preparations for disinfection without over-flaring the coronal part of highly curved canals is one of the greatest challenges in endodontic in strumentation. This is very true especially under the current concepts of dentine preservation in endodontics. Moreover, the risk of unexpected instrument separation of engine-driven nickel titanium files poses significant problems during curved canal management. There are two Figure 2: The effect of flaring in the curvature parameters. mechanisms that have been implicated with engine-driven canal trajectories. Unfortunately, instruments are not well instrument fracture, cyclic fatigue and torsional failure. As an constrained by the canal in a precise trajectory, because engine- driven instrument is activated inside a curved canal, instruments are not precisely shaped to fit the canal dimensions. continuous tensile and compressive stresses at the fulcrum of As a result, each instrument may follow its own trajectory inside the curvature may lead to instrument separation because of a curved canal guided by its restoring force and transporting cyclic fatigue. If the tip of an engine-driven instrument is the canal (Plotino et al, 2010). Usually, the greater increase in locked inside a canal and the shaft of the instrument keeps apical enlargement is targeted in curved canals, the more on moving, it may exceed an applied shear moment, excessive the dentine removal towards the outer apical curve resulting in torsional failure. Usually during curved canal becomes (Elayouti et al, 2011) and the more excessive the management both mechanisms can co-exist. As the inner curvature (danger zone) widening can get. complexity of the curvature increases, the number of cycles In order to avoid these complications, the more severe the before failure decreases for a given instrument, making canal curvature is, the more we tend to increase flaring and complicated canal management a real clinical challenge. reduce the apical instrumentation size (Roane, Clement, Carnes, 1985). Increasin g flaring under such circumstances Controlled memory files to minimise instrumentation risks would result in the reduction of the angle of curvature, in Nickel titanium alloys are softer overall than stainless steel, shortening the length of curvature, in increasing the radius of have a low modulus of elasticity (about one fourth to one fifth curvature and in relocating the curvature apically (Figure 2). that of stainless steel), greater strength, are tougher and more Smaller apical preparations in highly curved canals would be resilient and show shape memory and superelasticity preferable for two reasons: (Baumann, 2004). The nickel titanium alloys used in root • Smaller diameter preparations are related to less cutting of canal treatment contain approximately 56% (wt) nickel and the canal walls, less file engagement and consequently, a 44% (wt) titanium (Walia, Brantley, Gernstein, 1988). They lesser likelihood for the expression of undesirable cutting can exist in two different temperature-dependent crystal effects structures (phases) called martensite (low-temperature phas e, • Small diameter files are more flexible and fatigue resistant with a monoclinic B19’ structure) and austenite (high and therefore less likely to cause transportation during temperature or parent phase, with the B2 cubic crystal enlargement (Roane, Clement, Carnes, 1985). structure). The lattice organisation can be transformed from The aforementioned instrumentation approaches, although austenitic to martensitic and return again to austenitic phase safer, have inherent disadvantages. Unfortunately, flaring the by adjusting temperature and stress. During this reverse canal entrance in order to ac hieve easier negotiation to the transformation the alloy goes through an unstable intermediate apical third of curved canals will result in unnecessary crystallographic phase called R-phase. removal of dentine from a level that is considered Preparation of the root canal causes stress to nickel irreplaceable. Moreover, smaller apical preparations may titanium files and a stress-induced martensitic transformation result in increased difficulties for the irrigation solutions to be takes place from the austenitic phase of conventional nickel delivered to an appropriate canal depth. In highly curved titanium files to the martensitic phase within the speed of canals the ability of irrigation solutions to be delivered to the sound. A change in shape occurs, together with volume and critical apical third depends directly on the ability of our density changes.

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This ability of resisting stress without permanent deformation quantitative analysis based on the model of the fracture process – going back to the initial lattice form – is called zone showed that the martensite transformation in the shape superelasticity. Superelasticity is most pronounced at the memory nickel titanium alloy caused 47% increase in the beginning of the applied stress, when a first deformation of apparent fracture toughness (Wang, 2007). as much as an 8% strain can be totally overcome. After 100 Very recently, controlled memory thermomechanical deformations, the tolerance is about 6% and after 100,000 processing was combined with an innovative machining deformations it is about 4%. Within this ran ge, the so-called procedure for the manufacturing of rotary nickel titanium ‘memory effect’ can be observed (Baumann, 2004). endodontic files. The procedure is called electrical discharge Besides the stress-induced martensitic transformation, the machining (EDM) and results in instruments of increased lattice organisation of nickel titanium alloys can be altered surface hardness cutting efficiency and extreme fatigue also with temperature change. When a conventional nickel resistance. In the first paper published evaluating these files titanium austenitic microstructure is cooled, it begins to change (Pirani et al, 2015), spark-machined peculiar surface was into martensite. The temperature at which this phenomenon mainly noticed and low degradation was observed after begins is called the martensite start temperature (Ms). The multiple canal instrumentations. The authors also found high temperature at which martensite is again completely reverted values of cyclic fatigue resistance and a safe in vitro use in is called the martensite transformation finish temperature (Mf). severely curved canals. In agreement with these previews When martensite is heated, it begins to change into austenite. researchers, Pedulla et al (2015) reported higher values of The temperature at which this phenomenon begins is called fatigue resistance for EDM rotary files even when compared the austenite transformation start temperature (As). The with reciprocating files made from M-wire. temperature at which this phenomenon is complete is called The extreme flexibility and fatigue resistance of these files the austenite finish tem perature (Af), which means that at and combined with the lack of restoring force render them ideal to above this temperature the material will have completed its be used for the instrumentation of highly curved and shape memory transformation and will display its superelastic complicated canals. Whenever a conventional superelastic characteristics (Shen et al, 2011). nickel titanium file is rotating inside a curved canal, it creates Before 2011, the Af temperature for the majority of the its own trajectory guided by the restoring force of the file and available nickel titanium endodontic instruments was at or transporting the canal toward the outer apical curve (ElAyouti below room temperature. As a result, conventional nickel et al, 2011). The bigger the size or taper of the file used, the titanium endodontic instruments were in the austenitic phase more dentine is removed from the outer apical curve, resulting during clinical use (body temperature), showing shape in off-centred preparation at this level. memory and superelasticity. In 2011, so-called controlled Leseberg and Montgomery (1991) studied canal memory files were introduced in endodontics. These files had transportation at the level of the curve and documented the been manufactured utilising a thermomechanical processing that controls the material’s memory, making the files extremely flexible and fatigue resistant but without the shape memory and restoring force of other nickel titanium files (Coltene/Whaledent, 2012). The Af transformation temperature of controlled memory files is found to be clearly above body temperature. As a result, these files are mainly in the martensite phase in body temperature (Shen et al, 2011). When the material is in its martensite form, it is soft, ductile, without shape memory, can easily be deformed yet it will recover its shape and superelastic properties upon heating over the Af temperature. Moreover, a hybrid martensite microstructure (like the Hyflex CM controlled memory files) is more likely to have more favourable fatigue resistance than an austenitic microstructure. At the same stress Figure 3: Transportation dynamics of shape memory nicklel intensity level, the fatigue crack propagation speed of austenitic titanium rotary files. Notice that the instrument removes material structures is much faster than that of martensite ones. A by touching the outer apical curve and the inner middle curve.

