Balkan Journal of Stomatology

BALKAN JOURNAL OF STOMATOLOGY

Official publication of the BALKAN STOMATOLOGICAL SOCIETY

Volume 12 No 3 November 2008

ISSN 1107 - 1141 BALKAN JOURNAL OF STOMATOLOGY

Official publication of the BALKAN STOMATOLOGICAL SOCIETY

Volume 12 No 3 November 2008

ISSN 1107 - 1141

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L BALKAN JOURNAL OF STOMATOLOGY A ISSN 1107 - 1141 IC G LO TO STOMA

Editor-in-Chief Ljubomir TODOROVIĆ, DDS, MSc, PhD Faculty of Stomatology, University of Belgrade Clinic of Oral Surgery PO Box 506 Dr Subotića 4, 11000 Belgrade Serbia

Editorial board

ALBANIA ROMANIA Ruzhdie QAFMOLLA - Editor Address: Andrei ILIESCU - Editor Address: Emil KUVARATI Dental University Clinic Victor NAMIGEAN Faculty of Stomatology Besnik GAVAZI Tirana, Albania Cinel MALITA Calea Plevnei 19, sect. 1 70754 Bucuresti BOSNIA AND HERZEGOVINA Address: Romania Maida GANIBEGOVIĆ Faculty of Dentistry SERBIA Naida HADŽIABDIĆ Bolnička 4a Dragan STAMENKOVIĆ - Editor Address: Mihael STANOJEVIĆ 71000 Sarajevo Zoran STAJČIĆ Faculty of Stomatology BIH Miloš TEODOSIJEVIĆ Dr Subotića 8 BULGARIA 11000 Beograd Nikolai POPOV - Editor Address: Serbia Nikola ATANASSOV Faculty of Stomatology TURKEY Nikolai SHARKOV G. Sofiiski str. 1 1431 Sofia, Bulgaria Ender KAZAZOGLU - Editor Address: Pinar KURSOGLU Yeditepe University FYROM Julijana GJORGOVA - Editor Address: Arzu CIVELEK Faculty of Dentistry Ana STAVREVSKA Faculty of Stomatology Bagdat Cad. No 238 Ljuben GUGUČEVSKI Vodnjanska 17, Skopje Göztepe 81006, Istanbul Republika Makedonija Turkey GREECE CYPRUS Anastasios MARKOPOULOS - Editor Address: George PANTELAS - Editor Address: Haralambos PETRIDIS Aristotle University Huseyn BIÇAK Gen. Hospital Nicosia Grigoris VENETIS Dental School Aikaterine KOSTEA No 10 Pallados St.

Thessaloniki, Greece Nicosia, Cyprus

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BALKAN STOMATOLOGICAL SOCIETY L A IC G LO TO STOMA

Council President: Prof. A. Iliescu Members: R. Qafmolla E. Hasapis P. Kongo Past President: Prof. N. Atanassov D. Bratu H. Sulejmanagić A. Creanga President Elect: Prof. M. Vulović S. Kostadinović D. Stamenković Vice President: Prof. P. Koidis N. Sharkov M. Barjaktarević Secretary General: Prof. L. Zouloumis J. Mihailov E. Kazazoglu M. Carčev H. Bostançi Treasurer: Dr. G. Tsiogas J. Gjorgova G. Pantelas Editor-in-Chief: Prof. Lj.Todorović T. Lambrianidis F. Kuntay

The whole issue is available on-line at he web address of the BaSS (www.e-bass.org)

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VOLUME 12 NUMBER 3 November 2008 PAGES 129-180

Contents

OP E. Zabokova-Bilbilova Prevention of Enamel Demineralization During 133 T. Stafilov Orthodontic Treatment: An In Vitro Study Using GC Tooth Mousse A. Sotirovska-Ivkovska F. Sokolovska 133

OP N.K. Ersin Infraocclusion of Primary Molars: A Review and Report of Cases 138 U. Candan A.R. Alpoz 138

OP B. Obradovic Assessment of the Quality of Newly-Formed Bone for 143 Z. Stajcic Implant Insertion after Augmentation of the Maxillary Sinus Floor Lj. Stojcev Stajcic

OP S.D. Poštić Medication and Positive Remodelling of Osteoporotic Jaws 147

OP A.D. Kaya Surface Roughness of Posterior Condensable Composites 153 F. Ozata 153

OP D. Mingomataj Clinical and Radiological Evaluation of 158 D. Mingomataj Chronic Periodontitis Treated by “Beyond Apex” Fillings

OP E. Xhemo Dental Erosion: One of the Main Diagnostic 163 D. Brovina Symptoms of Gastric Oesophageal Reflux Disease E. Hoxha V. Demiraj A. Bylo

CR H. Develioglu Histo-Pathological Evaluation of Drug Allergy Observed With 166 Ö. Özgören Gingival Overgrowth Induced by Phenytoin: A Case Report M. Nalbantoglu K. Eren F. Göze

CR A. Delantoni Postextraction Inferior Alveolar Nerve Injuries - 170 P. Papademitriou-Delantoni Prevention and Treatment K. Antoniades 132 Balk J Stom, V ol 12, 2008

TR H.N. Alkumru Use of Polyethylene Fibre Ribbon Reinforced Composite Resin as 174 S.B. Turker Post-Core Build-Up: A Technical Report B. Evre

Book Review John W. Werning M. Gavrić Oral Cancer: Diagnosis, Management, and Rehabilitation 178

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Prevention of Enamel Demineralization During Orthodontic Treatment: An In Vitro Study Using GC Tooth Mousse

SUMMARY E. Zabokova-Bilbilova 1, T. Stafilov 2, A. One of the most difficult problems in orthodontic treatment with fixed Sotirovska-Ivkovska 1, F. Sokolovska 2 appliances is the control of enamel demineralization around the brackets. St. Cyril and Methodius University The bands/brackets and the different orthodontic elements that are used Skopje, FYROM (elastics, plastic, sleeves, springs) make the patient’s dental hygiene more 1Department of Pedodontic Dentistry difficult and the accumulation of plaque easier. The purpose of this study School of Dentistry 2Institute of Chemistry, Faculty of Natural was to measure the percentage of Ca, Na, K and Mg in the enamel before Sciences and Mathematics and after application of the topical gel - GC Tooth Mousse. In this study, 40 healthy extracted premolars without any clinical sign of decalcification were selected. All teeth were cleaned and cut in half in the bucco-lingual direction with a diamond disc. Thus, the control and test specimens were obtained from the same teeth. Orthodontic brackets were bonded with Fuji Ortho LC. They were divided in 2 groups according to the period of monitoring (14 days and 1 month). Then, they were coated with a topical gel - Tooth Mousse (GC Corp, Japan), for 5 minutes each day, and stored in artificial saliva until analyzing. We have measured the percentage of Ca, Na, K and Mg in the enamel by using the method of flame atomic absorption spectrometry, with a Varian Spectra AA 55 B atomic absorption spectrometer. The results obtained in this study refer to high percentage of Ca in enamel in the study group for the first examined period. The percentages of Ca in enamel were remarkably higher after 1 month from application of dental mousse. This indicates that, with an in vitro tooth-brackets model, inhibition of creating white spot could be achieved with the use of resin modified glass ionomer cement, supplemented with topical gel exposure. The mineral balance in the oral environment is accomplished by application of the Recal- TM dent CPP-ACP in the form of GC Tooth Mousse. ORIGINAL PAPER (OP) Keywords: Dental Caries; Enamel; Demineralization; Remineralization Balk J Stom, 2008; 12:133-137

Introduction These decalcification marks are seen as early as 4 weeks after band/bracket placement. One of the most difficult problems in orthodontic Several studies report different finding concerning treatment with fixed appliances is the control of enamel possible decalcification of teeth. Mizrahi found that the maxillary incisors and mandibular first molars are most demineralization around the brackets. The bands/brackets likely to exhibit signs of decalcification13. Trimpeneers and the different orthodontic elements that are used found the maxillary central incisors to be most susceptible ’ (elastics, plastic, sleeves, springs) make the patient s dental and Gorelick’s study reported the maxillary laterals11,24. hygiene more difficult and the accumulation of plaque One study measured the frequency of white spot formation easier2,15. After the use of fixed appliances, decalcification on the teeth and ranked them from most common to least marks are more pronounced at the gingival part of the common. The ranking is: maxillary lateral, mandibular teeth, were higher plaque accumulation usually occurs. second premolar, maxillary canine and maxillary first 134 E. Zabokova-Bilbilova et al. Balk J Stom, Vol 12, 2008 premolar26. The resistance of the mandibular segments has Material and Method been linked to the buffering capacity of saliva9. Much research has been focused on reducing the In this study, 40 healthy extracted premolars without occurrence of decalcification during orthodontic treatment. any clinical sign of decalcification were selected. All teeth Researchers have turned their attention toward appliance were cleaned and cut in half in the bucco-lingual direction design, bonding materials, use of fluorides, sealants with a diamond disc. Thus, the control and test specimens and improving oral hygiene7. Many products have been were obtained from the same teeth. Orthodontic brackets developed to prevent demineralization of enamel surface, were bonded with Fuji Ortho LC (GC America Chicago, like casein phosphopeptide-amorphous calcium phosphate III), a resin-modified glass ionomer cement. The teeth (CPP-ACP). were divided in 2 groups according to the period of CPP-ACP can be found in multiple products. monitoring (14 days and 1 month). Then, they were coated Recaldent™ is a unique complex containing amorphous with a topical gel - GC Tooth Mousse for 5 minutes each calcium phosphate (ACP) and casein phosphopeptide day, and stored in artificial saliva until analyzing. (CPP), obtained from milk casein. The preparation is We have measured the percentage of Ca, Na, K and recommended in need for hard tissue remineralization. The Mg in the enamel by using the method of flame atomic manufacturer compares the material to “liquid enamel”. absorption spectrometry (FAAS), with a Varian Spectra CPP-ACP complex make a strong binding with a bio- AA 55 B atomic absorption spectrometer. Determination of the Content of Calcium, film on teeth and form calcium and phosphate reservoir. Magnesium,Potassium and Sodium in Human Tooth Enamel They are then incorporated into the surface of enamel and Determination of Ca, Mg, K and Na by FAAS with dentine21. The effect of GC Tooth Mousse, with CPP- Varian Spectra AA 55 B atomic absorption spectrometer ACP complex is part of the new and modern approach is already described10,25. Hollow cathode lamps were to caries prevention. The CPP-ACP complex contained used as a source of electromagnetic radiation for each in Recaldent™ is hence an ideal system for transporting element. Lamps are optimized for 15 min before analysis. free calcium and phosphate ions, and GC Tooth Mousse, A mixture of acetylene and air was used for flame. Before containing this novel active ingredient, is the world’s first the analysis, instrumental parameters for better precision 12 product for professional use in the dental practice . and sensibility on analysis were optimized (Tab. 1). The proposed anticariogenic mechanism of CPP- ACP involves the incorporation of the nanocomolexes Table 1. Optimal instrumental parameters for Ca, Na, K and Mg into dental plaque and onto the tooth surface, thereby determination by FAAS acting as a calcium and phosphate reservoir. Studies have shows that CPP-ACP incorporated into dental plaque can Parameters Ca Na K Mg significantly increase the levels of plaque calcium and Wavelength/nm 422.7 589.0 766.5 285.2 phosphate ions. This mechanism is ideal for the prevention of enamel demineralization as there appears to be an Slit/nm 0,5 0,5 1,0 0,2 inverse association between plaque calcium and phosphate Lamp current/mA 10 5 5 4 levels and measured caries experience19. Several in vitro and in vivo studies have shown that The content of the investigated elements in the tooth treatment with CPP-ACP corresponds with a reduction in enamel was determined by FAAS after mineralization in a demineralization and increases in remineralization5,14,22. A microwave digestion system from Milestone, model Ethos clinical study by Iijima et al6, who used sugar free chewing Touch Control. The mineralization program is presented in gum containing 18.8 mg CPP-ACP, showed that CPP- table 2. ACP increased resistance to demineralization, increased remineralization and created remineralized enamel that Table 2. Teeth sample mineralization programme was more resistant to subsequent demineralization. Cai et al3 found that the used of sugar-free lozenges containing Step Temperature/°C Time/min Power/W Pressure/bar CPP-ACP significantly increased remineralization of 1 160 10 300 15 enamel subsurface lesions in situ, with 18.8 and 56.4 mg 2 210 10 450 15 of CPP-ACP increasing remineralization by 78 and 176% respectively. One study found that the treatment with 0.1% CPP-ACP, applied twice daily, resulted in a 14% Preparation of Teeth for Analysis decrease in smooth surface caries, and with 1.0% CPP- Teeth samples are stored in artificial saliva, then ACP resulted in a 55% decrease18. washed in de-ionized water and dried on room temperature The purpose of this study was to measure the for 2-3 hours. After crushing, powdered tooth (0.1 g) percentage of Ca, Na, K and Mg in the enamel before and were placed in Teflon vessel and subjected to a wet after application of the topical gel - GC Tooth Mousse. mineralization in a closed system with 2 ml nitric acid. Balk J Stom, Vol 12, 2008 Prevention of Enamel Demineralization During Orthodontic Treatment 135

