The first issue of the Balkan Journal of Dental Medicine was published in 2014 The Journal continues the tradition of the Balkan Journal of Stomatology which was published between 1997 and 2013 Publisher: DE GRUYTER OPEN
Editor-in-Chief Prof. Dejan Marković, DDS, PhD, School of Dental Medicine, University of Belgrade, Serbia [email protected] Associate Editors Prof. Ruzhdie Qafmolla, DDS, PhD, Faculty of Dentistry, University of Medicine-Tirana, Albania [email protected] Prof. Maida Ganibegović, DDS, PhD, Faculty of Dentistry, University of Sarajevo, Bosnia and Herzegovina [email protected] Assoc. Prof. Nikolai Sharkov, DDS, PhD, Faculty of Dental Medicine, Medical University, Sofia, Bulgaria [email protected] Assoc. Prof. George Pantelas, DDS, PhD, The School of Medicine, European University Cyprus, Cyprus [email protected] Prof. Ana Minovska, DDS, PhD, Department of Dentistry, Goce Delcev University of Štip, FYR of Macedonia [email protected] Prof. Anastasios Markopoulos, DDS, PhD, School of Dentistry, Aristotle University, Greece [email protected] Assoc. Prof. Mirjana Đuričković, Faculty of Medicine, University of Montenegro, Montenegro [email protected] Prof. Forna Norina Consuela, DDS, PhD, Faculty of Dentistry, Grigore T. Popa U. M. Ph. Iasi, Romania [email protected] Prof. Slavoljub Živković, DDS, PhD, School of Dental Medicine, University of Belgrade, Serbia [email protected] Prof. Ender Kazazoglu, DDS, PhD, Dental School, University of Yeditepe, Turkey [email protected] Editorial Board Assoc. Prof. Dorjan Hysi, DDS, PhD, Faculty of Dentistry, University of Medicine-Tirana, Albania Prof. Virgjini Mulo, DDS, PhD, Faculty of Dentistry, University of Medicine-Tirana, Albania Assoc. Prof. Naida Hadžiabdić, DDS, PhD, Faculty of Dentistry, University of Sarajevo, Bosnia and Herzegovina Dr. Mihael Stanojević, DDS, MSc, Medical Faculty Foca, Bosnia and Herzegovina Prof. Andon Filtchev, DDS, PhD, Faculty of Dental Medicine, Medical University, Bulgaria Prof. Georgi Todorov, DDS, PhD, Faculty of Dental Medicine, Medical University, Bulgaria Dr. Huseyn Biçak, DDS, General Hospital Nicosia, Cyprus Dr. Aikaterine Kostea, DDS, General Hospital Nicosia, Cyprus Assoc. Prof. Ilijana Muratovska, DDS, PhD, Department of Dentistry, Goce Delcev UN of Štip, FYR of Macedonia Assoc. Prof. Vera R. Nikolovska, DDS, PhD, Department of Dentistry, Goce Delcev UN of Štip, FYR of Macedonia Prof. Lambros Zouloumis, DDS, PhD, School of Dentistry, Aristotle University, Greece Prof. Athanasios Poulopoulos, DDS, PhD, School of Dentistry, Aristotle University, Greece Assoc. Prof. Zoran Vlahović, DDS, PhD, Faculty of Medicine, University of Priština, Montenegro Prof. Andrei Iliescu, DDS, PhD, Faculty of Dentistry, Grigore T. Popa U. M. Ph. Iasi, Romania Assoc. Prof. Paula Perlea, DDS, PhD, Faculty of Dentistry, Carol Davila University of Medicine and Pharmacy, Romania Assoc. Prof. Tamara Perić, DDS, PhD, School of Dental Medicine, University of Belgrade, Serbia Dr. Slobodan Anđelković, DDS, Private Dental Practice- Belgrade, Serbia Prof. Gül Işik Özkol, DDS, PhD, Istanbul University, Turkey Assoc. Prof. Zeynep Ozkurt Kayahan, DDS, PhD, Dental School, University of Yeditepe, Turkey Balk J Dent Med, Vol 21, 2017
International Editorial Board Prof. Nitzan Bichacho, DDS, PhD, The Hebrew University, Hadassah School of Dental Medicine, Israel Dr. Borko Čudović, DDS, Angle Society of Europe, Germany Prof. George Freedman, DDS, PhD, BPP University School of Health, Faculty of Dentistry, United Kingdom Assoc. Prof. Alex Grumezescu, PhD, Polytechnic University of Bucharest, Romania Prof. James Gutmann, DDS, PhD, Texas A&M University Baylor College of Dentistry, USA Prof. Christoph Hämmerle, DDS, PhD, Center of Dental Medicine, University of Zurich, Germany Dr. Chris Ivanoff, College of Dentistry, University of Tennessee Health Science Center, USA Dr. Barrie Kenney, DDS, Private practice- Los Angeles, USA Dr. Predrag Charles Lekic, DDS, PhD, University of Manitoba, Canada Prof. Joshua Moshonov, DDS, PhD, Hadassah School of Dental Medicine, Israel John Nicholson, PhD, DSc, Bluefield Centre for Biomaterials, United Kingdom Prof. Kyösti Oikarinen, DDS, PhD, University of Oulu, Finland Assoc. Prof. Sangwon Park, DDS, PhD, Chonnam National University, South Korea Prof. George Sandor, PhD, University of British Columbia, Canada Prof. Ario Santini, DDS, PhD, Faculty of General Dental Practice, United Kingdom Prof. Riitta Suuronen, DDS, PhD, Institute for Regenerative Medicine, University of Tampere, Finland Dr. Michael Weinlaender, DDS, Private Practice- Vienna, Austria Publications Committee Chair Prof. Ljubomir Todorović, DDS, PhD, Academy of Medical Sciences, Serbian Medical Society, Serbia [email protected] Editorial Medical Staff Assoc. Prof. Elizabeta Gjorgievska, DDS, PhD, Faculty of Dentistry, Ss. Cyril and Methodius UN, FYR of Macedonia Prof. Bojan Petrović, DDS, PhD, Faculty of Medicine, University of Novi Sad, Serbia Dr. Marijan Denkovski, DDS, FYR of Macedonia Dr. Georgios Tsiogas, DDS, Greece Dr. Ana Jotić, DDS, Private Dental Practice, Belgrade, Serbia Dr. Raša Mladenović, DDS, Faculty of Medicine, University of Priština, Serbia Translations supervisor Gordana Todorović Technical Editing Dr. Milica Cindrić, DDS Publishing Managers Jelena Jaćimović, PhD, School of Dental Medicine, University of Belgrade, Serbia [email protected] Res. Asst. Bojana Ćetenović, DDS, PhD, Institute for Nuclear Sciences „Vinca“ [email protected] Assis. Ana Vuković, DDS, PhD, School of Dental Medicine, University of Belgrade, Serbia [email protected] Statistical Advisor Prof. Biljana Miličić, MD, PhD, School of Dental Medicine, University of Belgrade, Serbia [email protected] Editorial Office: School of Dental Medicine, Clinic for Paediatric and Preventive Dentistry, Dr. Subotića 11, 11000 Belgrade, Serbia e-mail: [email protected], Tel: +381641149773, Fax: +381112685361 Papers published in the Balkan Journal of Dental Medicine are indexed in: Baidu Scholar, Case, Celdes, CNKI Scholar (China National Knowledge Infrastructure), CNPIEC, EBSCO Discovery Service, Google Scholar, J-Gate, JournalTOCs, KESLI-NDSL (Korean National Discovery for Science Leaders), Naviga (Softweco), Primo Central (ExLibris), ReadCube, Sherpa/RoMEO, Summon (Serials Solutions/ProQuest), TDOne (TDNet), WorldCat (OCLC).
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VOLUME 22 NUMBER 2 JULY 2018 PAGES 57-114
Contents
RP A. Theocharidou Adhesion to Enamel of Teeth Affected by 57 K. Arapostathis Molar Incisor Hypomineralization: Literature Review RP S. Sarafopoulou Enamel Defects During Orthodontic Treatment 64 A.A. Zafeiriadis A.I. Tsolakis
OP G. Chatzopoulos The Change of Patient Profile, Attitudes and Satisfaction in 74 M. Tsitsara University Dental Clinic after Onset of Economic Crisis in Greece K. Tzimas L. Tsalikis
OP O. Dimitrovski The Levels of Serum Immunoglobulin A, G and M in 81 V. Spirov Oral Inflammatory Cysts before and after Surgical Therapy B. Dastevski F. Koneski
OP S.E. Eryürük Comparison of Visual and Digital Color Measurement Methods on 87 C. Hekimoğlu Anterior Natural Teeth E.T. Akçin Y. Çavuşoğlu
OP E. Kongo Treatment of Maxillary Retrusion-Face Mask with or without RPE? 93
OP E. Anitua Biological Drilling: Implant Site Preparation in a 98 Conservative Manner and Obtaining Autogenous Bone Grafts
CR P. Tritsaroli A Case of Dental Fusion in Primary Dentition from 102 Late Bronze Age Greece
CR M.M. Açikgöz Primary Tuberculous Lymphadenitis: a Rare Case Report 106 A. Yurtseven G. Ak
CR F.F. Küçükekenci Management of Dens Invaginatus in a Maxillar Lateral Incisor with 111 A.S. Küçükekenci Open Apex and Persistent Sinus Tract: a Case Report
10.2478/bjdm-2018-0011
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Adhesion to Enamel of Teeth Affected by Molar Incisor Hypomineralization: Literature Review
SUMMARY Apostolina Theocharidou, Konstantinos Background/Aim: Molar incisor hypomineralization (MIH) is a Arapostathis qualitative defect of systemic origin, affecting permanent first molars and Department of Paediatric Dentistry, Aristotle often permanent incisors. The treatment modalities can include, amongst University of Thessaloniki, Greece others, fissure sealants for prevention of dental caries and composite restorations. Both require adhesion to tooth structure. The aim of this study was to review the literature on the adhesion to enamel affected by MIH. Material and Methods: A search of PupMed/Medline, ResearchGate and Google Scholar was performed and limited between 2003, when the judgement criteria for MIH were set, and 2016. Thirty-three papers were considered relevant to the subject including five in vivo and six in vitro studies. Studies involving less than ten teeth were excluded. Results: A four- year clinical trial showed that the application of a total-etch 2-step adhesive system prior to sealant placement is superior to the etch-seal technique. Despite the high success rate of composite restorations shown in three clinical longitudinal studies, there are conflicting results over self-etch being superior to total etch adhesive systems. Pretreating the enamel surface, prior to the adhesive system, with fluoride preventive solutions could reduce the mikroleakage under orthodontic brackets. Three in vitro studies provide inconsistent data about NaOCl pretreating potentials to improve adhesion of composite restorations. Resin infiltration, prior to resin restorations, could improve the microhardness of defected enamel, which may lead to increased bond strength, especially in combination with NaOCl pretreatment. Conclusions: Adhesion to enamel affected by molar incisor hypomeralization is inferior compared to normal enamel. Sealants applied with the etch-bond- seal technique have greater retention than with the etch-seal technique. Further research is required to provide evidence of the effectiveness of the adhesive system and pretreatment to achieve optimal bonding to MIH. Key words: Molar Incisor Hypomineralization, Adhesion, Etching, Bonding, Treatment, REVIEW PAPER (RP) Management Balk J Dent Med, 2018;57-63
Introduction set at the same conference3. The clinical appearance includes demarcated opacities, varying in color from Molar incisor hypomineralization is defined as white to yellow or brown4. These opacities are located on a dental defect of systemic origin, that affects 1 to 4 the occlusal and buccal surface of the tooth and ranging permanent first molars, and frequently is associated in size4, while the thickness of the enamel is normal. In with permanent incisors1. Many terms have been used severe cases, post eruptive breakdown of the enamel can in the past, such as “cheese molars” and “idiopathic occur due to masticatory forces4. These teeth are more hypomineralization of the enamel of the first molars” prone to caries, more sensitive to external stimuli and 2. The term of MIH was agreed in 2003 at the annual therefore may be more difficult to anaesthetize4. The conference of European Academy of Paediatric Dentistry etiology is yet unknown, but has been associated with in Athens3. The judgement criteria for MIH were also different hypotheses including genetics, medical problems 58 Apostolina Theocharidou, Konstantinos Arapostathis Balk J Dent Med, Vol 22, 2018 during pregnancy and postnatal medical problems4. The a higher carbonate content13, decreased mineral content prevalence has a wide variation from 2.4 to 40.2% all and increased amounts of proteins14. The amount and over the world and been reported to be increasing5. The the quality of the protein content depend on the severity treatment approaches are prevention of dental caries and of the defect. This high protein content contributes to enamel breakdown, restoration or extraction, depending lower mechanical properties in comparison with normal on the severity of the defect, the dental age of the patient, enamel15. It was shown in one study that the hardness the social background and expectations of the child and and the modulous of elasticity were reduced by 80%15. 4 their parents . Prevention can include fissure sealants and MIH enamel also presents greater porosity and lower restoration can include composite fillings. Both require mechanical resistance16. These structural weaknesses adhesion to tooth structure. Bonding of orthodontic could explain the post eruption breakdown17 and the brackets also requires adhesion. In 1955, etching the greater dental abrasion18, leaving the enamel rough and enamel with an acid was proposed in order to improve more susceptible to caries5. adhesion6. There are three etching patterns in the enamel, The aim of this paper is to review the literature known as Type I, II and III. In type I there is dissolution concerning the adhesion to enamel affected by MIH. of the prisms core, whereas in type II the periphery of the prisms is dissolved7. In type III deep etching is not achieved and only the crystals around the prisms are partially removed7. Type I and type II are considered to be effective etching patterns that can provide adequate Material and Methods adhesion, whereas type III is thought to be undesirable pattern7. Acid etching enamel, affected by MIH, may A search of Pubmed/Medline, ReasearchGate and produce a surface matching a type III pattern7. Google Scholar was performed and limited between Understanding the formation of the MIH enamel 2003, when the judgement criteria for MIH were set, and and its characteristics gives valuable information about December 2016. The used keywords were ‘molar incisor the structure available for bonding. The enamel is formed hypomineralization’, ‘adhesion’, ‘etching’, ‘bonding’ and ‘treatment management’. The number of papers through a process called amelogenesis and occurs in identified were 503, including duplicates. After assessing two phases, secretion and maturation8. In the first phase, their abstracts, studies involving less than ten teeth and ameloblasts deposit the organic matrix of the enamel in in language other than English were excluded. Finally, layers, which are going to form the full thickness of the thirty-three papers were included (5 clinical trials, 6 in future enamel8. In the second phase ions are transported 8 vitro studies, 3 systematic reviews and 1 policy document by the ameloblasts to mineralize the enamel . Any and 18 literature reviews) and their full text was then 9 alterations in this stage will affect its quality . MIH is a read. Only two papers, the review by Mathu-Muju and qualitative defect of the enamel. Therefore, an alteration Wright19 and the review by Sapir, were not assessed full has occurred in the maturation phase, affecting the text, as their content was not available even after emailing 10 ameloblasts . MIH affected enamel is histologically the authors. The reference list of each of these papers was presented with less distinct prism sheaths compared to also assessed to eliminate the exclusion of any additional normal enamel11. The crystals are disorganized11, loosely relevant paper. Table 1. shows the list of the five clinical packed12 with enlarged interprismatic space. There is also trials. Table 2. shows the list of the six in vitro studies. Table 1. Clinical trials Title, Authors Methods Results • prospective study • 52 molar teeth • 100% success of composite restorations Lygidakis et al. 200320 • evaluation after 7 days, 12, 24, 36, 48 months after 4 years • according to Ryge criteria • retrospective study • 85.3% success of composite restorations Mejáre et al. 200521 • 76 individuals with MIH after a mean period of 5 years • Ryge criteria • high need for retreatment • evaluation after a mean period of 5 years • retrospective study • 74,4% success of composite restorations • 72 children ( 36 MIH, 36 normal enamel) Kotsanos et al. 200522 after a mean period of 4.5 years • Ryge criteria • high need for retreatment • evaluation after a mean period of 4.5 years • prospective study • significantly greater retention when • 54 children with at least 2 contra-lateral FPMs with MIH Lygidakis et al. 200923 applying total-etch 2-step adhesive • 4 years split mouth study system prior to sealant • criteria: sealed- partly sealed- unsealed • prospective study de Souza et al. 201624 • 41teeth-2 groups (self-etch and total-etch) there was no significant difference between • USPHS criteria total etch and self-etch adhesive systems • evaluation after 1,6, 12 and 18 months Balk J Dent Med, Vol 22, 2018 Molar Incisor Hypomineralization 59
Table 2. In vitro studies
Title, Authors Methods Results • 55 teeth were tested for microshear bond strength • inferior bonding to MIH affected enamel (44 specimens of control enamel and 45 of compared to normal hypomineralized enamel)- Instron testing machine William et al. 200625 • no significant difference between total • 5 teeth(8 specimens control enamel and 8 etch and self-etch systems for MIH hypomineralized) under SEM to study etching affected enamel patterns, 3M and Kuraray used • 31 teeth organized in three groups ( control: etch • no difference between etch-seal and and sealant, group 1: 5% NaOCl-etch-seal, group Gandhi et al. 201226 bleach-etch-seal technique for MIH 2: 5% NaOCl-seal) affected enamel • studied under SEM • 75 teeth, 5 groups • self etching primer significantly increased (1:control, 2: demineralized/control with acid etching, microleakage at the adhesive bracket 3: 5% NaOCl for 1 min after acid etching, 4: self-etch interface Moosavi et al. 201327 primer, 5: 2% NaF for 4 min before acid etching • 2% NaF gel for 4min significantly • cariogenic solution used reduced microleakage at the enamel • microleakage was tested under stereomicroscope adhesive interface • 21 teeth, 3 groups • failure of NaOCl to produce significantly • (1: HCl etch-ethanol-infiltrant resin, 2: 0.95% improved results NaOCl – Icon, 3: HCl etch-0.95% NaOCl- Crombie et al. 201428 • caries infiltrant materials can penetrate ethanol- resin) and increase the hardness of MIH • Vickers microhardness test enamel, but unpredictably • SEM • 105 specimens-5 groups (1: normal, 2: hypomineralized, 3: hypomineralized pretreated • pretreatment with 5,25% NaOCl with Icon, 4: hypomineralized pretreated with significantly increased the mean Chay et al. 201429 5.25% NaOCl and Icon, 5: hypomineralized microshear bond strength values of pretreated with 5.25% NaOCl composite restorations • SEM • MSBS testing (Mecmesin testing machine) • 100 teeth-5 groups (1: 30 sec acid etch, 2: 120 sec acid etch, 3: laser-acid • self-etch primers produced significantly etch, 4: self etch primer, 5: APF- acid etch) Shahabi et al. 201430 lower shear bond strength at the enamel- • cariogenic solution adhesive interface • SBS test (Instron universal testing machine) • stereomicroscope
Results whole structure, allowing crack propagation25. The group treated with self-etching primer showed uneven preferential A) Etching and pretreatment dissolution of the peripheral inter-rod areas, producing a deeper pattern than in control enamel. It appeared that There is only one in vitro study about etching. An etching affects more the porous hypomineralized enamel in vitro study by William et al. has evaluated the etching and may expose its high organic part. pattern, produced by the application of 35% phosphoric There are four in vitro studies assessing the treatment acid etch and self-etching primer. The enamel of 16 outcome of NaOCl, when applied prior to the adhesive specimens, including control and hypomineralized, was system, to improve adhesion of composite restorations. sectioned perpendicular and parallel to the enamel rods, One of them uses artificially demineralized enamel and, etched and then examined under Scanning Electron therefore, it is not going to be taken into consideration Microscope (SEM). The perpendicular sectioned group at this point. The first study in 2012 by Gandhi et al. showed preferential dissolution of rod peripheries for investigates the tag formation between the conventional phosphoric acid, but not in a uniform way as in control technique of ‘etch and seal’ and the incorporation of 2.5% group25. There was loss of enamel between the rods, but the NaOCl with or without etching26. There was no significant intercrystal porosity was limited25. The parallel sectioned difference between the etch-seal and the bleach-etch- group showed partial removal of the intra rod enamel and seal technique and no benefit from using only NaOCl minimal increase of the area surface25. The formation of without etching26. This study also showed that poor microtags, important for bonding, is limited and the large sealant tag was obtained regardless the treatment. The interprismatic space may retain moisture and weaken the second in vitro study in 2014 by Crombie et al. assessed 60 Apostolina Theocharidou, Konstantinos Arapostathis Balk J Dent Med, Vol 22, 2018 the resin infiltration to MIH enamel with the conventional which is the removing of all defective enamel. The other technique and with incorporation of 0.95% NaOCl, before two studies provide no information about the exact and after etching with HCl28. This study concluded that procedure followed and the materials used. The in vitro NaOCl failed to produce significantly improved results study by William et al.25, as mentioned above, showed high for deeper resin penetration28. In the vitro study by Chay frequency of cohesive failures within the enamel, probably et al.29, there was comparison between various enamel due to the presence of defected enamel. pretreatments to improve the adhesion of resin composite There are not any studies investigating the bonding to hypomineralized enamel. After microshear bond strength of orthodontic brackets to MIH affected enamel. Two testing, the highest bond strength was associated with the in vitro studies have used cariogenic solution to mimic 5.25% NaOCl pretreatment followed by resin infiltration29. hypomineralized enamel and tested the microleakage and shear bond strength27,30. It was shown that pretreating the B) Sealants and adhesion enamel with 2% sodium fluoride for 4 minutes, before There is only one in vivo study about sealants. The etching, could significantly reduce the microleakage under etch-seal technique, as mentioned above, was shown orthodontic brackets27. The highest microshear bond to be insufficient for MIH affected enamel, because strength was achieved after the application of acidulated poor sealant tags were obtained26. The introduction of phosphate fluoride, but the difference was not statistically a new technique, known as etch-bond-seal, has shown significant30. significantly better results23. In a four-year split mouth study by Lygidakis et al., the two techniques were tested. 54 children with at least two MIH affected first permanent molars on opposite sides of the mouth, participated in this Discussion study. The teeth had occlusal opacities with no enamel breakdown. The color of the opacity, hence the severity, Acid etching enamel, affected by MIH, may produce was not mentioned. One side received one treatment a surface matching a type III pattern7, as William et al. assigned randomly, while the opposite side received has showed for 35% phosphoric acid. MIH enamel differs the other. It was concluded that significantly greater from normal enamel structurally due its high organic retention of sealants was achieved by applying total-etch content. Therefore, it is more susceptible to caries and 2-step adhesive system prior to sealant placement23 rather post eruption breakdown. Consequently, etching with than the etch-seal technique. This may be due to lower phosphoric acid will not produce the same pattern as viscosity of these adhesives and therefore their ability to with normal enamel. The persistence of carbonate in penetrate deeper in the enamel23. MIH affected enamel may decrease the solubility of There is only one in vitro and only one in vivo about the hydroxyapatite crystals31. Extraction of these teeth the adhesion system. The in vitro studied by William is required to study the etching pattern under scanning et al. found no significant difference between the ‘etch electron microscope. The availability, hence, of these teeth and rinse’ and self-etch adhesives systems25. Both is limited. Usually molars, severely affected and with systems have been shown to have inferior bond strength breakdown, are the ones extracted. These kinds of molars to MIH affected enamel compared to the normal one. were used in the only in vitro study that has examined High frequency of cohesive fractures within the enamel and compared the etching pattern produced by 35% was also noted25. In this study teeth with yellow brown phosphoric acid and self-etch primer on MIH enamel. opacities and with posteruptive breakdown were included, Although a more favorable etching pattern was produced without them receiving cavity preparation. The same with self-etching primer compared to normal enamel, it study also suggested that there might be some indication was not enough to provide higher bond strength. There for self-etching systems25. A recent in vivo study by Souza was no cavity preparation and no removal of defective et al., involving 41 teeth with conservative cavity design enamel. The exact etching time was not specified and showed no difference between the two adhesive systems24. whether the manufacturer’s instructions were followed was not mentioned. Further studies are needed to evaluate C) Composite restorations and Bonding of the etching pattern produced by phosphoric acid and orthodontic brackets self-etch primers applied for specific times on enamel There are three longitudinal in vivo studies, one without breakdown. Then the results, after increasing or prospective and two retrospectives, and one in vitro decreasing the application time, can be compared. The evaluating the success rate of composite restorations. The outcomes could give essential information to the clinician four-year prospective study by Lygidakis et al. showed when providing sealants or bonding orthodontic brackets. 100% success20. The two retrospective studies by Kotsanos In the effort to improve this irregular etching pattern, et al.22 and Mejàre et al.21 showed high success rates 74.4% a pretreatment of the enamel has been suggested19. The and 85.3% respectively, and high need for retreatment up pretreatment with NaOCl could theoretically remove the to 11 times. The first one states clearly the cavity design, entrapped proteins from MIH enamel. Nevertheless, the Balk J Dent Med, Vol 22, 2018 Molar Incisor Hypomineralization 61 studies so far have contradicting results, but cannot be If restorative treatment of the MIH affected teeth compared with each other, because dissimilar materials and is required, composite restorations will usually be the methods were used. These studies used scanning electron first choice, when one or two surfaces are involved, the microscope. The study by Gandhi et al.26 was qualitative defect is well defined with no cuspal involvement and and bond strength was not measured. The study by Crombie there are supragingival margins34. Stainless steel crowns et al.28 used Vickers hardness test and the one by Chay et are not aesthetic and far more invasive than composite al.29 used microshear bond strength test. Gandhi et al.26 fillings. Composite restorations have high success rate showed poor tag formation regardless the pretreatment, on MIH teeth, but there is also high need for retreatment. which enhances the results by William et al.25 of inferior The cavity design is of high importance. There are adhesion compared to normal enamel. Crombie et al.28 two potential cavity designs, removing all defective showed failure of NaOCl to promote deeper penetration enamel19 and removing only the porous enamel34. The of resin infiltrant materials. The study by Chay et al.29 has first one involves excessive tooth removal, but provides showed that NaOCl pretreatment with or without resin sound enamel for bonding4. The second one is more infiltration could significantly promote adhesion. NaOCl conservative, but there is high risk of unstable bonding4. potentials were shadowed by the excellent performance of The extent of the defect could theoretically affect the the total-etch 2-step adhesives before sealant placement. cavity design. Smaller defects could be approached with The different concentration percentage of NaOCl used in removing all defective enamel and extensive defects each study might be an important aspect. No conclusion conservatively in the effort to preserve as much enamel can be drawn, as further reasearch is required. Further high as possible. Placing composite restorations might though quality in vivo studies could enlighten these potentials and require the removal of all discolored hypomineralized the potentials of resin infiltration, which has been used so enamel20. This is supported by the high rate of cohesive far to aesthetically improve MIH incisors. fractures within the enamel found by William et al.25, This irregular etching pattern mentioned above is where defective enamel was not removed. In addition, certainly affecting the application of sealants, which Lydidakis et al.20 showed 100% success of composites are meant to protect teeth from caries. Lygidakis et al.23 after removing all defective enamel, although there is showed significantly increased retention of sealants with not any information about blinding of the operator. The the application of total-etch 2-step adhesive system prior studies by Kotsanos et al.22 and Mejare et al.21 provided to sealant placement. It is important mentioning that it was no information about the cavity design and the used a split mouth study minimizing this way the risks of bias, materials. Further studies with defined cavity design and although the color of the opacities, hence the severity, was treatment procedure should be conducted. not mentioned. Orthodontic treatment of children with MIH affected As far as adhesive systems are concerned, studies enamel appears to be challenging. Due to the inferior give insufficient results. Choosing the adhesive system is adhesion to these teeth, there may be increased treatment difficult as inferior bond is achieved to teeth affected by times or even a poorer orthodontic outcome. These MIH. This is supported by the in vivo studies of Kotsanos teeth could theoretically be benefited from application et al.22 and Mejàre at al.21 that showed the high need for of preventive solutions, especially before bonding retreatment for the MIH groups. William et al.25 suggest of orthodontic brackets, which can promote further that there may be an indication for the self-etching systems, demineralization. The studies so far in this area use as they could theoretically provide better results. The cariogenic solutions to mimic the hypomineralization, omission of etching and rinsing will eliminate the presence producing enamel that is different to the rich in protein of residual water, which can compromise the bonding4. MIH enamel. Treating the MIH affected enamel The lower viscosity will allow the adhesive to penetrate with fluoride varnish could theoretically enhance deeper in the enamel, increasing this way the total surface remineralization, especially when there is complain to available for bonding4. In addition, some of these systems external stimuli or spontaneous hypersensitivity4. The have the ability to bond both micromechanically and potential of these solutions should be further studied. chemically to hydroxyapatite and can also release fluoride along with their antibacterial properties32. Therefore, they are associated with less postoperative sensitivity, which is very important when restoring MIH affected teeth as they Conclusions might already be too sensitive33. Nevertheless, there is no study to prove the superiority of these systems. It is worth Adhesion to enamel affected by molar incisor mentioning that the study by Lygidakis et al.20, that showed hypomeralization is inferior compared to normal enamel. 