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Similar transportation dynamics with controlled memory were also demonstrated during the instrumentation of double curved canals (Burroughs et al, 2012). In simulated S-shaped canals, controlled memory files produced more overall transportation compared to SAF and M-wire instruments. Although the overall transportation was found bigger for no shape memory files, they always transported the double curved canal towards the outer curves. This is very important in highly curved and double curved canals because the initial dentinal thickness of human curved roots is always minimal at Figure 4. the convexity of the inner distal curves (danger zones) or the inner S-apical curves (Figure 5). distal (toward the midline) movement of the original canal. They showed that canal transportation is caused by a combination TCA instrumentation technique of forces resulting from the restoring force of the instrument that Root canal instrumentation involves the use of hand- or rotates around the clinical and proximal view curvatures. These engine-driven files to create suff icient space for irrigation and forces produce a transportation vector distally and axially at medication. The tactile feedback of the root canal anatomy this level. From their study it would appear that for the middle felt by the operator during this procedure depends on various third of a given curved canal, the greater the clinical and factors including: the initial canal shape (round, oval, long proximal view curvatures the faster the transportation would oval or flat canals), the canal length (the longer the canal the progress toward the distal concavity of the root. The dynamics more frictional resistance is expected), the canal taper of apical and middle third transportation, as the result of the (tapering discrepancy between a gauging instrument and the restoring force of the instrument and the degree of canal canal may cause false binding sensation), the canal curvature curvature, can be seen in Figure 3. (curved canals can cause deflection of the instruments and However, controlled memory files have no restoring force after increase frictional resistance), the canal content (fibrous or bending in body and room temperature. Whenever an instrument calcified canal content can create different degrees of with controlled memory characteristics is activated inside a frictional resistance), canal irregularities (attached pulp stones, curved canal, it moves passively inside the anatomy producing denticles and reparative dentine can create convexities on minimal forces of transportation. In highly curved canals, the lack root canal walls) and the type of instrument used (rigidity, of restoring force keeps the CM files rotating towards the outer flexibility, tapering and restoring force can alter the frictional canal wall at the fulcrum of the curvature (Figure 4). feedback) (Jou et al, 2004).

Figure 5: Cases treated with Hyflex CM files. The arrows point to the areas of dentine preservation.

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Figure 6: Tactile controlled activation (TCA) technique explained.

For a given root canal and a given file, the operator’s After accessing the pulp chamber and locating the canal tactile feedback during the instrumentation procedure differs orifices, technical patency to length is confirmed (Figure 6a). according to the kinematics of the file used. Passively inserted The first file to be used is mounted on the handpiece of an files (non-activated) give a tactile sensation that is determined endodontic motor and inserted passively inside the canal until by the frictional resistance generated when the file engages maximum frictional resistance (Figure 6b – point B). The file is the dentinal walls. The tactile sensation with an activated file activated and pushed apically (in-stroke) until the activated file (rotating or reciprocating) however, as the result of cutting, resists further advancement (Figure 6c – point A) and can more accurately be determined by the ability of the file withdrawn from the canal (Figure 6d). After file withdrawal, to resist advancement around curvatures while in action the file is inactivated, the flutes are cleaned and checked for (McSpadden, 2007). any possible deformations. Irrigation and patency confirmation Keeping in mind the complexity of root canal systems and follows. The second time that the same file will be inserted the need to minimise file engagement during instrumentation, passively inside the same canal it will reach deeper inside the a novel approach was developed and named as the TCA anatomy (Figure 6e – point P). Activating the file again the instrumentation technique. same way will guide the file even more apically closer to length The TCA technique can be defined as the activation of a (Figure 6f – point A). The work to be done by this file is motionless engine-driven file only after it becomes fully completed when the file can reach working length without engaged inside a patent canal (Chaniotis, Filippatos, 2015). having to activate it and is then withdrawn (Figure 6g). TCA utilises file activation only after maximum engagement of Instrumentation to larger apical preparations is achieved the flutes is reached and a tactile feedback of the anatomy is the same way until the desired apical instrumentation width felt. Inserting files passively (non-activated) inside the root is achieved. TCA technique aims to minimise the time of canals and using controlled memory instruments that can be engagement with an activated file by using file activation pre-curved before file insertion is suggested to be only when needed for advancement. With this advantageous, especially when complicated canal systems instrumentation technique, most of the anatomical root canal are encountered and limited mouth opening hinders canal variations can be enlarged safely to the desired negotiation and visualisation. TCA technique can be divided instrumentation size, irrespective of the degree and into in-stroke and out-stroke components. complexity of canal curvatures, by maintaining a tactile