Teflon vessels were placed in microwave oven and were Table 5 shows mass fraction of Na, K and Mg in mineralized by programme given in table 2 after the second enamel in the group of examined teeth compared with the step system ventilations (20 min). The mineralization control group 14 days after application of the topical gel. product was transferred quantitatively into 25 ml and For this time period, no statistically significant difference de-ionized water was added. The samples could by was found between mass fractions of K, Mg in the enamel subjected to FAAS after this treatment. between both groups. Mass fractions of Na in the enamel Construction of Calibration Dagram Calibration diagram is constructed by using a method displayed increased value, with 0.89% in the examined of standard solutions using regression analysis, where group and 0.60% in the control group, the difference being functional relationships between mass concentration and statistically significant. absorbance of Ca, Na, K and Mg were obtained. For the construction of calibration diagram standard solutions of Ca, Na, K and Mg, with concentration of 1 mg/L, were Table 5. Values on the mass fraction of Na, K and Mg in enamel used. Means of absorbance for each calcium standard 14 days after application of the topical gel solution are given in table 3. group parameters n x SD t p Table 3. Absorbance for appropriate mass concentrations of calcium in tooth enamel test Na 30 0.89 0.05 2.37 0.02* γ(Ca)/μg/ml A control Na 30 0.60 0.06 00 test K 30 0.042 0.018 10 0,086 20 0,165 1.88 0.06 30 0,224 control K 30 0.04 0.009 Analytical dependence on absorbance of concentration of Ca is test Mg 30 0.27 0.08 given by equation: A = 0,0078· γ(Ca)/μg/ml -0.33 0.74 Correlation coefficient is 0,992. control Mg 30 0.23 0.07

For statistical evaluation, a one-way analysis of variance (ANOVA) was initially used to see if there was a significant difference between groups. Table 6. Values on the mass fraction of Ca in enamel 1 month after application of the topical gel

group n x SD t p Results test 30 23.04 4.51 Table 4 shows the percentage of Ca in enamel in the 3.21 0.003** experimental group of teeth 14 days after application of the topical gel - GC Tooth Mousse. Average value of Ca control 30 21.02 3.84 in the examined group of teeth was 22.38%, and 20.06% in the control group. For this time period, statistically significant difference was found between mass fractions of Ca in the tooth enamel between groups. Table 6 shows the mass fraction of Ca in enamel in the group of examined teeth compared to the control group Table 4. Values on the mass fraction of Ca in enamel 14 days of teeth 1 month after application of the topical gel. It after application of the topical gel shows highly significant statistical difference of the values (23.04% in the examined group, compared to 21.02% in group n SD t p x the control group). Values of the mass fraction of Na, K test 30 22.38 4.58 and Mg in enamel of both groups of teeth, 1 month after -2.23 0.033* application of the topical gel, is shown in table 7. These values were higher in the examined group compared to the control 30 20.06 3.78 control group of teeth. 136 E. Zabokova-Bilbilova et al. Balk J Stom, Vol 12, 2008

Table 7. Values on the mass fraction of Na, K and Mg in enamel and lower micro strain than might be found in normal 1 month after application of the topical gel tooth enamel17. Enamel demineralization in vitro was inhibited to group parameters n x SD t p a certain degree in our study. Similar decalcification prevention has been reported by many authors for other test Na 30 0.91 0.14 fluoride-releasing materials1,4,8. However, significant -8.96 0.000000** difference in demineralization inhibition was observed between 2 periods of monitoring. control Na 30 0.67 0.05 The results obtained in this study refer to high test K 30 0.042 0.017 percentage of Ca in enamel in the study group for the first examined periods. The percentages of Ca in enamel were 19.09 0.000000** remarkably higher after 1 month from application of dental control K 30 0.017 0.007 mousse. The finding from this in vitro study indicate test Mg 30 0.29 0.09 that fluoride-releasing adhesives may inhibit enamel decalcification adjacent to orthodontic brackets during -2.3 0.02* the examined period by forming a protective deposit of control Mg 30 0.25 0.04 calcium fluoride-like particles on the enamel surface.

Conclusions Discussion Demineralization during orthodontic treatment is a significant clinical problem. Enamel decalcification around orthodontic bands The results of this study indicate that with an in vitro and brackets has long been a concern. Studies show that tooth-brackets model, the creation of white spot inhibition orthodontic appliances increase the accumulation and could be achieved with the use of resin modified glass adherence of plaque in mouth. Streptococcus mutans and ionomer cement, supplemented with topical gel exposure. Lactobacillus concentrations in the oral cavity increase The effects of CPP-ACP have so far shown promising in conjunction with orthodontic treatment and fixed dose-related increases in enamel remineralization within appliances. These and other bacteria ferment carbohydrates already demineralized enamel lesion. The mineral balance to produce organic acids. These acids can, over time, lead in the oral environment is accomplished by application to the dissolution of calcium and phosphate ions from the of the RecaldentTM CPP-ACP in the form of GC Tooth enamel surfaces. This process of decalcification may lead Mousse. to white spot lesions and even capitation in as little as 4 weeks16,20,23. Clinical experience shows that the use of fixed appliances in orthodontic treatment increases the risk of References enamel demineralization, especially in conjunction with compromised oral hygiene. Together with topical gel GC 1. Artun J, Brobakken BO. Prevalence of caries white spots Tooth Mousse applications, the development and use after orthodontic treatment with multibonded appliances. of fluoride-releasing orthodontic materials may reduce Eur J Orthod, 1986; 8:229-234. the risk of enamel demineralization during orthodontic 2. Basdra EK, Huber H, Komposch. Fluoride released from orthodontic bonding agents alters the enamel surface and treatment. inhibits enamel demineralization in vitro. Am J Orthod In this in vitro study we examined the percentage of Dentofac Orthop, 1996; 109:466-472. calcium, its effect on enamel demineralization, and the 3. Cai F, Shen P, Morgan MV, Reynolds EC. Remineralization alterations that are observed on the enamel surface after of enamel subsurface lesions in situ by sugar-free lozenges the use of fluoride-releasing orthodontic bonding system containing casein phosphopeptide-amorphous calcium (Fuji Ortho LC). phosphate. Aus Dent J, 2003; 48(4):240-243. Enamel lesion which have been remineralized with 4. Corry A, Millett DT, Creanor SL, Foye RH, Gilmour WH. topical exposure to CPP-ACP have been shown to be Effect of fluoride exposure on cariostatic potential of orthodontic bonding agents: an in vitro evaluation. J Orthod, more resistant to subsequent acid challenge, and capable 2003; 30(4):323-329. to promote remineralization of enamel subsurface lesions 5. Chang HS, Walsh LJ, Freer TJ. Enamel demineralization with hydroxyapatite. In addition, the relatively low during orthodontic treatment. Aetiology and prevention. Aus carbonate environment of the CPP-ACP treated crystalline Dent J, 1997; 42(5):322-327. Balk J Stom, Vol 12, 2008 Prevention of Enamel Demineralization During Orthodontic Treatment 137

6. Iijima Y, Cai F, Shen P, Walker G, Reynolds C, Reynolds EC. 18. Reynolds EC. Anticariogenic complexes of amorphous Acid resistance of enamel subsurface lesions remineralized calcium phosphate stabilized by casein phosphopeptides: a by a sugar-free chewing gum containing casein review. Spec Care Dentist, 1998; 18(1):8-16. phosphopeptide-amorphous calcium phosphate. Caries Res, 19. Reynolds EC, Cai F, Shen P, Walker GD. Retention in 2004; 38(6):551-556. plaque and remineralization of enamel lesion by various 7. Featherstone JD. The science and practice of caries forms of calcium in a mouthrinse or sugar-free chewing prevention. J Am Dent Assoc, 2000; 131:887-899. gum. J Dent Res, 2003; 82:206-211. 8. Featherstone JD, Glena R, Sharaiti M, Shields CP. 20. Robinson C, Shore RC, Brookes SJ, Strafford S, Wood SR, Dependence of in vitro demineralization of apatite and Kirkham J. The Chemistry of Enamel Caries. Crit Rev Oral remineralization of dental enamel on fluoride concentration. Biol Med, 2000; 11(4):481-495. J Dent Res, 1990; 69:620-625. 9. Ferguson DB. Salivary electrolytes. In: Tenovuo J, ed. 21. Rose RK . Effects of an anticariogenic casein phosphatide Human Saliva: clinical chemistry and microbiology. Vol. 1. on calcium diffusion in streptococcal model dental plaques. Boca Raton, FL: CRC Press, 1989; pp 75-99. Arch Oral Biol, 2000; 45(7):569-575. 10. Flame Atomic Absortion Spectrometry, Analitical Methods, 22. Schupbach P, Neeser JR, Golliard M, Rouvet M, Varian, Australia Pty Ltd, Publication No 85-100009-00 Guggenheim B. Incorporation of caseinoglycomacropeptide Revised March 1989. and caseinophosphopeptide into the salivary pellicle inhibits 11. Gorelick L, Geiger AM, Gwinnett AJ. Incidence of white adherence of mutans streptococci. J Dent Res, 1996; spot formation after bonding and banding. Am J Orthod, 75(10):1779-1788. 1982; 81(2):93-98. 23. Shen P, Cai F, Nowicki A, Vincent J, Reynolds EC. 12. Manton D, Shen P, Cai F, Cocharne NJ, Reynolds C, Messer Remineralization of enamel subsurface lesions by sugar-free LB, Reynolds EC. Remineralization of White Spot Lesions chewing gum containing casein phospopeptide - amorphous th in situ by Tooth Mousse. Abstract 185-84 General Session calcium phosphate. J Dent Res, 2001; 80(12):2066-2070. of the IADR, 28 June - 1 July, 2006, Brisbane, Australia. 24. Trimpeneers LM, Dermault LR. A clinical evaluation of 13. Mizrahi E . Enamel demineralization following orthodontic the effectiveness of a fluoride-releasing visible light- treatment. Am J Ortod, 1982; 82(1):62-67. activated bonding system to reduce demineralization around 14. Mellberg JR. Remineralization A status report. Part III. Am J orthodontic brackets. Am J Orthod Dentofacial Orthop, Dent, 1:85-89. 1996; 110(2):218-222. 15. Ögaard B, Rolla G, Arends J, ten Cate JM. Orthodontic appliances and enamel demineralization. Part 2: prevention 25. Tsalev DL, Zaprinov ZK. Atomic Absorption Spectrometry and treatment of lesions. Am J Orthod Dentofac Orthoped, in Occupational and Environmental Health Practice. Volume 1988; 94:123-128. I. Analytical Aspects and Health Significance,. Boca Raton, 16. Reich E, Lussi A, Newbrun E. Caries-risk assessment. Int Florida: CRC Press, 1983. Dent J, 1999; 49:15-26. 26. Vorhies AB, Donly KJ, Staley RN, Wefel JS. Enamel 17. Reynolds EC. Remineralization of enamel subsurface lesions demineralization adjacent to orthodontic brackets bonded by casein phosphopeptide-stabilized calcium phosphate with hybrid glass ionomer cements: an in vitro study. Am J solutions. J Dent Res, 1996; 76(9):1587-1595. Ortod Dentofacial Orthop, 1998; 114(6):668-674.