100% success of composite restoration, used total-etch Acid etching this enamel can cause more enamel loss and 2-step adhesive system20. Further studies of high quality are exposure of its organic content, leaving an undesirable needed to evaluate and compare the performance of these etching pattern for bonding. The application of total- two adhesive systems. etch 2-step adhesive system can increase the retention 62 Apostolina Theocharidou, Konstantinos Arapostathis Balk J Dent Med, Vol 22, 2018 of sealants. There is no evidence to support that self- 13. Jälevik B, Odelius H, Dietz W, Norén J. Secondary etching adhesive systems are more effective than total ion mass spectrometry and X-ray microanalysis of etch systems when placing composite restorations. hypomineralized enamel in human permanent first molars. Arch Oral Biol, 2001;46:239-247. Deproteinazation of the protein enriched MIH enamel 14. Farah RA, Monk BC, Swain MV, Drummond BK. Protein with NaOCl pretreatment could theoretically enhance content of molar-incisor hypomineralisation enamel. J Dent, adhesion. Further prospective randomized clinical trials 2010;38:591-596. are required to provide evidence based solutions to the 15. Mahoney EK, Rohanizadeh R, Ismail FSM, Kilpatrick NM, clinician to treat effectively teeth affected by molar incisor Swain M V. Mechanical properties and microstructure of hypomineralization. hypomineralised enamel of permanent teeth. Biomater, 2004;25:5091-5100. 16. Mahoney EK, Ismail FSM, Kilpatrick NM, Swain M V. Mechanical properties across hypomineralized/hypoplastic enamel of first permanent molar teeth. Eur J Oral Sci, References 2004;112:497-502. 17. Da Costa-Silva CM, Jeremias F, De Souza JF, De Cássia 1. Weerheijm KL. Molar incisor hypomineralization (MIH): Loiola Cordeoro R, Santos-Pinto L, Cilense Zuanon AC. clinical presentation, aetiology and management. Dent Molar incisor hypomineralization: prevalence, severity and Update, 2004;31:9-12. clinical consequences in Brazilian children. Int J Paediatr 2. Mast P, Rodriguez Tapia MT, Daeniker L, Krejci I. Dent, 2010;20:426-434. Understanding MIH: Definition, epidemiology, differential 18. Voronets J, Jaeggi T, Buergin W, Lussi A. Controlled diagnosis and new treatment guidelines. Eur J Paediatr toothbrush abrasion of softened human enamel. Caries Res, Dent, 2013;14:204-208. 2008;42:286-290. 3. Weerheijm KL, Duggal M, Mejàre I, Papagiannoulis L, 19. Mathu-Muju K, Wright JT. Diagnosis and treatment of Koch G, Martens LC et al. Judgement criteria for molar molar incisor hypomineralization. Compend Contin Educ incisor hypomineralisation (MIH) in epidemiologic studies: Dent, 2006;27:604-610. a summary of the European meeting on MIH held in 20. Lygidakis NA, Chaliasou A, Siounas G. Evaluation of Athens, 2003. Eur J Paediatr Dent, 2003;4:110-113. composite restorations in hypomineralised permanent 4. Lygidakis NA, Wong F, Jälevik B, Vierrou AM, Alaluusua molars: a four year clinical study. Eur J Paediatr Dent, S, Espelid I. Best Clinical Practice Guidance for clinicians 2003;4:143-148. dealing with children presenting with Molar-Incisor- 21. Mejàre I, Bergman E, Grindefjord M. Hypomineralized Hypomineralisation (MIH): An EAPD Policy Document. molars and incisors of unknown origin: Treatment outcome Eur Arch Paediatr Dent, 2010;11:75-81. at age 18 years. Int J Paediatr Dent, 2005;15:20-28. 5. Jälevik B. Prevalence and Diagnosis of Molar-Incisor- 22. Kotsanos N, Kaklamanos EG, Arapostathis K. Treatment Hypomineralisation (MIH): A systematic review. Eur Arch management of first permanent molars in children with Paediatr Dent, 2010;11:59-64. Molar-Incisor Hypomineralisation. Eur J Paediatr Dent, 6. Buonocore MG. A Simple Method of Increasing the 2005;6:179-184. Adhesion of Acrylic Filling Materials to Enamel Surfaces. J 23. Lygidakis NA, Dimou G, Stamataki E. Retention of fissure Dent Res, 1955;34:849-853. sealants using two different methods of application in teeth with hypomineralised molars (MIH): a 4 year clinical study. 7. Bozal CB, Kaplan A, Ortolani A, Cortese SG, Biondi AM. Eur Arch Paediatr Dent, 2009;10:223-226. Ultrastructure of the surface of dental enamel with molar 24. de Souza JF, Fragelli CB, Jeremias F, Paschoal MAB, incisor hypomineralization (MIH) with and without acid Santos-Pinto L, de Cassia Loiola Cordeiro R. Eighteen- etching. AOL, 2015;28:192-198. month clinical performance of composite resin restorations 8. Maria Da Costa-Silva C, Mialhe FL, Maria C, Silva C. with two different adhesive systems for molars affected Considerations for clinical management of molar-incisor by molar incisor hypomineralization. Clin Oral Investig, hypomineralization: A literature review Considerações 2017;21:1725-1733. para o manejo clínico da hipomineralização molar-incisivo: 25. William V, Burrow MF, Palamara JEA, Messer LB. Revisão de literatura. Rev Odonto Cienc, 2012;27:333-38. Microshear bond strength of resin composite to teeth 9. Suga S. Enamel hypomineralization viewed from the affected by molar hypomineralization using 2 adhesive pattern of progressive mineralization of human and monkey systems. Pediatr Dent, 2006;28:233. developing enamel. Adv Dent Res, 1989;3:188-198. 26. Gandhi S, Crawford P, Shellis P. The use of a “bleach-etch- 10. Weerheijm KL, Jälevik B, Alaluusua S. Molar–Incisor seal” deproteinization technique on MIH affected enamel. Hypomineralisation. Caries Res, 2001;35:390-391. Int J Paediatr Dent, 2012;22:427-434. 11. Elhennawy K, Schwendicke F. Managing molar-incisor 27. Moosavi H, Ahrari F, Mohamadipour H. The effect of hypomineralization: A systematic review. J Dent, different surface treatments of demineralised enamel on 2016;55:16-24 microleakage under metal orthodontic brackets. Prog 12. Fearne J, Anderson P, Davis GR. 3D X-ray microscopic Orthod, 2013;14:2. study of the extent of variations in enamel density 28. Crombie F, Manton D, Palamara J, Reynolds E. Resin in first permanent molars with idiopathic enamel infiltration of developmentally hypomineralised enamel. Int hypomineralisation. Br Dent J, 2004;196:634-638. J Paediatr Dent, 2014;24:51-55. Balk J Dent Med, Vol 22, 2018 Molar Incisor Hypomineralization 63
29. Chay PL, Manton DJ, Palamara JEA. The effect of resin 33. Croll TP. Enamel microabrasion: observations after 10 infiltration and oxidative pre-treatment on microshear bond years. J Am Dent Assoc, 1997;128:45S-50S. strength of resin composite to hypomineralised enamel. Int 34. Fayle SA. Molar incisor hypomineralisation: restorative J Paediatr Dent, 2014;24:252-267. management. Eur J Paediatr Dent, 2003;4:121-126. 30. Shahabi M, Ahrari F, Mohamadipour H, Moosavi H. Microleakage and shear bond strength of orthodontc Received on May 2, 2017. brackets bonded to hypomineralized enamel following Revised on July 1, 2017. different surface preparations. J Clin Exp Dent, Accepted on October 26, 2017. 2014;6:e110-115. 31. Weatherhell J, Deutsch D, Robinson C, Hallsworth A. Correspondence: Fluoride concentrations in developing enamel. Nature, 1975;256:230-232. Apostolina Theocharidou 32. Sapir S, Shapira J. Clinical solutions for developmental Department of Paediatric Dentistry defects of enamel and dentin in children. Pediatr Dent, Aristotle University of Thessaloniki, Greece 2007;29:330-336. e-mail: [email protected]
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Enamel Defects During Orthodontic Treatment
SUMMARY Stavroula Sarafopoulou1, Anastasios A. Background/Aim: Orthodontic treatment has an inherent potential Zafeiriadis2, Apostolos I. Tsolakis3 for causing defects to enamel in the course of bonding and debonding 1 Faculty of Dentistry, Marmara University, procedures, interproximal enamel stripping and induce the presence of Istanbul, Turkey white spot lesions, enamel discoloration or wear. The aim of this study is 2 Faculty of Dentistry, Aristotle University of to present the stages of orthodontic therapy associated with potential Thessaloniki, Greece 3 damage to enamel and list the enamel alterations observed in each stage. National and Kapodistrian University of Athens, Greece Material and Methods: A literature search was carried out in MEDLINE- PubMed database for papers published up to and including February 2015. Results: Enamel loss is induced by cleaning with abrasives before etching, the acid etching process itself, forcibly removing brackets, and mechanical removal of composite remnants with rotary instruments. Loss of enamel or topographic changes in the form of cracks, scarring and scratches may occur. Clinicians may cause structural damage of enamel by interproximal enamel stripping. Additionally, the enamel surface may become demineralized due to plaque accumulation around the orthodontic attachments. Additional complications are enamel color alterations due to its microstructural modifications or discoloration of adhesive remnants and enamel wear due to contact with the brackets of the opposing teeth. Conclusions: Therapeutic procedures performed in the course of orthodontic treatment may cause irreversible physical damage to the outermost enamel. To avoid this, the orthodontic practitioner should take great care in every stage of the treatment and manage the enamel surface conservatively. Moreover, patients should follow an effective oral hygiene regimen. Given these conditions enamel damage during orthodontic therapy is eliminated and longevity of the dentition is promoted. REVIEW PAPER (RP) Key words: Enamel, Lesion, Discoloration, Stripping, Demineralization Balk J Dent Med, 2018;64-73
Introduction is not homogeneous; in permanent teeth they are vertical at the cusp tip or incisal edge, then become oblique toward the Tooth enamel is the most mineralized, and the hardest, middle part of the occlusal surface and are aligned towards of all substances in the human body. It is composed of 96 the root in the cervical region3. The mechanical properties wt% of mineral content combined with 4 wt% of organic of enamel and its high resistance to mastication forces are material and water1,2. The mineral phase is generally attributed to this complex structure4,5. The enamel exhibits referred to as calcium hydroxyapatite. The tightly packed, a variable thickness over the tooth surface, often being hexagonal, needleshaped crystallites of the hydroxyapatite the thickest at the incisal edge and cusp tips of molars and are arranged into prisms1. Crystallites within the prism premolars, up to 2.5 mm; and is thinnest where it meets head run parallel to the rod direction, while their angle with the cementum at the cementoenamel junction. At the respect to the rod direction increases to reach angles as high cervical area of teeth, as well as at the pits and fissures of as 60◦ within the tail. Orientation of prisms in the enamel the tooth, there is a surface of aprismatic layer of enamel Balk J Dent Med, Vol 22, 2018 Enamel Defects 65 with thickness of 20-30 μm. This surface layer of enamel cups or polishing brushes, are used in combination with is harder and more resistant to dissolution and often has a a paste containing abrasives such as pumice, silica, and higher mineral content and lower water content than the zirconium silicate19. Sandblasting has also been proposed subsurface enamel6, and to contain a greater proportion for enamel cleaning20. It has been shown that the use of of fluoride than deeper zones4,7. Despite this, therapeutic the polishing brush causes greater enamel loss than that procedures performed in the course of orthodontic of the rubber cup, while no difference was found among treatment may cause irreversible physical damage to the various slurries. An initial prophylaxis using a bristle outermost enamel2. brush for 10-30 seconds per tooth can abrade away During orthodontic treatment, loss of enamel or as much as 10.7-14.38 μm of enamel, compared with topographic changes comprising cracks, scarring and the 1.07-6.9 μm that can be lost when a rubber cup is scratches may occur8. Stages of therapy associated with used9,12,19. In vivo studies have demonstrated that enamel potential damage to enamel include cleaning with abrasives cleaning prior to etching has no effect on the shear bond prior to the application of an acid etchant, acid etching, strength or the rates of bracket failure significantly, bracket removal, mechanical removal of composite regardless if conventional resin or resin-modified glass remnants with rotary instruments and the rebonding of ionomer bonding systems are used21,22. Consequently, failed brackets2,9-13. Additional enamel loss may be caused it has been recommended that enamel prophylaxis could as a result of intentional enamel reduction; a procedure be omitted, in order to avoid enamel scratching and loss. is commonly applied in cases where space is required for However, in the case where self-etching primers are used, aligning the teeth in situations of moderate crowding and enamel cleaning prior to etching could be beneficial in correct tooth size discrepancies14. Moreover, common order to increase the bond strength5,11,12,18. complications encountered during orthodontic treatment include the demineralization of enamel and formation Enamel etching of white spot lesions due to the accumulation of plaque During etching the degree of depth penetration of the on the fixed orthodontic appliances, together with the acid into enamel depends on the type and concentration discolouration of enamel, or enamel wear due to its contact of the acid, the duration of the etching, and the chemical with the brackets of the opposing teeth2,15-17. composition of the enamel surface2,10,23. Traditionally, The aim of the present investigation was to present the surface of enamel has been prepared by etching with the stages of orthodontic therapy associated with potential orthophosphoric acid at concentrations ranging from damage to enamel and discuss the possible complications 30% to 50% for 15 to 90 seconds, which has proved of orthodontic treatment on the integrity of enamel by to remove enamel of thickness from 1.11 to 20 μm, means of a critical review of the relevant literature. respectively5,9-12,24-28. One effect due to etching with phosphoric acid comprises the dissolution of the hydroxyl apatite of the enamel leading to demineralization of the uppermost layer of enamel. A selective dissolution Material and Methods of either the enamel prism cores or boundaries and the creation of microporosity of the enamel surface, varying An electronic search of MEDLINE-PubMed database in depth from 10 to 80 μm is also caused by phosphoric was carried out up to and including February 2015. The acid. However, it has been detected that tag formation search included all types of publications. The search may extend down to depths of 100 to 170 μm in porous terms that were used included each stage of orthodontic etched enamel5,10,27-30. In order to control excessive treatment associated with potential enamel damage. Both enamel loss, maleic and polyacrylic acids, and self- in vitro and in vivo studies were included in this review. etching primers have been applied as alternatives to The papers resulting from this search were used as a phosphoric acid31. Self-etching primers have proved to further source for relevant articles. affect more slightly the enamel structure, but reduce bond strength, but to a clinically accepted level5,32-33. Due to the weak bond with enamel, less residual resin cement remaining on the teeth was observed and low risk of Results enamel micro-fractures at debonding, when self-etching primers were used5,11,27,29,32-34. Enamel preparation before etching Enamel defects caused by debonding procedures Enamel preparation before conditioning aids to remove organic debris from its surface, including plaque Enamel fractures caused during bracket removal and acquired pellicle, which might possibly inhibit Debonding is used to remove the existing attachment optimal etching18. For the prophylactic cleaning of and the adhesive resin from the tooth in order to restore enamel, rotary instruments at slow speed, such as rubber the surface as nearly as possible to its pretreatment 66 Stavroula Sarafopoulou et al. Balk J Dent Med, Vol 22, 2018 condition. The process of debonding involves several significantly reduced. Another advantage is that they factors. The most important among these are the type of provide easier clean up after debonding than conventional bracket and adhesive used, the instruments employed orthodontic adhesives50-52. The mean level of enamel loss for bracket removal, and the armamentarium for resin after cleaning and finishing the enamel surface of the teeth removal9-10,35-40. bonded with resin-modified glass polyalkenoate cements The ideal method of orthodontic bracket bonding was 22.8 μm53. should ensure sufficient bond strength to satisfactorily Zarinnia et al.39 compared the efficacy of three retain orthodontic brackets, resist the forces of mastication bracket removing instruments; the How plier, the ligature and the stress due to the arch wires and simultaneously cutter, and a bracket removing plier and found that the allow bracket debonding without resulting in damage to bracket removing plier consistently produced a separation the enamel surface2. Various studies have suggested that at the bracket-resin interface and left the enamel the bond strength should range from 2.8 to 12.75 MPa as surface intact36,54-56. The use of Weingart pliers proved this would be adequate for clinical situations as well as inappropriate for bracket removal, as it is associated with preventing damage to the enamel during debonding41-44. enamel stress and micro-cracks57. Arici and Minors56 The procedure for debonding a bracket from a tooth reported that the forces required to initiate debonding of carries the risk of iatrogenic damage to the surface of the ceramic brackets are related to the contact area between enamel. Bond failure can take several forms: between the tips of the pliers and the adhesive. This can be the bracket and the adhesive; within the body of the minimized by either using pointed plier tips or placing a adhesive itself; or between the surface of the tooth and conventional pair of debonding pliers diagonally opposite the adhesive, or may involve a combination of these to the corners of the bracket, in order to protect the enamel modes45. There are two perspectives on the amount of surface from extensive forces. In a study comparing the adhesive left on the tooth surface after debonding. From enamel fractures locations and incidence in different one point of view, the failure at bracket-adhesive interface debonding load modes, findings from scanning electronic leaving the adhesive resin mainly on the enamel surface microscopy and mechanical testing showed no significant reduces the probability of enamel fracture, however this difference in sizes and incidences of enamel fractures carries the disadvantage of requiring the mechanical produced, regardless if tension, shear or torsion forces removal of the residual adhesive after debonding. On the were exerted. The enamel fractures locations coincided other hand, the failure at enamel-adhesive resin interface, with the areas where these three debonding forces were leaving much less adhesive left on the enamel surface exerted58. reduces the degree of clean-up required while increasing Metal brackets can be debonded relatively ease the possibility of damage to the enamel. When adhesion by applying forces to peel the bracket base away from failure occurs between the adhesive resin and the enamel the tooth. Most often, forces that squeeze the bracket surface occurs, there is an inevitable degree of enamel loss at the base result in bond failure at the adhesive-bracket due to the micromechanical bond between the composite interface, with most of the adhesive remaining on the resin bonding agent and the acid-etched enamel46. enamel surface after debonding, constituting a safer However, it needs to be borne in mind that enamel procedure for enamel5,8,38,59-60. One possible reason fracture and crazing is certain to occur when debonding is that the tendency of stainless steel brackets to flex forces exceed the mechanical strength of the enamel2. when the debonding pliers are used may dissipate the Enamel breakouts after debonding were detected in 10.5- debonding forces, thereby protecting the enamel61. The 33% of cases with mean depth of 44.9-100 μm10,46-48. debonding and removal of ceramic brackets have attracted Resin-modified glass cements have been used particular attention because of the potential for enamel progressively as orthodontic bonding agents in recent fracture, flaking and enamel cracks, and the increased years. A factor encouraging their use as orthodontic risk of pulp damage. The attachment between ceramic bonding agents is the ability not only to release fluoride, brackets and the adhesive have aided by increasing but also the possibility to eliminate enamel loss following mechanical retention using indentations or recesses in the orthodontic treatment12,28,49. Resin modified glass bracket base or by coating the ceramic bracket base with ionomer cements were shown to produce lower, but an intermediate layed of glass and then using a silane clinically acceptable bond strengths. Summers et al.50 coupler that form a chemical bond between the bracket found that the survival rates of resin-modified glass and the adhesive5,26,46. Many authors have asserted ionomers after 1.3 years were similar with those of that chemical retention brackets produce significantly conventional composite adhesive, and concluded that higher bond strengths than brackets with mechanical resin-modified glass ionomers were able to provide retention or mechanical retention with polymer base, thus adequate bond strengths clinically51-52. Resin modified entailing damage risks for the enamel surface26,54,59,61,62. glass ionomer cements demonstrated greater incidence Nevertheless, the strength of adhesion between the resin of enamel-adhesive failure, but minimal enamel damage and the ceramic bracket base has reached a point where since the level of force needed to cause bond failure was the commonest site of bond fracture during debonding Balk J Dent Med, Vol 22, 2018 Enamel Defects 67 has moved from the bracket base-adhesive interface the least amount of scarring clinically. According to to the enamel-adhesive interface, thus increasing the Albuquerque et al.76 a 32-fluted tungsten carbide bur at frequency of enamel cracks, or the length of the resulting high speed provided the best enamel roughness results. cracks following debonding10,38,59,63,64. The numerous The use of a 12-fluted tungsten carbide finishing bur studies evaluating the bond strengths of ceramic brackets at high speed with adequate air cooling, finishing with have shown significantly stronger bond strengths, with graded medium, fine and superfine Sof-Lex discs at low more frequent failures at the enamel/adhesive interface speed, and a final finishing with a rubber cup and Zircate compared with conventional metal brackets26,38,62,64,65. In paste was recommended by Retief and Denys36 and addition, the rigidness and brittleness of ceramic brackets Zarinnia et al39. Other authors, however, suggested using which exclude bracket deformation when shearing forces tungsten carbide burs at high speed with water spray are applied, may support the increased incidence of instead of air cooling67,74,75,77. enamel cracks when debonding ceramic brackets26,38,66. In contrast, many authors found in scanning electron It has been reported that 18-40% of teeth showed microscopy studies that the use of high speed tungsten increased number of severity in enamel cracks following carbide burs after debonding is damaging the enamel the debonding of ceramic brackets38,55. Some studies, surface due to the degree of enamel loss and the creation however, do not show statistically significant difference of large pits and facets also causing significant enamel in bond strength and number or length of cracks between loss9,11,12,35,63,78. 46 ceramic and metal brackets . It has been reported that the use of diamond finishing bur to remove adhesive remnants after debonding caused Mechanical removal of composite remnants with rotary severe roughness, as pits, scratches and grooves with instruments superimposed abrasion marks on the enamel surface Although the primary goal in orthodontic treatment is were visible both clinically and in scanning electron to return the enamel surface to its original state following micrographs36,37,67,74. the removal of orthodontic attachments, the mechanical removal of any remaining composite after debonding Remnant removal with hand scalers, adhesive has proved detrimental to the enamel surface, causing a removing pliers, stainless steel finishing burs, ultrasonic significant amount of enamel loss and irreversible enamel scalers, Er:YAG laser, Sof-Lex aluminum oxide finishing damage. The presence of prominent areas or grooves on disks, Shofu tips or rubber cup with Zircate paste proved the tooth surface can contribute to enamel staining and to be insufficient, in spite of progressive decrease in the plaque accumulation which may cause esthetic concerns surface irregularities, because they leave much residual and enamel demineralization67. adhesive on enamel surface while causing great enamel 9,11,39,67,71,72,76-79 After completing the adhesive removal procedures loss . following debonding, it has been estimated that 14.3-160 Different polishing methods, such as hand μm of enamel surface may be removed dependening on instruments, sandpaper disks, green rubber wheels, the method applied10,11,13,24,25,40,63,68. The need to find silicon or aluminum oxide discs and pumicing, slightly an efficient and safe method of adhesive resin removal smoothened the rough surfaces obtained after adhesive following debonding produced the introduction of a wide removal, but they could not entirely remove the deeper array of instruments and procedures including manual scratches or gouges left by tungsten carbide burs, 35,37,48,67,68,72,80 removal using hand scalers or band removing pliers, ultrafine diamond burs and Er:YAG laser . tungsten carbide burs with a 8- to 32-fluted configuration SEM studies confirmed that no method eliminated all for low or high speed hand pieces, Sof-Lex disks, and the irregularities left after the bonding/debonding of special composite finishing systems with zirconia brackets37,40,60,68,76. The most effective polishing is paste or slurry pumice, as well as ultrasonic and laser achieved with Sof-Lex disks, which restore the enamel applications12,67,69. closer to its original roughness39,77. Employing final Tungsten carbide burs used at low speed followed by polishing with a rubber cup and Zircate paste was found to pumice and/or polishing cups have been recommended be essential in reducing the abrasive marks induced by the for resin removal not only because they produce the rotary instruments9,24,39. In theory, scratches and grooves finest scratch pattern with the least enamel loss of 7.4 have the potential to contribute to plaque accumulation, μm, but also due to the superior accessibility to different enamel discoloration and demineralization through developmental irregularities and other difficult-to-reach bacterial activity15,24,37,81,82,83. Although restoration of a areas5,35,37,40,67,70,71. relatively smooth surface while preserving the topographic Other authors recommended the use of tungsten qualities of the enamel is the key to a successful debonding carbide burs at high speed39,67,72-76. Campbell74 reported procedure, adequate clean-up without enamel loss and that the use of 30-fluted tungsten carbide burs in high restoration of the enamel to its original roughness is speed hand-piece was the most efficient modality for difficult to achieve, suggesting an irreversible effect on removing resin remnants after debonding and produced enamel texture9,10,35,37,48,68,73,74,80. 68 Stavroula Sarafopoulou et al. Balk J Dent Med, Vol 22, 2018