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www.3mespe.co.za

3M South Africa (Pty) Ltd 146a Kelvin Drive Woodmead 2128 Toll free: 0800 1333 66 Facebook: 3MESPESA ID-AE MayJune 2016_49-64_Layout 1 2016/05/25 8:24 AM Page 10

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Figure 7: Instrumentation of challenging cases to larger apical preparations with tactile controlled activation (TCA) and controlled memory files.

sensation of the anatomy throughout the whole procedure. are considered easy and straightforward cases for most For dilacerated canals, the controlled memory files can be instrumentation systems available today and they pose no pre-curved in order to negotiate passively below the fulcrum significant problems to the clinician. The enhanced physical of the abrupt curvature, activated at the point of maximum properties of controlled memory files manufactured with the engagement and withdrawn from the canal (out-stroke) electrical discharge machining procedure makes it possible instead of advancing them deeper. to shape a canal with the use of a single file in 360o The next time that the same file will be inserted passively continuous movement. Most of these cases can be shaped inside the dilacerated canal engagement of the flutes will quite quickly, effectively and safely by using a single Hyflex be felt more apically. The file is activated the same way EDM file 25 (Coltene) with the TCA technique. and withdrawn from the canal. This way, engine-driven files The one EDM Hyflex file has a tip size of 25 with a 0.08 can negotiate the apical third of dilacerated canals safely taper. The taper is a constant 0.08 in the apical 4mm of the by maintaining a tactile sensation of the anatomy instruments but reduces progressively up to 0.04 in the coronal throughout the whole instrumentation procedure (Chaniotis, portion of the instrument. The file has three different Filippatos, 2015). cross-sectional areas over the entire length of the working part Challenging cases of extreme canal curvature that were (rectangular in the apical part and two different trapezoidal manag ed with TCA instrumentation technique with controlled cross sections in the middle and coronal part of the instrument) memory files can be seen in Figure 7. to increase its fracture resistance and cutting efficiency (Pedulla et al, 2015). Whenever larger apical preparations are Controlled memory file sequencing required, three finishing Hyflex EDM files of constant taper can The file sequencing during endodontic instrumentation is be used (40/04, 50/03 and 60/02). directly related to the anatomical challenge encountered. In Constricted and obliterated canals, thin and long roots, a roentgenographic investigation of frequency and degree of curved canals of more than 27o and S-shaped canals with canal curvatures in human permanent teeth, 84% of the root smaller than 5mm radius of curvature are considered canals were found curved and 17.5% of t hem presented a challenging for all instrumentation systems available second curvature and were classified as S-shaped root canals nowadays. With controlled memory files, these cases are (Schäfer et al, 2002). From all the curved canals, 75% were more effectively, safely and predictably enlarged with the soft, found to have a small curvature of less than 27 degrees, 15% ductile and fatigue resistant Hyflex CM files by following a a medium curvature ranging from 27 to 35 degrees and 10% simple standardised protocol and TCA technique. a severe curvature of more than 35 degrees. After flaring with the 25/08 Hyflex CM flaring file and Usually, patent root canals with a curvature of less than 27o glide path creation to 10/02 hand file, Hyflex CM files can