Correspondence and requests for offprints to:

Dr. Efka Zabokova-Bilbilova Dr. Trajce Stafilov Department of Pedodontic Dentistry Institute of Chemistry School of Dentistry Faculty of Natural Sciences and Mathematics Vodnjanska 17 St. Cyril and Methodius University 1000 Skopje 1000 Skopje E-mail: [email protected] E-mail: [email protected]

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Infraocclusion of Primary Molars: A Review and Report of Cases

SUMMARY Nazan Kocatas Ersin, Umit Candan, The aim of this study was to describe the distribution and degree Ali Riza Alpoz of infraocclusion and to evaluate the influence of the age of diagnosis Ege University, Faculty of Dentistry and treatment outcomes of primary molars during a period of 2 years. 21 Dept. of Paediatric Dentistry patients, aged between 6 to 11 years, participated in the study. The children Bornova, Izmir were subjected to clinical and radiographic examinations every 6 months Turkey during 2 years. Parameters assessed were age, gender, distribution and degree of infraocclusion based on radiographs, ankylosis, altered position of adjacent and successor teeth and treatment outcome. It has been found that the most frequently affected teeth were primary second molars located in the lower arch as bilateral occurrence. The degree of infraocclusion was considered as mild in 35, moderate in 15 and severe in 6 teeth. The successors were congenitally absent in 10 infra-occluded teeth. Tipping of neighbouring teeth and the delayed eruption of the permanent successors were found to be the most frequent complications. The treatment outcome was favourable in 78% of the cases. It could be concluded that early diagnosis, correct treatment approach and follow-ups were the main factors of a successful treatment of infra-occluded primary molars. ORIGINAL PAPER (OP) Keywords: Infraocclusion; Primary Molars; Children; Ankylosis Balk J Stom, 2008; 12:138-142

Introduction familial tendency was also indicated as the aetiology of infraocclusion8. The term “infraocclusion” describes a tooth which lies Infra-occluded teeth are more common with the below the occlusal plane. Other terms used in the literature primary teeth than the permanent teeth, and mandibular are submerged, impaction, reimpaction, re-inclusion and primary molars tend to be infra-occluded more frequently secondary retention. However, it is suggested that the term than maxillary primary molars2,8,9. “infraocclusion” gives a good description of the clinical The aim of the study was to describe the distribution appearance and has gained increasing use during recent and degree of infraocclusion in a group of children aged years1. The term “ankylosis” has been also most widely between 6 to 11 years, and to evaluate the influence of the used because of the clinical, radiographic and histological age of diagnosis and treatment outcomes during a period evidence, which suggested that the majority of infra- of 2 years. occluded teeth were ankylosed. This term refers to one possible cause or frequent association with infraocclusion. It is assumed that because of tooth ankylosis, the infra- occluded tooth remains in a fixed position while eruption Material and Methods of adjacent teeth appear2. The other factors involved in infraocclusion of 21 patients aged between 6 to 11 years, who were primary teeth are congenitally missing permanent teeth, referred to the Department of Paediatric Dentistry, defects in the periodontal membrane, local mechanical Ege University, due to their dental problems, enrolled trauma, a disturbed local metabolism, injury to the in the study. The infra-occluded teeth were observed periodontal ligament, precocious eruption of the permanent after clinical and radiographic examinations including first molar or a combination of the mentioned factors3-7. A orthopantomograph and periapical radiographs. The follow- Balk J Stom, Vol 12, 2008 Infraocclusion of Primary Molars 139 up examinations also comprised clinical and radiographic of the infra-occluded teeth, lack of a permanent successor examinations every 6 months during 2 years. The radio- and extent of root resorption. graphs were evaluated for resorption and ankylosis of the infra-occluded teeth and comparisons were made with radiographs taken before. Parameters assessed were age, gender, distribution Results and degree of infraocclusion based on radiographs, ankylosis, altered position of adjacent and successor teeth, 56 infra-occluded teeth were detected in 21 patients and treatment outcome. The degree of infraocclusion was (11 boys and 10 girls) whose mean age was 9.4± 0.8 years considered as mild, moderate or severe, as described by (Tab. 1). At the time of first examination, all the patients 10 Brearly and Mc Kibben . Mild was described as occlusal were in the mixed dentition stage. 18 patients had more surface located approximately 1 mm below the expected than 1 infra-occluded tooth while 3 patients had 1 tooth occlusal plane for the tooth. Moderate was described as in infraocclusion. 11 (19.7%) infra-occluded teeth were occlusal surface approximately level with the contact point located in the upper jaw while 45 (80.3%) teeth were of one or both adjacent tooth surfaces. Severe was described found in the lower jaw. 24 (42.9%) of the infra-occluded as occlusal surfaces level with or below the interproximal gingival tissue of one or both adjacent tooth surfaces. teeth were primary first molars and 32 (57.1%) of them Mobility test was performed by direct finger pressure were second molars. The degree of infraocclusion and percussion sound was recorded after tapping the was considered as mild in 35 (62.5%), moderate in 15 crown of the tooth vertically as well as horizontally with (26.8%) and severe in the remaining 6 (10.8%) teeth. the handle of a probe by the first examiner to determine Agenesis of premolars was diagnosed in 10 (17.9%) infra- ankylosis. occluded teeth. Ankylosis was detected in 29 lower infra- A therapeutic approach was chosen according to the occluded molars after mobility and percussion tests, and patient’s age, occlusal status, development and condition radiographic examination.

Table 1. Distribution of 56 infra-occluded primary molars by gender, degree of infraocclusion and location in 21 patients

Gender Number of Location Degree of infraocclusion Lack of permanent teeth Girls Boys Maxilla Mandible Mild Moderate Severe successor Primary first 3 5 24 2 22 16 7 1 - molar Primary second 7 6 32 9 23 19 8 5 10 molar Total 10 11 56 11 45 35 15 6 10

Out of 46 infra-occluded teeth which had permanent present in 62.5% of the cases, and the treatment outcome successors, 19 ankylosed teeth were extracted and 5 was favourable in 78% of the cases. space maintainers were fitted and remained in place until For 2 patients who had severely infra-occluded teeth, the eruption of the successors. 27 infra-occluded teeth extraction followed by orthodontic treatment was planned, were left undisturbed waiting for the normal exfoliation, but the patients refused the treatment and showed poor but monitored every 6 months fulfilling their function compliance to the follow-up examinations. After 2 years, as space maintainers. At the end of 2 years, 6 teeth were they were recalled and their orthopantomographs were exfoliated and the permanent successors erupted with a taken. In figure 1a, the patient was 9-year-old boy and his mean period of 9 months later than on the normal, contra- medical history was unremarkable. The patient had 2 infra- lateral side, and 10 teeth were extracted because of the occluded teeth, upper right primary first molar and lower root development of the successors. The remaining 11 left primary second molar with caries. It was decided teeth were still being monitored every 6 months. After to extract the infra-occluded teeth and an orthodontic orthodontic evaluation of the occlusion, it was decided treatment was planned, but he refused the extraction and to allow the 10 infra-occluded ankylosed molars with failed to come to the follow-up examinations. After 2 agenesis to persist. Composite build-ups were placed to years, he was recalled and an orthopantomogram was 6 infra-occluded teeth with agenesis in order to restore taken, shown in figure 1b. The degree of root resorption the occlusion and interproximal contacts and waited for was unaltered in both of the infra-occluded primary resorption. The degree of root resorption was unchanged molars. The carious teeth had been restored in a private or minimal in the infra-occluded teeth with agenesis at the dental clinic. The infraocclusion had worsened in both the end of 2 years. Migration of the neighbouring tooth was upper and lower regions and tipping of the neighbouring 140 N.K. Ersin et al. Balk J Stom, Vol 12, 2008 teeth was diagnosed. The upper and lower primary incisors treatment was considered with fixed appliance therapy. had exfoliated and the permanent incisors had erupted as The patient refused the orthodontic treatment because of well as the permanent first molars. financial circumstances. After 2 years, orthopantomogram In figure 2, the patient was an 8-year-old girl and and clinical examination revealed that the degree of root her medical history was unremarkable. The patient had resorption of the infra-occluded tooth was unchanged referred to our clinic for her non-erupted permanent first although the root of the permanent successor has central incisor. Her orthopantomogram and intraoral developed, but a resorption was observed at the distal clinical examination showed a lower left second root of the symmetrical primary second molar (Fig. 3a primary infra-occluded molar with the tipping of the and b). The positions of the non-erupted upper permanent permanent first molar and a malocclusion in the upper first central incisor, second premolar and first molar was left region (Fig. 2a and b). In view of the severity of the unaltered and the remaining teeth in her mouth had a infraocclusion and the malocclusions, an orthodontic normal resorption and eruption.

Figure 1a: Orthopantomograph of a patient at the initial examination, Figure 1b: Orthopantomograph of the same patient after 2 years, showing severely infra-occluded molars showing worsened infraocclusion. The infra-occluded teeth are more impacted with the tipping of the adjacent teeth, leading to a malocclusion in the permanent dentition

Figure 2a: Orthopantomograph of a patient at the initial examination, Figure 2b: The intraoral view of a patient showing the infra-occluded showing a severe infra-occluded primary molar. The left lower lower left second primary molar permanent first molar shows a severe mesial tipping Balk J Stom, Vol 12, 2008 Infraocclusion of Primary Molars 141

Figure 3a: Orthopantomograph of the same patient after 2 years, Figure 3b: The intraoral view of the patient showing eruption of the showing no resorption of the infra-occluded primary second molar roots, lower left permanent canine and the first premolar and no alterations at the left upper region with a severe malocclusion