Rebonding of failed brackets from the incisors, 0.3-0.5 mm from the canines and 0.5- Bracket failure constitutes another frequently 0.6 mm from posterior teeth of upper or lower jaw96-101. occurring undesirable problem during treatment. This Following stripping, the surface properties of usually results from either of parafunctional forces exerted enamel are altered, with significant changes in roughness, by the patient, or from poor bonding technique2. something which may lead to plaque accumulation and Some degree of enamel scarring after rebonding increase the susceptibility of proximal enamel surfaces procedures is unavoidable but this can be minimized by to demineralization and dental caries93,98. Review of the the use of right protocol. Tungsten carbide burs used at available literature shows that smoother enamel surface low speed with adequate air cooling possibly comprise the is obtained with the use of diamond-coated discs or best method to produce an acceptable enamel surface and strips or 8-straight blade tungsten carbide burs, followed provides good rebond strength71. by polishing with Sof-lex discs. Enamel reduction with In the study of Thompson and Way19 a progressive 37% orthophosphoric acid or rotary instruments at high degree of enamel loss was observed after three speed without surface polishing induces severe enamel 86,89,90,92,93,96,97 consecutive bondings/debondings when prophylaxes irregularity . Many studies with scanning using a bristle brush or a rubber cup with prophylactic electron microscopy demonstrated that, regardless of paste followed by etching were used between bonds. the polishing and finishing method amplied, furrows of While initial enamel loss was estimated from 10.8 to 15.8 10-30 μm depth remain on enamel surface, leading to 87,91,92,94,96 μm, after repeated bonding/debonding, the values for total plaque retention and enamel demineralization . enamel loss ranged from 45.4 to 71.5 μm. Other authors supported that polishing enamel after stripping achieved similar morphological characteristics Intentional enamel reduction (stripping) and smoothness as intact enamel86,90,93,96. It is generally believed that these lesions will recover at some extent Stripping is commonly used in cases requiring through natural remineralization with saliva even in a additional space to align the teeth where there is moderate period of 1-9 months after the orthodontic appliances crowding and to correct tooth size discrepancies, as removal and oral hygiene is restored. The processes of 12,84 well . There is, in addition, a newly introduced natural wear and attrition that produce a smooth surface treatment technique using transparent aligners without the around the contact point may also play a significant employment of conventional orthodontic appliances for role17,87,92. moving teeth, indicating that the frequency of stripping in Although irregularities remained after stripping routine orthodontic practice may increase as a method of which might facilitate plaque and bacteria retention 12 generating space enamel reduction . and caries development, there is no inevitability about Several methods utilizing mechanical or chemical this becoming a clinically significant event. Many means, or a combination of both, have been presented follow-up studies indicate that there is not a significant as safe and effective methods of choice for enamel relationship between enamel stripping and development reduction85-87. Thus, the use of perforated diamond- of interproximal caries on anterior or posterior teeth, for a coated discs, diamond or tungsten carbide burs utilized study period of 1-10 years following the application of the in conjunction with air-rotor or micromotor handpieces, technique17,94. diamond-coated strips adapted to handpieces or manually Significant preventive measures are good oral used have all been proposed. Acid etching of enamel hygiene, regular prophylactic checkups for caries by means of 37% orthophosphoric acid can be used in and fluoride application86,88,92. Many authors have combination with mechanical stripping, to enable faster suggested the application of fluoride containing products stripping procedures87,88. immediately after stripping in order to prevent further Stripping leaves a relatively rough enamel surface mineral loss and promote remineralization14,86,87,91. and must be indispensably followed by polishing in It is necessary, however, to conduct further long-term every stage, which restores appropriate anatomical form researches to study the association of interproximal to the tooth and reduces roughness of the interproximal enamel reduction to demineralization and caries surfaces86,88,89,90. For this purpose there have been utilized susceptibility. fine and ultrafine Sof-lex discs, cattle disks or fine pumice media, polishing strips used in handpiece or manually or Enamel demineralization- white spot lesions fine and ultrafine diamond burs may assist the operator in Demineralization is a frequent side effect associated achieving a smooth contact area, which will presumably with fixed appliance orthodontic treatment2,49. The prevent excessive plaque accumulation85,91,92. Various components of the appliances and the bonding materials authors have deemed a reduction by 50% of the original promote the retention of food particles, plaque accumu enamel coat to be acceptable93-95. It has been suggested lation and bacterial colonization, especially Streptococcus that reduction should not exceed 0.2-0.5 mm of surface mutans and Lactobacillus28, by impeding access to the Balk J Dent Med, Vol 22, 2018 Enamel Defects 69 tooth surfaces for cleaning. Decalcifications in the form spot lesions may be reduced111,120,124,125,131. Fluoride of white spot lesions appear frequently in orthodontic therapy can reduce the enamel solubility, control plaque patients as small lines along the bracket periphery and in activity through blocking bacterial enzyme systems, and a few patients as large decalcifications with or without assist in the enamel remineralization102. Several studies cavitations102. have shown that the natural remineralization through The incidence rate of enamel decalcification in saliva, as well as the combination of daily brushing with orthodontic patients ranges from 2% to 96% and it is a fluoridated dentifrice, coupled with daily or weekly mainly caused by pH changes in the oral environment that rinsing with a 0.05% or 0.2% sodium fluoride mouthrinse favor the diffusion of calcium and phosphate ions out of respectively, will provide complete protection for the enamel103-104. It is reported that any tooth surface in the orthodontic patient by inhibiting demineralization, or by mouth can be affected with the common ones being the promoting remineralization, of surfaces at risk111. cervical and middle thirds of the crowns of maxillary After debonding white spot lesions may regress lateral incisors, canines and molars and mandibular depending on the severity of the lesions102,110. A period premolars and molars103-105. Accessibility to the free flow of 2-6 months should be allowed for the remineralisation of saliva may be a major factor in avoiding decalcification of the lesion by the effect of saliva49,111,112. If it of enamel. Due to the presence of major salivary glands appears that the capacity of the saliva is insufficient and the easy access of saliva, the mandibular anterior to effect spontaneous remineralization, then fluoride portion is cleaned more rapidly than the maxillary portion, supplementation should be applied. Although high-dose 104-105 which, on the other hand, receives little saliva . No fluoride (20,000-25,000ppm) is effective, best practice differences were found between the frequency of white dictates the frequent application of low doses similar 125 spots lesions on teeth that were bonded or banded . to those in toothpastes (1000- 1500 ppm) or fluoride However, it remains controversial if there is a correlation mouthwashes, such as 0.05% sodium fluoride daily between length of treatment and the incidence or number rinse or 0.2% sodium fluoride weekly rinse and topical 105 of white spot formations . fluoride agents in the form of solutions, varnishes or The formation of white spot lesions is considered gels102,103,111. Casein phosphopeptide amorphous calcium a precursor of enamel caries since it makes the area phosphate is another agent that attracted attention because 103 slightly softer than surrounding sound enamel . Previous of its its anticariogenic mechanism. This involves the studies evaluating the mechanical and crystallographic incorporation of the nanocomplexes into the dental characteristics of these incipient carious lesions have plaque and thus, onto the tooth surface, where they act shown an approximate 10% reduction in the mineral as a calcium and phosphate reservoir78,113. The localized content of the enamel involved. The reduction in the casein phosphopeptide amorphous calcium phosphate inorganic content of white spot lesions increases abrasion nanocomplexes subsequently act as buffer to the free in vivo, making the risk of enamel loss during debonding 106-107 calcium and phosphate ions in the plaque fluid, and procedures greater . maintain a state of supersaturation of amorphous calcium It has been suggested that demineralization can phosphate with respect to enamel mineral, so that enamel occur very rapidly in susceptible individuals, and visible demineralization is constrained and remineralization is white lesions may develop within the initial months of enhanced112,113. fixed appliance treatment and continue to appear at a slower rate later107-111. Postorthodontic white spot lesions Enamel color alteration after the orthodontic are shown to decrease during the initial period after treatment debonding. The clinical reduction or healing of white spot lesions observable after orthodontic treatment can be Several studies clearly indicate that after explained by the removal of the etiologic factor, i.e. the comprehensive orthodontic treatment with fixed cariogenic plaque adhering to fixed orthodontic elements, appliances the colour of natural teeth can be subjected combined with abrasion of the surface enamel during to a number of changes. This undesirable effect proved tooth brushing as well as remineralization109-110. to be inevitable due to the irreversible nature of enamel Various methods have been tried to minimize the microstructural modifications associated with bonding and white spot lesions formation and incipient caries lesions debonding procedures15. associated with orthodontic treatment, the commonest Apart from the permanent iatrogenic enamel effects of these to promote the formation of fluorapatite, since associated with bonding, debonding, and cleaning this aids in the remineralization of small decalcified procedures, the exogenous and endogenous discoloration lesions and causes a reduction in the formation of of the remaining adhesive material and the dental and pulp new lesions. If preventive measures, such as fluoride tissue alterations related to orthodontic tooth movement supplementation, balanced diet and good oral hygiene, may also play a role to enamel discoloration16,82. are followed and maintained throughout the course of Exogenous discoloration of adhesive remnants may orthodontic treatment, then the number and size of white arise from the superficial absorption of color pigmentation 70 Stavroula Sarafopoulou et al. Balk J Dent Med, Vol 22, 2018 of food dyes, colored mouth rinses, and plaque, while imposing a potential risk for enamel demineralization endogenous irreversible discolorations may be attributed and formation of white spot lesions. Additional adverse to changes in the chemical structure of the adhesive effects of orthodontic treatment are enamel loss as a result material82. Moreover, enamel discoloration can be caused of intentional enamel reduction, enamel discoloration or by the direct absorption of food colorants and products enamel wear from the brackets of the opposing teeth. formed from the corrosion of the orthodontic appliance, For all these reasons, every orthodontic practitioner even after orthodontic treatment114. should be cautious, follow the current guidelines as regarding the clinical management of enamel and make Enamel abrasion from brackets of the opposing every effort to minimize enamel defects. Moreover, the teeth patients have to follow a good oral hygiene regimen, Enamel surfaces can be abraded by contact with and to undergo regular prophylactic checkups for either metal or ceramic brackets of the opposing teeth115. demineralization and caries development. Under these The enamel abrasions frequently occur on upper canine circumstances orthodontic treatment can be a safe tips, since the tip of the cusp strikes the lower canine procedure for enamel structure. brackets during retraction. It can also be observed on the incisal edges of upper anterior teeth when ceramic brackets have been positioned on lower incisors of a patient with increased overbite2. Douglass116 observed References enamel abrasion on the lingual surfaces of maxillary central incisors that were in contact with ceramic brackets 1. Tziafas D. Biology of dental tissues. Development, placed on the facial surfaces of lower incisors, just six Structure and Function. Thessaloniki: University Studio weeks after placement of the brackets. Press, 1999:121-127. Ceramic brackets tend to induce more enamel 2. Arhun N, Arman A. Effects of orthodontic mechanics on abrasion than stainless steel brackets with enamel tooth enamel: a review. Semin Orthod, 2007;13:281-291. 3. 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Revised on May 1, 2017. 101. Jarjoura K, Gagnon G, Nieberg L. Caries risk after Accepted on September 26, 2017. interproximal enamel reduction. Am J Orthod Dentofacial Orthop, 2006;130:26-30. Correspondence: 102. Øgaard B. White spot lesions during orthodontic treatment: Stavroula Sarafopoulou mechanisms and fluoride preventive aspects. Semin Orthod, Faculty of Dentistry, Marmara University, Istanbul, Turkey. 2008;14:183-133. e-mail: [email protected]
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L BALKAN JOURNAL OF DENTAL MEDICINE A ISSN 2335-0245 IC G LO TO STOMA
The Change of Patient Profile, Attitudes and Satisfaction in University Dental Clinic after Onset of Economic Crisis in Greece
SUMMARY Georgios Chatzopoulos1, Maria Tsitsara2, Background/Aim: The aim of the study was to evaluate and compare Konstantinos Tzimas3, Lazaros Tsalikis4 patient profile, attitude and satisfaction of patients visiting a university 1 Division of Periodontology, Department of periodontal clinic before and during the financial crisis in Greece. Material Developmental and Surgical Sciences, University and Methods: In this cross-sectional study, adult consecutive patients that of Minnesota, Minneapolis, USA visited the undergraduate Periodontology clinic of the Aristotle University 2 Private practice, Patras, Greece of Thessaloniki from October 2014 to July 2015 were invited to participate 3 Department of Operative Dentistry, School of anonymously. The only exclusion criterion that was set was the age: all Dentistry, Aristotle University of Thessaloniki, individuals had to be ≥18 years old. The questionnaire utilized in this Greece study included six parts of questions: 1) demographic characteristics; 2) 4 Department of Preventive Dentistry, environmental and behavioral characteristics; 3) diagnosis of periodontal Periodontology and Implant Biology, School of disease; 4) medical history; 5) difficulties-satisfaction-proposals about Dentistry, Aristotle University of Thessaloniki, periodontal treatment; and 6) history of periodontal therapy. One hundred Greece and fifty individuals, mean aged of 51.6±12.3 years were interviewed concerning their demographic and behavioral characteristics. Satisfaction level, reasons for selecting the university dental clinic and oral hygiene habits were also recorded. Results: The profile of the patient attending the university periodontal clinic was a female (54.0%), 51-year-old on average, of high education (76.0%), good oral hygiene habits (brushing ≥2 times/day: 49.3%, use of additional oral health care: 66.0%), heavy smoker (>15 cigarettes/day: 51.9%) and chronic periodontal disease (96.7%). Economic difficulties led the participants to seek periodontal treatment in the university clinic (30.7%), but the vast majority of them were highly satisfied (81.3%), confident (82.0%) and informed (51.3%) about the treatment. Before the financial collapse in Greece, the profile of the patients in the clinic was characterized by low socioeconomic status with poor oral hygiene, none or basic education and unemployed (no income) and retired individuals. Heavy smoking, diagnosis of chronic periodontal disease and satisfaction were also reported prior to the financial crisis. Conclusions: The demographic characteristics of those who seek treatment in a university setting have changed dramatically and younger, more highly educated and employed individuals attend the undergraduate Periodontology clinic of the Aristotle University of Thessaloniki, Greece compared with those who attended the university dental clinic prior to the financial crisis. Key words: Economic Recession, Patient Satisfaction, Attitude, Periodontal Disease, ORIGINAL PAPER (OP) Student Health Services Balk J Dent Med, 2018;74-80
Introduction arises is in what degree is oral health care affected by the socio-economic crisis that has arisen in Greece. Assessment of patient profile prior to and during the financial crisis in In Greece, economic crisis and the implementation of Greece may provide valuable information. austerity led to significant reductions in disposable income In a retrospective study, demographic characteristics, and increased unemployment with negative effects on periodontal and medical history of 427 patients were patients’ access to healthcare services1. The question that reported from data collected in a private periodontal Balk J Dent Med, Vol 22, 2018 Change of Patient Profile and Attitudes 75 practice in Greece in 2014. The profile of this cohort was problems that visited the undergraduate clinic of the females (56.7%), non-smokers (60%) with a mean age of Aristotle University of Thessaloniki, Greece. All adults 48.3 years and a diagnosis of severe periodontal disease that visited the undergraduate periodontal clinic from (82.4%)2. In a study from the Emergency Clinic of Athens October 2014 to July 2015 were invited to participate in Dental School in Greece, data were analyzed from 553 this study anonymously. The only exclusion criterion that patients who visited the dental school seeking emergency was set was the age: all individuals had to be ≥18 years dental care3. A predominance of female subjects (53.5%) old. All participants were informed about the purpose among the dental emergency patients was reported, while of the study, their participation was voluntary, and it patients between 31 and 50 years were significantly more was explained that their participation will not influence than any other age group. The occupational status of the the provided treatment. Signed consent forms were patients varied significantly with unemployment being obtained from all participants. The protocol of the study the most reported status, while individuals working in was approved by the Ethical committee of the Aristotle the public sector and those who were self-employed University of Thessaloniki, School of Dentistry. represented significantly lower proportions when compared During the last session of periodontal treatment, the to those working in the private sector3. The general participants were asked to answer several questions that profile of an examined cohort at the Aristotle University evaluated their attitude and satisfaction regarding the of Thessaloniki, Greece included 53.5% females, 41.3% provided treatment. The interviews were carried out by smokers and 7.7% diabetics. The mean age of the one of the investigators without the presence of the dental included individuals was 50.5 years and 56.4% was in student in order to keep anonymous answers and have an need of non-surgical or surgical periodontal therapy as it unbiased result. was determined by the community periodontal index of The questionnaire utilized in this study included six treatment needs (CPITN)4. parts of questions: 1) demographic characteristics (age, Oral hygiene is effective in preventing caries and gender, occupation, family status, education level, area periodontal disease and oral health may be maintained of residency, smoking history, alcohol consumption); when tooth brushing is performed twice a day5. From a 2) environmental and behavioral characteristics total of 100 Greek adult patients between 18 to 25 years (brushing frequency, additional oral health care, types of age who answered a questionnaire of 23 items, 85% of additional care, previous dental visit); 3) diagnosis of reported brushing at least twice a day, while 56% declined periodontal disease; 4) medical history (hypertension, the use of dental mouthrinse6. Approximately three quarters hypotension, diabetes mellitus type 2, hyperthyroidism, of the examined population visited a dental office at least hypothyroidism, osteoporosis, psychological disorders, once a year and prevention was the primary reason of bleeding problems and cancer); 5) difficulties-satisfaction- dental visit (69%)6. The frequency of dental visits in proposals about periodontal treatment; and 6) history of Europe has been reported to be 2 times per year on average, periodontal therapy. Patients’ satisfaction was determined and for Greece, 2.7 visits annually have been recorded7. based on the answers to three questions: 1) satisfaction The mean reason of dental visits for Europeans is dental (little, quite, very), information provided (not at all, check-up or debridement, while 42% of Greeks attend a little, quite, very) and confidence (not at all, maybe/ dental practice for prevention according to the European not sure, sure). Findings at the clinical and radiographic Committee with women and young adults showing higher examination suggested the diagnosis of periodontal frequency than men and older adults, respectively7. disease which was made by the assigned dental student Although the profile of patients attending public and the supervising faculty member. entities and private practices in Greece as well as behavioral After the end of the interviews, the anonymous characteristics have been reported in the literature, patient questionnaires were collected and the data were analyzed satisfaction has been explored very limited. In addition, using a statistical software (SPSS v.19.0, IBM, Armonk, the effect of national economic collapse in Greece on NY, USA). Descriptive statistics such as mean values patients’ characteristics has not been compared adequately and standard deviations were conducted for continuous in Dentistry. Therefore, the purpose of this study was to variables. Total counts and percentages were calculated evaluate and compare patient profile, attitude and satisfaction for categorical variables. Associations between categorical of patients visiting a university periodontal clinic before and variables were examined using the chi-square test. The during the financial crisis in Greece. significance level was set to 0.05.
Material and Methods Results
This study was conducted to assess the profile, One hundred sixty-five adult periodontal patients attitude and satisfaction of individuals with periodontal aged between 18 and 85 years visited the undergraduate 76 Georgios Chatzopoulos et al. Balk J Dent Med, Vol 22, 2018 periodontal clinic of the School of Dentistry for periodontal 1b). The vast majority of the participants resided in urban therapy. Fifteen of them (9.1%) were refused to participate areas (83.3%) and were married (66%). Fifty-two percent due to limited available time or for personal reasons. The of the the population were smokers and 51.9% of them used final sample of the study consisted of 150 individuals, to smoker more than 15 cigarettes per day. With respect to mean aged of 51.6±12.3 years (age range from 18 to 85), the alcohol consumption, 26% of the sample population 46% of them were males, while 54% were females. When reported regular alcohol consumption. Self-reported asked about their occupation, 37.3% were employed, 33.3% medical history was significant for at least one condition in unemployed and 29.3% retired (Figure 1a). Regarding their the 59.3% of the participants with most frequent medical educational level, 51.3% had received secondary education, conditions being hypertension (55.7%), diabetes mellitus 24.7% higher and only 16.7% elementary education (Figure type 2 (23%) and cancer (18%).
Figure 1a. Characteristics of included population in regards to Figure 1b. Characteristics of included population in regards to occupational status educational status.
A portion of the population has been brushing their were mainly diagnosed with mild/early periodontal disease teeth more than twice a day, whereas 42% twice a day. The (50%) compared to married (29.3%), widower (33.3%) majority of the male patients (68.1%) reported brushing and divorced (11.1%) individuals. As far as the gender is once a day or less, whereas 64.2% of the female individuals concerned, male patients were more prone to be diagnosed at least twice a day (Figure 2a, p=0.001). Sixty-six percent with severe periodontal disease (46.4%) compared to of the patients reported that they had additional oral hygiene females (28.4%). Neither the level of education (p=0.11), habits, such as the use of interdental brush (47.5%), floss nor the residential area (p=0.26) were related significantly (16.1%), mouthwash (8.1%), or combination of them with the severity of the disease. (28.3%). Female subjects (77.8%) were more likely to use additional dental care habits compared to male participants (Figure 2b, 52.2%, p=0.001). With respect to the educational level, significant differences were observed in regards to the oral hygiene habits (Figure 3a). Individuals with no education reported only in 27.3% use of additional oral hygiene aids compared to participants with elementary (60%), secondary (71.4%) and university (70.3%) education (Figure 3b, p=0.028). Dental pain was the most frequent reason for a dental visit, while only 6% reported that they had a dental visit more than once a year. Severe periodontitis was the most common diagnosed disease (36.7%), whereas only 0.7% were diagnosed with aggressive periodontitis. Significant difference in the diagnosis was detected between retired, employed and unemployed. More than 50% of the retired participants (52.3%) were diagnosed with severe periodontal disease in comparison with the unemployed (36%) and the employed (25%) subjects (p=0.023). Additionally, statistically significant differences were identified regarding the family status (p<0.001), gender (p=0.05) and age (p<0.001). Particularly, single participants Figure 2a. Clustered columned graph presenting the frequency of brushing between male and female subjects. Balk J Dent Med, Vol 22, 2018 Change of Patient Profile and Attitudes 77
When asked about the reason of choosing dental school, the 30.7% claimed economic crunch, 22.7% had friends who visited the periodontal clinic in the past and 12.7% knew a student. In this section of the questionnaire multiple answers were accepted. The satisfaction ratio of the services and the attendant student proved to be extremely high (81.3%), whereas only 2.7% showed little satisfaction. High satisfaction was determined when on a scale from 1 to 3 patients selected 3, while little was considered in case they answered 1. Some patients had some proposals for changes (42%) concerning the working hours (30.2%), the organization of the clinic (11.1%), the location of the clinic (6.3%), as well as the dental instruments been used (9.5%). Approximately 50% of the patients felt very informed about the etiology of their oral disease and 38.7% adequately informed. A considerable
Figure 2b. Clustered columned graph presenting the use of additional percentage (82%) of the patients felt confident about their oral hygiene care between male and female subjects. treatment outcome, whereas only 16.7% felt doubtful about its success. Statistically significant more female participants (87.7%) reported confidence in the success of the treatment compared to males (75.4%, p=0.026). The treatment plan of 60 patients included tooth extractions with an average of 2.65±2.14 teeth per individual. The number of extractions ranged from 1 to 12. As for those planned extractions, the 48.8% of the patients did not show significant concern about their teeth loss but 18.6% felt very bad about losing a tooth. The last part of the questionnaire explored the history of periodontal therapy. In particular, 59.7% of the patients had received periodontal therapy in the past, such as scaling and root planing (57.3%) and prophylaxis (42.7%). Regarding the provider of the therapy, 67.4% of the participants was treated by a general dentist, 21.3% had received therapy from an undergraduate student and only 11.2% was treated by a periodontist. When asked Figure 3a. Clustered columned graph presenting the frequency of about the reason for stopping the therapy, data indicates brushing in reference to education. that 28.1% of the sample thought that the therapy was over after the initial treatment, 21.4% admitted negligence to continue their therapy and 14.6% claimed quitting due to financial reasons.