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be used with the TCA technique in a standardised simple Coltene/Whaledent (2012) Hyflex CM [brochure] protocol of 15/04-20/04-25/04-30/04 and 35/04. Elayouti A, Dima E, Judenhofer MS, Löst C, Pichler BJ (2011) Increased apical enlargement contributes to excessive dentin removal in curved root This sequence is easy to remember and can work effectively canals: a stepwise microcomputed to mography study. Journal of and safely even in the most challenging situations of root Endodontics 37: 1580-4 Estrela C, Bueno MR, Sousa-Neto MD, Pécora JD (2008) Method for canal instrumentation. determination of root curvature radius using cone-beam computed The final enlargement will be dictated by the initial tomography images. Brazilian Dental Journal 19: 114-8 anatomy of each root. For glide path creation, the EDM Jou Y-T, Karabucak B, Levin J, Liu Donald (2004) Endodontic instrumentation width: current concepts and techniques. Dental Clinics of 10/05 glide path file can also be used after flaring and North America 48: 323-335 initial canal scouting. In multi-canal teeth, easier canals can Leseberg DA, Montgomery S (1991) The effects of Canal Master, Flex- be instrumented with a single EDM file 25, and the R, and K-Flex instrumentation on root canal configuration. Journal of Endodontics 17: 59 complicated ones with the aforementioned CM file Günday M, Sazak H, Garip Y (2005) A comparative study of three sequence. In this way, safe and predictable instrumentation different root canal curvature measurement techniques and measuring the to adequate apical preparation size that respects canal canal access angle in curved canals. Journal of Endodontics 31: 796-8 Hulsmann M, Peters O, Dummer P (2005) Mechanical preparation of anatomy can be achieved. root canals: shaping goals, techniques and means. Endodontic Topics 10: 30-76 Conclusions McSpadden J (2007) Mastering endodontic instrumentation. Chattanooga, Tennessee, USA. Cloudland Institute • Controlled memory files have no shape memory effect, Nagy CD, Szabó J, Szabó J (1995) A mathematically based increased flexibility and fatigue resistance. As a result they classification of root canal curvatures on natural human teeth. Journal of move passively inside the highly curved or double curved Endodontics 21: 557-60 Peters OA (2004) Current challenges and concepts in the preparation canals guided only by the anatomy and not by the of root canal systems: A review. Journal of Endodontics 30: 559-67 restoring force of other files Plotino G, Grande N, Mazza C, Petrovic S, Gambarini G, Testarelli L (2010) Influence of size and taper of artificial canals on the trajectory of • The TCA instrumentation technique minimises the time that NiTi rotary instruments in cyclic fatigue studies. Oral Surg Oral Med Oral the files are under engagement inside challenging canals Pathol Oral Radiol Endod 109: e60-e66 and results in maintaining a continuous tactile feedback of Pirani C, Iacono F, Generali L, Sassatelli P, Nucci L, Lusvarghi M, Gandolfi G, Prati C (2015) HyFlex EDM: superficial features, the anatomy throughout the whole instrumentation metallurgical analysis and fatigue resistance of innovative electro proce dure discharge machined NiTi rotary instruments. International Endodontic • Although the TCA technique can be used with all Journal [Epub ahead of print] Pedulla E, Lo Savio F, Boninelli S, Plotino G, Grande N, La Rosa G, instrumentation systems available (rotary or reciprocation), Rapisarda E (2015) Torsional and cyclic fatigue resistance of a new controlled memory systems are the only ones where the files Nickel-Titanium Instrument Manufactured by electrical Discharge can be pre-bent for easier negotiation of challenging cases Machining. Journal of Endodontics 42(1): 156-9 Pruett JP, Clement DJ, Carnes DL Jr (1997) Cyclic fatigue testing of nickel- (abrupt curvatures, ledges and limited mouth opening titanium endodontic instruments. Journal of Endodontics 23: 77-85 patients) Roane JB, Sabala CL, Duncanson MG Jr (1985) The ‘balanced force’ • EDM files with controlled memory characteristics have concept for instrumentation of curved canals. Journal of Endodontics 11: 203-11 increased cutting efficiency and fatigue resistance. This Schäfer E, Diez C, Hoppe W, Tepel J (2002) Roentgenographic makes it feasible to use a single file instrumentation investigation of frequency and degree of canal curvatures in human protocol for approximately 75% of human root canals. permanent teeth. Journal of Endodontics 28: 211-6 Shen Y, Qian W, Abtin H, Gao Y, Haapasalo M (2011) Fatigue testing of controlled memory wire nickeltitanium rotary instruments. Journal References of Endodontics 37: 97-1001 American Association of Endodontists (2012) Glossary of Endodontic Schilder H (1974) Cleaning and shaping the root canal. Dental Clinics Terms: Eighth edition of North America 18: 269-96 Baumann MA (2004) Nickel-titanium: options and challenges. Dental Schneider SW (1971) A comparison of canal preparations in straight Clinics of North America 48: 55-67 and curved root canals. Oral Surg Oral Med Oral Pathology 32: 271- Boutsioukis C, Gogos C, Verhaagen B, Versluis M, Kastrinakis E, Van 5 der Sluis LW (2010) The effect of apical preparation size on irrigant flow Walia H, Brantley WA, Gerstein H (1988) An initial investigation of in root canals evaluated using an unsteady Computational Fluid Dynamics bending and torsional properties of nitinol root canal files. Journal of model. International Endodontic Journal 43: 874-81 Endodontics 14: 346-351 Burroughs JR1, Bergeron BE, Roberts MD, Hagan JL, Himel VT (2012) Wang GZ (2007) Effect of martensite transformation on fracture Shaping ability of three nickel-titanium endodontic file systems in simulated S- behavior of shape memory alloy NiTi in a notched specimen. International shaped root canals. Journal of Endodontics 38: 1618-21 Journal of Fracture 146: 93-104 Chaniotis A, Filippatos C (2015) Root Canal treatment of a dilacerated mandibular premolar using a novel instrumentation approach. A case Reprinted with permission by ENDODONTIC PRACTICE report. International Endodontic Journal (e-print ahead of publication) May 2016

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CLINICAL

Immediate screw-retained CAD/CAM provisionalisation with an integrated digital approach

Sepehr Zarrine1 and Jerome Vaysse2

Introduction Successful immediate implant placement associated with immediate loading remains one of the biggest clinical challenges. In addition to the placement of an implant into a tooth socket concurrently with extraction, the creation of a screw-retained CAD/CAM provisional prosthetic restoration is critical for the aesthetic outcome.