Discussion primary second lower molars (57.1%), as in a bilateral occurrence in our study. The infraocclusion is a common eruption disturbance, The degree of infraocclusion can be from mild to which constitutes a major clinical problem1. It is reported severe. Depending on the degree of infraocclusion, the occlusion and the position of the tooth germ could be that the prevalence of children with infra-occluded affected. Infra-occluded teeth could have a high potential primary molars in the various population ranges from to malocclusion. In the literature, complications of infra- 1.3% to 38.5%8,11. The prevalence could be changed due occluded primary molars were stated as tipping of the to the age of the children, ethnic differences, differences neighbouring teeth, loss of space, extreme eruption in number of remaining primary molars, and differences of the antagonist, posterior open bite and rotations in 12 in the criteria used . the successor teeth12,15. In the present study, tipping of Infraocclusion is found from 3 years of age and neighbouring tooth was found to be the most frequent prevalence of infraocclusion has been reported to reach complication. a peak at ages from 6 to 11 years of age1. It is also Infraocclusion in children seemed to be associated mentioned that the variations in the age could possibly be with agenesis; the prevalence of missing successors related not only to genetic predisposition to infraocclusion underneath primary molars with infraocclusion varied but also to the inception of this condition and the from 5 to 67%1. In the present study, the prevalence of exfoliation time the infra-occluded tooth3. The age range missing successors was found as 17.9% of the total cases. from 6 to 11 years is in the present study, too. When considering treatment options for the infra- Infraocclusion of primary molars is usually occluded primary molars, there is no general agreement16-18. found not to be sex linked. However, a more frequent It was reported that the most important influencing factor occurrence in girls than in boys has been reported in was the presence or absence of the permanent successor some studies1,2. No gender predominance was observed and when successor is absent, root resorption was slow 16 in our study. Most investigations have reported that the and spontaneous exfoliation less likely . In this study, the degree of root resorption was unchanged or minimal in the primary second molars were most commonly found in infra-occluded teeth with agenesis after 2 years. infraocclusion. However, it has recently been reported Teague et al19 reported that treatment depends upon that the primary first molars were more often found in the patient’s age, the condition of the primary molar, infraocclusion1,9,13. This difference is most probably due the patient’s preference, jaw relationship and occlusion. to the fact that mandibular primary first molars ankylose When the successor was present, the infra-occluded earlier, produce less infraocclusion and usually exfoliate tooth could exfoliate normally. However, exfoliation was on time, which means that they may go undetected. In usually delayed by only 6 to 12 months compared with contrast, mandibular primary second molars produce more contra-lateral unaffected tooth and infra-occluded tooth severe infraocclusion and a slight delay in the eruption should not be extracted solely to prevent an increase in of their successors13. In children with more than 1 tooth infraocclusion1. Kurol and Koch20 compared extraction affected, bilateral occurrence was reported to be more and non-extraction management of contra-lateral teeth in common1,5,12,14. The most frequently affected teeth were patient’s with bilateral infra-occluded primary molars and 142 N.K. Ersin et al. Balk J Stom, Vol 12, 2008 found that there was no significant delay in exfoliation 6. Kurol J, Magnusson BC . Infraoclusion of primary molars: a of non-extracted infra-occluded teeth. Mc Donald et al21 histologic study. Scand J Dent Res, 1984; 2:564-576. suggested that if cooperation of patients was obtained, 7. Rogers JV. Amalgam restoration in a submerged tooth. Oral observation was the best approach. On the other hand, Surg Oral Med Oral Pathol, 1984; 57:233-234. 8. Koyoumdjisky-Kaye E, Steigman S. Ethnic variability in the some authors recommended early tooth extraction for the prevalence of submerged primary molars. J Dent Res, 1982; treatment of infra-occluded teeth and treatment regimens 61:1401-1404. 5 could remain contraversial . 9. Via WF . Submerged deciduous molars: familial tendencies. In the present study, therapeutic extraction was J Am Dent Assoc, 1964; 69:127-129. chosen in patients with several occlusal disturbances, risk 10. Brearley LJ, McKibben DH. Ankylosis of primary molars of impaction of a permanent tooth or ankylosed teeth with (I) Prevalence and characteristics (II) Longitudinal study. J significant delay in root resorption. We suggest that infra- Dent Child, 1973; 40:54-63. occluded primary molar should not be extracted before the 11. Steigman S, Koyoumdjisky-Kaye E, Matrai Y. Submerged deciduous molars and congenital absence of premolars. J time it should exfoliate if the successor is present, unless Dent Res, 1973; 52:322-326. ankylosis was detected. Only when the resorption did 12. Teague MA, Philip B, Parry JW. Management of the not proceed normally and ankylosis was observed, then submerged deciduous tooth: 1. aetiology, diagnosis and extraction should be considered. In case of agenesis, it potential consequences. Dent Update, 1999; 26:292-296. was suggested that persistence of infra-occluded primary 13. Kula K, Tatum BM, Owen D, Smith RJ, Rule J. An occlusal molars could serve as a semi-permanent solution for the and cephalometric study of children with ankylosis of patients. primary molars. J Pedod, 1984; 8:146-159. 14. Antoniades K, Kavadia S, Al Milioti K. Submerged teeth. J Clin Pediatr Dent, 2002; 26:239-242. 15. Ertuğrul F, Tuncer AV, Sezer B. Infraocclusion of primary molars. A review and report of a case. J Dent Child, 2002; Conclusion 69:166-171. 16. Gulati AK, Welbury RR. The use of resin-bonded porcelain It was revealed that, in the management of the crowns for primary molars in infra-occlusion. Br Dent J, infraocclusion, early diagnosis and correct treatment 1998; 184:588-591. approach play significant roles in eliminating the dental 17. Evans RD, Briggs PFA. Restoration of an infra-occluded problems, particularly malocclusion. Multidisciplinary primary molar with an indirect composite onlay: a case treatment and periodic follow-ups could be suggested report and literature review. Dent Update, 1996; 23:52-54. in order to prevent the complications of infra-occluded 18. Altay N, Cengiz B. Space-regaining treatment for a submerged primary molar: a case report. Int J Paed Dent, primary molars. 2002; 12:286–289. 19. Teague MA, Philip B, Parry JW. Management of the submerged deciduous tooth: 2. treatment. Dent Update, 1999; 26:350-352. References 20. Kurol J, Koch G. The effect of extraction of infraocluded deciduous molars: a longitudinal study. Am J Orthod, 1985; 1. Kurol J. Infraocclusion of primary molars: an epidemiological, 87: 46-55. familial, longitudinal clinical and histological study. Swedish 21. McDonald RE. Dentistry for the child and adolescent. 2nd Dent J, 1984; Supplement 21, pp 5-7. ed. St Louis: CV Mosby Co, 1974; pp 79-84. 2. Douglas J, Tinanoff N . The etiology, prevalence, and sequelae of infraocclusion of primary molars. J Dent Child, 1991; 58:481-483. 3. Biederman W. Etiology and treatment of tooth ankylosis. Correspondence and request for offprints to: Am J Orthod, 1962; 48:670-684. 4. Pilo R, Littner MM, Marshak B. Severe infraocclusion Dr. Nazan Kocatas Ersin Ege University, Dental Faculty ankylosis: report of three cases. J Dent Child, 1989; Dept of Paediatric Dentistry 56:144-146. 35100 Bornova, Izmir 5. Atrizadeh F, Kennedy J, Zonder H. Ankylosis of teeth Turkey following thermal injury. J Periodont Res, 1971; 6:159-167. E-mail: [email protected]

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Assessment of the Quality of Newly-Formed Bone for Implant Insertion after Augmentation of the Maxillary Sinus Floor

SUMMARY B. Obradovic1, Z. Stajcic2, Lj. Stojcev Stajcic3 Background: Presence of the maxillary sinus and low bone density in 1University of Banja Luka, Medical School, this area often could create a problem for prosthetic rehabilitation with den- Banja Luka, Bosnia and Herzegovina tal implants. Sinus floor augmentation technique can successfully increase 2Dental/Medical Centre for Maxillofacial dimensions of the posterior maxilla for implant placement. Surgery “Beograd-centar”, Belgrade, Serbia 3 Objective: To assess quality of newly formed bone for implant insertion Clinic of Oral Surgery, Faculty of Stomatology, University of Beograd, Serbia after augmentation of the floor of the maxillary sinus using Digora for Win- dows computer programme. Materials and Methods: 30 patients with indications for sinus lift procedure were involved in this clinical study. Bone density was analysed by Digora for Windows computer programme. Results: 16 patients completed this clinical study with preoperative and postoperative orthopantomographs. Conclusion: Cases with sufficient density and bone volume in the posterior maxilla require sinus lift technique with adequate bone graft for implant insertion. This is confirmed by pre- and post-operative analysis of radiographic images in Digora for Windows programme. ORIGINAL PAPER Key words: Posterior Maxilla; Sinus Lift; Computer Analysis Balk J Stom, 2008; 12:143-146

Introduction The maxillary sinus floor augmentation technique has been extensively used in the last 20 years to successfully Contemporary prosthetic rehabilitation of the increase the dimensions of the posterior maxilla for 3 posterior maxilla, instead classic dental prostheses, implant placement . This technique is based on elevation comprises implant insertion and subsequent rehabilitation. of the Schneiderian membrane from the floor of maxillary sinus and introduction of a bone graft or a bone substitute. However, implant placement in the posterior maxilla In these cases, the residual height of the alveolar ridge was usually presents a challenging clinical situation. When less than 8 mm14 . Sinus lift was introduced by Boyne planning implant restoration in this region, several in the 1960s and it was soon more popularized9. This parameters need to be considered: height and width of procedure is technically demanding and involves many the alveolar ridge in the posterior maxilla, and bone factors that might affect implant survival, such as the type density. Due to the presence of maxillary sinus and low of graft used for augmentation, surgical technique and the bone density in this area, it is usually required to use type of implants4. shorter implants, which can result in the increased risk Since survival rates in the posterior maxilla are of failure5. Sufficient density and appropriate volume of different from other sites/locations in the mouth, it bone are therefore crucial factors for successful implant would be interesting to analyse implant survival after treatment7,8. sinus augmentation. The aim of this clinical study was to 144 B. Obradovic et al. Balk J Stom, Vol 12, 2008 assess quality of newly-formed bone for implant insertion after augmentation of the floor of maxilla sinus by using modern computer analysis programme.

Material and Methods

The study was carried out on a group of 30 patients, of different age and gender, who required bone augmentation of the posterior maxilla and subsequent implant restoration. All surgical procedures were carried out in Dental/Medical Centre for Maxillofacial Surgery “Beograd-centar” in Belgrade, Serbia, under local Figure 1. OPG X ray in Digora started for analysis anaesthesia. All patients had residual sinus floor of less than 8 mm high and low bone density. They had good oral hygiene, did not suffer from diabetes mellitus or other serious general diseases. In the period from 2006 to 2007, 30 sinus grafting operations were performed. The sinus lift was carried out using 1 of the familiar techniques depending on clinical condition. Duration of rehabilitation between the sinus lift procedure and implant placement was 6 months. The particulate bovine bone Bio-Oss® was used for the sinus floor augmentation in majority of cases, as well as an autogenous bone graft from the mandible (symphysis, retromolar region) in cases of severe pneumatization. The type of implants used in the second stage procedure were Branemark, Straumann, and Replace Select Tappered Figure 2. Analysis in Digora preoperatively postoperatively according to the thickness of the bone and patient preferences. Quality of newly formed bone (bone density) and implant stability was evaluated on the basis of computer programme Digora for Windows (Soredex Finland). Preoperative and postoperative analysis of height of the sinus floor was also performed in Digora for Windows programme. Figure 1 shows ortthopantomography (OPG) in Digora, started for analysis. To perform more precise computer interpretation of height of maxillary sinus line, a calibrate method was used. Figures 2 and 3 show analysis of height of the posterior maxilla in Digora, pre- and postoperatively. In Digora for Windows programme, Figure 3. Analysis in Digora after augmentation the height of the posterior maxilla can be obtained automatically choosing the part of the posterior maxilla for height analysis (vertical line) with cursor (principle is the same on pre- and postoperative X-rays). Figures 4 and 5 show analysis of bone density pre- and postoperatively in Digora. Principle of bone density assessing in Digora for Windows programme can be obtained automatically as well by using cursor. Length for assessing bone density preoperatively was preformed in side of rectangle in bone zone planned for augmentation and subsequent implant insertion. The same principle was used on postoperative X-rays in the zone where bone augmentation was performed. Figure 4. Analysis in Digora of bone density bone preoperatively Balk J Stom, Vol 12, 2008 Implant Insertion into Augmented Maxillary Bone 145

Results

16 patients completed the study with preoperative and postoperative OPGs, what was the requirement for analysis of bone height (the distance between the sinus floor and the top of the alveolar ridge) and bone density. Preoperative mean-value of bone height was 7.03 mm and 15.82 mm after augmentation. Preoperative and postoperative values of the bone density in the posterior maxilla in the region of the maxillary sinus floor were of 50.80 and 114 respectively. These findings significantly improved bone conditions for implant placement. According to the highest level of bone density in peri-implant region of 177.50 and clinical observation, all Figure 5. Analysis in Digora of density postoperatively implants were stable in the second-stage surgery.