Discussion
In late 2009, the national economy in Greece started to collapse after a long period of prosperity. The present study aimed to evaluate the profile, the attitude and the satisfaction of individuals with periodontal problems attended a pre-doctoral periodontal clinic in Greece during financial crisis and compare it with data before the economic collapse8. The present study aims to add new knowledge in regards to the change of patient profile Figure 3b. Clustered columned graph presenting the use of additional and attitudes through a period of time before and after the oral hygiene care in reference to education. economic crisis in Greece. 78 Georgios Chatzopoulos et al. Balk J Dent Med, Vol 22, 2018
Table 1. Examined characteristic of the included population as of the included population as well as the population well as the population analyzed prior to the financial crisis analyzed prior to the financial crisis by Giannelis et al.8 are presented in Table 1. According to that study, the Characteristic Present study Previous study8 majority of the population of the clinic was females Gender with an average of 55 years of age, low socioeconomic Male (%) 69 (46.0) 63 (42.0) background, poor oral hygiene and smoking habits. Five Female (%) 81 (54.0) 87 (58.0) years later, in the present study, the age of the periodontal Occupation Employed (%) 56 (37.3) 59 (39.3) patients of the university clinic has been reduced to 51.6 Unemployed (%) 50 (33.3) 59 (39.3) years, while an increase in the number of males and Retired (%) 44 (29.3) 32 (21.3) smokers was detected. Oral hygiene has been improved Education showing that almost half of the sample population brushes No education (%) 11 (7.3) 5 (3.3) at least twice a day and two thirds uses additional oral Elementary (%) 25 (16.7) 56 (37.3) hygiene aids in a daily basis. In a similar study of 200 Secondary (%) 77 (51.3) 67 (34.6) adult dental patients who visited the periodontal clinic of University education (%) 37 (24.7) 22 (14.6) the University of Athens School of Dentistry for dental Residence treatment, similar number of female patients (53.5%) Urban (%) 125 (83.3) 123 (82.0) participated in the study9. The population seeking Rural (%) 25 (16.7) 27 (18.0) periodontal treatment was consisted by employed people Smoking (37.3%) with secondary education (51.3%) and university Yes (%) 78 (52.0) 63 (42.0) No (%) 72 (48.0) 87 (58.0) education (24.7%). Females (77.8%) and individuals with Alcohol secondary (71.4%) and university education (70.3%) Yes (%) 39 (26.0) 32 (21.3) presented to be statistically significantly more likely to No (%) 111 (74.0) 118 (78.8) use additional oral hygiene habits compared to males and Brushing frequency individuals with no education. Oral hygiene is a critical <1 time/day (%) 25 (16.7) 50 (33.3) factor for oral health and quality of life10. Female gender, 1 time/day (%) 51 (34.0) 63 (42.0) high level of education and non-smoking status have been 2 times/day (%) 63 (42.0) 35 (23.3) associated with satisfactory oral hygiene habits11. >2 times/day (%) 11 (7.3) 2 (1.3) The level of education and the occupation of the Additional care patients of the university dental clinic have changed Yes (%) 99 (66.0) 21 (14.0) dramatically during the last 5 years. In the previous study, No (%) 51 (34.0) 129 (86.0) retired people and housewives were primarily patients of Previous dental visit the periodontal clinic and 41.3% of the individuals had In pain (%) 83 (55.3) 98 (65.3) received none or only basic education8. The results could <1 time/year (%) 28 (18.7) 5 (3.3) 1 time/year (%) 30 (20.0) 33 (22.0) be attributed to the financial crisis that led employed >1 time/year (%) 9 (6.0) 14 (9.3) people and individuals with higher education that are Satisfaction currently unemployed to seek periodontal treatment in Little (%) 4 (2.7) 15 (10.0) clinics with low treatment cost. It is generally reported Quite (%) 24 (16.0) 80 (53.3) that subjects with low socioeconomic status are more Very (%) 122 (81.3) 55 (36.7) prone to develop periodontal disease compared to Proposal for changes individuals with high status12. According to our findings, No (%) 87 (58.0) 33 (22.0) retired individuals were statistically significantly more Yes (%) 63 (42.0) 117 (78.0) likely to be diagnosed with severe periodontal disease Information provided compared to employed and unemployed participants. In Not at all (%) 5 (3.3) 1 (0.7) agreement with this finding, Chatzopoulos and Tsalikis Little (%) 10 (6.7) 14 (9.3) found that older patients have increased periodontal Quite (%) 58 (38.7) 85 (56.7) treatment needs and males were more prone to have Very (%) 77 (51.3) 50 (33.3) complex treatment needs than females13. On the other Confidence hand, an insignificant association between education level Not at all (%) 2 (1.3) 1 (0.7) Maybe/ not sure (%) 25 (16.7) 25 (16.7) and periodontal disease was found. Sure (%) 123 (82.0) 124 (82.7) Smoking has been found to play a pivotal role in the onset, progression and treatment outcome of periodontal disease. Cross-sectional and case-control studies have A similar study was conducted in the undergraduate reported that smoking is significantly associated with an periodontal clinic at the Aristotle University of impaired periodontal health status, and cohort studies Thessaloniki in 2010, when the signs of the financial have demonstrated that there is an increase periodontal depression were not evident8. Examined characteristic destruction rate in smokers compared to non-smokers14. Balk J Dent Med, Vol 22, 2018 Change of Patient Profile and Attitudes 79
A meta-analysis of six clinical studies concluded that The results of the present study are limited to smokers have an increased risk for severe periodontal self-reported data and they should be interpreted with disease with odds ratio of 2.8215. According to this caution. Another limitation of the study is that the study study, 52% of the sample was smokers, 19.5% of them participants were in active periodontal treatment and was characterized as heavy smokers (>20 cig/day), were willing to participate in the survey. Therefore, the while 51.9% smokes at least half a pack of 20 cigarettes. sample may primarily consist of satisfied individuals that Smoking history and severity of periodontal disease were decided to continue their treatment in the undergraduate not significantly associated in the present study (p=0.5), periodontal clinic. There may be a difference in the while a previous study from our group demonstrated that satisfaction level for patients that discontinued the smokers were more likely to have periodontal pockets of treatment. Finally, the total number of the participants at least 6 mm than non-smokers in an older population in could be considered limitation of the study. However, it Greece13. Confounding factors including age may have represents the average size of the population that receives attributed to this finding. periodontal treatment in the pre-doctoral Periodontology The primary reason of seeking dental treatment at clinic of the Aristotle University of Thessaloniki. the university clinics was the limited financial resources. Similarly, other studies have reported that low cost was the most critical factor that led individuals to dental school clinics.16,17 Twenty-four percent of the sample Conclusions was motivated by multiple reasons including economic reasons, a relative or friend and a familiar student. The Within the limitations of this cross-sectional study, patients also proposed changes including working hours, the economic collapse in Greece after a long period of organization of the clinic, clinic location and instruments/ prosperity has affected patient profile and attitude. The units. Forty-two percent of the sample found that changes demographic characteristics of those who seek treatment are needed in the future, while the vast majority of them in a university setting have changed dramatically and (82%) were confident about the success of the treatment younger, more highly educated and employed individuals and 81.3% were completely satisfied with the quality of with higher socioeconomic status and good oral hygiene the services. Similar levels of satisfaction and confidence habits attend the undergraduate Periodontology clinic of have been reported in the literature8,18-20. Communication the Aristotle University of Thessaloniki, Greece compared with the dentist played a key role in overall patients’ with those who attended the university dental clinic prior satisfaction in a dental school setting in Japan21. to the financial crisis. With respect to the history of periodontal therapy, 60% of the sample population reported previous periodontal therapy, 57.3% of them reported having scaling and root planing by a general dentist (67.4%), References undergraduate student (21.3%) or periodontist (11.2%). The high percentage of individuals with history of 1. Karanikolos M, Mladovsky P, Cylus J, Thomson S, Basu periodontal therapy was expected due to the high S, Stuckler D, Mackenbach JP, McKee M. Financial crisis, frequency of periodontal disease diagnosis which is austerity, and health in Europe. Lancet, 2013;381:1323-1331. also related to the high prevalence of smoking (52%) 2. Delatola C, Adonogianaki E, Ioannidou E. Non-surgical and supportive periodontal therapy: predictors of compliance. J and other risks factors of periodontal disease such as Clin Periodontol, 2014;41:791-796. diabetes mellitus (23%). Previous research has also 3. Farmakis ET, Palamidakis FD, Skondra FG, Nikoloudaki G, shown that diabetics, overweight or obese, smokers Pantazis N. Emergency care provided in a Greek dental school and older subjects are significantly associated with and analysis of the patients’ demographic characteristics: a higher periodontal treatment needs than non-diabetics, prospective study. Int Dent J, 2016;66:280-286. individuals with normal weight (body mass index 18.5-25 4. Chatzopoulos GS, Tsalikis, Menexes G. Influence of Body 2 4 Mass Index and other periodontitis-associated risk factors kg/m ), non-smokers and younger patients, respectively . and risk indicators on periodontal treatment needs: a cross- The proposed treatment plan included extractions in sectional study. Oral Health Prev Dent, 2017;15:191-197. 60 patients with a mean value of 2.65±2.14 teeth per 5. Choo A, Delac DM, Messer LB. Oral hygiene measures patient (range from 1 to 12 teeth). Almost half of the and promotion: review and considerations. Aust Dent population (48.4%) was not concerned about the proposed J, 2001;46:166-173. extractions, while only 18.6% were very frustrated. In 6. Chatzopoulos GS, Koidou VP. Oral Hygiene and Nutrition Habits of Young People in Greece Aged 18 to 25 and Review contrast, a study in the United Kingdom reported that 45% of the Literature. Balk J Dent Med, 2014;18:133-143. of the study participants were unprepared to accept tooth 7. TNS opinion and social (co-ordinated by Directorate loss and in another study, Bergendal et al. acknowledged General Communication) Report for Oral Health special that total tooth teeth loss is a serious life event22,23. Eurobarometer. 330/ Wave 72-3, February 2010. 80 Georgios Chatzopoulos et al. Balk J Dent Med, Vol 22, 2018
8. Giannelis G, Tsalikis L, Koumpias A, Konstantinidis A. 18. Lafont BE, Gardiner DM, Hochstedler J. Patient satisfaction Profile, attitude, and satisfaction of patients visiting a in a dental school. Eur J Dent Educ, 1999;3:109-116. University clinic. Balk J Stom, 2010;14:8-15. 19. Damiano P, Warren J. A profile of patients in 6 dental 9. Karydis A, Komboli-Kodovazeniti M, Hatzigeorgiou D, school clinics and implications for the future. J Dent Educ, Panis V. Expectations and perceptions of Greek patients 1995:59:1083-1090. regarding the quality of dental health care. Int J Qual Health 20. Alvesalo I, Uusi-Heikkilä Y. Use of services, care-seeking Care, 2001;13:409-416. behavior and satisfaction among university dental clinic 10. Petersen PE, Kwan S. Evaluation of community-based patients in Finland. Community Dent Oral Epidemiol, oral health promotion and oral disease prevention- WHO 1984;12:297-302. recommendations for improved evidence in public health 21. Imanaka M, Nomura Y, Tamaki Y, Akimoto N, Ishikawa C, practice. Community Dent Health, 2004;21:319-329. Takase H et al. Validity and reliability of patient satisfaction 11. Al-Shammari KF, Al-Ansari JM, Al-Khabbaz AK, Dashti questionnaires in a dental school in Japan. Eur J Dent Educ, A, Honkala EJ. Self-reported oral hygiene habits and 2007;11:29-37. oral health problems of Kuwaiti adults. Med Princ Pract, 22. Davis DM, Fiske J, Scott B, Radford DR. The emotional 2007;16:15-21. effects of tooth loss: A preliminary quantitative study. Br 12. Craig RG, Boylan R, Yip J, Bamgboye P, Koutsoukos Dent J, 2000;188:503-506. J, Mijares D et al. Prevalence and risk indicators for 23. Bergendal B. The relative importance of tooth loss and destructive periodontal diseases in 3 urban American denture wearing in Swedish adults. Community Dent minority populations. J Clin Periodontol, 2001;28:524-535. Health, 1989;6:103-111. 13. Chatzopoulos GS, Tsalikis L. Periodontal treatment needs and systemic diseases in an older population in Greece. J Received on June 6, 2017. Clin Exp Dent, 2016;8:e32-37. Revised on August 1, 2017. 14. Bergstrom J. Periodontitis and smoking: an evidence-based Accepted on November 11, 2017. appraisal. Review. J Evid Based Dent Pract, 2006;6:33-41. 15. Papapanou PN. Periodontal diseases: Epidemiology. Ann Correspondence: Periodontol. 1996;1:1-36. Georgios S. Chatzopoulos, DDS 16. Damiano P, Warren J. A profile of patients in 6 dental Advanced Education Program in Periodontology, school clinics and implications for the future. J Dent Educ, Division of Periodontology, 1995:59:1083-1090. Department of Developmental and Surgical Sciences, 17. Francis JL, Niemann SS, Koerber LG. The ex-dental clinic University of Minnesota, Minneapolis, MN 55455, USA patient: what can we learn? J Dent Educ, 1989;53:244-245. e-mail: [email protected]
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The Levels of Serum Immunoglobulin A, G and M in Oral Inflammatory Cysts before and after Surgical Therapy
SUMMARY Oliver Dimitrovski1,2, Vancho Spirov1, Blagoja Background/Aim: Cysts which appear in the orofacial region are Dastevski3, Filip Koneski2 represented as common pathological changes which underlying mechanism 1Department of Oral Surgery and Implantology, of development is still not fully clear. In recent years, а dominant role in University Dental Clinical Center “St. Pantelejmon”, the pathogenesis of cysts belongs to the immunopathological reactions. Skopje, FYR Macedonia 2 It is assumed that the loss of bone in cysts is due to the presence of Department of Oral Surgery, Faculty of Dental complementary cascades, prostaglandins synthesis and numerous neutrophil Medicine, Ss. Cyril and Methodius University in Skopje, FYR Macedonia granulocytes. The main objective was to determine the levels of Ig G, A and 3Department of Prosthodontics, Faculty of Dental M in serum and saliva of patients with radicular, residual and periodontal Medicine, Ss. Cyril and Methodius University in cysts before and after the surgical treatment. Material and Methods: The Skopje, FYR Macedonia study included 185 patients, of which 150 patients were diagnosed with inflammatory cysts (radicular, periodontal and residual), while the control group consisted of 35 patients without presence of inflammatory cyst. The immunoglobulins were determined prior to the surgical removal of the cyst and one month after the procedure, when complete clinical wound healing was observed. The levels of these immunological markers were compared to each other before and after the cyst extirpation, taking into consideration the different cyst types. A comparison was also made between both examination and control group. Results: The difference of the basic values of the immunoglobulins before therapy and the basic values of the immunoglobulins in the control group was statistically significant only in the group of residual and pеriodontal cysts for IgG and IgM The difference of the average values of immunoglobulins (IgG, IgA and IgM) in the group with residual cysts before and one month after therapy is statistically significant (p=0.0000; p=0.0371; p=0.0276). A significant difference was registered in IgA among the three examined groups one month after surgical intervention. Conclusions: The levels of serum immunoglobulins in patients with inflammatory cysts were elevated before the treatment and dropped after the cyst removal. This study suggests that the IgA, IgG and IgM may play an important role in the occurrence, development and persistence of the cystic lesions. Key words: Periodontal Cyst, Radicular Cyst, Residual Cyst, Inflammation, Pathogenesis, ORIGINAL PAPER (OP) Immunoglobulins, Surgical Treatment Balk J Dent Med, 2018;81-86
Introduction controversial issues and enigmas associated with the complicated and insufficiently clarified etiopathogenic Cysts which appear in the orofacial region are changes in this pathological processes. common pathological changes with no clear underlying It is believed that the cysts are usually a consequence mechanism of development. For many years, scientists of a more complex pathogenic mechanism, in which the have been working on finding answers to many carrier of the pathogenic effect and reduced immunological 82 Oliver Dimitrovski et al. Balk J Dent Med, Vol 22, 2018 defense is mentioned, locally in the tissue and wider in mechanisms were also investigated in another study, the organism. There are numerous unresolved questions which points out that the complex interactions between for the initiating stimulus that is still unexplained and for numerous cytokines and other inflammatory mediators which there are numerous controversies. stimulate the tissue breakdown10. In recent years, а dominant role in the pathogenesis Piattelli et al. performed immunochemical and of cysts belongs to the immunopathological reactions. biological characterization of outer membrane proteins of Piattelli et al. showed that the appearance and Porphyromonas endodontalis. The authors indicated that development of the inflammatory cysts is conditioned the OMP-1 preparation contained numerous proteins with by the imunopathological reactions1. This insight does molecular mass with kDa 3111. not rule out the possibility that the mechanisms of The main objective of this study is to determine the development in the orofacial cysts are similar, but as levels of Ig G, A and M in serum and saliva of patients responsible factors there are other factors mentioned, with radicular, residual and periodontal cysts before and some of which are different in every cyst. after the surgical removal. Bernardi et al. suggest that for the sustenance and growth of apical cysts are responsible a number and combination of many factors involving an epithelial- stromal interactions2. Moreover, it was suggested that Material and Methods some systemic diseases and conditions may affect the outcomes of the treatment of the cytic lesions, suggesting Study design and sample collection that these factors may also have influence on their The study included 185 patients, of which 150 development3. comprised the examination group with clinically and Immune components in the periapical lesions radiogically diagnosed with inflammatory cysts in the may be the cause for bone destruction, as shown by orofacial region, and a control group consisted of 35 some experimental evidence4. It is assumed that the patients, without cystic lesions, confirmed with panoramic loss of bone is due to the presence of complementary x-ray. The examination group was subdivided into three cascades, prostaglandins synthesis and numerous groups, depending on the type of the cyst: radicular, neutrophil granulocytes. Moreover, changes in the CRP residual and periodontal cysts. All of the patients who levels, immunoglobulin levels, interleukins, tumor were included in this study were clinically monitored at necrosis factors, transforming growth factors and acute the Clinic for Oral Surgery at the Dental Clinical Center phase proteins were found to be elevated in patients St. Pantelejmon in Skopje. All the examinations were with periapical pathology in previous studies. These made after getting a positive response from the ethical findings suggest that the periapical lesions lead to committee from the Faculty of Dentistry in Skopje and increased systemic inflammation response5,6. Although signed informed consent from the patients. The inclusion the pathogenesis of chronic periodontal diseases is not criteria for the examination group was a presence of one clarified completely, it is still believed that the hydrolytic of the mentioned inflammatory cysts in the jaws (radicular, enzymes that facilitate destructive processes have their periodontal or residual). Both groups included patients at own impact on the pathogenesis. 20-60 years of age. The exclusion criteria for both groups Despite the evident role of the immune system in the represented presence of other inflammatory conditions pathogenesis of periodontal diseases, the importance of the humoral and cellular immune reactions is not exactly in the jaw not classified as cyst, as well as taking anti- emphasized. It is suggested that the chronic periodontitis inflammatory or antibiotic medication. Pregnant women is a result of the joint influence by both immune reactions, and patients with chronic and uncontrolled chronic disease but the difference in clinical manifestation is directly were also excluded from the study. The laboratory analysis associated with the quality of the immune responses. were performed in blood collected from the cubital vein Marton and Kiss found that several regulation from all of the patients. In the examination group, the mechanisms overlap during the formation of periapical blood collections were made right before the surgical inflammation and further, in the development of the treatment of the cyst and one month afterwards. inflammatory cysts. These pathways consist of complex Surgical treatment immunological changes of reparation and destruction7. In another review study of Marton et al. it is pointed out that The surgical treatment of the cysts in the examination the immune response of the host to the bacteria arising group was performed under local anesthesia. The from the tooth root canal system plays an important role mucoperiostal design was planned and performed in the development of such lesions8. depending on the localization and dimension of the Meyle et al. summarized that the innate immunity is lesion. A complete removal of the cystic lesion was primary responsible for the rapid molecular and cellular done with combined sharp and blunt dissection. It was response of the host in the inflammatory processes9. These ensured that the cysts were enucleated in toto, i.e. with Balk J Dent Med, Vol 22, 2018 The Levels of Serum Immunoglobulin 83 their whole epithelial lining and capsule. In cases with Results radicular and periodontal cysts, the teeth from which the cysts were arising were extracted. The bony walls of The immunological trials of the humoral immunity the cystic defect were further checked for consistency were made by blood analysis of the immunoglobulins and absence of any granulation or epithelial tissue. The before and one month after the surgical intervention. The confirmation of the clinical and radiological diagnosis difference of the basic values of the immunoglobulins was made with a histological evaluation. The presence before therapy and the basic values of the of chronic epithelium surrounding the cystic cavity and immunoglobulins in the control group was statistically cholesterol crystals were clear signs for setting the final significant only in the group of residual and pеriodontal diagnosis. The second blood collection from the patients cysts for IgG and IgM (Table 1). from the examination group was made one month after the procedure, after the complete clinical wound healing was Table 1. Average values of immunoglobulins before surgery in observed and in conditions of absence of postoperative the three examined groups and in the control group complications or early recidives. Control group Radicular cysts Laboratory analyses IgA IgG IgM IgA IgG IgM The laboratory analyses were done in the National Institute for Transfusion Medicine in the Faculty of Average 2.28 12.39 1.20 6.5 15.6 5.1 Medicine in Skopje. The immunological status in every participant from both examined and control groups was SD 1.019 3.96 0.35 19.8 8.8 14.1 registered through quantitative and qualitative evaluation of the humoral immunity. The humoral immune response p 0.2920 0.0872 0.1779 was monitored by determining immunoglobulins in the Control group Residual cysts serum from the collected blood, as previously described. Immunoglobulins IgA, IgG and IgM in the serum were IgA IgG IgM IgA IgG IgM determined with microelisa technique by Rook & Cameron, Engvall and Ulman12, 13. 96 microwell disks with flat Average 2.28 12..39 1.20 2.5 15.2 2.8 bottom were used for implementing the competitive type of microelisa technique. The concentration of SD 1.019 3.96 0.35 0.9 1.4 1.3 immunoglobulins in serum in this technique is inversely p 0.3429 0.0000 0.0000 proportional to the intensity of the enzymatic reaction by determining the optical density on basis of the level of Control group Periodontal cysts coloring. The isolated human immunoglobulin binds to the solid phase of the microwell disk and the excess binding IgA IgG IgM IgA IgG IgM sites are blocked by the non-reactive protein. The examined Average 2.28 12.39 1.20 2.5 15.3 3.2 serum or saliva and the conjugated antibody with enzyme were added equally to the plates after previous rinsing. SD 1.019 3.96 0.35 1.1 7.0 1.7 They compete with each other for binding sites in the same time. The concentration of the present antibody is in inverse p 0.4058 0.05 0.0000 correlation with the intensity of the enzymatic reaction, i.e. the higher concentration of the antibody means the lower enzymatic reaction and lower coloring. An appropriete The difference of the average values of conjugate Rubbitanihuman IgG, IgM or IgA HRP was used immunoglobulins (IgG, IgA and IgM) in the group with for determining each immunoglobulin. The normal values radicular cyst before and after one month after therapy is for IgA range from 0,90 to 4,50 g/L, for IgG from 8 to 18 statistically insignificant (p=0.1042; p=0.6284; p=0.1982); g/L and for IgM from 0,60 to 2,65 g/L. (Table 2. and Figure 1a). The difference of the average values of Statistical analyses immunoglobulins (IgG, IgA and IgM) in the group with The carried data was statistilcally analyzed in the residual cysts before and one month after therapy is software program Statistica version 7 for Microsoft statistically significant (p=0.0000; p=0.0371; p=0.0276); Windows. The distribution was checked with (Table 2. and Figure 1b). The difference of the average Colmogorov-Smirnof test. The differences between the values of immunoglobulins (IgG, IgA and IgM) in the parameters in the groups were tested with analysis of group with periodontal cysts before and one month the variance (ANOVA test) for dependent variables. The after therapy was statistically insignificant (p=0.0647; significance was set for p-value lower than 0,05. p=0.1966; p=0.1237); (Table 2. and Figure 1c). 84 Oliver Dimitrovski et al. Balk J Dent Med, Vol 22, 2018
Figure 1a. Mean values of immunoglobulins before and one month after Figure 1b. Mean values of immunoglobulins before and one month after the treatment of radicular cysts the treatment of residual cysts
Table 2. Average values of immunoglobulins before and one month after therapy in the three examined groups
No Average Minimum Maximum SD Radicular cysts IgA-before 50 6.44960 0.250000 103.0000 19.83398 IgG- before 50 15.56420 1.600000 45.7300 8.84192 IgM- before 50 5.10900 0.500000 102.0000 14.09074 IgA-after 1 m 50 1.95300 0.100000 4.7500 1.08098 IgG- after 1 m 50 14.96700 1.800000 42.7100 8.90236 IgM- after 1 m 50 2.51220 0.200000 7.8000 1.61098 Residual cysts IgA- before 50 2.55100 1.140000 4.6000 0.93140 IgG- before 50 15.15440 4.600000 102.0000 13.96158 IgM- before 50 2.86360 1.200000 6.6000 1.29485 IgA- after 1 m 50 3.52120 1.800000 8.9000 1.19220 IgG- after 1 m 50 13.27040 2.100000 33.2000 6.17416 IgM- after 1 m 50 2.29600 0.700000 4.6000 0.89768 Periodontal cysts IgA- before 50 2.54780 0.200000 4.7000 1.08287 Figure 1c. Mean values of immunoglobulins before and one month after IgG- before 50 15.35840 1.500000 35.9000 7.04143 IgM- before 50 3.20920 0.400000 7.9000 1.71278 the treatment of periodontal cysts IgA- after 1 m 50 2.06000 0.100000 4.7000 1.04335 IgG- after 1 m 50 13.39200 1.600000 41.6000 7.85264 IgM- after 1 m 50 2.26400 0.200000 6.8000 1.26568
Table 3. Difference among IgA, IgG and IgM prior to and after surgical intervention
SS df MS SS df MS F p IgA- before 507.0523 2 253.5261 19375.91 147 131.8089 1.92344 0.149763 IgG-before 4.1984 2 2.0992 15811.66 147 107.5623 0.01952 0.980675 IgM-before 146.1750 2 73.0875 9954.81 147 67.7198 1.07926 0.342523 IgA-1m 76.7634 2 38.3817 180.24 147 1.2261 31.30288 0.000000 IgG-1m 89.5644 2 44.7822 8772.77 147 59.6787 0.75039 0.473983 Igm-1m 1.8228 2 0.9114 245.15 147 1.6677 0.54652 0.580134
The difference between the average values of between the average values of immunoglobulins in the immunoglobulins before therapy and the average values examined groups was not statistically significant. Significant of immunoglobulins in the control group was statistically differences were observed in IgA values among the three significant only in the group with residual and periodontal examined groups one month after surgical intervention, cysts for IgG and IgM (Table 3). The difference registered compared to the levels before the procedure (Table 3). Balk J Dent Med, Vol 22, 2018 The Levels of Serum Immunoglobulin 85