1 Dr Sepehr Zarrine, DDS, oral surgeon. Exclusive private implantology practice (Saint Die, France). Speaker ITI France. European Master in Dental Implantology. Surgery, prosthetics, bone grafts (Frankfurt/Main, Germany). University diploma in surgical maxillofacial rehabilitation (Medicine, Paris VII). [email protected] Fig. 1 surgitechstudies.com

2 Jerome Vaysse, DT, Managing Director of the Laboratoire HTD (High Tech Dental) in Toulouse, France. Member of the ITI and i nternational instructor at the Straumann Lab Academy. Dental lab specialized in CAD/CAM, implantology, esthetics, and guided surgery (CoDiagnostix) Fig. 2 Fig. 3 [email protected]

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Currently, the procedure can be achieved using a Muehlmann. The roots were decayed and fractured, with the conventional approach resulting in a high number of patient gum suffering from inflammation in 14 and 15 without appointments with time-consuming steps for the dentist. For the abscess and sinusitis. Tooth 47 underwent an eruption, and patient, the day of the immediate loading treatment remains bridge from 47 to 43 seemed to follow this new curve of a long and tiring experience from the surgery to the occlusion. This situation does not allow for sufficient interarch provisional restoration. Instead of exposing the patient to a height in order to have number 16 as an antagonist. ‘marathon’ day, the treatment could be shortened considerably To prevent an over-infection as well as for aesthetic and by fully involving the patient, the surgeon and the dental comfort-related reasons, the urgency consisted in the treatment technician and by having a predictable treatment protocol for of sector 1. The overall health condition and drug treatment the tooth extraction and the prosthetic restoration design reinforced our decision to use a non-invasive surgical (including the individual emergence profiles prior to the approach. surgery). The treatment plan was as follows: This would also lead to a better patient experience and #47 and #43: recreating sector 4 with two individual improved satisfaction. The goal of this clinical report is implant-borne restorations (Straumann Soft Tissue Level Implant therefore to introduce an innovative one-step surgical RN, Roxolid material, SLActive surface) respecting the approach for immediate screw-retained CAD/CAM oc clusion curves. provisionalisation by using the latest technological #26: root treatment with a tooth-borne restoration in the improvements in prosthetic and surgical planning software and occlusal plane. seamlessly integrating the dental technician into the #35# 36, placing of two individual implantborne development of the fully digital treatment planning and new restorations (Straumann Soft Tissue Level Implant WN, Roxolid prosthetics options. material, SLActive surface). From #13 to #16: implant-borne restoration after tooth Initial situation extraction of 13, 14 and 15 (Straumann Bone Level Implant The patient was 65 years old, female, non-smoking, with a RC, Roxolid material, SLActive surface). fragile health conditio n, and willing to get back an adequate The patient will have a reduced arch. However, the chewing capability. The patient suffered from cachexia occlusion will be balanced and provide a good masticatory following a stomach ablation, resulting in an obvious coefficient. The current situation forced us to compromise (Fig. compromised digestion that is an aggravating factor in the 2) and to place three implants in place of three teeth: canine, dental condition (Fig. 1). premolar and molar. The molars in sector 3 were missing, tooth 26 had to be The aim was to extract atraumatically the three decayed restored and the occlusion curves adjusted. Teeth 13, 14 and teeth and to perform an immediate implant placement after 15 had a mobility classification of 3 according to Lindhed an extraction with flapless surgery in conjunction with

Fig. 4 Fig. 5

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Fig. 6 Fig. 7

Fig. 8 Fig. 9

Fig. 10 Fig. 11

immediate loading enabling restoration of the other sectors. Planning In order to maximise accuracy and to reduce the number of After detailed three-dimensional diagnostics, teeth 13, 14 and steps, a fully digital approach using guided surgery was 15 were virtually extracted in the implant planning software selected, allowing us to preoperatively produce a (coDiagnostiX, Dentalwings). The prosthetic design was screw-retained CAD/CAM provisional restoration. created with Straumann CARES Visual (Fig. 3).

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Fig. 12 Fig. 13

Fig. 14 Fig. 15

The prosthetic project was shared with the implant planning (Dreve Dentamid, Germany, Fig. 11) and finally sealed then software using the integrated online platform Synergy sent to the dental practice with the jaw model and the surgical (Dentalwings). The threedimensional radiographic DICOM guides. data and the prosthetic design project STL file were matched in coDiagnostiX. The integrated platform allows for real-time Surgery collaboration between the dentist and dental technician for On the day of surgery (Figs. 12 & 13), the surgical protocol finalising the treatment planning from both implant placement provided by the implant planning software guides the clinician and restorative design (Fig. 4). through the surgical procedure and supports him in the use of The surgical guide was designed with coDiagnostiX (Fig. the appropriate instruments from the guided surgery surgical 5) and produced using threedimensional printing technology kit (drill heights, drill handles, etc, Figs. 14 & 15). (Objet Eden260VS Dental Advantage (Stratasys, Minnesota, To avoid deformation of soft tissue s that could influence the Fig. 6). The surgical guide was teeth- and mucosa-supported stability of the surgical guide, we performed regional on the palate. To avoid lateral movement, fixation screws were anesthesia: added (Straumann Bone Block Fixation). An individualised Vestibular: high tuberosity anaesthesia for the alveolar nerve twopiece splinted three-unit bridge was virtually designed (Fig. supra-posterior, and high canine anaesthesia that reaches the 7) and CAD/CAMfabricated from a PMMA-based restoration supra-anterior alveolar branch of the maxillary nerve. material cemented to a pre-fabricated bonding base Palatal: analgesia of the nasopalatal nerve in the (Straumann Variobase for bar and bridges + Polycon ae, retro-incisive area and the large palatal nerve in the area of Straumann CARES X-Stream, Figs. 8–10). The bridge design the large palatal fora.men and the occlusion were checked on a printed jaw model The crowns were removed; the root of tooth #13 was cut