Figure 6. Posterior maxilla before and after augmentation

Analysis in Digora showed no differences between are found in voluminous and highly mineralized bone. bone density of xenotransplants and autotransplants. In the region of the posterior maxilla, bone is largely Figures 6 and 7 show OPGs before and after augmentation cancellous with low level of mineralization11. Its height of the posterior maxilla, with obvious effect. is usually limited by the extended maxillary sinus. But, the amount of residual alveolar bone height is often cited as an important prognostic factor for the success of sinus augmentation procedure9. Discussion During the study, main parameters for analysis of the posterior maxilla were the height of the residual alveolar Dental implants have reached a high level of bone and bone density. Preoperative results during Digora reliability and a considerable rate of success1. Best results analysis of height (mean-value 7.03 mm) and bone density 146 B. Obradovic et al. Balk J Stom, Vol 12, 2008

(50.80) have revealed poor bone quality, and doubtful 5. Chuang SK, Tian L, Wei LJ, Dodson TB. Predicting dental osseointegration of the placed implant in the future. This implant survival by use of the marginal approach of the anatomical handicap could be resolved with a sinus floor semi-parametric survival methods for clustered observations. augmentation procedure9. J Dent Res, 2002; 81:851-855. Postoperative results of the bone height after bone 6. Cordaro L. Bilateral simultaneous augmentation of the maxillary sinus floor with particulated mandible. Report of a graft procedure (mean-value of 15.82 mm) and bone technique and preliminary results. Clin Oral Impl Res, 2003; density after 6 months (middle value 114) were confirmed 14:201-206. by successful implant survival. Implant failure is more 7. Friberg B, Jemt T, Lekholm U. Early failures in 4641 common with implants placed in bones of low density consecutively placed Branemark dental implants, a study 7,8 than in bones of high density . Analysis of implant from stage I surgery to the connection of completed stability in Digora programme after few months showed prostheses. Int J Oral Maxillofac Impl, 1991; 6:142-146. satisfactory bone density (of mean-value 177.50), which 8. Jaffin RA, Berman CL. The excessive loss of Branemark is an important factor for implant osseointegration in the fixture in type IV bone: A 5-year analysis. J Peridontol, newly formed bone, which means close apposition of bone 1991; 62:2-4. to the implant surface, “contact osseogenesis”2. 9. Jensen OT, Shulman LB, Block MS, Iacono VJ. Report of the In this study, a xenograft Bio-Oss® was applied for Sinus Consensus Conference of 1996. Int J Oral Maxillofac augmentation. In cases with defect of the buccal cortex Impl, 1998; 13(Suppl 1):1-45. 10. Jensen OT. The Sinus Bone Graft. Chicago: Quintessence, of the maxilla, autogenous bone grafts from the mandible 1999. (symphysis, retromolar region) were applied to achieve 11. McCarthy C, Patel RR, Wragg PF, Brook IM. Sinus 6,12 highly predictable bone augmentation . It would be augmentation bone grafts for the provision of dental interesting to predict what will happen with these implants implants: Report of clinical outcome. Int J Oral Maxillofac in the future. However, that would imply a long-term Impl, 2003; 18:377-382. follow-up findings of another clinical study. 12. Merkx MA, Maltha JC, Stoelinga PJ. Assessment of the value of inorganic bone additives in sinus floor augmentation: A review of clinical reports. Int J Oral Maxillofac Surg, 2003; 32:1-6. References 13. Pinholt EM . Branemark and ITI dental implants in the human bone-grafted maxilla: A comparative evaluation. Clin 1. Adell R, ErikssonB, Lekholm U, Branemark PI, Jemt T. A Oral Impl Res, 2003; 14:584-592. long term follow-up study of osseointegrated implants in the 14. Stajcic Z., Stojcev Lj. Atlas of Oral Implantology. Belgrade: treatment of totally edentulous jaws. Int J Oral Maxillofac Grafolik, 2001, p 102. (in Serb) Implants, 1990, 5:347-359. 2. Albrektsson T, Branemark PI, Hansson HA, Lindstrom J. Osseointegrated titanium implants. Requirements for ensuring a long-lasting, direct bone-to-implant anchorage in man. Acta Orthopaed Scand, 1981; 52:155-170. 3. Boyne PJ, James RA. Grafting of the maxillary sinus floor with autogenous marrow and bone. J Oral Surg, 1980; 38:613-616. Correspondence and request of offprints to: 4. Buser D, Mericske-Stern R, Bernard JP, Behneke A, Behneke B. Obradovic N, Hirt HP, Belser UC, Lang NP. Long term evaluation of University of Banja Luka, Medical School nonsubmerged ITI implants. Part I. 8-year life table analysis Banja Luka of a prospective multi-center study with 2359 implants. Clin Bosnia and Herzegovina Oral Impl Res, 1997; 8:161-172. E-mail: [email protected]

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Medication and Positive Remodelling of Osteoporotic Jaws

SUMMARY Srdjan D. Poštić Osteoporosis causes micro-degradations and jaw-bone reduction. Initial University of Belgrade, Faculty of Stomatology, positive turnover and bone recover should make hasten by local medication Clinic of Prosthetic Dentistry of osteoporotic jaws. The aim of this study was to present improvement of jaw Belgrade, Serbia pattern by local application of calcitonin and calcium throughout prosthetic treatment of selected osteoporotic patients. Patients undergoing study were osteoporotic and toothless (9 males and 27 females), with no malignancy. Non-osteoporotic complete denture wearers, 7 men and 7 women were controls. DPX-L (Lunar) was used in detection of skeletal degradations. Pano- ramic radiographs (Orthopantomograph 10, Siemens) and digital densitometer DT II 05 (England) were used in the analysis of bone density. T-results indicated systemic osteoporosis. After application of calcium and calcitonin in solutions, moderate increase of density (p<0.05) was verified, compensating up to 3% of total mandibular loss. The second section of results was restorative effect of prosthetic treatment of osteoporotic patients. In this study, osteoporosis affected women patients earlier than men. Regardless the necessity of careful selecting of patients for this kind of treatment, calcitonin and calcium in solutions should be considered as the priority of local therapy in osteoporotic toothless patients, providing positive bone remodelling, as well as success at the second level of therapy - positioning of dentures. ORIGINAL PAPER (OP) Keywords: Jaw; Osteoporosis; Calcitonin; Bone Remodelling Balk J Stom, 2008; 12:147-152

Introduction systemic medication, it could be of particular importance to focus dependable medical oral treatment approaches Osteoporosis is the most common type of bone disease in osteoporotic affections4,16,17,19. Calcitonin accelerates over the lifetime, affecting human bones indiscriminately influx of calcium, improving bone density and mineral and haphazardly. A variety of micro-structural osteoporotic content of bone, either in local, or systemic level7-9,10,14. degradations and macroscopic resorption of oral bones This positive remodelling of osteoporotic bones could was very well evidenced3,4,6,7,10-12,14,17. Moreover, it was be finally reached in mandibular bone, as well as in reported that osteoporosis of human oral bones damaged other human bones2,5,7-9,15-19. The aim of this study is to not only bone support of remaining teeth, but induced present improvement of mandibular-bone pattern by local reductions of denture retention and stability, too17. Analysis application of calcitonin and calcium throughout prosthetic of bone layer’s appearance on panoramic radiographs is the treatment of selected osteoporotic patients. valuable method of assessing bone changes in any of bone turnovers1,3,7,14,20. Diet and nutritional factors are of extreme significance for prevention of osteoporosis, but minor results should Material and Method be expected regarding initiation of positive remodelling of fragile osteoporotic bone8,10. Considering assorted The experimental group comprised 9 men (aged literature data on multiple drug therapy and possibilities of 64-90; mean age 87 years), and 29 women (aged 56-81; 148 S.D. Poštić Balk J Stom, Vol 12, 2008 mean age 58 years), edentulous and osteoporotic, with no malignant diseases (Fig. 1). 7 toothless men and 7 toothless women patients were controls (Fig. 2). Patients were selected concerning dental-oral history, questionnaire (age, probable treatments of osteoporosis in the past, history of fractures, menopausal periods, calcium and microelements of plasma-blood, additional Pyrilinx-D and Prolagen-C tests), oral examination (bone consistency and resorptions) and skeletal density. 3 women from the experimental group (on estrogens) and 3 osteoporotic men patients were Figure 3. Panoramic radiograph of osteoporotic jaws of the patient of on systemic therapy of osteoporosis after hospitalization. the experimental group DPX-L analysis (Lunar, U.S.A.) and T-results of patients were provided.

Figure 4. Grid positioned onto regions of particular interest of the osteoporotic mandible of the patient of the experimental group, prior to densitometric assessment

Figure 1. Oral status of osteoporotic patient of the experimental group before treatment

Figure 5. Determined regions of interest - Pr, M1r, M2r, Pl, M1l,M2l

Figure 2. Non-resorbed jaw of the patient of the control group

Panoramic radiographs of each patient (Orthopantomo- graph 10; serial no. 01492; Siemens, Germany), focused osteoporotic remodelling of jaws (Figs. 3-5). Calcitonin (Miacalcic, Novartis, Switzerland; Calcitonin Huber, Galenika AD, Serbia), and calcium gluconate (Sterop, Brussles, Belgium), or calcium Figure 6. Local application of anaesthetic on mucosal surface before glubionat (Calcium-Sandoz amp., Switzerland) were used injecting medicament – solution of calcitonin with calcium Balk J Stom, Vol 12, 2008 Remodelling of Osteoporotic Jaws 149

Figure 7. Submucous injection of therapeutic solution of calcitonin and ion calcium onto buccal bone surface of osteoporotic mandible of the patient of the experimental group Figure 9. Complete dentures restored all of the supporting tissues and occlusion - dentures in the mouth , after necessary increments of bone density of the lower jaw

Figure 8. Injection of therapeutic solution of calcitonin and calcium to Figure 10. Panoramic radiograph of the patient after local increase of the right side of the buccal mandibular osteoporotic surface density of the edentulous mandible

locally to improve bone pattern in osteoporotic patients. The results of medication of supporting bone tissues Up to 1.5 ml of calcitonin and calcium solution (1:2) was primarily affected by osteoporosis were favourable in injected submucously onto mandibular bone surfaces this study. Increase of density of mandibular segments (Figs. 6-8). Complete dentures were fabricated for each of the patient of the experimental group (Fig. 9). after the therapy was significant, particularly for Pr and Digital densitometer DT II 05 (England, UK) was Pl segments (p < 0.01). Following application of calcium used in the analysis of mandibular segments’ bone density and calcitonin in solutions, moderate increase of jaw-bone 10,15 at panoramic radiographs after the therapy (Fig. 10) . density was observed (p < 0.05), compensating up to 3% of total mandibular-bone loss (Tabs. 1 – 3). Results The second section of results were restorative effects of oral-prosthodontic treatment of the selected T results indicated systemic osteoporosis. The numerical values of T result ranged from -2.4 to -2.6 for osteoporotic patients. Edentulous osteoporotic patients male patients, and -2.5 to -2.6 for female patients. were rehabilitated in the observation period (Fig. 9). 150 S.D. Poštić Balk J Stom, Vol 12, 2008

Table 1. Increase of mandibular density of the experimental Table 2. Statistical significance and differences of numerical group and bone pattern improve values of mandibular density between the control and the experimental group

-1.6 Differences of numerical Prs values of optical density Pls M1rs Segment regarding the baseline of the M1ls control group and the baseline of M2rs -1.8 M2ls experimental group

Pr P < 0.01

-2.0 Pl P < 0.01 M1r P < 0.05 M1l P < 0.05 -2.2 M2r P < 0.05 M2l P < 0.05

-2.4

-2.6 baseline 9th months later

Table 3. Percentage of increase of density within mandibular segments uring 7 week interval of application of solution of calitonin and calcium