Discussion immunoglobulins in radicular cysts (IgA- 488.9 mg/100 ml, IgG – 2535.4 mg/100 ml, IgM – 135.6 mg/100 ml), There are still concerns about the possible unlike the follicular (IgA -2308.4 mg/100ml, IgG – 1618.2 etiopathogenetic mechanisms responsible for the mg/100 ml, IgM – 155.6 mg/100 ml) and especially the emergence and development of cysts, which are a common odontogenic keratocysts (IgA – 135.6 mg/100 ml, IgG – appearance in the oral cavity. In theory, many potential 491.9 mg/100 ml, IgM – 54.1 mg/100 ml). etiological factors are mentioned, including microbiological Piattelli found that the specific antigens IgM, IgG allergologic, immunological and others. According to and IgA from the secreting cells (SFC) were enzymatically the literature data, all these factors participate in the dissociated into single cells suspended from chronically expression and development of cysts, despite their nature. inflamed periapical tissues11. In patients with radicular However, the present data are insufficient to support this cysts main isotopes of spontaneous SFC are IgG. These statement strongly. The contemporary knowledge about findings are in accordance with the results obtained in the nature of immune responses is more complex, but still our study. In the mentioned study from Piattelli et al., the it is impossible to fully define the detailed mechanisms. radicular cysts OMP-2 specific IgG were 0.13% of the Namely, when stimulated by foreign antigens, the organism total IgG. This finding is in accordance with the values may respond by creating specific antibodies (humoral gathered in our study, because the main immunoglobulin immune response) or by activation of the sensitized subdivision in the radicular cysts was the IgM. Parallel T-lymphocytes (cellular immune response). with these findings, the author confirmed that none of these The complementary system belongs to the category mononuclear cells produce antibodies specific to OMP-1, of amplification systems, and is activated by classical or liposaccharides for Porphiromonas endodontalis. and alternative way. Experimentally it has been proven In defining the role and importance of the that by activation of the complement different biological complex immune reactions among these diseases can changes happen, which include: cell lysis, immune help the parameters derived from the analysis of the 14 adherence, neutralization of viruses etc . inflammatory cell infiltrate in the periapical lesions and Unlike the humoral immunity, carriers of cellular its surroundings11. Although there are different findings in immune response are the T-lymphocytes and their role the literature, certain immunological parameters can play is manifested through the ability of a specific immune a role in the etiopathogensis of inflammatory cysts. response to foreign antigens in the organism. Antigenic Sometimes the presence of B-cells prevails over stimulation causes blast transformation of T-lymphocytes the presence of T-lymphocytes. In some studies the data that create true offspring of different T-cells. It is proven is contradictory, and T-cell population is more dominant. that for different activities of T-lymphocytes special These, and similar findings open new fields for research in populations exist. The breakthrough of monoclonal these still unclear fields. antibodies has serious participation in the discovery of some specific subclasses of T-cells: cytotoxic, helper, suppressor, killer etc. The mechanisms and pathways of the immune response are very complex, with a lot of different Conclusions cytokines and other inflammatory mediators being involved in the development of apical and periodontal The levels of immunoglobulins in the patients with pathological conditions7,8,9,10. Our examination of the level of immunoglobulins in the three examined groups inflammatory cysts in the orofacial region before the has shown certain changes. Before the surgical removal surgical treatment were elevated, depending on the type of of the cysts, different levels were obtained. Elevated IgA the cyst. The surgical removal of the cysts influenced the values were observed in participants with radicular cysts, levels of the immunoglobulins which significantly dropped. IgG were increased in all groups, while IgM levels were These findings suggest that the IgA, IgG and IgM may elevated in participants with radicular cysts. However, play an important role in the occurrence, development statistically significant findings were found only in those and persistence of the cystic lesions. Future studies are for IgG and IgM in radicular and periodontal cysts. After necessary to point out if these markers are associated with the cysts surgical removal and evaluation of the difference other systemic responses and factors and if their detection of average values between the level of immunoglobulins may be of importance in completely understanding the before and one month of therapy, there were statistically process of early formation of the cystic lesions. significant values in the group with radicular cysts for the three classes of immunoglobulins. The analysis of variance between the three groups one month after prescribed therapy showed no significant References difference in the values of IgA and IgM, but they did for IgA. Other authors determined similar results, 1. Piattelli A, Rubini C, Iezzi G, Fioroni M. CD1a-positive such as Kubota15, who found the highest values of cells in odontogenic cysts. J Endod, 2002;28:267-268. 86 Oliver Dimitrovski et al. Balk J Dent Med, Vol 22, 2018
2. Bernardi L, Visioli F, Nör C, Rados PV. Radicular Cyst: 11. Piattelli A, Fioroni M, Santinelli A, Rubini C. P53 protein An Update of the Biological Factors Related to Lining expression in odontogenic cysts. J Endod, 2001;27:459-461. Epithelium. J Endod, 2015;41:1951-1961. 12. Rook GA, Cameron CH. An inexpensive, portable, battery- 3. Aminoshariae A, Kulild JC, Mickel A, Fouad AF. operated photometer for the reading of ELISA tests in Association between Systemic Diseases and Endodontic microtitration plates. J Immunol Methods, 1981;40:109-114. Outcome: A Systematic Review. J Endod, 2017;43:514-519 13. Engvall E, Perlmann P. Enzyme-linked immunosorbent 4. Tay JY, Bay BH, Yeo JF, Harris M, Meghji S, Dheen ST. assay (ELISA). Quantitative assay of immunoglobulin. G. Identification of RANKL in osteolytic lesions of the facial Immunochemistry, 1971;8:871-874 skeleton. J Dent Res, 2004;83:349-353. 5. Gomes MS, Blattner TC, Sant’Ana Filho M, Grecca 14. Takeda Y, Oikawa Y, Furuya I, Satoh M, Yamamoto H. FS, Hugo FN, Fouad AF, et al. Can Apical Periodontitis Mucous and ciliated cell metaplasia in epithelial linings of Modify Systemic Levels of Inflammatory Markers? odontogenic inflammatory and developmental cysts. J Oral A Systematic Review and Meta-analysis. J Sci, 2005;47:77-81. Endod, 2013;39:1205-1217. 15. Kubota Y, Ninomiya T, Oka S, Takenoshita Y, Shirasuna 6. Graves DT, Cochran D. The contribution of interleukin-1 K. Interleukin-1alpha-dependent regulation of matrix and tumor necrosis factor to periodontal tissue destruction. J metalloproteinase-9 (MMP-9) secretion and activation in Periodontol, 2003;74:391-401. the epithelial cells of odontogenic jaw cysts. J Dent Res, 7. Márton IJ, Kiss C. Overlapping protective and destructive 2000;79:1423-1430. regulatory pathways in apical periodontitis. J Endod, 2014;40:155-163. Received on December 14, 2017. 8. Márton IJ, Kiss C. Protective and destructive immune Revised on January 27, 2018. reactions in apical periodontitis. Oral Microbiol Immunol, Accepted on January 29, 2018. 2000;15:139-150. 9. Meyle J, Dommisch H, Groeger S, Giacaman RA, Costalonga M, Herzberg M. The innate host response in Correspondence: caries and periodontitis. J Clin Periodontol, 2017;44:1215- Oliver Dimitrovski 1225. Department of Oral Surgery and Implantology 10. Silva N, Abusleme L, Bravo D, Dutzan N, Garcia-Sesnich University Dental Clinical Center “St. Pantelejmon” J, Vernal R, et al. Host response mechanisms in periodontal Majka Tereza 43, 1000, Skopje, FYR Macedonia diseases. J Appl Oral Sci, 2015;23:329-355. e-mail: [email protected]
10.2478/bjdm-2018-0015
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Comparison of Visual and Digital Color Measurement Methods on Anterior Natural Teeth
SUMMARY Sait Ege Eryürük1, Canan Hekimoğlu2, Elif Background/Aim: The purpose of this study was to evaluate Tuba Akçin1, Yeliz Çavuşoğlu3 compatibility between visual and digital color measurement methods. 1 Private Practice, Ankara, Turkey Material and Methods: The color measurement components of intact 2 Department of Prosthodontics, Faculty of natural maxillary right central incisor and left canine teeth of eighty Dentistry, Hacettepe University, Ankara, Turkey 3 patients were measured with visually shade guide and, digitally, with Acibadem University, Istanbul, Turkey digital device. The color matchings were performed for each teeth on labial surfaces divided into three regions: cervical, middle and incisal. Ligthness, MLR (M: means middle hue, L designates greener, R designates redder) and chroma levels were assessed for each tooth on divided regions respectively. Measurements were performed by the same and experinced dentist with healthy eyes. The data were analyzed with Kappa and weighted Kappa coefficient (p< 0.05). Results: The compatibility between visual and digital methods did not exist for MLR and chroma. The compatibility between both methods were determined only for ligthness of maxillary central and canine teeth at all regions of labial surfaces. Conclusions: There was compatibility only for ligthness of intact natural teeth at all regions with both methods. ORIGINAL PAPER (OP) Key words: Natural Teeth, Teeth Color, Color Measurement Devices Balk J Dent Med, 2018;87-92
Introduction dimension. Moreover, there are some optical properties like transparency, translucency or opacity, related to In dentistry, there are different devices for color appareance of an object. Besides, metamerism and matching such as conventional shade guides and flourence might affect the appareance of an object under technological products1. Conventional clinical shade different lightening conditions4. guides are easily available in dental clinics. It seems that There are two major methods for specification of technological products would have more effeciency for color3; one of the methods is color order system such shade matching for prosthetic and restorative treatments. as Munsell System, Ostwald System, OSA-UCS, DIN Different methods could raise doubts for detecting color System, Coloroid Color System and Natural Color and color parameters. It may be confusing for dentists System and Coloroid Color System. These methods are to choose a most appropriate at times. Therefore, it was used especially in color education and industry. The emphasized that there is no standardization for color second main method is colorimetry. Colorimetry is based matching2. on color science and used for color measurement and There is consensus that color matching is challenging procedure in restorative dentistry1. It is respected that specifying. Color measuring instruments are components restoration in mouth could have ideal or acceptable color, of colorimetry. Colorimetry is spesified with light source, 3 in harmony with natural teeth and patient’s face. object and human eye . Color is defined as physicophysical sensation that Color measurement depends on subjective variables; results in perceptual response of eye to the light reflected therefore, findings and results of color measurements from objects3. Color is specified by hue, colorfulness can be different among clinicians and, also, in the same and brigthness. This means perception of color in three person at different times5. The colorimetry is designed for 88 Sait Ege Eryürük et al. Balk J Dent Med, Vol 22, 2018 flat surfaces6 but in dentistry it is used by clinicians for consistently matched with all shade guides and various natural teeth with curved surfaces7,8. surfaces of ligth3. Because of that, maxillary central Color matching could be difficult for observers9. incisors and canine teeth were selected for the present Because there are some deliminations related to observers study. The surfaces of each teeth were divided into three such as difference of color perception, sensivity, parts cervico-incisally for both measuring methods. experience, receiver’s age, fatigue of eye, mood, usage Firstly, the color of each teeth of patients was of drugs and medication. Besides metamerism, surface evaluated using shade guide. The findings were recorded properties of the teeth, variation of color for different teeth on the chart. Then, digital color measurement device in the same person and light source may complicate the was used acccording to instructions of the manufacturer. 10-14 dedection of the color . Consequently, lightness level, MLR (M means middle Color measurements for restorative materials can hue, L designates greener, R designates redder) and be performed with standard guides, spectophotometers, chroma level of each teeth were determined with both colorimeters, or digital photography in routine clinical matching systems3. 1,3 application . Besides, color matching of soft tissues, Chi square test and extension of Fisher’s exact test such as gingiva and human skin, should be taken in to r*c tables were used to determine the distrubution of 15 consideration in some cases . lightness, hue and chroma values with respect to age and Some studies have been focused on shade matching gender regarding to methods. Agreement between visual of natural teeth and restorative materials - ceramic 16-19 shade matching and digital matching methods lightness crowns, merely porcelain - metal crowns . Other and chroma data was determined with Kappa and studies have been carried out using different shade weighted Kappa coefficient and also, MLR data with the matching systems for human teeth2,5,20-22. same approach. Level of significance was determined with The purpose of this study was to evaluate the color p value (p< 0.05). matching of natural anterior teeth using shade guide and digital measurement methods. The null hypothesis was that there would not be a significant difference between visual and digital color measurement methods. Results
The frequencies of age groups of participants included Material and Methods in the present study are shown in table 1. Lightness, MLR and chroma measurements for each teeth with two methods Color matching procedure were performed for and gender are presented in Figures 1 and 2. eighty healthy volunteers (42 females and 38 males), with a mean age of 48.11 years (range 18 to 80) and with their Table 1. Distributions of patients according to age group maxillary natural and intact anterior teeth surrounded Age Frequency Percent with healthy periodontal tissue, using shade guide and digital measurement device. The exclusion criteria were < 40 28 35.1 an existence of a systemic disease, usage of medication, 40-59 29 36.3 a history of fever disease and taking antibiotics during childhood and having teeth that have been bleached ≥ 60 23 28.6 before. Total 80 100.0 Two methods were employed by the same experienced researcher; a visual shade matching (Vitapan D - Master Tooth Guide, Vita Zahnfabrik, Bad- Säckingen, Gemany) There were no difference at three regions (cervical, and digital imaging (Vita Easyshade Compact Vita middle and incisal of labial surfaces) of central incisors Zahnfabrik, Bad-Säckingen, Germany). The measurements for ligthness, MLR and chroma values regarding gender were performed in the same clinic and on the same dental with visual measurement method (Table 2). The similiar unit that was used for seating of each participant under results were found at cervical (p> 0.05) and middle region day light at 2 o’clock pm. Firstly, teeth were brushed by (p> 0.05) for ligthness values and also for MLR values at participants according to the modified Stillman method23. all regions (p> 0.05) and chroma values at incisal region Patients were asked to remove facial make ups and eye (p> 0.05) with digital measurement regarding gender; glassses and jewelllery. The patient was seated in upright however, ligthness value at incisal region (p< 0.05) and position with mouth level at the researcher’s eye level. chroma values at cervical (p< 0.05) and middle regions Maxillary incisor locates in the center of the face and (p< 0.05) of central incisors showed significant difference stomatognatic system, and the canine was the tooth most with digital measurement (Table 2). Balk J Dent Med, Vol 22, 2018 Measurement on Anterior Teeth 89
V-F: Visual measurement of female patients V-M: Visual measurement of male patients D-F: Digital measurement of female patients D-M: Digital measurement of male patients MLR: Middle (M) means middle hue, L designates greener, R designates redder Lightness (1,2,3,4,5): A lower number corresponds to higher lightness Chroma (1, 1.5, 2, 2.5, 3): Higher number corresponds to more chromatic Figure 1. Percentage of lightness, MLR and chroma for central incisors with visual and digital measurement methods
V-F: Visual measurement of female patients V-M: Visual measurement of male patients D-F: Digital measurement of female patients D-M: Digital measurement of male patients MLR: Middle (M) means middle hue, L designates greener, R designates redder Lightness (1,2,3,4,5): A lower number corresponds to higher lightness Chroma (1, 1.5, 2, 2.5, 3): Higher number corresponds to more chromatic Figure 2. Percentage of lightness, MLR and chroma for canins with visual and digital measurement methods 90 Sait Ege Eryürük et al. Balk J Dent Med, Vol 22, 2018
Table 2. The results of the measurements with both methods regarding gender for central incisors and canine teeth
Central incisors Canine teeth Visual measurement Digital measurement Visual measurement Digital measurement Cervical Middle Incisal Cervical Middle Incisal Cervical Middle Incisal Cervical Middle Incisal Lightness NS NS NS NS NS S S S S S S S MLR NS NS NS NS NS NS NS NS NS NS NS NS Chroma NS NS NS S S NS NS NS NS NS NS NS MLR: Middle (M) means middle hue, L designates greener, R designates redder S: Significant NS: Nonsignificant
When canins were considered with gender, there were middle regions with digital measurement method were significant differences for lightness values at cervical, significantly different. Differences between MLR values middle and incisal regions with both measurement methods of incisal and cervical regions determined with visual (p< 0.05). The results at three regions of MLR and chroma method and digital measurement were not statically values were not significantly different (p> 0.05) (Table 2). significant (p>0.05). Chroma values of all regions with When it comes to age; for the central incisors, ligthness values at all regions showed significant visiual measurement were not statically significant. differences with both visual and digital measurement Chroma values were found statically significant at methods. Similarly, MLR values of middle region cervical and middle region with digital measurement with visual method and MLR values of cervical and method but for incisal region (Table 3).
Table 3. The results of the measurements with both methods regarding age for central incisors and canins
Central incisors Canine teeth
Visual measurement Digital measurement Visual measurement Digital measurement Cervical Middle Incisal Cervical Middle Incisal Cervical Middle Incisal Cervical Middle Incisal
Lightness S S S S S S S S S S S S
MLR NS S NS S S NS NS NS NS NS NS NS Chroma S S S S S NS S S S NS NS NS MLR: Middle (M) means middle hue, L designates greener, R designates redder S: Significant NS:Nonsignificant
For canins, ligthness values showed statically these values were not significantly different for digital significant differences with visual and digital measurement (Table 3). measurements method similar to the central incisors. When the findings were analyzed with Weighted However, chroma values of cervical, middle and incisal Kappa; ligthness, MLR and chroma values of central regions were significantly different when determined incisors and canins, measured by visual and digital with visual measurement method. MLR values did measurement methods, showed harmonic results among not show any significant differences. Additionally each other (Table 4).
Table 4. Results of compatibility of visual and digital methods
Central incisors* Canine teeth* Cervical Middle Incisal Cervical Middle Incisal Lightness 0.85 0.92 0.87 0.83 0.89 0.76 MLR 0.53 0.38 0.54 0.42 0.37 0.31 Chroma 0.58 0.45 0.32 0.29 0.32 0.44 MLR: Middle (M) means middle hue, L designates greener, R designates redder *Kappa coefficient: 0.80-1.00 Excellent, 0.60-0.80 high harmonic, 0.40-0.59 intermediate, 0.40< slight Balk J Dent Med, Vol 22, 2018 Measurement on Anterior Teeth 91
Discusion There is a disaggrement about which method is the best for color measurement. It was already Digital and visual methods color measurements of emphasized in previous studies that representing color space of natural teeth can not be determined using shade teeth were employed in this study. Both methods have the guides21,27, whereas, in another study, it is implied that same components such as of lightness, MLR and chroma. visual measurement is the best method in spite of the According to the results, the null hypothesis that there developments of color matching systems4. would not be a significant difference between visual and An in vivo study aimed to compare the agreement digital color measurement methods was rejected. rate of three digital color measurement devices with the Regarding gender, ligthness values at incisal region visual shade identification. It was reported that agreement and chroma values at cervical and middle regions of rates were significantly different among the digital color central incisors showed significant difference with digital measurement devices compared to visual shade guide28. measurement. Regarding age, ligthness values of the After all, a well trained observer is needed to achieve central incisors at all cervical, middle and incisal regions accurate dental color measurement29. showed significant differences both visual and digital measurement methods. Similarly, MLR values at middle region with visual method and MLR values at cervical and middle regions with digital measurement method were Conclusions statically significant. Ligthness values of the canine teeth showed statically significant differences with visual and Within the limitation of the present study, these digital measurements method. conclusions can be drawn: There is an investigation performed by Goodkind and 1. There was no compatibility between visual and Schwabaher25 with a similar method to the present study. digital methods for MLR and chroma measurements of Chroma scan colorimeter was used to measure the color maxillary central incisors and canine teeth at all regions; of maxillary and mandibular anterior teeth considering 2. The measurements of lightness, the compatibility color ranges, demographics, age group and tooth position. between visual and digital methods were excellent for It was concluded that the middle region of the teeth central incisors and canine teeth at all regions; represents the best color and that teeth tend to become 3. Natural teeth with curved surfaces are darker and more reddish with advancing age. Additionally, polychromatic and translucent. A specified method for canins are darker than incisors. color measurement of natural teeth is needed. The color of the maxillary central incisor tooth in the center of labial surface and also attached gingiva, lips and facial skin was measured with spectroradiometer respecting age and gender in a study done by Gozalo- References Diaz et al26. According to the results of that study, age and gender were found to be statistically significant 1. Chu SJ, Thrushkowsky RD, Paravina RD. Dental color matching instruments and systems. Review of clinical and determinants in predicting the color of central incisors. 2 research aspects. J Dent, 2010;38s:e2-e16. In an in vivo study, Paul et al. determined the color 2. Paul S, Peter N, Pietrobon N, Hämmerle CHF. Visual of maxillary central incisors by visual analysis with a spectrophotometric shade analysis of human teeth. J Dent shade guide and spectrophotometer. They concluded that Res, 2002;81:149-152. spectrophotometric analysis is more accurate than visual 3. Paravina RD, Powers JM. Esthetic color training in assesment for color matching. Additionally, Schropp24 dentistry. St. Louis: Elsevier Mosby; 2004. performed an in vitro study comparing visual and 4. Vichi A, Louca C, Corciolani G, Marco F. Color related to ceramic and zirconia restorations: a review. Dent Mater, digital color measurement method comprising digital 2011;27:97-108. photography and computer software. It was concluded 5. Hammad IA. Intrarater repeatability of shade selections with that digital photographs and computer software were more two shade guides. J Prosthet Dent, 2003;89:50-53. confidential than conventional methods. 6. Havwood VB, Leonard RH, Nelson CF, Brunson WD. A study examining color differences between Effectiveness, side effects and long term status of night guard all ceramic crowns for maxillary central incisors vital bleaching. J Am Dent Assoc, 1994;125:1219-1226. and intact natural maxillary central incisors in 6 7. Seghi RR, Johnston WM, O’Brien WJ. Performance areas of labial surface was performed using a dental assesment of colorimetric devices on dental porcelains J 10 Dent Res, 1989;68:1755-1759. spectrophotometer . It was emphasized that individual 8. Goodkind RJ, Keenan KM, Schwabacher WB. A methodology widely used in many studies. Color comparison of chromascan and spectrophotometric color measuring instruments had the varied factors which have measurements of 100 natural teeth. J Prosthet Dent, been used for indiustrial use and also variations in objects. 1985;53:105-109. 92 Sait Ege Eryürük et al. Balk J Dent Med, Vol 22, 2018
9. Laugouvardos PE, Dramanti H, Polyzois G. Effect of 21. Hugo B, Witzel T, Klaiber B. Comparison of in vivo visual individual shades on realibility and validity of observers in and computer-aided tooth shade determination. Clin Oral color matching. Eur J Prosthodont Restor Dent, 2004;12:51-56. Invest, 2005;9:244-250. 10. Fondires J. Shade matching in restorative dentistry: The 22. Wee AG, Kang EY, Jere D, Beck FM. Clinical color match science and strategies. Int J Periodontics Rest Dent, of porcelain visual shade-matching systems. J Esthet Restor 2003;23:467-479. Dent, 2005;17:351-358. 11. Ahmad I. Three-dimensional shade analysis: Perspectives of 23. Newman MG, Takei H, Klokkevold P, Caranza FA. color. Part II. Pract Periodont and Esthet Dent, 2000;12:557- Caranza’s clinical periodontology. 10th ed. Los Angeles: 564. Sauders; 2012. 12. Miller LL. Shade selection. J Esthet Dent, 1994;6:47-60. 24. Schropp L. Shade matching assisted by digital photography 13. Wang H, Xiong F, Zhenhua L. Influence of varied surface and computre soft ware. J Prosthodont, 2009;18:235-241. texture of dentin porcelain on optical properties of porcelain 25. Goodkind JR, Schwabacher WB. Use of a fiber-optic specimens. J Prosthet Dent, 2011;105:242-248. colorimeter for in vivo color measurements of 2830 anterior 14. Douglas RD, Steinhauer TJ, Wee AG. Intraoral teeth. J Prosthet Dent, 1987;58:535-542. determination of the tolerance of dentists for perceptibility 26. Gozalo-Diaz D, Johnston WM, Wee AG. Estimating the and acceptability of shade mismatch. J Prosthet Dent, color of maxillary central incisor based on age and gender. J 2007;97:200-208. Prosthet Dent, 2008;100:93-98. 15. Jahangiri L, Reinhardt SB, Mehra RV, Matheson PB. 27. Sproull RC. Color matching in dentistry. Part II. Practical Relationship between tooth shade value and skin color: An applications of the organization of color. J Prosthet Dent, observational study. J Prosthet Dent, 2002;87:149-152. 1973;29:556-566. 16. Ishikawa-Nagai S, Yoshida A, Sakai M, Kristansen J, Da 28. Igiel C, Weyhrauch M, Wentaschek S, Scheller H, Lehmann Silva JD. Clinical evaluation of perceptibility of color KM. Dental color matching: A comparison between visual differences between natural teeth and all-ceramic crowns. J Dent, 2009;37:e57-e63. and instrumental methods. Dent Mater, 2016;35:63-69. 17. Cook WD, McAree DC. Optical properties of esthetic 29. Knezović D, Zlatarić D, Illeš IŽ, Alajbeg M, Žagar. In restorative materials and natural dentition. J Biomed Mater Vivo Evaluations of Inter-Observer Reliability Using VITA Res, 1985;19:469-488. Easyshade® Advance 4.0 Dental Shade-Matching Device. 18. Raigrodski AJ, Chiche GJ, Aoshima H, Spiekerman CF. Acta Stomatol Croat, 2016;50(1):34-39. Efficacy of a computurized shade selection system in matching the shade of anterior metal ceramic crown: a pilot Received on September 9, 2017. study. Quintessence Int, 2006;37:793-802. Revised on November 8, 2017. 19. Paul SJ, Peter A, Rodoni L, Pietrobon N. Conventional Accepted on December 2, 2017. visiual vs. spectrophotometric shade taking for porcelain fused to metal crowns. A clinical comparison. Int J Correspondence: Periodontics Restorative Dent, 2004;24:222-231. Elif Tuba Akçin 20. Fani G, Vichi A, Davidson CL. Spectrophotometric and İlkbahar Mahallesi Güneypark Küme Evleri 23F/41 visual shade measurements of human teeth using three shade Oran TR-06450 Ankara/Turkey guides. Am J Dent, 2007;20:142-146. e-mail: [email protected]
10.2478/bjdm-2018-0016
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Treatment of Maxillary Retrusion- Face Mask with or without RPE?