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Fig. 16 Fig. 17

Fig. 18 Fig. 19

and removed in fragments. The avulsions were created using guiding transfer pieces that ensured the final positioning delicately; the alveoli were curetted and debrided under (depth and angle). irrigation. Papillae were detached to allow for the The implants were stabilised with a torque of 50 Ncm (Fig. regularisation of the bone crest by removing bone that was 17). After removal of the surgical guide, the bone chips too thin, anticipating the post-extraction resorption. ha rvested during the drilling sequences were used to shape The surgical guide was placed and the position was the crest and to fill the gaps. Interdental papillae were secured using 14 mm fixation screws in the maxilla at region repositioned buccally by rotation. 17 (Fig. 16). The drilling sequences were performed through A conjunctive tissue graft was partially dissected from the the guide. To avoid bone overheating, high irri - gation was palate while remaining pedicle in order to recreate the performed using the up and down drilling technique. Tapping interdental papillae. Sutures helped to stabilise the and profile drilling were essential despite the maxillary soft gingivoplasty (Fig. 18). The screw-retained two-piece bone. This is critical in order to follow all the steps necessary CAD/CAM bridge was finalised before surgery and for correct implant positioning according to the planning. In immediately placed and screwed onto the three implants (Figs. order to maximise the precision in th e implant placement, we 19–20). Slight tension was detected during the screwing, but chose shorter implants than usual. This allowed us to achieve with no consequences for the implants since they were not yet a quicker implant positioning through the surgical guide by osseointegrated and the mechanical stress was too low. The

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Fig. 20

Fig. 21 Fig. 22

only change to the temporary bridge consisted in slightly Results adapting the under-occlusion. Immediate implant placement associated with immediate Additionally, the SLActive surface stimulates the adsorption loading is a predictable protocol with some variables. The of blood proteins and enhances the fibrin network formation, digital tooth extraction was integrated with the production of which allows for the faster maturation of the bone. This is a a screwretained CAD/CAM provisional restoration prior to major asset in immediate implant placement after tooth the surgery and was successfully achieved and placed without extraction and in immediate aesthetics. Checkups at 10 days any cementing steps in the dental practice. The entire post -op (Fig. 21) and at four weeks (Fig. 22) were used to treatment workflow was done fully digitally. Only a single verify correct gingival healing and implant integration. The surgical step was required to provide an entire individualised postoperative courses were not painful and no oedema or prosthetic rehabilitation. haematoma was observed. Reprinted with permission by CAD/CAM 1_2016

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CASE REPORT

Esthetics in the anterior maxilla: a team-oriented approach

Sofie Velghe1, Aryan Eghbali2

Multidisciplinary collaboration plays a significant part in achieving predictable treatment results. This article raises awareness of the importance of accurate case analysis and preoperative planning.

This case report describes the reconstruction of two lost central incisors in the anterior maxilla. After tooth 11 was extracted, measures for preserving the alveolar ridge were performed. After eight weeks, an implant was placed and a screw-retained temporary bridge was fabricated. Prior to inserting the temporary bridge, tooth 21 was extracted and immediately replaced by an implant.

Introduction The impen ding loss of a tooth in the esthetic zone can be a distressing experience for the patient.1 As the success rates and predictability of dental implants have improved over the years, implant-based treatments are gaining in popularity.2,3 Osseointegration is no longer the only criterion for successful implant therapy; the esthetic outcome of the implant reconstruction is also important. An esthetic imp lant restoration may be defined as a restoration that is in harmony with the perioral facial structures.

The esthetic peri-implant tissues should be in harmony with the healthy surrounding dentition in terms of height, volume, shade and contours. The restoration should imitate the life-like appearance of the missing tooth in terms of shade, shape, structure and size as well as the optical properties.4 In a multidisciplinary team approach, several treatment modalities such as minimal invasive methods, ridge preservation protocols, connective tissue grafting, provisionalization and plastic-esthetic periodontal surgery should be considered. In addition, a thorough analysis, e.g. with the Digital Smile Design, is crucial.5

Case report A few years ago, both central incisors of this young male patient were restored with metal-ceramic crowns. From today’s perspective, the restoration must be categorized as an esthetic failure (Fig. 1). Both teeth showed significant amounts of gingival recession, visible crown margins and a loss of harmony between the gingival architecture and the restoration. The treatment plan was to replace the two central incisors by two implants with screw- retained monolithic lithium disilicate crowns. To create a harmonious esthetic appearance, the two lateral incisors would be built up 1 Sofie Velghe with composite material. Policlinic Tandheelkunde Veemarkt 16 Surgical phase 8500 Kortrijk The initial assessment Belgium resulted in a treatment plan [email protected] where both incisors were to be replaced by implants 2 Aryan Eghbali (NobelActive, Nobel Tandheelkundige Kliniek Biocare). In order to Vrije Universiteit Brussel maintain the central papilla Laarbeeklaan 103 between the incisors, a 1090 Brussels (Jette) gradual extraction of the two Figure 1: Disharmonious transition between the gingival Belgium teeth was performed, margin and the PFM crown. The “collapse” of the emergence [email protected] starting with tooth 11. A few profile at site 11 is clearly visible.

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CASE REPORT

Figure 2: Eight weeks after extraction of tooth 11: convex Figure 3: After insertion of the implant at site 11. Ten weeks later, contour of the alveolar ridge and preservation of the soft tissue. an impression was taken and a temporary bridge with an extension for site 21 was fabricated.