Mandibular segments Percentage of considered increase of density

Pr 0.8% ± 0.8

Pl 0.85% ± 0.6

M1r 0.84% ± 0.1

M1l 0.83% ± 0.2

M2r 0.84% ± 0.4

M2l 0.84% ± 0.3 Pr+Pl+M1r+M1l +M2r+M2l ≅ 3%

Discussion as well as the fact that certain interruptions of immune response were described as possible complication of the In dental literature there were few reports on the extended bisfosfonate usage - it seemed reasonable to treatment and local medication of jaw-bones. Based apply calcitonin and calcium in solutions locally, in vivo, on certain medical studies and monographs, there to osteoporotic jaws2,4,5,18,19. The effects of treatment were 2 major approaches to the treatment. The first is difficult to compare to different calcitonin effects as treatment approach has been related to application of they were acquired in experimental animals, but not in bisfosfonates4,7,10,17-19. The second approach considered humans9,10,15,16. calcitonin as the primary accelerator of calcium’s influx to Calcitonin was described as the substance strongly the bone4,10,17-19. Additionally, there were considerations of regulating influx of calcium4. Calcium influx should application of calcitonin, as well as bisfosfonates, locally have been provided by mobilization of “free” calcium to jaw-bones and denture-supporting areas2,5,7,9,10,15,16. ion from blood plasma, as well as by exchanging calcium Considering various facts on bisfosfonates - studies were ion of the medicament (calcium gluconate or calcium mainly conducted on patients undergoing systemic therapy glubionas)4,10. Respecting specificity of blood flow to with bisfosfonates, and there is only a few of studies on the human mandible, and the fact that mandible usually application of bisfosfonates on the local (oral) level, is not supplied by plenty of blood, it seemed reasonable Balk J Stom, Vol 12, 2008 Remodelling of Osteoporotic Jaws 151 to assume that calcium ions from blood vessels do not considered as the priority of local oral treatment. In spite provide a needed intensity of calcium influx towards of the limited value of local application, calcitonin and osteoporotic degradations7,11. Furthermore, additional calcium should be the absolute prerequisite for organizing sources of calcium ion, directed towards credible local positive bone remodelling and turnover of segments storage near enough to the mandible bone, should have of jaws which should be, this way, prepared for better beneficial effect. acceptance of denture surface. Regardless the absence of There is no enough evidence in dental literature on macroscopic evidence of bone tissue regeneration, local local application of calcitonin and calcium into hard application of calcitonin with calcium could be crucial for oral tissues. Because of that, it should be not possible to the success at the first level of the treatment (turnover and compare the results of the present study with results of positive bone remodelling), as well as for the second level credible studies regarding the percentage of calcium and of treatment (fabrication and positioning of dentures). calcitonin in train solution7,9,10,15. Moreover, in this point of view, it should not be possible to adjoin if the increment of concentration of calcium has to be applied to the surface of edentulous ridge, or the concentration References of calcium in solution has to be ultimately changed (or decreased) in cases of persistence of roots of the remaining 1. Ardakani FE, Niafar N. Evaluation of Changes in the teeth. Mandibular Angular Cortex Using Panoramic Images. J Certainly, on the basis of the results of this study, it Contemp Dent Pract, 2004; 5:1-15. may be stated that calcitonin in calcium solution should 2. Cheng A, Mavrokokki A, Carter G, Stein B, Fazzalari have been applied to edentulous ridge prior to positioning NL, Wilson DF, Goss AN. The dental implications of bisphosphonates and bone disease. Australian Dent J, 2006; of the denture onto supporting tissues, that is delivery of 50(Suppl 2):S4-S4. prosthesis. More precisely, it should be injected towards 3. Drozdzowska B, Pluskiewicz W. Longitudinal changes in bone support in the initial steps of denture fabrication, i.e. mandibular bone mineral density compared with hip bone taking preliminary impression, and previous to functional mineral density and quantitative ultrasound at calcaneus and impression, or even in the procedure of determining jaw hand phalanges. Br J Radiol, 2002; 75:743-747. relations with occlusal rims. 4. Kanis AJ. Osteoporosis. 2nd edn. Oxford: Blackwell Science, Calcitonin and calcium liquid is not a „supernatural 1996; pp 22-147. drop“ for instant recover of osteoporotic bone layers. 5. Mendes Duarte P, César-Neto JB, Wilson Sallum A, Antonio However, careful selection of patients, as well as repeated Sallum E, Nociti FHJr. Alendronate Therapy May Be application of calcitonin and calcium in solutions to bone Effective in the Prevention of Bone Loss Around Titanium Implants Inserted in Estrogen-Deficient Rats. J Periodontol, layers, may significantly improve oral bone condition 2005, 76:107-114. and ability to accept prosthetic restoration on denture- 6. Poštić SD, Rakočević Z, Krstić M, Pilipović N. A densitometric supporting areas. appraisal of mandibular segments in osteoporotic subjects. The local application of calcitonin with calcium Progress in Osteoarthrology, 1997; 2:81. could be repeated, if necessary. However, there must be 7. Poštić SD. The analysis of osteoporotic changes of mandible the necessity of careful selecting the patients, because of and their clinical significance. PhD Thesis, University of the fact that application of calcium should not be indicated Belgrade, 1998. (in Serb) for patients with heart disease, kidney disease or serious 8. Poštić SD, Vujasinović-Stupar N, Rakočević Z, Palić- blood problems. Also, patients with malignant diseases Obradović D. Prevention and reduction of osteoporotic must not be included in the local therapy of osteoporotic rarefaction in mandibular segments. Acta Orthop Scand, 1999; 70(Suppl 287):42-43. oral bones. In spite of the limitations, local application of 9. Poštić SD. Local hormone therapy increased density in calcitonin and calcium should be the absolute prerequisite mandibular segments-a case report. Acta Orthop Scand, of organizing positive bone remodelling and turnover 1999, (Suppl 287)70: 43. of segments of jaws. Thus, these segments should be 10. Poštić SD. Osteopenic and osteoporotic changes in prepared for better acceptance of denture surface. mandible. Belgrade: Zadužbina Andrejević, 2000, pp. 5-79. Edentulous osteoporotic mandibular bone should (in Serb) ultimately be the first of oral bones for application of 11. Poštić SD. Changes in mandible due to osteoporosis. Serbian calcitonin-ion calcium solution. Additionally, respecting Dent J, 2007; 54:16-27. levels of the concentration of the applied calcium ion, 12. Poštić SD. Quantitative study on changes in osteoporotic edentulous mandibular ridges and metacarpal bones. Revue the osteoporotic maxillary bone could be treated with the de la Societe Anthropologique de Yugoslavie-Glasnik ADJ, solution of the same kind, in the prolonged period of time. 2007; 42:249-261. (in Serb) It seems that osteoporosis of the mandible affects 13. Poštić SD. Assured mandibular density increase in women women earlier than men. Also, osteoporosis was more wearing complete dentures. Proceedings of 31st Annual frequent in women. Usage of calcitonin and calcium in Conference of European Prosthodontic Association, 2007; solutions for osteoporotic toothless patients should be O60-page 91. 152 S.D. Poštić Balk J Stom, Vol 12, 2008

14. Poštić SD. Comparison of differences and methods in 19. w w w.FDA.GOV/OHRMS/DOCKETS/AC/98/ measurement of edentulous ridges on panoramic radiographs. TRANSPT/3463t 2.rtf. Revue de la Societe Anthropologique de Yugoslavie-Glasnik 20. Yasar F, Akgunlu F. The differences in panoramic mandibular ADJ, 2008 ; 43:153-161. (in Serb) indices and fractal dimension between patients with and 15. Poštić SD. Bone positive remodelling - clinical aspects and without spinal osteoporosis. Dentomaxillofac Radiol, 2006; th medications of osteoporotic jaw-bone. 13 Congress of 35:1-9. BaSS, 2008; O88- page 117. 16. Ramirez-Yanez GO, Seymour GJ, Symons AL. Local application of prostaglandin E2 reduces trap, calcitonin receptor and metalloproteinase-2 immunoreactivity in the rat Correspondence and request for offprints to: periodontium. Arch Oral Biol, 2005; 50:1014-1022. Srdjan D. Poštić 17. Torrens JI, Duncan WE. Osteoporosis: an update for the Faculty of Stomatology, Clinic of Prosthetic Dentistry dental professional. J Practical Hyg, 1997; 1:45-48. Rankeova 4, 11000 Belgrade 18. Wechter WJ, Horton JE. Methods of treating bone resorption Serbia http://www.freepatentsonline.com/4501754.html E-mail: [email protected]

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Surface Roughness of Posterior Condensable Composites

SUMMARY Aysegiil Demirbas Kaya, Ferit Ozata Objective: The purpose of this study was to evaluate the surface rough- Ege University, School of Dentistry ness of posterior condensable composites. Department of Restorative Dentistry Methods: Posterior condensable composites, Alert (Jeneric/Pentron) Bornova - Izmir, Turkey and Surefil (Dentsply), and hybrid composite Z100 (3M), were used in this study. The study material was placed into, and hardened in cavities. After the finishing and polishing procedures were completed, specimens were randomly separated into 3 groups. While the surface roughness values of the first group of specimens were determined with a profilometer, the surfaces of the second group were evaluated using SEM; Vickers micro-hardness mea sures were applied to the third group of specimens. Data were analyzed using Kruskal-Wallis and Mann-Whitney U tests. Results: All 3 groups were found to be different mutually (p<0.05). The surface roughness of condensable posterior composites was greater than that of hybrid composite resins (p<0.05). A direct correlation was found between the micro-hardness value and the surface roughness value, indicating that a composite with higher hardness value yielded a higher roughness value (r=0.738). SEM images support the statistical evaluation. ORIGINAL PAPER (OP) Keywords: Posterior Condensable Composites; Surface Roughness; Micro-hardness Balk J Stom, 2008; 12:153-157

Introduction The surface smoothness of restoration material used orally, is important in providing a plaque-free environment Resin based composite restorations are being used and insuring wear resistance9,10. Many composites form as aesthetic material in restorative dental medicine for the a rough and dull surface because finishing and polishing past 30 years. Since they were first manufactured in 1960 procedures are not well done11-16. This problem arises by Rafael Bowen, until today they have been constantly from the difference between the micro-hardness of the improved. The usage of resin based composite materials polymeric matrix and the inorganic components that make in posterior teeth as an alternative to amalgam, over the up the composite material12,14,15,17. Size of the fillers which past few years, has presented a number of problems when compose the inorganic component and their dispersion used in class II and III cavities, such as placement in the within the matrix are different. Therefore their abilities cavity1-3. These problems have made the development for polishing are also different18. In this study, the surface of composites that are more suitable for the posterior roughness of posterior condensable composites, which teeth necessary2,4. Due to their physical and chemical have been produced over the last few years, was evaluated properties, posterior condensable composites have been developed for various cavities in the posterior region. The using a profilometer and scanning electron microscope matrices and organic and inorganic structures composing (SEM) and compared with surface roughness of a hybrid these composite materials have been changed5-8. Another composite. In addition to this, in order to understand the concern in the clinical use of resin-based composite relationship between the micro-hardness and surface restorative materials is their ability to withstand occlusive roughness of posterior condensable composites and forces and stresses of the oral environment, particularly in hybrid composites, their micro-hardness values were also posterior situations1,3. determined and compared. 154 A.D. Kaya, F. Ozata Balk J Stom, Vol 12, 2008

Material and Methods Surface Roughness Measurement Surface roughness (Ra-value or arithmetic average A total of 3 resin-based composites, 2 posterior roughness) was determined using a Mahr Concept condensable and 1 hybrid composite, were used in the perthometer tool (Perthen Mahri Germany) with a study. The names, batch numbers and manufacturers of 0.2μm tip radius and wave length ± 250 that can take these products are shown in table 1. measurements within a 3.00 mm2 area. The average was taken of 5 Ra-values taken from each specimen. Table 1. Composites used in the study SEM Analysis Specimens with the finishing and polishing Product Batch number Manufacturer procedures completed were prepared to be examined under SEM (Joel JSM 5200, Tokyo, Japan). Specimens were Jeneric Pentron, Wallingford, Alert N15CB o CT, USA plated with 200 A gold. Scanning Electron Micrographs made at original magnifications of x100 and x500 were Surefill 9812000106 Dentsply, Weybridge,Surrey evaluated and compared for surface texture and roughness. Z 100 3 M. St. Paul, MN, USA The samples were tilted and examined at a 10° angle. Surface Micro-hardness Measurement Acryl blocks with 6 mm wide and 2 mm deep cavities 10 samples randomly selected from each study were prepared. The composites were placed into these material with the finishing and polishing procedures cavities following the manufacturer’s recommendations, completed were used to perform micro-hardness a transparent strip band (Du Pont Co, Wilmington, Del) measurements. The vickers M41 Photoplan Microscope was placed on top and they were pressed down with glass. with micro-hardness attachment (Vickers Instruments, After the glass plate was removed, they were irradiated for York, UK), which is a pneumatically loaded micro- 40 seconds under visible light (Cavex clearlicht HL 500, hardness tester, was used to measure the surface hardness. Cavex Holland BL). The specimens were then immersed This test involves applying a 136° diamond pyramid in distilled water for 1 week and incubated at 37°C. At the shaped indenter into the surface of the material being end of this period, finishing and polishing procedures were tested, and measuring the diagonals of the indentation completed for all of the specimens. As surfaces of all the produced. 10 readings were taken at different locations on specimens would be appropriate for clinical settings, they the surface of the specimen. The lengths of the diagonals were processed under water with a flame-shaped diamond of the indentation were measured and then averaged. Using mill without applying pressure. This procedure took 15 this value, VHN was obtained from 100 g Vickers Hardness seconds. Scale. This procedure was repeated for all specimens. One type of polishing system was used in this The results obtained by using the above tests for study. (Hawe Neos Dental, Dr. HV Weisserfluh Ltd, the ability of polishing of the 3 types of resin based 19 Switzerland) . In this system, coarse (white), medium composite restorations used were statistically evaluated (blue), fine (yellow), and X-fine (pink) polishing disks by Kruskal-Wallis and Mann-Whitney tests. The presence were applied under water (according to the manufacturer’s of a correlation between the surface roughness and micro- recommendation), starting from course to fine, for 15 hardness values was also evaluated. seconds each, with a 30000 rpm rotating tool. After each successive change in abrasive, the specimens were rinsed thoroughly to remove all debris from the previous abrasive. Then white rubber was applied for 15 seconds, Results and the last step of the polishing procedure was completed using a rubber cup (Crescent Dental Mfg Co, Lyons III) The surface roughness values (Ra-values), and luster paste (Sybron/Kerr, Romulus, Mic.). arithmetic means, standard deviation and median values During the polishing of each specimen, care was of the resin based composite materials used in this taken to apply the same amount of pressure in the same study are as shown in table 2. According to the Kruskal- direction. All finishing and polishing procedures were Wallis test, the difference between all the study groups done by the same investigator on the same day to reduce in respect to surface roughness values was found to be variability. significant (p< 0.05). From each group of study material for which the When the surface roughness values were analyzed finishing and polishing procedures were completed, 15 according to the Mann-Whitney test, 3 different resin- specimens were randomly picked for the surface roughness based composite resins were found to be different from measurements and SEM analysis, and 10 specimens were each other. The obtained results are as summarized in randomly picked for micro-hardness measurements. table 3. Balk J Stom, Vol 12, 2008 Surface Roughness of Condensable Composites 155