SUMMARY Elona Kongo Background/Aim: Maxillary transverse deficiency often combines Faculty of Medical Science, Albanian University, with retruded maxillary skeletal position causing a skeletal class III Albania malocclusion. In these cases combination of rapid palatal expander and a facial mask to protract the maxilla is a very effective treatment protocol. When the maxilla is not deficient is it necessary to use palatal expansion before protracting? Should we use this combination because it has been proved to be effective? The aim of this paper is to show that maxillary protraction is also effective when applied without expanding the maxilla although there are some statistically significant changes. Material and Methods: Two groups of 20 patients each, were created for this study. The first group were treated with rapid palatal expansion and face mask. In the second group, patients were treated only with face mask. Results: Measurements made at T0 (prior to treatment) and those at T1 (after treatment) were statistically analyzed. At the end of the treatment patients of the 1st group showed significant difference for the values of SNA, SNB, ANB angles (p=0.000). Significant changes were observed also for the second group (SNA, SNB, ANB). The only differences between the two groups were observed regarding SNA angle (p=0.040) and maxillary incisor inclination (p=0.028). Conclusions: At the end of treatment, all patients showed skeletal class III correction and improved facial appearance. Significant changes of SNA angle were observed for each group. There were also significant changes in the position of the mandible. These changes contributed in skeletal class III correction but there was no significant difference between them. ORIGINAL PAPER (OP) Key words: Maxillary Retrusion, Face Mask, Rapid Palatal Expansion Balk J Dent Med, 2018;93-97
Introduction advancement suggested attempts to advance the maxilla, with the aim of balancing the mandible. In 1960 Jean Class III malocclusion is a multifactorial etiology Delaire, a French surgeon who dealt with the treatment dysmorphosis that encompasses a broad spectrum of of palatoschisis used the facial mask to protract the dental alterations or skeletal, which have in common maxilla. a disharmonious proportion between the maxilla and In the coming years other authors have made mandible, with mandibular protrusion, maxillary modifications to the mask or and anchoring elements. The retrusion and the combination of both. Various authors expansion is intended to open the circummaxillary sutures in their studies have found maxillary retusion the most or “disarticulate” the maxilla to allow for its protraction. common cause of skeletal class III malocclusion1-7. The combination of rapid expansion and postero- In 1944 Oppenheim convinced that it was anterior traction of maxilla through facial mask protocol impossible to control growth or mandibular constitutes an almost unique treatment of skeletal class III 94 Elona Kongo Balk J Dent Med, Vol 22, 2018 malocclusion caused by maxillary transverse deficiency Material and Methods and retrusion. By using this protocol several effects can be achieved The sample for this study consisted of 40 patients (21 such as anterior displacement and counterclockwise girls, 19 boys), average age (10y, 7mos) with maxillary rotation of the maxilla, downward and backward rotation retrusion and/or transverse maxillary deficiency. Inclusion of the mandible, forward movement of upper incisors, criteria were: Skeletal class III caused by maxillary retroclination of mandibular incisors, and increase in the retrusion ANB (-), molar and/or canine class III, no 2,8.9 previous orthodontic treatment. lower face height . Among this treatment effects there The sample was divided in 2 groups with 20 patients is also the improvement of the profile with an esthetic each. The first group (11 girls, 9 boys, and mean age 10y, benefit for the patients with maxillary retrusion. The 5mos) was treated with postero-anterior traction with change of the profile and also the remarkable change of facial mask (FM). The second group (10 girls, 10 boys, the facial appearance almost always encourage a better and mean age 10y, 1mos) was treated with maxillary cooperation from the patients. expansion and postero-anterior traction (RPE-FM). The aim of this paper is to show that maxillary Initial treatment records included study models, extra protraction is also effective when applied without and intraoral photographs, panoramic and lateral X-rays. expanding the maxilla although there are some Cephalometris analysis was performed using 15 angular statistically significant changes. and linear measurements (Figures 1 & 2).
Figure 1. Angular measurements Figure 2. Linear measurements
Treatment protocol
For the patients of FM group the Verdon double arch served as anchor unit (Figure 3).
Figure 3. The double arch Verdon
All patients were asked to wear the facial mask 14 hours/day. A total force of 600gr were used, traction Fiureg 4. Direction of traction direction was 300 under the occlusal plane (Figure 4). Balk J Dent Med, Vol 22, 2018 Maxillary Retrusion 95
The second group RPE-FM was treated by applying FM group the extraoral traction after maxillary expansion. Same wearing of facial mask was asked. The force was 600 gr At the end of the treatment patients of this group and traction direction was 300 under the occlusal plane. showed significant difference for the values of SNA, Statistical analysis SNB, ANB angles (p=0.000). The increase of SNA Measurement made at T0 (prior to treatment) and angle with 1.550 indicates the efficacy of facial mask those at T1 (after treatment) were statistically analyzed. by advancing the maxilla. There were also linear After determining the distribution of the data and measurements that confirmed the efficacy of the homogeneity of variance, an independent sample test was used to assess the differences between the groups. treatment such as increase of A point and Wits. The Statistical significance was indicated by a p value 0.05. vertical measurement showed no significant differences (Table 4). Dental effect were also observed and the end of the Results treatment. The inclination of maxillary incisors was 4.550 Descriptive analysis for the 1st and 2nd group are (p=0.000). This can be considered a desired effect since showen in Table 1. and 2. The t-test was used to make the they are retruded as well as the maxilla in the patients comparison between the groups (Table 3). with skeletal class III.
Table 1. Descriptive analysis for the 1st group
Ave SE DS Measurement p T0 T1 T0 T1 T0 T1 SNA 78.39 80 0.496 0.464 2.1 2.02 0.000 SNB 81 79.61 0.474 0.295 2.06 1.2 0.000 ANB -2.5 0.39 0.361 0.358 1.57 1.560 0.000 SNGOME 33.37 33.89 0.568 0.586 2.47 2.55 0.123 FH-GOME 26.39 26.68 0.790 0.508 3.442 2.212 0.020 Y axis 66.68 67.00 0.2841 0.301 1.238 1.312 0.360 U1-PP 100.50 105.13 0.848 0.770 3.697 3.358 0.000 L1-GOME 87.58 88.42 1.041 0.797 4.53 3.083 0.069 Co-A 80.05 81.74 1.329 0.762 5.795 3.32 0.107 Co-Gn 105.45 109.13 2.132 1.83 9.29 7.9841 0.000 Wits -3.553 -1.97 0.2475 0.272 1.078 1.184 0.000 A point -2.58 -0.74 0.240 0.214 1.044 0.933 0.000 Go-Me 73.1316 75.02 1.506 1.425 6.576 6.214 0.502 Se-N 69.736 72.23 1.620 1.614 7.063 7.036 0.222 E line -.0631 -0.39 0.362 0.295 1.579 1.286 0.348
Table 2. Descriptive analysis for the 2nd group Measurement Ave SE DS p T0 T1 T0 T1 T0 T1 SNA 77.47 79.77 0.499 0.4552 2.23 2.03 0.000 SNB 79.98 78.80 0.437 0.354 1.93 1.58 0.000 ANB -2.55 0.075 0.28 0.38 1.25 1.72 0.000 SNGOME 32.95 33.67 0.506 0.504 2.26 2.255 0.000 FH-GOME 25.25 26.13 0.7159 0.656 3.20 2.933 0.000 Y axis 66.55 66.93 0.357 0.331 1.59 1.480 0.030 U1-PP 103.98 108.58 1.348 1.048 6.02 4.68 0.000 L1-GOME 85.53 85.45 1.221 1.030 5.462 4.605 0.977 Co-A 80.18 81.22 1.29 1.260 5.779 5.637 0.000 Co-Gn 104.53 106.58 1.894 1.603 8.470 7.168 0.009 Wits -4.20 -1.73 0.255 0.234 1.140 1.045 0.000 A point -2.950 -1.20 0.2638 0.236 1.179 1.056 0.000 Go-Me 73.03 75.05 1.781 1.8205 7.964 8.141 0.065 Se-N 66.90 67.7 1.395 1.339 6.240 5.99 0.060 E line -0.50 -0.03 0.295 0.263 1.318 1.175 0.011 96 Elona Kongo Balk J Dent Med, Vol 22, 2018
Table 3. Comparison using t test between the groups RPE-FM group Group FM RPE-FM Measurement Mes DS Mes DS p As shown in Table 5 after expansion and traction SNA 80 2.02 79.77 2.03 0.040 there is significant maxillary advancement (at T0 SNA- 0 0 SNB 79.61 1.2 78.80 1.58 0.227 angle 77.47 atT1 79.77 , p=0.000). In achieving better ANB 0.39 1.560 0.075 1.72 0.265 correction of skeletal class III helps also reduction of SNGOME 33.89 2.55 33.67 2.255 0.777 SNB (p=0.000). Maxillary advancement by this treatment FH-GOME 26.68 2.212 26.13 2.933 0.436 protocol is confirmed also by the increment of A point Y axis 67.00 1.312 66.93 1.480 0.793 with 1.75mm and Wits with 2.47mm. Clinically changes U1-PP 105.13 3.358 108.58 4.68 0.028 observed in the vertical plane helped in correction of cross L1-GOME 88.42 3.083 85.45 4.605 0.321 bite and better facial aesthetics. Co-A 81.74 3.32 81.22 5.637 0.848 Co-Gn 109.13 7.9841 106.58 7.168 0.062 Table 5. The p value for the 2nd group Wits -1.97 1.184 -1.73 1.045 0.572 A point -0.74 0.933 -1.20 1.056 0.136 Measurement T0 T1 dif p Go-Me 75.02 6.214 75.05 8.141 0.992 SNA 77.47 79.77 2.30 0.000 Se-N 72.23 7.036 67.7 5.99 0.061 SNB 79.98 78.80 -1.47 0.000 E line -0.39 1.286 -0.03 1.175 0.294 ANB -2.55 0.075 2.625 0.000 SNGOME 32.95 33.67 0.725 0.000 Table 4. The p value for the 1st group FH-GOME 25.25 26.13 0.88 0.000 AKSI Y 66.55 66.93 0.325 0.030 Measurement T0 T1 dif p U1-PP 103.98 108.58 4.60 0.000 SNA 78.39 80 1.550 0.000 L1-GOME 85.53 85.45 0.029 0.977 SNB 81 79.61 -1.47 0.000 Co-A 80.18 81.22 1.04 0.000 ANB -2.5 0.39 2.89 0.000 Co-Gn 104.53 106.58 2.05 0.009 SNGOME 33.37 33.89 0.526 0.123 Wits -4.20 -1.73 -2.47 0.000 FH-GOME 26.39 26.68 0.29 0.120 Pika A -2.950 -1.20 -1.75 0.000 Y axis 66.68 67.00 0.32 0.360 Go-Me 73.03 75.05 2.2 0.065 U1-PP 100.50 105.13 4.550 0.000 Se-N 66.90 67.7 0.8 0.060 L1-GOME 87.58 88.42 0.8 0.069 Linja E -0.50 -0.03 0.475 0.011 Co-A 80.05 81.74 2.00 0.001 Co-Gn 105.45 109.13 3.775 0.107 Analysis of two protocols confirmed their efficacy Wits -3.553 -1.97 1.06 0.000 in the treatment of skeletal class III malocclusion due A point -2.58 -0.74 -1.82 0.000 to maxillary retrusion (Table 6). The only differences Go-Me 73.1316 75.02 0.25 0.502 between the two groups were SNA angle (p=0.040) and Se-N 69.736 72.23 1.56 0.222 maxillary incisor inclination (p=0.028). Regarding the other E line -.0631 -0.39 -1.07 0.348 measurements no significant differences were observed.
Table 6. The p value for the comparison between 2 groups
Group FM RPE-FM Measurement T0 T1 dif T0 T1 dif p SNA 78.39 80 1.550 77.47 79.77 2.30 0.040 SNB 81 79.61 -1.47 79.98 78.80 -1.47 0.227 ANB -2.5 0.39 2.89 -2.55 0.075 2.625 0.265 SNGOME 33.37 33.89 0.526 32.95 33.67 0.725 0.777 FH-GOME 26.39 26.68 2.336 25.25 26.13 0.88 0.436 Y axis 66.68 67.00 0.32 66.55 66.93 0.325 0.793 U1-PP 100.50 105.13 4.550 103.98 108.58 4.60 0.028 L1-GOME 87.58 88.42 0.8 85.53 85.45 0.029 0.321 Co-A 80.05 81.74 2.00 80.18 81.22 1.04 0.848 Co-Gn 105.45 109.13 3.775 104.53 106.58 2.05 0.062 Wits -3.553 -1.97 1.06 -4.20 -1.73 -2.47 0.572 A point -2.58 -0.74 -1.82 -2.950 -1.20 -1.75 0.136 Go-Me 73.1316 75.02 0.25 73.03 75.05 2.2 0.992 Se-N 69.736 72.23 1.56 66.90 67.7 0.8 0.061 E line -.0631 -0.39 -1.07 -0.50 -0.03 0.475 0.294 Balk J Dent Med, Vol 22, 2018 Maxillary Retrusion 97
Discussion Conclusions
One of the most important effects of this treatment In absence of maxillary transverse deficiency by the increase in SNA angle observed in other studies1,3,7 protracting maxilla it is possible to correct skeletal class can be observed in this paper as well. Respectively, III without expanding. This means that is not always 1.50 degree and 2.30 degree for the FM group and necessary to expand because maxillary protraction can RPE-FM group were the changes indicating maxillary correct skeletal class III malocclusion. advancement. Significant changes in the mandibular position also contributed to the class III correction in both groups. The downward and backward movement of the chin expressed in this study was described by Ishii et References al.6, Takada et al.12, and Nartallo-Turley10 using palatal expansion with a facemask. Various soft tissue changes 1. Kapust AJ, Sinclair PM, Turley PK. Cephalometric effects combined to improve the patient’s class III profile. The of facemask/expansion therapy in Class III children: a comparison of three age groups. Am J Orthod Dentofacial changes of the profile was more convex due to forward Orthop, 1998;113:204-212. movement of the upper lip and retraction of the lower 2. Baik HS. Clinical results of the maxillary protraction lip, thus soft tissue pogonion moving back and menton in Korean children. Am J Orthod Dentofacial Orthop, moving down as described by Kapust et al.1. 1995;108:583-592. A very important factor in the successful treatment 3. Baccetti T, McGill JS, Franchi L, McNamara JA Jr, Tollaro I. of skeletal class III malocclusion is patient`s age. Takada Skeletal effects of early treatment of Class III malocclusion et al.12 examined 61 Japanese female patients with class with maxillary expansion and face-mask therapy. Am J III malocclusion, divided into three groups (7 to 10 years, Orthod Dentofacial Orthop, 1998;113:333-343. 4. Ellis E, McNamara JA Jr. Components of adult Class III 10 to 12 years, and 12 to 15 years). They concluded that malocclusion. J Oral Maxillofac Surg, 1984;42:295-305. a greater orthopedic effect was observed when therapy 5. Guyer EC, Ellis EE, McNamara JA Jr, Behrents RG. was applied before or during the pubertal growth spurt Components of Class III malocclusionin juveniles and (7 to 12 years). Baik2 studied maxillary expansion and adolescents. Angle Orthod, 1986:56:7-30. protraction in 47 Korean subjects, divided into three 6. Ishii H, Morita S, Takeuchi Y, Nakamura S. Treatment effect groups (<10 years, 10 to 12 years, and 12 years or older). of combined maxillary protraction and chincap appliance He concluded that age did not show any statistically in severe skeletal Class III cases. Am J Orthod Dentofacial significant difference in treatment effects of expansion/ Orthop, 1987;92:304-312. 7. Kim JH, Viana MA, Graber TM, Omerza FF, BeGole EA. The facemask therapy. Braun11 studied 63 subjects aged 4–13 effectiveness of protraction face mask therapy: a meta analysis. and found that expansion/facemask therapy produces Am J Orthod Dentofacial Orthop, 1999;115:675-685. dentofacial changes that combine to improve class III 8. Macdonald KE, Kapust AJ, Turley PK. Cephalometric malocclusion. They reported that, although early treatment changes after the correction of Class III malocclusion may be the most effective, facemask therapy can provide a with maxillary expansion/facemask therapy. Am J Orthod viable option for older children as well. Dentofacial Orthop, 1999;116:13-24. Mean age of patients for this study was 10.7 years. 9. McNamara JA Jr. An orthopaedic approach to the treatment The result obtained are in accordance with previous of Class III malocclusion in growing children. J Clin Orthod, 1987;21:598-608. studies2,11,12 but cannot be compared in order to determine 10. Nartallo-Turley PE, Turley PK. Cephalometric effects of the best age for starting the treatment. In order to find combined palatal expansion and facemask therapy on class such conclusion the sample must be larger and divided III malocclusion. Angle Orthod, 1998;68:217-224. according to age. At the end of treatment, all patients 11. Braun S. Extra oral appliances:a twenty-first century update. showed skeletal class III correction and improved Am J Orthod Dentofacial Orthop, 2004;125:624-629. facial appearance. Significant changes of SNA angle 12. Takada K, Petdachai S, Sakuda M. Changes in dentofacial were observed for each group. This indicates maxillary morphology in skeletal class III children treated by a advancement. There were also significant changes in the modified protraction headgear and a chin cup; a longitudinal cephalometric appraisal. Eur J Orthod, 1993;15:211-221. position of the mandible. These changes contributed in skeletal class III correction but there was no significant Received on April 17, 2017. difference between them. Revised on June 8, 2017. The significant difference of SNA angle in RPE- Accepted on July 22, 2017. FM group has not only statistical significance. Clinically implies more stable results. This may also help in Correspondence: compensation in case of unfavorable mandibular growth. The other difference found regarding maxillary incisors Elona Kongo Department of Dentistry, in the RPE-FM group could be considered desired effect Faculty of Medical Science since they were retruded and more proclination not Albanian University, Tirana, Albania affecting the aesthetics. e-mail: [email protected]
10.2478/bjdm-2018-0017
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Biological Drilling: Implant Site Preparation in a Conservative Manner and Obtaining Autogenous Bone Grafts
SUMMARY Eduardo Anitua Background/Aim: The drilling process for insertion of an implant Eduardo Anitua Foundation, Vitoria, Spain should be as conservative as possible, as not to damage the future implant bed. If this drilling is conservative additional bone can be obtained to be used afterwards, during the same surgery, as bone graft particulate if needed. The objective of this study was to evaluate the efficiency of a biological low-speed drilling and to analyse the bone obtained in order to ascertain viability and vitality of the contained bone cells. Also, the bone obtained from the low-speed drilling was compared with bone obtained with high speed drilling and irrigation, collected through a filter in aspiration system. Material and Methods: In this pilot study, samples of biological drilling (low speed without irrigation) were collected in five patients undergoing implant surgery. In the same patients a high speed drilling with irrigation was also used. Bone of the drilling was collected through a filter in the aspiration system. Subsequently the samples were analysed by conventional histology and cultivated in order to observe cell growth. Results: The samples of bone obtained by biological drilling showed live cells in the conventional optical microscopy and cell growth after cultivation. The bone obtained with drilling at high revolutions showed no living cells and no cell growth after cultivation. Conclusions: The biological drilling at low speed offered two advantages compared to drilling at high speed with irrigation. The first of these is the perfect control of the drilling depth as the marks of the burs are visible during drilling; the second is possibility of collection of a large number of viable particulate bone grafts without increasing time and complexity of the surgery, which allows immediate augmentation of bone if needed. ORIGINAL PAPER (OP) Key words: Biological Drilling, Bone Viability, Regeneration Balk J Dent Med, 2018;98-101
Introduction avoid over-heating of the bone and preserve cell viability, in addition to reducing the time required for preparation of The objective of drilling for the insertion of a dental the implant site1-3. implant is realization of a new alveolus that is adapted The objective of this study was to evaluate the to the morphology of the implant that will be placed. It efficiency of a biological low-speed drilling and to is accomplished by using burs to withdraw bone at the analyse the bone obtained in order to ascertain viability implant site. This preparation of the implant site should be as conservative as possible to avoid damage of bone cells and vitality of the contained bone cells. Also, the bone that will be responsible for successful osseointegration of obtained from the low-speed drilling was compared with the implant once inserted. Most of the implant systems on bone obtained with high speed drilling and irrigation, the market use a drilling at high speed with irrigation to collected through a filter in aspiration system. Balk J Dent Med, Vol 22, 2018 Implant Site Preparation 99
Material and Methods The bone collected during biological drilling remained embedded in PRGF-Endoret fraction 2 (not In this pilot study, samples of biological drilling (low activated) until the time of its analysis. Plasma rich in speed without irrigation) were collected in five patients growth factor was prepared using PRGF-Endoret Kit undergoing implant surgery. In the same patients a high (BTI, Vitoria, Spain). Briefly, citrated venous blood was speed drilling with irrigation was also used. Bone of the centrifuged at 480 rpm for 8 minutes to separate blood drilling was collected through a filter in the aspiration components. Then, plasma column was fractioned into system (Figures 1 & 2). fraction 2 (F2) defined as the 2 ml of plasma above the buffy coat and fraction 1 (F1) defined as the plasma column above the F2. The bone collected from the high speed drilling (filter) was preserved in saline solution (0.9%). Flap elevation and Bone drilling: patients received respectively 1 g of amoxicillin 1 hour before surgery and 1 g of acetaminophen 30 minutes before surgery. Under local anaesthesia, a full-thickness flap was reflected to expose the alveolar crest for implant site preparation. Bone drilling was performed at low velocity (150 rpm) without irrigation and the drilling sequence was adapted to the bone type in the selection of the diameter of the last bone drill used before implant placement. The last implant inserted at high revolutions was made with the same sequence of burs but to 1200 rpm with constant irrigation Figure 1. Collection of bone during biological drilling from the bur throughout the process. Once the implants were inserted, the flap was repositioned and closed with 5/0 monofilament suture. Histopathological analysis: A portion of each sample was analysed by conventional histological processing and optical microscope (haematoxylin-eosin and Masson’s trichrome). Isolation and culture cells: Alveolar bone cells were obtained by biological drilling (entrapped into drills) and high speed drilling (filter). The cells were collected in phosphate-buffered saline PBS with antibiotics and antimycotics. Tissue was explanted in Osteoblast Medium with antibiotics, 15% foetal bovine serum (FBS, Biochrom AG, Leonorenstr, Berlin, Germany) and osteoblast growth supplements (Sciencell Research Laboratories, Carlsbad, California, USA). Alveolar bone cultures (Figure 3) were incubated at 37ºC Figure 2. Collection of bone during high speed drilling from the filter in a humidified 5% CO2 atmosphere and medium was changed twice a week. Cells derived from alveolar bone were characterized The inclusion criteria were patients aged over 18 by immunofluorescence. Expression of two osteoblast years, implants insertion in sound bone and the need for markers was analysed by osteopontin (Sigma-Aldrich) more than one implant to be able to compare the collected and osteocalcin (Acris Antibodies GmbH, Schillerstr, bone after low speed and high speed drilling. Herford, Germany) antigens. Moreover, alkaline Prior to surgery and in order to make a proper phosphatase activity (Sigma-Aldrich) was detected in treatment plan, all patients underwent standard diagnostic all the primary bone cultures. In all cases the osteoblast protocol consisting of reviewing the medical and dental phenotype was confirmed by the high positivity of the history, diagnostic casts, and radiographic evaluation three markers. (panoramic radiographs and cone-beam CT scan). The When osteoblasts reached 60-70% confluence cone-beam CT scans were analysed with diagnostic (after approximately 3-4 weeks), they were detached and software (BTI Scan II, Biotechnology Institute, Vitoria, serially passaged. Cell viability was tested by Trypan Blue Spain) to measure both the residual bone height and the dye exclusion (Sigma-Aldrich, St Louis, Missouri, USA) bone density at implant sites. - Figure 4. 100 Eduardo Anitua Balk J Dent Med, Vol 22, 2018
Figure 5. Sample obtained after high speed drilling process. Compact bone (hematoxylin-eosin x10 - Optical Microscopy) - the bone has no cells
Figure 3. Alveolar bone cultures with osteoblasts
Figure 6. Sample obtained after biological drilling process. In this case the cells are alive (hematoxylin-eosin x60- Optical Microscopy)
Figure 4. Cell viability tested by Trypan Blue dye exclusion
Results Figure 7. Images obtained with an inverted optical microscope x20 of primary cultures of osteoblasts derived after biological drilling bone Looking at all samples with conventional optical using the technique of explant microscopy, we observe one essential difference. Bone in the filter was acellular, without living cells in the bone spaces where they should be placed (Figure 5), while Due to the absence of cells in bone obtained by in the bone obtained by biological drilling we observe high speed drilling, it was not possible to cultivate and living cells intact in their bone structure The bone of the expand osteoblasts. Bone obtained through biological biological drilling with optical microscopy shows alive drilling was cultivated by the technique of explants. cells, maintained bone architecture and the size of bone This bone was distributed in fragments on the surface particles was significantly higher (Figure 6). of cultivation. Once distributed, ObM was added with Balk J Dent Med, Vol 22, 2018 Implant Site Preparation 101 antibiotics and antifungals (300 µl) and maintained in References incubator white room. A periodic review of the surfaces of cultivation was done. The follow-up was realized 3 days 1. Shapurian T, Damoulis PD, Reiser GM, Griffin TJ, Rand a week, and annotation was done at the day in which the WM. Quantitative evaluation of bone density using cells in culture appeared. The migration and proliferation the Hounsfield index. Int J Oral Maxillofac Implants, of osteoblasts was positive in all the samples cultures 2006;21:290-297. obtained by biological drilling (Figure 7). 2. Lekohlm UZG. Patient selection and preparation. In: Branemark PIZG, Alberktsson T (Eds.). Tissue-integrated prostheses: Osseointegration in clinical dentistry. Quintessence Publishing, Chicago. 1985; pp:199-209. 3. Misch CE. Density of bone: effect on treatment plans, Discussion surgical approach, healing, and progressive bone loading. Int J Oral Implantol, 1990;6:23-31. Insertion of a dental implant carries perforation of 4. Trisi P, Todisco M, Consolo U, Travaglini D. High bone to form a cavity that allows placing a dental implant. versus low implant insertion torque: a histologic, This procedure is an aggression to the bone due to the histomorphometric, and biomechanical study in the sheep withdrawal of part of its mass and heat that is generated in mandible. Int J Oral Maxillofac Implants, 2011;26:837-849. the workplace4-8. To remedy the excessive heating of bone 5. Sennerby L, Meredith N. Resonance frequency analysis: in the area of drilling, generally, irrigation with saline measuring implant stability and osseointegration. Compend solution is used. This irrigation minimizes the temperature Contin Educ Dent, 1998;19:493-498. of bone, but makes impossible the collection of bone 6. Szmukler-Moncler S, Salama H, Reingewirtz Y, Dubruille removed by drilling process8-10. Biological drilling at low JH. Timing of loading and effect of micromotion on bone- dental implant interface: review of experimental literature. J revs maintains a safe temperature of bone, and bone can Biomed Mater Res, 1998;43:192-203. be collected during preparation of the implant bed. During 7. Chen YC, Hsiao CK, Ciou JS, Tsai YJ, Tu YK. Effects of 11 such a drilling, cellular vitality is not affected . implant drilling parameters for pilot and twist drills on Therefore, the bone graft obtained after biological temperature rise in bone analog and alveolar bones. Med drilling and embedded in the patient’s plasma proteins Eng Phys, 2016;38:1314-1321. (PRGF®-Endoret fraction 2) is a comparable alternative 8. Pandey RK, Panda SS. Drilling of bone: A comprehensive to the use of autologous grafts or other biomaterials for review. J Clin Orthop Trauma, 2013;4:15-30. bone augmentation procedures. 9. Augustin G, Zigman T, Davila S, Toma Udilljak T, Staroveski T, Brezak D et al. Cortical bone drilling and thermal osteonecrosis. J Clin Biomech, 2012;27:313-325. 10. Noble B. Bone microdamage and cell apoptosis. Eur Cell Conclusions Mater, 2003;6:46-56. 11. Anitua E, Alkhraisat MH, Piñas L, Orive G. Efficacy of biologically guided implant site preparation to obtain Biological drilling at low revs gives us two adequate primary implant stability. Ann Anat, 2015;199:9-. advantages compared to drilling at high speed with irrigation. The first of these is the perfect control of the Received on November 11, 2017. drilling depth as the marks of the burs are visible at all Revised on December 24, 2017. times to minimize the invasion of anatomical structures Accepted on January 8, 2018. by accident. The second advantage is the collection of a large number of viable particulate bone grafts, without Correspondence: increasing the time and complexity of the surgery. This Eduardo Anitua collection of bone allows us the treatment of areas C/ Jose Maria Cagigal 19 in the same surgical phase that would require bone 10005 Vitoria, Spain augmentation. e-mail: [email protected]