Figure 4: The second implant was placed immediately after Figure 5: The temporary bridge with the extension for site 21 extraction of tooth 21. was screwed to implant 11. After two months, the buccal contour at the site of 21 was corrected with a connective tissue graft.

weeks later, tooth 21 was extracted, followed by immediate impression coping respectively (Figs 6a and b). The resulting implant placement. A temporary bridge with an extension as plaster model was modified by grinding at site 21. Then, a tooth 21 was fabricated in order to contour the soft tissue. silicone impression material was used to record the Figures 2 to 5 show the surgical phase aimed at preserving emergence profile of pontic 21 of the temporary bridge (Figs the soft tissues. 7a to c). This information was transferred to a standard impression coping, which resulted in an individualized Prosthetic phase impression at implant site 21 (Figs 8a and b). Preserving the soft tissue plays an important part in the success At the next step, the situation was assessed using a DSD of the treatment. Transmitting these data to the dental analysis (Figs 9a and b). The evaluation revealed a technician pr esents a challenge.6 To replicate the soft tissue disproportionate distribution of volume between the central architecture, a standard impression coping on implant 11 was and lateral incisors. The lateral incisors were too narrow individualized. Then, an impression was taken of the implants compared with the wide and square shape of the central at site 11 and 21 using an individualized and standard incisors. In order to enhance the harmony, the volume should

6a 6b 7a

Figure 6a and b: Fabrication of the individualized impression Figure 7a to c: Impressions of the implants at site 11 and 21 with coping for the implant at site 11. The emergence profile of the an individualized and standard impression coping and the model temporary should be transferred to the final restoration. This fabricated on the basis of these impressions. procedure prevents the emergence profile from “collapsing” during impression taking.

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VELGHE / EGHBAL

8a 8b

Figure 8a and b: Implant model. The basal region at site 21 was modified by grinding and the emergence profile of the pontic at site 21 of the temporary bridge was recorded using silicone.

9a 9b

Figure 9a and b: Analysis and planning using the Digital Smile Design method. Compared with the lateral incisors, the central incisors were too wide. The entire volume should be distributed across the four anterior teeth.

be distributed across the four incisors. New screw-retained (Bluephase® Style). First, the palatal “enamel shell” was build temporaries were fabricated. Prior to this, a wax model was up using IPS Empress Direct Enamel in shade A2 and a palatal adapted and tested intra-orally to visualize the outcome. silicone key created from the mock-up. Dentin A3 was used for A silicone key was created to first build up the lateral the dentin core and the mamelons. A natural looking result was incisors with a temporary composite material.7 With the achieved due to the translucent incisal effect created between temporary crowns and the composite mock-up of the lateral the mamelons with the help of IPS Empress Direct Trans Opal. incisors, the shape of the wax-up could be transferred. This After that, the build-up was covered with a layer of IPS Empress “blueprint” served to evaluate the “new smile” intra-orally prior Direct Enamel A2. The morphological structures were contoured to fabricating the permanent restorations. Shade selection was and accentuated using fine diamond grinders, Arkansas stones, performed with the help of cross-polarized light. Unwanted green grinders and polishing discs. Silicone polishers and reflections were effectively eliminated with a polar eye filter. diamond paste were used for polishing. To fabricate the final prosthetic restorations, the temporaries The outcome was a harmonious appearance of the anterior were duplicated and 1:1 copies were made using IPS e.max® maxillary front in terms of shape, shade and size (Figs 11a and b). Press (monolithic lithium disil icate). Screw-retained IPS e.max Press crowns were placed on the Discussion implants and the screw openings were filled with Teflon (PTFE) Although the presence of the papilla may not be the key issue and covered with composite. Once the restorations were following single implant treatment,8-10 preserving the papilla placed, the lateral incisors were built up with IPS Empress® between two implants remains a challenge. The decision in Direct composite. A palatal matrix made of silicone putty was this case was to extract the two teeth in stages and use used as an auxiliary. The shade match of the chosen temporary restorations to preserve the papilla. In addition, composite and the IPS e.max ceramic was deemed ideal. A connective tissue grafts carried out at various points in time rubber dam was used for isolation (OptraDam® Plus). ensured ideal soft tissue contours. Although only a few A composite stratification technique was used to build up the references regarding the stability of connective tissue grafts incisors (Fig. 10). The enamel was slightly roughened, etched can be found in the literature, recent studies have shown (37% phosphoric acid, 15 seconds, total etch) and then coated promising results.11 with a light-curing adhesive (Adhese® Universal). The adhesive Since the aim is to establish a harmonious balance between was scrubbed into the bonding surface and then light-cured the teeth and ensure appropriate white esthetics, preoperative

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VELGHE / EGHBAL

Figure 10: Individual stages in the intraoral fabrication of the composite build-14 ups on the lateral incisors.

11a 11b

Figure 11a and b: Result: Shade, shape and size of the anterior teeth create a harmonious appearance.

planning and a detailed case analysis are advisable.12 part. Here, photo- and video-based evaluations present It is also important to think carefully about which materials to powerful instruments. use. In contrast to zirconium oxide and titanium, monolithic lithium All prosthetic procedures were conducted by Sofie Velghe, a disilicate restorations do not stimulate a subgingival attachment prosthodontist, and all restorations were fabricated by Stephan to the soft tissue.13 Therefore, a hybrid abutment consisting of van der Made, a dental technician. zirconium oxide or titanium could present an alternative. The authors thank the dental lab Kwalident and especially Conclusion Stephan van der Made for their contribution. A multidisciplinary team approach is mandatory to achieve a Literature available from the editors on request predictable treatment outcome. Besides that, a detailed analysis and preoperative planning procedure play a crucial Reprinted with permission by Reflect 1_2016