Table 2. Surface roughness (Ra-value) in μm of composites used in this study

Product Mean SD Median Alert 0.3150 5.720E-02 0.2950 Surefill 0.2010 2.283E-02 0.1950 Z 100 0.1720 1.229E-02 0.1700

Table 3. Composites compared in respect to their surface roughness (Mann-Whitney test)

Alert Surefill Z 100 A Alert - 0.000* 0.000* Surefill - - 0.000* Z 100 - - - * - significant (p<0.05)

The surface profile tracings obtained from resin based composites are as shown in figure 1. The SEM analysis was generally coherent with the profilometric data. Particles broke off from the surface of the first group of posterior condensable composites had the highest surface roughness values. The surface compactness of B this group could be observed under x500 magnification. Figure 2. Scanning electron micrographs depicting surface profiles of Stick and spherical particles were observed to be exposed Alert (magnification: A - x100; B - x500) from the surface (Fig. 2). In the second group of posterior condensable composites parallel to the surface roughness data, a more homogeneous surface can be observed with rarely a few particles sticking out of place. There are scratches and striations on the surface (Fig. 3). The smoothest surface among all study groups was observed in the hybrid composites, which make up the third group. Composite filler structure was observed. In addition to this, the surface was well polishable (Fig. 4).

A A

C B Figure 1. Surface profile tracing of composites finished and polished Figure 3. Scanning electron micrographs depicting surface profiles of (A - Alert; B - Surefill; C - Z 100) Surefill (magnification: A – x100; B - x500) 156 A.D. Kaya, F. Ozata Balk J Stom, Vol 12, 2008

Table 5. Composites compared in respect to their micro-hardness (Mann-Whitney test)

Alert Surefill Z 100 Alert - 0.004* 0.000* Surefill - - 0.005* Z 100 - - - * - significant (p<0.05)

When the presence of a correlation between micro- hardness and surface roughness of resin based composites used in the study was evaluated, roughness was observed to increase as micro-hardness increases in all of the Figure 4. Scanning electron micrograph depicting surface profiles of groups; correlation coefficient was found to be r=0.73 Z 100 (magnification x100) with p=0.000 (Fig. 5).

Micro-hardness values are as shown in table 4. The difference between all 3 groups in respect to micro- hardness was significant according to the Kruskal Wallis test (p<0.05). The results obtained when study materials were compared according to the Mann-Whitney test in respect to their micro-hardness values are shown in table 5.

Table 4. Micro-hardness (VHN) of composites used in this study

Product Mean SD Median Alert 127.24 37.62 114.42 Surefill 87.34 17.47 82.70 Figure 5. Correlation graph depicts hardness value and surface Z 100 68.16 10.74 65.35 roughness value

Discussion a different surface roughness than the hybrid composite, the two condensable posterior composites used in the Among the 3 different resin-based composite study were also different from each other. Alert, which has materials, finished and polished in the same manner and sticks, 60-80 μm long and 6 μm in diameter and particles conditions, the condensable posterior composites in which of various cross sections in its structure, had a rougher the filler structure and proportions were changed for usage surface than Surefil that has particles of various cross in posterior situations were found to have, unlike hybrid sections and sizes in its structure. The Vickers micro- composites, a rougher surface. The SEM images of the hardness measurements, profilometric measurements and specimens are supported by profilometric measurements. SEM images of the specimens, were on the same line. The The roughness values were in this order: Alert; Surefil; Z composite material with the highest surface roughness 100. In fact, the particles of Alert and Surefil condensable value, that does not have a homogenous surface observed posterior composites have broken off from the surface in the SEM images, also had the highest VFN values. during the finishing and polishing procedures structure Studies have been conducted on physical properties (Figs. 2 and 3). The scratches formed during the finishing of condensable posterior composites developed over the procedure have not been eliminated by the polishing past few years for use in class II and III cavities, as a form procedure. On the other hand, with the hybrid composite, of composite material used as an alternative to amalgam to which the same finishing and polishing procedures in posterior teeth. In these studies physical properties in were applied, a reasonably smooth surface was obtained question are reported to be no better than those of hybrid during the polishing procedure (Fig. 4). Although the composites. In addition to this, it is reported that filler condensable posterior composites were found to have proportion has been increased to increase viscosity in Balk J Stom, Vol 12, 2008 Surface Roughness of Condensable Composites 157 these composites, and this is reported to cause an increase 6. Ross W . A report on a new condensable composite resin. in porosity5-7. In condensable posterior composites the Compendium, 1998; 19:230-237. particle surfaces are made rough to make placement 7. Combe EC, Burke FJT. Contemporary resin-based composite in cavity easier. This causes an increase in surface materials for direct placement restorations: Packables, roughness4-7,20. As the 2 types of condensable posterior flowables and others. Dent Update, 2000; 27:326-336. composites used in this study have higher micro-harness 8. Miller MB . Packable composites. In: Reality 2000. Houston: values than the conventional hybrid composite, their Reality Publishing; 2000; pp 1444-1450. surface roughness values are also greater. The American 9. Kaplan AB, Goldstein GR, VijayaraghavanTV, Nelson IK. The effect of three polishing systems on the surface roughness Dental Association (ADA) Council Dental Materials of four hybrid composites: A profilometric and scanning considered composites containing filler particles size electron microscopy study. J Prosthet Dent, 1996; pp 34-38. up to 5 μm as “polishable” composites10,21. Sizes of the 10. Tjan AHL, Chan CA. The polishability of posterior condensable composites used in this study were much composites. J Prosthet Dent, 1989; 61:138-146. bigger and this clearly exposes the problem in their ability 11. Lee HL, Swartz ML. Scanning electron microscope study of for polishing. composite restorative materials. J Dent Res, 1970; 49:149-158. 12. Johnson LN, Jordan RE, Lynn JA. Effects of various finishing devices of resin surfaces. J Am Dent Assoc, 1971; 83:321-331. Conclusions 13. Dennison JB, Craig RG. Physical properties and finished surface texture of composite restorative resins. J Am Dent Posterior condensable composites with large Assoc, 1972; 85:101-108. filler particles produce a significantly higher surface 14. Chandler HH, Bowen RL, Paffenbarger GC. Method for roughness values than those with small filler particles. finishing composite restorative materials. J Am Dent Assoc, Statistical correlation was observed between the micro- 1971; 83:344-348. hardness value (VHN) and surface roughness value. 15. Weitman RT, Eames WB. Plaque accumulation on composite Composites with a higher micro-hardness value produce a surfaces after various finishing procedures. J Am Dent correspondingly higher roughness value (r). Assoc, 1975; 91:101-106. SEM study indicated that there are scratches and 16. Savoca DE, Felkner LL. The effect of finishing composite exposed filler particles on the surface of posterior resin surfaces at different. J Prosthet Dent, 1980 ; 44:167-170. 17. Christensen RP, Christensen GJ. Comparison of instruments condensable composites, whereas the surface of the hybrid and commercial pastes used for finishing and polishing composite is fairly smooth and homogeneous. In order composite resin. Gen Dent, 1981; 21:40-45. to benefit from the obtained properties of condensable 18. Jordan RE . Esthetic composite bonding -techniques and posterior composites and to correct their surface materials. 1st ed. Phiadelphia: BC Decker Inc, 1986; p 8. roughness, a layer which has better polishable properties 19. Kaya AD, Piskin B. An evaluation of two, finishing and should be formed on the surfaces of these restorations. polishing systems for composite resins. Ege Dişhek Fak Derg, 1996; 17:45-48. 20. Dennison JB, Fan PL, Powers JM. Surface roughness of microfilled composites. J Am Dent Assoc, 1981; 102:859-862. References 21. American Dental Association Council of Dental Materials, Instruments and Equipment. ANSI/ADA SPESiFiCATION 1. Denehy GE, Vargas M, Cobb DS. Achieving long-term NO.27 (revised): Resin-based filling materials. Chicago: success with class II composite resins . Calif Dent Inst American Dental Association, 1993. Contin Educ, 1996; 59:27-36. 2. Bayne S, Heymann H, Swift E. Update on dental composite restorations. J Am Dent Assoc, 1994; 125:687-701. 3. Christensen GJ. Conservative posterior tooth restorations. J Esthet Dent, 1993; 5:154-160. 4. Cobb DS, Macgregor KM, Vargas MA. The physical Correspondence and request of offprints to: properties of packable and conventional posterior resin- Dr. Aysegul Demirbas Kaya based composites: A comparison. J Am Dent Assoc, 2000; Ege Universitesi DisHekimligi Fakultesi 131:1610-1615. Dis Hastalıkları ve Tedavisi AD. 5. Leinfelder K, Prasad A. A new condensable composite 35100 Bornova - Izmir for the restoration of posterior teeth. Dent Today, 1998; Turkey 17(2):112-116. E-mail: [email protected]

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Clinical and Radiological Evaluation of Chronic Periodontitis Treated by “Beyond Apex” Fillings

SUMMARY Doris Mingomataj1, Dhurata Mingomataj2 Background: The treatment of complications of the tooth pulp 1 UFO University, Dept. of Stomatology inflamma tion, such as periapical lesions, has been very important for denti- Tirana, Albania stry, especially endodontics. Healing of periapical lesion can allow continua- 2 MINGOMATAJ Stomatology Clinic tion of mastication and aesthetic functions of the tooth, depending from the Tirana, Albania quality of treatment and the level of fillings of pulp canals. Material and Method: 80 cases in 70 subjects (33 males and 47 females), aged 20-55, which has been treated for periapical complications and the fillings „beyond apex“ were evaluated. The situation of teeth with this diagnosis was evaluated clinically and radiographically during 1997- 2003, being controlled directly after filling until 6 years after treatment. Results: The treated patients with this diagnosis (most of them in 1 single visit), with additional antibiotic treatment, showed a long term success, clinically and radiographically, in case of “beyond apex” fillings (in 86% of the cases). Conclusion: A manifold control indicated that teeth filled “beyond apex” keep their aesthetic and functional value, and are valid as posts for prosthetic restorations. ORIGINAL PAPER (OP) Keywords: Chronic Periodontitis Balk J Stom, 2008; 12:158-162