10.2478/bjdm-2018-0018
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A Case of Dental Fusion in Primary Dentition from Late Bronze Age Greece
SUMMARY Paraskevi Tritsaroli Background/Aim: Dental fusion is a developmental abnormality The Malcolm H. Wiener Laboratory for that can occur in primary and/or permanent dentition. Case report: A Archaeological Science, ASCSA case of double primary teeth from a Late Bronze Age cemetery in Greece is presented. Age estimation of the skeleton was based on dental eruption and development as well as on fusion of primary ossification centres of the cranial and post-cranial skeleton. Analysis of double teeth used morphology, anatomy, location, tooth count and radiological examination. Results showed a 18 month infant. Primary lower right central and lateral incisors were joined by the dentin, and they had distinct crowns and separated pulp chambers; each tooth maintained its own root canal and resembled a normal primary central and lateral incisor shape respectively. Diagnosis showed that double teeth were the result of partial fusion rather than gemination. No other dental abnormalities or lesions were recorded and subsequent teeth were not affected. Conclusions: This is the first example of double teeth in primary dentition reported in the literature from archaeological assemblages in Greece. Being one of the rare examples of dental fusion in the bioarchaeological record, this report adds further to the mapping of dental anomalies in past populations. CASE REPORT (CR) Key words: Fused Teeth, Primary Dentition, Greece, Late Bronze Age Balk J Dent Med, 2018;102-105
Introduction populations several cases of fused teeth, primary or permanent, have been documented including either two or Double teeth are a developmental anomaly that three adjacent teeth or involving surnumerary teeth2-3,12-17. describes adjacent teeth joined by the dentin or pulp and Few examples of double teeth are included in the modern occur in two different ways: by gemination and by fusion1,2. clinical record in Greece18,19. In gemination, one tooth splits into two teeth while fused Tooth fusion is rare in archaeological populations and teeth are two separate teeth that have fused into one tooth. only a small number of cases are documented20-23. The aim Gemination and fusion may look virtually identical. of this report is to present a case of fusion of two adjacent Differential diagnosis between fusion and gemination primary teeth displayed by an infant from a Late Bronze Age is difficult to make especially if a supernumerary tooth is cemetery in central Macedonia and make this data available involved2-6. Differences between the frequency, distribution for comparative analysis. To our knowledge, this is the first and associated developmental anomalies suggest that fusion example reported from an archeological context in Greece. and gemination result from independent mechanisms and probably have different genetic control3. Double teeth affect less than 1% of children among Caucasians6 while 2.8% of primary dentitions would be Case Report affected in Japanese, Chinese and possibly Amerindian children7; this frequency shows little variation depending The case presented here came from the Late Bronze on the population sample examined7-11. In living Age (LBA) cemetery of Rema Xydias. The site was Balk J Dent Med, Vol 22, 2018 Dental Fusion 103 located on the foothills of Mount Olympus in southern Pieria, in close proximity to the modern village of Platamonas. The excavation at Rema Xydias was carried out in 2014 and revealed a LBA settlement and cemetery (1400-1200 BCE); the cemetery was one of the very few and richly furnished LBA cemeteries in Northern Greece and it testified the presence of the Mycenaean civilization at the southern border of central Macedonia (Koulidou, unpublished data). The Minimum Number of Individuals (MNI) of the sample was 45. Cist Grave 18 revealed a double burial including an infant skeleton in primary position (skeleton 18.1) and the disturbed primary burial Figure 2. Lingual view of the fused incisors of a child (skeleton 18.2); the double teeth were recorded on skeleton 18.1. Human skeletal remains were analyzed at the Malcolm H. Wiener Laboratory for Archaeological Science (ASCSA) in 2016. Analysis used the methods outlined in Buikstra and Ubelaker for complete skeletons24. Age estimation for subadults was based on dental eruption and development25 and it was assisted by radiography in order to take into account teeth buds in the alveolar bone; age estimation also considered fusion of primary ossification centres of the cranial and post- cranial skeleton26. Similarly, double teeth were analyzed macroscopically under normal light conditions and radiographically. Age-at-death of skeleton 18.1 was estimated at 18m±6months; no attempt was made to estimate the sex of this infant from its bones because methods published for sexing infant skeletons are either not fully validated or have low accuracy26,27. Fourteen primary teeth and eight Figure 3. Labial view of the mandible and the fused incisors permanent teeth buds were preserved (the fused teeth were counted as one). The maxilla was poorly preserved and ten maxillary teeth and teeth buds were recorded without their alveolar bone. On the contrary, the mandible was almost complete; all preserved primary teeth were erupted except both primary second molars and permanent first molars’ buds that were in the alveolar bone (Figures 1a & b).
Figure 4. Apical view of the fused Figure 5. Radiograph of the fused incisors incisors, labial view
Figure 1. Radiograph of the preserved right (a) and left (b) parts of the In apical view, the teeth showed two roots fused mandible together with two distinct root canals (Figure 4). Radiographic examination confirmed that the teeth were Macroscopic examination revealed that the primary joined by the (confluent) dentin, they had separated pulp lower right central and lateral incisors were joined; they chambers and each tooth maintained its own root canal did not show mirror image of the coronal halves but they (Figure 5). Finally, the number of teeth in the dental arc was reduced because fused teeth were counted as one had ‘separate’ crowns and roots. Vertical labio-lingual unit. The development of the permanent dentition seemed grooves defined two distinct, coronal and root, segments unaffected and no extra or missing teeth were observed each one resembling a normal primary central and lateral macroscopically or radiographically according to the dental incisor shape respectively (Figures 2 & 3). age of the individual. No dental caries were recorded. 104 Paraskevi Tritsaroli Balk J Dent Med, Vol 22, 2018
Discussion macroscopic and radiographic examinations support the diagnosis of incomplete fusion rather than gemination; In their review of literature, Schuurs and van partial fusion suggests that the affected teeth fused later Loveren2 reported various diagnostic criteria for fusion in development, after the calcification stage and the and gemination including morphology, anatomy, location, formation of crowns6,28. Fused teeth were free of dental crowding and counting; in addition to radiography, Uӱs diseases and no other dental abnormalities were recorded. and Morris6 used also histology. In the present report, the Obviously, this unique case of fused incisors cannot be differential diagnosis was based on morphology, anatomy, used to make inferences on the genetic background of this location, tooth count and radiological examination. In infant nor the population from which it came. general, fusion usually shows differences in the two halves of the joined crown while in gemination these are often mirror images. In addition, fused teeth have two distinct pulp chambers and two discernable roots Conclusions and root canal systems while in gemination there is only one root2,28,29. Finally, counting teeth can be useful to In sum, this report includes the first evidence differentiate between fusion and gemination (the double of double teeth in primary dentition reported from teeth are counted as one): if the dental arcade contains a archaeological context in Greece and one of the rare normal set of teeth, then the double teeth are recorded as examples of dental fusion in the bioarchaeological record. gemination. On the contrary, if the dental arc misses one Finally, this report adds further to the mapping of dental tooth, then the double teeth are classified as fusion30. anomalies in past populations. Dental fusion is a developmental anomaly that can occur in primary and/or permanent dentition. This Acknowledgements defect arises through the union of two or more normally The author wishes to thank the Institute of Aegean 28,29 separated tooth germs during odontogenesis . The Prehistory (INSTAP) for funding the analysis of human union of adjacent teeth, jointed by the dentin, may involve skeletal remains, the excavator Sophia Koulidou either the crown or the root or both of them. Fusing can be (Ephorate of Antiquities of Pieria) for providing complete or incomplete (partial) depending on time when archaeological information, and Anastasia Bania for the force causing the narrowing of the space between conserving human remains. Special thanks are also due the tooth germs appeared during development29. Fused to Dr. Dimitris Michailidis (The M.H. Wiener Laboratory teeth affect more frequently the primary than permanent for Archaeological Science, ASCSA) for x-ray analysis, dentition, they are found usually unilateral than bilateral, Professor Maria Liston (University of Waterloo) for mostly in the lower than upper dentition, and most helpful assistance and the anonymous reviewers for their commonly in the incisor and canine region2,7,14,29,31; substantial comments. epidemiological studies have shown that both genders are equally affected2. The causative factors of this anomaly remain unknown but could be the interplay of environmental influences and genetic predisposition. It is reported in References the literature that the pressure or physical forces can 1. Hagman FT. Anomalies of form and number, fused primary produce close contact between two developing teeth; this teeth, a correlation of the dentitions. ASDC J Dent Child, contact causes the necrosis of the epithelial tissue that 1988;55:359-361. separates them and leads to their fusion. Other researchers 2. Schuurs AHB, van Loveren C. Double teeth: review of the suggest a relationship between fusion and fetal alcohol literature. ASDC J Dent Child, 2000;67:313-325. exposure, thalidomide embryopathy, hypervitaminosis A 3. Gurri FD, Balam G. Inheritance of Bilateral Fusion of the as well as a variety of syndromes3,11,14,29,32. Furthermore, Lower Central and Lateral Incisors: A Pedigree of a Maya heredity seems to have an important implication in the Family from Yucatan, Mexico. Dent Anthropol, 2006;19:29-34. development of this anomaly as evidenced in family 4. Nunes E, Moraes IG, Novaes PM, Sousa SMG. Bilateral and twin studies3,12,33. Fused teeth are vulnerable to Fusion of Mandibular Second Molars with Supernumerary be affected by caries in the groove dividing the bifid Teeth: Case Report. Braz Dent J, 2002;13:137-141. crown, periodontal disease and spacing problems4,34,35. 5. Ntaoutidou S, Dermata A, Dimitraki D, Arapostathis K. Dental fusion and gemination in primary dentition. Furthermore, fusion of primary teeth may be associated Paidodontia, 2016;30:67-75. with development disturbances in the permanent 6. Uÿs H, Morris D. ‘Double’ teeth – a diagnostic conundrum. successors such as microdontia, delayed tooth formation Dent Update, 2005; 32:237–239. 8,9,13,33,36,37 or even congenital absence of tooth . 7. Yonezu T, Hayashi Y, Sasaki J, Machida Y. Prevalence of The infant from Rema Xydias in Greece showed congenital dental anomalies of the deciduous dentition in double teeth with ‘separate’ crowns and roots. The Japanese children. Bull Tokyo Dent Coll, 1997;38:27-32. Balk J Dent Med, Vol 22, 2018 Dental Fusion 105
8. Grahnen H, Granath LE. Numerical variations in primary 24. Buikstra JE, Ubelaker DH. Standards for Data Collection dentition and their correlation with the permanent dentition. from Human skeletal remains. Fayetteville, Ark.: Arkansas Odontol Revy, 1961;12:348-357. Archaeological Survey; 1994. 9. Hagman FT. Anomalies of form and number, fused primary 25. Ubelaker DH. Human Skeletal Remains: Excavation, teeth, a correlation of the dentitions. ASDC J Dent Child, Analysis, Interpretation. Washington D.C.: Texaracum; 1999. 1988;55:359-61. 26. Scheuer L, Black S. Developmental Juvenile Osteology. San 10. Kapdan A, Kustarci A, Buldur B, Arslan D, Kapdan A. Diego: CA; 2000. Dental anomalies in the primary dentition of Turkish 27. Lewis ME. The Bioarchaeology of Children. Perspectives children. Eur J Dent, 2012;6:178-183. from Biological and Forensic Anthropology. Cambridge: 11. Sekerci AE, Sisman Y, Yasa Y, Sahman H, Ekizer A. Cambridge University Press; 2007. Prevalence of fusion and gemination in permanent teeth in 28. Killian CM, Croll TP. Dental twinning anomalies: the Cappadocia region in Turkey. Pak Oral Dent J, 2011;31:17-22. nomenclature enigma. Quintessence Int, 1990;21:571-576 12. Croll TP, Killian CM. Double Dental Twinning in Two 29. Knežević A, Travan S, Tarle Z, Šutalo J, Janković B, Ciglar Children. Inside Dentistry, 2012;8 (available online at: I. Double tooth. Coll Antropol, 2002;26:667-672. https://www.dentalaegis.com/id/2012/05/double-dental- twinning-in-two-children). 30. Kelly JR. Gemination, fusion, or both? Oral Surg Oral Med 13. Mehta M. Fusion of Primary Mandibular Anterior Teeth Oral Pathol, 1978;45:326-327. Associated with Partial Anodontia of Primary and 31. Favalli O, Webb M, Culp J. Bilateral twinning: report of Permanent Dentition: A Case Report. J Dent Health Oral case. ASDC J Dent Child, 1998;65:268-271. Disord Ther, 2015;3:00090. 32. Shafer WG, Hine MK, Levy BM. A Textbook of Pathology 14. Ortner D. Identification of Pathological Conditions in (4th ed.). Philadelphia: WB Saunders Company; 1983. Human Skeletal Remains. San Diego: CA; 2003. 33. Nik-Hussein NN, Abdul Majid Z. Dental anomalies in the 15. Prabhu RV, Chatra L, Shenai P, Prabhu V. Bilateral fusion in primary dentition: distribution and correlation with the primary mandibular teeth. Indian J Dent Res, 2013;24:277. permanent dentition. J Clin Pediat Dent, 1996;21:15-19. 16. Rao PK, Mascarenhas R, Anita A, Devadiga D. Fusion 34. Hunasgi S, Koneru A, Manvikar V, Vanishree M, Amrutha in Deciduous Mandibular Anterior Teeth – A Rare Case. R. A Rare Case of Twinning Involving Primary Maxillary Dentistry, 2014;S2:1-2. Lateral Incisor with Review of Literature. J Clin Diagn Res, 17. Shilpa G, Nuvvula S. Triple tooth in primary dentition: A 2017;11:9-11. proposed classification. Contemp Clin Dent, 2013;4:263-267. 35. Tsujino K, Yonezu T, Shintani S. Effects of different 18. Donta-Bakogianni E, Sabatakaki M, Spyropoulos ND. combinations of fused primary teeth on eruption of the Anomalies in the form of teeth. Presentation of eight cases permanent successors. Pediatr Dent, 2013;35:64-67. of gemination and fusion. Odontostomatological Progress, 36. Ansari AA, Pandey P, Gupta VK, Pandey RK. Bilateral 1992;46:49-58. Fusion of the Mandibular Primary Incisors with 19. Synodinos PN, Siskos GJ, Kouimtzis Th, Yiagtzis S, Hypodontia: A Case Report. Austin J Clin Case Rep, Sykaras ChS. Multidisciplinary treatment of fused 2014;1:1057. and geminated teeth: literature review and case report. 37. Gellin ME. The distribution of anomalies of primary Endodontologia, 2009;4:121-130. anterior teeth and their effect on the permanent successors. 20. Benazzi S, Buti L, Franzo L, Kullmer O, Winzen O, Dent Clin N Am, 1984;28:69-80. Gruppioni G. Report of Three Fused Primary Human Teeth in an Archaeological Material. Int J Osteoarchaeol, 2010;20:481-485. Received on June 20, 2017. 21. Padgett BD. Triple Fusion in the Primary Dentition from Revised on August 19, 2017. Accepted on October 2, 2017. Law’s Site, Alabama (1MS100): A Case Report. Dent Anthropol, 2010;23:25-27. 22. Scott GR, Turner CG. The anthropology of modern human Correspondence: teeth. Cambridge: Cambridge University Press; 1997. Paraskevi Tritsaroli 23. Silva AM, Silva AL. Unilateral Fusion of Two Primary The Malcolm H. Wiener Laboratory for Archaeological Science Mandibular Teeth: Report of a Portuguese Archeological American School of Classical Studies, Athens, Greece Case. Dental Anthropology, 2007;20:16-18. e-mail: [email protected]
10.2478/bjdm-2018-0019
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Primary Tuberculous Lymphadenitis: a Rare Case Report
SUMMARY Mustafa Mert Açikgöz, Ayşem Yurtseven, Background/Aim: Our aim is to describe multidisciplinary approach Gülsüm Ak to primary tuberculous lymphadenitis with a case report. Case Report: İstanbul University, Faculty of Dentistry, A 6-year-old boy was referred to İstanbul University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery with the symptoms of Turkey painless extra-oral abscess and lymphadenopathy. The diagnosis of primary tuberculous lymphadenitis was proved by microbiological culture and ultrasound imaging. Conclusions: Combine tuberculosis treatment should be applied and long term follow up is necessary. Excisional biopsy for tissue diagnosis and bacterial examination with culture should be performed for an early diagnosis as a delay in treatment can lead to devastating consequences. CASE REPORT (CR) Key words: Primary Tuberculous Lymphadenitis, Tuberculous Treatment Balk J Dent Med, 2018;106-110
Introduction in the oral cavity, while other oral tissues may be infected with TBC4,11. Oral tuberculous lymphadenitis can develop Tuberculosis (TBC) is a major public health problem primarily by direct contact with the infectious factor, worldwide. Because of its relation with AIDS, TBC rates or generally it can spread from the lungs and develop are on the increase1. The disease can also be related to as secondary tuberculosis. Primary oral tuberculous leprosy2 and there is a report that it can be seen with oral lymphadenitis is generally seen in young individuals. squamous cell carcinoma3. Although %95 of individuals Individuals who exposed to Mycobacterium tuberculosis who exposed to Mycobacterium Tuberculosis do not show can develop infection. It is difficult to differentiate with clinical signs and symptoms alone. It is mostly painless any clinical symptoms, %5 of individuals develop the with lesions that cause caseification in the related lymph disease. Primary tuberculosis mostly affects the lungs. nodes. On the other hand, secondary form is seen in elderly In many patients, infectious disease forms the caseous individuals13. The drugs are most important factors in the focus in the lungs and generally does not spread to extra treatment of tuberculosis (Table 1). pulmonary organs. In secondary form, the infection Success in the treatment plan should be ensured by spreads from the lungs to the other organs through the right combination of drugs. Due to the highest count 4-6 sputum, blood or lymphatic system . of bacilli at the beginning of treatment, resistant mutant Primary infection can also affect the pharynx, strains are most likely to occur in this stage. Four standard 2 cervical lymph node, intestine, or oral mucosa . The drugs should be used in the beginning (Table 2). 7 salivary glands can also be affected or the disease can During the maintenance period, two drugs should be seen as tuberculous osteomyelitis of the mandible with be used at least. Regular and adequate use of medicines cervical tuberculous lymphadenitis6,8. Primary tuberculous is the key and has great importance in this treatment. lymphadenitis of the oral cavity is very rare. In these rare Otherwise it is occured drug resistance, treatment failure cases, the most common site is cervical lymph nodes. or recurrence14. This is referred to as scrofula9,10. Primary tuberculous The aim of this study is to present multidisciplinary lymphadenitis of the oral cavity constitutes 0.05-5% of all approach to primary tuberculous lymphadenitis with a TBC cases11,12. It’s most commonly seen area is the tongue case report. Balk J Dent Med, Vol 22, 2018 Tuberculous Lymphadenitis 107
Table 1. The drugs used in the treatment of tuberculosis There was not any lesion compatible with tuberculosis on (Ministry of Health 2011) chest x-ray of our patient (Figure 5). This result supported the early diagnose of the lesion which was primary Daily Doses tuberculous lymphadenitis. The abscess was drained Pediatric under local anesthesia and sample was taken with fine Adult Patients Maximum Patients needle for microbiological culture (Figure 6-8). Infectious material was submitted directly to the laboratory without mg/kg mg/kg Mg delay and protected from excessive heat and cold. After H (Izoniazide) 5 (4-6) 10-15 300 decontamination and neutralization, Lowenstein Jensen R (Rifampicin) 10 (8-15) 10-15 600 Media was inoculated with specimen. The medium was 0 incubated in a CO2 atmosphere at 35-37 C and protected Z (Pyrazinamide) 25 (20-30) 15-30 2000 from light. Tubed media was incubated for one week M (Morfozinamide) 40 25-45 3000 with loosened caps to allow the circulation of CO2 for the initiation of growth. Caps were tightened after one week E (Ethambutol) 20 (15-20) 15-20 1500 in order to prevent dehydration of media. The media was S (Streptomycin) 15 (12-18) 15-30 1000 examined daily for the first week, then weekly for the next 8 weeks. The first growth was seen in second week and then tested by Ziehl-Neelsen staining because of being acid-fast bacilli. Acid decolorizing solution was Table 2. Treatment protocol of tuberculosis applied after staining for removing the red dye from the (Ministry of Health 2011) background cells except mycobacteria which retain the dye and therefore referred to as acid fast bacilli. After this Induction Phase Continuation Phase Case Category discoloration methylene blue was applied for staining the (daily doses) (daily doses) background material, providing a contrast colour against New Cases 2 months HRZE 4 months HR which the red AFB could be seen. Histopathological analysis showed large lymphocytes, necrotic debris and 2 months HRZES Relapse Cases 5 months HRE 1 month HRZE epitheloid cells. In summary, Lowenstein Jensen media used for microbiological culture and the growth were Treatment failure, Standart second-line therapy confirmed with Ziehl-Neelsen stain. As a consequence, Chronic cases the diagnosis of primary tuberculous lymphadenitis was established by microbiological culture of abscess, histopathological analysis and ultrasound imaging. Our prediagnosis of primary tuberculous lymphadenitis due to Case Report the suspection of unhealing abscess was proved. In order to provide the treatment of tuberculosis, we consulted to A 6-year-old boy was referred to İstanbul department of pediatrics. Combined tuberculosis treatment University, Faculty of Dentistry, Department of Oral and regimen given. Symptoms recovered in 6 month (Figure Maxillofacial Surgery with the symptoms of painless 9). In 2 years follow-up period there was no recurrence extra-oral abscess and lymphadenopathy that continue for (Figure 10). 2 weeks after the extraction of relevant tooth (#85) in the right mandibular area (Figure 1, 2). Primary tuberculous lymphadenitis was suspected due to the extra-oral abscess that did not recover despite antibiotic therapy (Figure 3). Our patient does not have any systemic disease. In order to strengthen our diagnosis before biopsy, we got MRI and ultrasound results from our patient. In the MRI image, lymphadenopathies which are cystic and necrotic centrally with marked contrast enhancement and conglomerations in post-contrast sections were observed in the right submandibular region with a size of 3*2 cm. Inflammation was seen in peripheral region. Ultrasonography showed results compatible with infected lymphadenopathy showing abscess formation with heterogeneous internal structure including cystic areas with size of 3*2*19 mm (Figure 4). This result has supported our pre-diagnosis which was tuberculosis. Figure 1. Extra-oral abscess that continues for 2 weeks 108 Mustafa Mert Açikgöz et al. Balk J Dent Med, Vol 22, 2018
Figure 2. Intraoral examination Figure 3. Suspected primary tuberculous lymphadenitis due to the extra- oral abscess that did not recover despite antibiotic therapy
Figure 4. Ultrasound imaging
Figure 5. Chest x-ray
Figure 6. Applying local anesthetics Figure 7. Drainage of the lesion Balk J Dent Med, Vol 22, 2018 Tuberculous Lymphadenitis 109
Discussion
Tuberculosis is a global health problem that affects more than 8 million people around the world and 3 million people die of complications associated with the disease. The risk of infection is higher in countries with low socioeconomic status12. Although most of the cases are primary lung tuberculosis, all part of the body can be affected from tuberculosis11,15-17. In our case, there were extra-oral abscess and lymphadenopathy that did not recover despite antibiotic therapy for 2 weeks. Less than 0.1% of all TB cases occur in the oral region according to the study of Farber et al 18. According to Tiecke, this frequency varies between 0.8-3.5% in cases with pulmonary tuberculosis19. Pulmonary involvement has not been observed in our case. Primary tuberculous lymphadenitis of oral region was diagnosed. Primary oral tuberculosis is very rare and mostly seen in children’s and adolescents20 . The dorsal aspect of Figure 8. Suturing after drainage the tongue is the most frequently affected area, followed by the lower jaw, buccal mucosa and lips17. Intraoral examination showed that there was not any lesions. Anti-tubercular therapy (ATT) is administered to the patient after definitive diagnosis of tuberculosis. Drugs that used in the treatment are primarily isoniazid, rifampicin, prazinamide and ethambutol17. In our case, anti-tubercular therapy was arranged according to protocols and no recurrence was observed.