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CPD QUESTIONNAIRE 6.3.1

Article: Planning for esthetics - Part II: Adjacent implant Article: How effective are different ridge augmentation strategies restorations. Martin et al. page 18 at resolving horizontal alveolar ridge deficiencies prior to (staged 1. “High risk” factors which can influence esthetic outcomes include: approach), or simultaneous with dental implant placement? a Gingival biotype Hartshorne, page 30 b Restorative status of neighboring teeth c Soft tissue and bone anatomy 6. In lateral ridge augmentation procedures using the staged approach, d All of the above which combination provides the best outcomes: e None of the above a The combination of bone replacement grafts and barrier membranes b The combination of bone blocks, particulate grafts, and barrier membranes

2. According to the author, in the case of the bone-level implant design, 7. Increased morbidity and postoperative complications were observed it is critical to place the implant shoulder: with: a At a minimum of 4mm apical to the planned mucosal margin a. Bone blocks combined with particulate graft material b At a minimum of 2mm apical to the planned mucosal margin b. Bone blocks combined bio absorbable membranes c At a minimum of 3mm apical to the planned mucosal margin 8. Ridge augmentation procedures should always follow a prosthetically 3. The ITI Esthetic Risk Analysis rates as moderate the Level of Risk of the driven treatment plan to allow placement of the implant in the correct width of edentulous span as: 3D position a 1 tooth (≤ 7mm) a True b 1 tooth (≥ 7mm) b False c 2 teeth or more 9. Participants in the trials had to be: 4. Determine of the facial-palatal dimension of the bone site is done by: a >18 years a Examination of the soft tissue b <18 years b Examination of the hard tissue c Neither of the above 10. Which statement is correct: Early detection of the above syndrome can include: 5. If developed papillae are to be viable in the long term, the provisional a The simultaneous approach can be recommended in situations with small restorations (and subsequent definitive restorations) should provide or single tooth or self-containing bone defects (dehiscence or fenestration proximal contacts which extend to within: defects) a 3-5mm of the inter-implant bone and remaining bone crests b The staged approach can be recommended in situations with small or b 2-4mm of the inter-implant bone and remaining bone crests single tooth or self-containing bone defects (dehiscence or fenestration c 5–6mm of the inter-implant bone and remaining bone crests defects) ID-AE MayJune 2016_65-80_Layout 1 2016/05/25 10:54 AM Page 11 ID-AE MayJune 2016_65-80_Layout 1 2016/05/25 10:54 AM Page 12

CPD QUESTIONNAIRE 6.3.2

Article: Tactile controlled activation technique with controlled Article: Esthetics in the anterior maxilla: a team-oriented memory files. Chaniotis, page 50 approach. Velghe, Eghbali, page 68

11. Which of the following comments is incorrect: 16. According to the authors, osseointegration is no longer the only a The restoring force of an instrument is able to return to its original linear criterion for successful implant therapy: shape a True b The restoring force of an instrument is directly related to its size and taper b False c The restoring force of an instrument becomes smaller as its mass increases 17. Which is correct: The restoration should imitate the life-like 12. What are the best ways to avoid canal transportation: appearance of the missing tooth in terms of: a. Increase the size of the apical preparation a Shade b Decrease coronal flare b Shape, size amd structure c Increase coronal flare and size of apical preparation c Optical properties d None of the above d All of the above 13. Which of the following comments is incorrect: a The austenitic finish transformation temperature of controlled memory 18. What disproportionate distribution of volume between the central files is above body temperature and lateral incisors was revealed using a DSD analysis: b Controlled memory files exist in the martensitic phase rather than the a The lateral incisors were too wide compared with the w ide and autenistic phase square shape of the central incisors. c Controlled memory files exhibit no shape memory b The lateral incisors were too narrow compared with the wide and d None of the above square shape of the central incisors.

14. Tactile controlled activation (TCA) involves which of the following 19. In the case described, preserving the papilla was achieved by: techniques: a Extracting the two teeth in stages a Allowing the motorised file to engage the walls of the canal b Using temporary restorations b The file is inserted passively inside the canal until maximum frictional c Neither of the above resistance d Both of the above c Maximising file engagement before motorising the file d All of the above 20. In contrast to zirconium oxide and titanium, monolithic lithium 15. Which statement is correct: disilicate restorations do not stimulate a subgingival attachment to a EDM files with controlled memory characteristics have decreased the soft tissue: cutting efficiency and fatigue resistance a. True b EDM files with controlled memory characteristics have increased b. False cutting efficiency and fatigue resistance ID-AE MayJune 2016_65-80_Layout 1 2016/05/25 10:54 AM Page 13

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TOLLFREE 0800 111 796 www.dentalwarehouse.co.za visual visual r 3 NO. 6 VOL. IN THIS ISSUE augmentation augmentation strategies at resolving horizontal alveolar ridge deficiencies prior to (staged approach), or simultaneous with dental implant placement? Bastian Wagne How How effective are different ridge adjacent adjacent implant restorations Johan Hartshorne Dean Dean Morton Planning for esthetics – Part II: See, recognize, realize: controlled activation technique Tactile with controlled memory files Immediate screw-retained CAD/CAM provisionalisation with an integrated digital approach Esthetics in the anterior maxilla: shade shade analysis and its realization into a ceramic crown Antonis Chaniotis Sepehr Sepehr Zarrine and Jerome Vaysse and Sofie AryanVelghe Eghbali a team-oriented approach Julian Julian Webber Shaping canals with confidence: GOLD single-file WaveOne reciprocating system William C Martin, Emma Lewis,