Conclusions
After diagnosis of oral tuberculosis, consultation with department of infectious diseases is necessary. Figure 9. After 6 months Combine tuberculosis treatment should be applied and long term follow up is necessary. Excisional biopsy for tissue diagnosis and bacterial examination with culture should be performed for an early diagnosis as a delay in treatment can lead to devastating consequences.
References
1. Kolokotronis A, Antoniadis D, Trigonidis G. Oral tuberculosis. Oral Dis, 1996;2:242-243. 2. Ganesan V, Mandal J. Primary oral tuberculosis in a patient with lepromatous leprosy: Diagnostic dilemma. Int J Mycobacteriol, 2016;5:102-105. 3. Agrawal A, Gadbail A, Hande A, Chaudhary M, Gawande M, Patil S, Tare K. The Coexistence of Tuberculous Lymphadenitis with Oral Squamous Cell Carcinoma: Figure 10. 2 years follow-up Review of Four Cases. Oral Maxillofac Pathol J, 2016;7:676-678. 110 Mustafa Mert Açikgöz et al. Balk J Dent Med, Vol 22, 2018
4. Neville B, Damm D, Allen C. Soft tissue tumors. In: Oral 14. Ministry of Health, Guideline for Diagnosis and Treatment and Maxillofacial Pathology, 2nd ed. W.B. Saunders: of Tuberculosis, Ankara, 2011. Philadelphia, 2002, pp:458-461. 15. De Aguiar MC, Arrais MJ, Mato MJ, De Araujo VC. 5. Rivera H, Correa MF, Castillo-Castillo S, Nikitakis NG. Tuberculosis of the oral cavity: a case report. Quintessence Primary oral tuberculosis: a report of a case diagnosed by Int, 1997;28:745-747. polymerase chain reaction. Oral Dis, 2003;9:46-48. 16. Nagalakshmi V, Nagabhushana D, Aara A. Primary 6. Sheikh S, Pallagatti S, Gupta D, Mittal A. Tuberculous tuberculous lymphadenitis: A case report. Clin Cosmet osteomyelitis of mandibular condyle: a diagnostic dilemma. Investig Dent, 2010;10:21-25. Dentomaxillofac Radiol, 2012;41:169-174. 17. Kumar V, Singh AP, Meher R, Raj A. Primary Tuberculosis 7. Dangore-Khasbage S, Bhowate RR, Degwekar SS, Bhake of Oral Cavity: A Rare Entity Revisited. Indian J Pediatr, AS, Lohe VK. Tuberculosis of parotid gland: a rare clinical 2011;78:354-356. entity. Pediatr Dent, 2015;37:70-74. 18. Farber JE, Freidland E, JacobsW F. Tuberculosis of tongue. 8. Bai S, Sun CF. Tuberculous osteomyelitis of the mandible Am Rev Tuberc 1940;42:766-775. with diffuse swelling of the floor of the mouth: a case 19. Tiecke RW. Oral pathology, 1st ed. New York: Mc GrawHill report. J Oral Maxillofac Surg, 2014;72:e1-6. Book Co; 1965. p: 495-500. 9. Haleen A, Hiday E, Errays MM. A 26 year old male 20. Sezer B, Zeytinoglu M, Tuncay U, Ünal T. Oral mucosal with lower neck masses. Ann Trop Med Public Health, ulceration: a manifestation of previously undiagnosed 2008;1:31-32. pulmonary tuberculosis. J Am Dent Assoc, 2004;135: 10. Shetty D, Shetty DC, Singh HP, Aggarwal P. Tuberculosis 336-340. lymphadenitis presenting a diagnostic dilemma. Int J Health Allied Sci, 2012;1:118-121. Received on January 26, 2017. 11. Mignogna MD, Muzio LLO, Favia G. Oral tuberculosis: a Revised on March 24, 2017. clinical evaluation of 42 cases. Oral Dis, 2000;6:5-30. Accepted on July 2, 2017. 12. Hegde S, Rithesh KB, Baroudi K, Umar D. Tuberculous Lymphadenitis: Early Diagnosis and Intervention. J Int Oral Correspondence: Health, 2014;6:96-98. Mustafa Mert Açıkgöz 13. Hashimoto Y, Tanioka H. Primary tuberculosis of İstanbul University, Faculty of Dentistry the tongue: report of a case. J Oral Maxillofac Surg, Department of Oral and Maxillofacial Surgery 1989;4:744-746. e-mail: [email protected]
10.2478/bjdm-2018-0020
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Management of Dens Invaginatus in a Maxillar Lateral Incisor with Open Apex and Persistent Sinus Tract: a Case Report
SUMMARY Funda Fundaoğlu Küçükekenci, Background/Aim: Dens invaginatus is a developmental anomaly Ahmet Serkan Küçükekenci of teeth. The endodontic treatment of these teeth may be difficult because Faculty of Dentistry, OrduUniversity, Ordu, of adversity in accessing the root canals and also complicated variations Turkey of internal structure. In this case, the report is presented the nonsurgical management and follow-up of a tooth with class II dens invaginatus with an open apex and sinus tract. Case Report: In the radiographic examination, there are two root canals; a primary (main) canal and an invaginated canal. The main canal wide-open at the portal of exit and associated with a large chronic periapical lesion extending to the apex of the maxillary left central incisor. An invaginated canal was not reaching the apex. In a clinical examination, a sinus tract was detected in the labial gingiva. After apexification with using MTA was applied, the endodontic treatment was completed. In 12 month recall, a gray discoloration was detected and internal bleaching with 35% hydrogen peroxide was applied. Finally, the tooth was restored using composite resin. 12 months follow-up radiographs revealed resolution of periapical radiolucency, trabecular bone formation, and closure of the root apex with the totally asymptomatic tooth. Conclusions: The case report shows that tooth with DI that has wide apex and sinus tract can be treated with non-surgical methods, such as immature tooth without anomalies. CASE REPORT (CR) Key words: Dens in Dente, Dens Invaginatus, Apexification Balk J Dent Med, 2018;111-114
Introduction DI radiographically seems as radiopaque lines within the dentin5. Clinically, DI exhibits unusual crown Dens invaginatus (DI) is a developmental morphology2. The enamel lining is sometimes defective malformation of teeth, that perhaps results from an and develops caries, which can lead to dentin or pulpal invagination of enamel organ into dental papilla1. DI, exposure and eventual pulpal pathosis. The affected further known as ‘dens in dente’ can spread out to the pulp tissue frequently undergoes necrosis6. If DI is roots and the pulp cavity, occasionally attaining the apex2. detectable early, it is possible to prevent pulp infection Oehlers has classified the DI into three categories. Type by invagination. There are various treatment options I defines a small invagination, covered by enamel, in for an invaginated tooth such as preventive sealing, the crown. In Type II, the DI lengths to the root. It may endodontic treatment, periapical surgery, and extraction7. contact or not with the pulp. In Type III, the invagination Clinicians should be make a plan to prevention for teeth invades through the root, reaching the apical space with with DI before pathological of pulp signs occur8. Tooth a secondary foramen. There is no contact with the dental with type I and for some forms of Type II may be treated pulp. The invagination is entirely covered by enamel or employing conservative therapy, whereas DI Type III cement3,4. that the infection has extended, causing pulp necrosis is 112 Funda Küçükekenci Fundaoglu, Ahmet Serkan Küçükekenci Balk J Dent Med, Vol 22, 2018 necessary endodontic therapy6. Some cases show that Case report DI sometimes associated with wide apical foramen and apical periodontitis9,10. In some cases, it is imperative A 21-year-old female patient applied to, Ordu to provoke the closure of the apical foramen with University, Faculty of Dentistry owing to discontent with mineralized tissue or to achieve an unnatural apical barrier the esthetic view of her maxillary lateral tooth. Clinically, to let for condensation of the root filling material11. In both of right (#12) and left lateral incisors (#22) showed an cases, DI with open apices could be used MTA to promote abnormal coronal shape, with smaller mesiodistal diameter. an apical seal12. MTA is a biomaterial with excellent 12 was showed tenderness when exposed to the cold test biocompatibility and good sealing property that is usable and electric pulp test but 22 wasn’t positive for sensitivity. even in the presence of moisture. Moreover, there was a sinus tract in the periapical side Furthermore, both the patient and the clinicians around the 22 and the patient was asymptomatic (Figure utilize from the use of MTA as the total treatment time is 1a). Upon radiographic examination, the anomalous was reduced13. Unfortunately, many studies have shown that detected the internal structure of 22 that was consistent with MTA cause to be discoloration14,15. Should discoloration Oehlers’ Type II dens invaginatus but the malformation occur with the use of MTA, the internal bleaching may be didn’t show on 12 (Figure 1b). A large radiolucent lesion used to improve the esthetics16. around the apex of the 22 along with wide-open apical end The present case report describes apexification was detected by intraoral periapical radiograph (Figure using MTA followed by the endodontic treatment of DI 1c). Because of the periradicular lesion was associated in a maxillary lateral incisor with an open apex and sinus with the main canal, a diagnosis of pulpal necrosis with tract, moreover intracoronal bleaching efficacy on the asymptomatic apical periodontitis was made. Nonsurgical discoloration caused by MTA. endodontic treatment and apexification were planned.
Figure 1 (a) Photograph shows that maxillary left incisor has a sinus tract, (b) panoramic radiograph shows that the contralateral tooth did not reveal malformation, (c) periapical radiography shows that a dens invagination and periradicular lesion
Figure 2 (a) Photograph of the access cavity shows that ınvagination and main canal, (b) radiograph shows that placement of MTA, (c) radiograph shows that root canal filling
Proper aseptic precautions were carried out, and file. The final irrigation was made using 5 ml of 17 % access (Figure 2a). Necrotic pulp and other organic EDTA (ImidentMed, Konya, Turkey) for 1 min and 5 ml debris were extirpated using barbed broach under copious of 2.5 % NaOCl for 1 min. After irrigation, root canals irrigation using 2.5% sodium hypochlorite (NaOCl) were dried, and short term canal dressing with calcium (ImidentMed, Konya, Turkey) solution. The root canal hydroxide (Ca(OH2)) was placed and the access cavity was was prepareted using K-type hand files. The root canals temporarily sealed with Cavit (3M ESPE US, Norristown, were irrigated with 2 ml 2.5 % NaOCl after use of each PA, USA) for a period of two weeks for disinfection. Balk J Dent Med, Vol 22, 2018 Management of Dens Invaginatus 113
The patient was recalled, Ca(OH2) dressing of symptoms. At 6-month recall, the tooth exhibited mobility tooth was removed. Irrigation was performed using 2.5% within physiologic limits and no evidence of periodontal sodium hypochlorite, 17% EDTA followed by normal pockets and was functioning normally. Unfortunately, saline. Margelos et al. showed that using the combination gray discoloration was detected on the tooth (Figure 3a). of EDTA + NaOCl removed more CH compared to using Radiographic examination revealed repair of the lesion these irrigants alone17. The canal was dried, and MTA (Pro (Figure 3b). 12 months follow-up radiographs revealed Root MTA; Dentsply Tulsa dental, Tulsa, UK) was mixed resolution of periapical radiolucency, trabecular bone with distilled water to the sandy consistency and was formation, and closure of the root apex with a totally placed with MTA carrier in the apical portion of the canal. asymptomatic tooth (Figure 3c). Because of discoloration, Hand pluggers were used to condensing the increments internal bleaching was planned. The 35% hydrogen till the thickness of 3-4 mm (Figure 2b). A wet cotton peroxide (H2O2) was placed into the pulp chamber. was inserted into the canal, and the access cavity was (Opalescence®Endo; Ultradent Products Inc., South sealed. The patient was call back following day and the Jordan, UT, USA). The access cavity was sealed using root canal was filled using lateral condensation technique Cavit. After four days the cavit was removed, the H2O2 was with gutta percha (Meta BioMed, Korea) and AHPlus irrigated with distilled water, and a fresh H2O2 was placed sealer (DentsplyDetreyGmbH, Germany) (Figure 2c). The into the access cavity. Next appointment tooth color was direct restoration was done with resin-based composite satisfactory so that bleaching was stopped. Ca(OH2) was (Filtek Z350, Body A2, 3M ESPE, USA) and the patient placed access cavity for antioxidizing effect and the cavity was evaluated subsequently. The patient was recalled sealed temporarily. After a week tooth was restored using a month later and demonstrated no clinical signs and composite resin (Figure 3d).
Figure 3 (a) Photograph shows that discoloration of tooth, (b) 6 months follow up with radiographically, (c) 1 year follow up with radiographically, (d) photograph of after bleaching and aesthetic restoration
Discussion root canal19. Currently, advanced CBCT imaging can help the indication as well as the treatment plan and follow- DI is clinically important because of the resultant up of teeth with DI20. But before CBCT examination, aberration in anatomy. Teeth with DI have profound a consideration of danger against utility should be fissures, which can harbor structural deformity. It considered, particularly in juvenile patients. In this case, is possible for dental caries to easily reach the pulp periapical radiographs were sufficient for defining the type chamber in DI cases. This relationship is caused by dental and pulpal relationship of DI. pulp infection and necrosis, followed by periapical or The complicated anatomy of teeth with DI makes periodontal abscess18. endodontic therapy challenging, particularly in cases This case report shows of Oehlers’ type II DI with a with wide apex. But conservative root canal treatment of sinus tract, necrosis pulp, and a periradicular pathology. a tooth with DI is probable in some cases10,21. We chose The left lateral incisor wasn’t tender to the pulp sensitivity nonsurgical endodontic procedures in the present case. test. Two canals were identified in the tooth. The MTA can bu use in cases of DI with open apex for invaginated canal did not reach the apex. The only main apexification. MTA is both of biocompatibility and it canal was associated with a periapical lesion. In spite is less cytotoxic because of its alkaline pH22. Due to of the fact that the invagination is not a real canal and it the presence of calcium and phosphate ions in MTA, doesn’t reach to apex, obturation is important because the it can support cementum deposition23. Current data enamel and dentin of the invagination are poor, and that’s show that MTA may be used as an apical barrier in teeth why irritants may smoothly diffuse to the main canal and with necrotic dental pulp and open apex24. However, cause infection7. Some cases report that the main canal was apexification with MTA apical plug requires specific supposed to include vital pulp, and CBCT examination did facilities such as points and carriers to facilitate its not show any contact between the invagination and the insertion, and correct adaptation within the ideal apical 114 Funda Küçükekenci Fundaoglu, Ahmet Serkan Küçükekenci Balk J Dent Med, Vol 22, 2018 limit may be more difficult in extremely large foramina. 10. Demartis P, Dessi C, Cotti M, Cotti E. Endodontic treatment We used MTA plugger for placed MTA into apically. and hypotheses on an unusual case of dens invaginatus. J The pluger enables insertion of the MTA easier, although Endod, 2009;35:417-421. 11. Al Ansary MA, Day PF, Duggal MS, Brunton PA. radiographic confirmation at this stage cannot be Interventions for treating traumatized necrotic immature 25 overlooked . We benefited from radiography to display permanent anterior teeth: inducing a calcific barrier & root the MTA plug at this stage. Another disadvantage of MTA strengthening. Dent Traumatol, 2009;25:367-379. is that it causes tooth discoloration26. The discoloration 12. Reddy YP, Karpagavinayagam K, Subbarao CV. associated with the use of MTA was observed. The Management of dens invaginatus diagnosed by spiral computed tomography: a case report. J Endod, discoloration was bleached with intracoronal bleaching 2008;34:1138-1142. technique. The aesthetic restoration of the tooth was 13. Simon S, Rilliard F, Berdal A, Machtou P. The use of mineral accomplished using a composite resin that provides an trioxide aggregate in one-visit apexification treatment: a aesthetic appearance. prospective study. Int Endod J, 2007;40:186-197. The 6 months follow-up, the tooth was asymptomatic 14. Kohli MR YM, Setzer FC, Karabucak B. Spectrophotometric Analysis of Coronal Tooth Discoloration Induced by Various and there was a reduce in the dimension of the periapical Bioceramic Cements and Other Endodontic Materials. J lesion. The 12 months follow-up, the tooth offered no Endod, 2015;41:1862-1866. tenderness to percussion, and the periodontal structure 15. Kang SH SY, Lee HS, Kim SO, Shin Y, Jung IY, Song JS. was healthy and aesthetic appearance was satisfaction. Color changes of teeth after treatment with various mineral Radiographic examination indicated an improvement of trioxide aggregate-based materials: an ex vivo study. J Endod, 2015;41:737-741. the lesion. 16. Belobrov I, Parashos P. Treatment of tooth discoloration after the use of white mineral trioxide aggregate. J Endod, 2011;37:1017-1020. 17. Margelos J, Eliades G, Verdelis C, Palaghias G. Interaction Conclusions of calcium hydroxide with zinc oxide-eugenol type sealers: a potential clinical problem. J Endod, 1997;23:43-48. 18. Cengiz SB, Korasli D, Ziraman F, Orhan K. Nonsurgical The case report shows that tooth with DI that has root canal treatment of dens invaginatus: reports of three wide apex and sinus tract can be treated with non-surgical cases. Int Dent J, 2006;56:17-21. methods, such as immature tooth without anomalies. 19. Pitt Ford HE. Peri-radicular inflammation related to dens invaginatus treated without damaging the dental pulp: a case report. Int J Paediatr Dent, 1998;8:283-286. 20. Patel S. The use of cone beam computed tomography in the conservative management of dens invaginatus: a case report. References Int Endod J, 2010;43:707-713. 21. Chen YH, Tseng CC, Harn WM. Dens invaginatus. Review 1. Vier-Pelisser FV, Morgental RD, Fritscher G, Ghisi of formation and morphology with 2 case reports. Oral Surg AC, Borba MG, Scarparo RK. Management of Type III Oral Med Oral Pathol Oral Radiol Endod, 1998;86:347-352. Dens Invaginatus in a Mandibular Premolar: A Case Report. 22. Jung M. Endodontic treatment of dens invaginatus type III Braz Dent J, 2014;25:73-78. with three root canals and open apical foramen. Int Endod J, 2. Hulsmann M. Dens invaginatus: aetiology, classification, 2004;37:205-213. prevalence, diagnosis, and treatment considerations. Int 23. Maroto M, Barber´ıa E, Planells P, Vera V. Treatment of a Endod J, 1997;30:79-90. non-vital immature incisor with mineral trioxide aggregate 3. Oehlers FA. Dens invaginatus (dilated composite (MTA). Dent Traumatol, 2003;19:165-169. odontoma). I. Variations of the invagination process and 24. Nair PN. Pathogenesis of apical periodontitis and the associated anterior crown forms. Oral Surg Oral Med Oral causes of endodontic failures. Crit Rev Oral Biol Med, Pathol, 1957;10:1204-1218. 2004;15:348-381. 4. Bramante CM, de Sousa SM, Tavano SM. Dens invaginatus 25. Chueh LH, Ho YC, Kuo TC, Lai WH, Chen YHM, Chiang in mandibular first premolar. Oral Surg Oral Med Oral CP. Regenerative endodontic treatment for necrotic Pathol, 1993;76:389. immature permanent teeth. J Endod, 2009;35:160-164. 5. Gound TG, Maixner D. Nonsurgical management of a 26. Parirokh TM. Mineral trioxide aggregate: a comprehensive dilacerated maxillary lateral incisor with type III dens literature review-Part III: Clinical applications, drawbacks, invaginatus: a case report. J Endod, 2004;30:448-451. and mechanism of action. J Endod, 2010;36:400-413. 6. de Sousa SM, Bramante CM. Dens invaginatus: treatment choices. Endod Dent Traumatol, 1998;14:152-158. Received on March 26, 2017. 7. Yang J, Zhao Y, Qin M, Ge L. Pulp revascularization of Revised on May 24, 2017. immature dens invaginatus with periapical periodontitis. J Accepted on June 2, 2017. Endod, 2013;39:288-292. 8. Tsurumachi T. Endodontic treatment of an invaginated Correspondence: maxillary lateral incisor with a periradicular lesion and a healthy pulp. Int Endod J, 2004;37:717-723. Ahmet Serkan Küçükekenci 9. Steffen H, Splieth C. Conventional treatment of dens Department of Prosthodontics, Dentistry Faculty invaginatus in maxillary lateral incisor with sinus tract: one Ordu University, Ordu, Turkey year follow-up. J Endod, 2005;31:130-133. e-mail address: [email protected]
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616.31
BALKAN Journal of Dental Medicine : official publication of the Balkan Stomatological Society / editor-in-chief Dejan Marković. - Vol. 18, no. 1, (March 2014)- . - Belgrade : Balkan Stomatological Society, 2014- . - 30 cm
Tri puta godišnje. - Je nastavak: Balkan Journal of Stomatology = ISSN 1107-1141 ISSN 2335-0245 = Balkan Journal of Dental Medicine COBISS.SR-ID 206352140