Introduction and could this tooth be functional and serve as post for prosthetic needs? The treatment of complications of the tooth pulp inflammation, such as periapical lesions, has been very important for dentistry, especially endodontics2,3. In our opinion, this matter will persist as long as caries and its Material and Method consequences exist. In this trial, 80 cases (70 subjects) among 100 In respect of complications of the tooth pulp of cases with pulpits (period of time 1997-2005), inflammation, it should be remembered that periapical were analyzed. Including criteria were the presence infections are considered risk factors for health3,4. On the of periodontitis and filling “beyond apex”; excluding other hand, if these infections could heal, it could allow criterion was the presence of periodontal abscess. 33 that particular teeth retain their mastication and aesthetic subjects were male (aged 22-55), and 47 were female functions, and included into prosthetic planning. This will (aged 20-45). Among the treated teeth, there were more depend on the quality of treatment and the level of filling multi-radicular teeth (50 cases) than mono-radicular (30 3,4,18 of pulp canals . cases). Diagnostically, chronic periodontitis (associated The aim of this study was to evaluate, clinically with non-vital tooth) was revealed in 80 cases (34 multi- and radiographically, the local periapical area of cases radicular, 30 mono-radicular), and in 16 cases a diffuse in which the used medication, even involuntarily, went granulomatous periodontitis was found. “beyond apex”. The questions were: is there, clinically After preceded clinical and radiographic evaluation, and radiographically, any problem in the successive years, the root was treated according to principles of step back/ Balk J Stom, Vol 12, 2008 Treatment of Chronic Periodontitis 159 step down technique until its apex under a radiographic time. However, in more than 85% of cases the treatment control. The next step was an abundant but careful rinsing required only one visit. with solutions of H2O2 (3%) or sodium hypochlorite (5%), The successive clinical and radiographic controls sterile drying, followed by a ZnO-Thymol-Eugenol or followed in a week (if periodontal reaction occurred), a Endomethason, Eugenol-Thymol mummy filling; gutta- month, 3-12 months, and later (3-8 years). percha points were then added until lateral condensation (under instrument-guided radiographic monitoring). Finally, the treatment of the tooth coronal part followed. Antibiotics were prescribed to all patients, comprising Results administration of 3 g. of amoxicillin or 2 g. of tetracycline in the single dose at the precedent day. When a periodontal Long term positive effects (in our case appreciatively reaction, as a consequence of treatment, occurred (pain in 86% of cases), or low rate of complications, indicated or moderate oedema), the administration of antibiotics correct treatment of root canals, because in their followed for 3 consecutive days (2 g. per day). Particular mechanical treatment consists the basis for the success attention was paid to the occlusion. In cases with pulp of one-visit treatment. In figures 1-7, several examples of secretion during treatment, the visit took additional successful periapical treatment are shown.

a b c Figure 1. Patient IL, male, aged 44 a) Chronic periodontitis of the tooth 46, exacerbation immediately after treatment; b) The same tooth, 16 months later; c) The same tooth after 8 years - recovered, unabsorbed filling

a b c Figure 2. Patient OD, female, aged 24 a) Pain and oedema immediately after treatment of the tooth 36 with perforation of the mesial root; b) The same tooth after 1 year - without clinical symptoms, obturated perforation, absorbed filling; c) The same tooth after 3 years - recovered, absorption of overfilled material

abc

Figure 3. Patient EL, female, aged 29 a) Chronic periodontitis, exacerbated of the teeth 46 and 47; b) Immediately after treatment (46), during the treatment (47); c) The same teeth 4 years later - recovered 160 D. Mingomataj, D. Mingomataj Balk J Stom, Vol 12, 2008

a b c Figure 4. Patient HR, male, aged 47 a) Abscess immediately after treatment of the tooth 21; b) The same tooth 1 year later; c) The same tooth after 8 years - no complains, partially unabsorbed mum, new bone trabeculae

abc Figure 5. Patient LZ, male, aged 28 a) Pain and oedema during treatment of the tooth 45; b) Filling of the tooth; c) The same tooth 6 months later - reduced periapical radiolucency, new bone trabeculae

ab c Figure 6. Patient PM, male, aged 18 a) Teeth 11 and 21 prior to the treatment; b) The same teeth immediately after treatment; c) The same teeth 14 years later, reconstructed with pins and resin-crowns, recovered. Total absorption of the extruding material

abc Figure 7. Patient DZ, female, aged 37 a) Chronic periodontitis of the tooth 36, tender to percussion, with spontaneous pain, immediately after treatment; b) The same tooth 3 years later; c) The same tooth 4 years after treatment - recovered Balk J Stom, Vol 12, 2008 Treatment of Chronic Periodontitis 161

Discussion Meanwhile, the filling “beyond apex” is used recently4,20. In the 30s of previous century, soft mums In this trial we aimed to evaluate the long term consisting of iodoform were used, later on mums success in cases of filling “beyond apex”, with respect consisting mild phenols, and hard cement mums during to function, clinical symptoms, radiographic finding and 50s-60s years20. Independently to the success, for a period possible use as posts for prosthetic appliances. It is usually of time they were abandoned because of focal infection accepted that the success of root canal filling depends on theory, but in the next time endodontic inflammation many factors, such as the cleaning and the treatment of was therapeutically treated based on the new knowledge root canal, its sterilization, hermetical filling that isolate regarding root canals, and new techniques of root canal foci from the canal, as well as immunological reactivity treatment (step back or step down technique), and root of the subject (age, general health situation, etc)1,4,8,10,12,21. canal filling (lateral or apical condensation)2,3,5,7,10- In this respect, the rate of clinical-radiographic, as well 12,18,20,21. as histological success, depend on the level of root canal In cases presented here, significant differences filling18, which is in accordance with the Ketterl diagram between ZnO-Eugenol-Thymol and Endomethason- (Fig. 8). However, with respect to histological aspects, the Eugenol mums were not established4,6,9,11-13,15-17,19,20,22. treatment of inflamed pulp can not assure a total periapical The recovery of periapical defect began on the first th th recovery and a required periodontal obturation2,3,18,20. Our month and finished in the interval between 8 and 12 findings confirm the opinion shared by many worldwide month after the treatment. In this respect, all medicaments prominent authors. could induce the bone reparation due to alkaline phosphatase activation5,11. Bone regeneration begins from the peripheral area towards central region, firstly dissolving the “linear” focal border, whereas subsequently bone trabeculae can be find, refilling the previous defect2,5,10,12,18,20,21. The needed recovery time depends on the dimension of the focus. After a successful treatment, the treated teeth recover clinically and radiographically (negative axial and vertical percussion, disappeared focus, normal bone trabeculae, detectable periodontal line radiographically), and they can support prosthetic appliances independently to the amount of the resorbed medicament1,8,13,15. In any case, endodontics will evolve like all components of the life, but their problems will persist as long as caries and its consequences do exist!

References

1. Asllani Xh . Terapia stomatologjike. Tirana, 1974; pp 406- 419. (in Albanian) 2. Buchanan S. The art of endodontics. Fact and fiction. Dentistry Today, 1993; 12(8):32-35. 3. Cohen S, Burns RC. Pathways of the pulp. 4th ed. St. Louis: The CV Mosby Co, 1987; pp 183-246. 4. Hofer O, Reichenbach E. Lehrbuch der klinischen Zahnheilkunde. Band I, 2nd Aufl. Leipzig: JA Barth Verlag, 1960; pp 100-106. 5. Ingle I, Taintor J. Endodontics. 3rd ed. Philadelphia: Lea Febiger, 1985; pp 226-290. 6. Koja L, Biturku V, Qerimi D, Beligradi I, Berberi N. Mjekimi endodontik i lezioneve periapikale. Rev Mjekesore, 1988; 1:112-116. (in Albanian) 7. Kongo P, Brovina D, Rusi L, Mingomataj Ç, Kuvarati E. Terapia Stomatologjike. Universiteti i Tiranes, 1994. (in Albanian) Figure 8. Diagram of Ketterl: histologically the most successful 8. Kongo P . Rezultatet e mjekimit te peridontiteve kronike me treatments are those with fillings up to 0.9 mm short from the apex nje seance. Bul Stomatologjik, 1979; 1:36-42. (in Albanian) 162 D. Mingomataj, D. Mingomataj Balk J Stom, Vol 12, 2008

9. Kuvarati M . Long term results after endodontic treatment of 17. Nura Q. Rezultatet tona ne mjekimin me krezofen dhe necrotic teeth with periapical lesions in one single visit by endomethason te pulpiteve gangrenoze. Bul Stomatol, 1978; gutta-percha lateral condensation method is Albania. Balk J 2: 3-5. (in Albanian) Stom, 1998; 2(1):37-41. 18. Pilz W, Wannenmacher J, Taatz H. Grundlagen der Kariologie und Endodontie. 3. Aufl. Leipzig: JA Barth 10. Laurichesse IM, Mastreoni F, Breillat I. Endodontie Verlag, 1980; pp 559-573. clinique. Paris: Editions CDP, 1986 ; pp 421-428. 19. Prifti K. Rezultatet e mjekimit te periodontiteve kronike ne 11. Linn WE, Eijkman AM. Misserfolge bei Zahnersatzlichen nje seance. Bul Stomatol, (in Albanian) Behandlung. Köln: Deutsche Arztl Verlag, 1998; pp 247-257. 20. Walkhoff A, Hess H. Lehrbuch der Konservierenden 12. Mitschell DA, Mitschel L, Burton P. Oxford Handbook of Zahnheilkunde. 6. Aufl. Leipzig: JA Barth Verlag, 1960; pp Clinical Dentistry. 4th ed. 2005; pp 433-439, 607-619. 285-300. 13. Mingomataj Ç, Mingomataj D. Ndikimi i jonoforezes 21. Weine FS. Endodontic Therapy. 5th ed. Philadelphia, New medikamentoze me eugenol 5% ne mjekimin e gangrenave. York, London: Mosby 1996; pp 314-351. Rezultate kliniko-radiologjike. Rev Mjekesore, 1987; 2:87- 22. Zoto F. Rezultatet tona paraprake ne mjekimin e periodontiteve kronike me pasten Ca(OH) – CHI me 93. (in Albanian) 2 3 seanca te shkurtuara. Rev Mjekesore, 1984; (4-5):125-128. 14. Mingomataj Ç, Mingomataj D. Mundesia e mjekimit (in Albanian) te dhembeve ballore te absceduar ne nje seance. Rev Mjekesore, 1988; 1:106-112. (in Albanian) 15. Mingomataj D. Studim kliniko-radiologjik mbi rezultatet e Correspondence and request for offprints to: arritura ne trajtimin e pulpiteve dhe faktoret qe ndikojne ne suksesin e tyre. Bul Stomatol, 1981; 2:15-23. (in Albanian) Dr. Doris Mingomataj UFO University, Dept. of Stomatology, Tirana, Albania 16. Neziri P. Pervoja jone ne trajtimin e nekrozes pulpare dhe te Rruga Myslym Shyri, Pall. 47, Sh. 1, Apt. 15 gangrenes se thjeshte e te komplikuar. Bul Stomatol, 1979; Tirana, Albania 2:27-32. (in Albanian) E-mail: [email protected]

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Dental Erosion: One of the Main Diagnostic Symptoms of Gastric Oesophageal Reflux Disease

SUMMARY Edlira Xhemo, Diana Brovina, Passage of the gastric contents into the oesophagus (gastric oesopha- Ergysejda Hoxha, Vigjilenca Demiraj, geal reflux - GER) can be manifested by changes of tooth hard tissues. Tooth Anyla Bylo erosions that are consequence of GER are known as gastric oesophageal Faculty of Medicine, Department of Dentistry reflux disease (GERD). GERD is the complication of GER status. Further- Tirana, Albania more, tooth erosion is one of the main symptoms that gives evidence of the digestive disorders, being present in early stages of the disorder. Every acid content that is found in the mouth area, with a pH<5.5, may cause melting of the enamel hydroxyapatite crystals. Gastric juice in GERD has a pH value under 2.0. So it is very important to make the right differential diagnosis promptly, as well as the decision. ORIGINAL PAPER (OP) Keywords: GERD; Gastric Juice Balk J Stom, 2008; 12:163-165

Introduction 7. Hypersensitivity to hot and cold agents. 8. Symptoms or history of GERD; Many systemic diseases and pathologic conditions are 9. Excessive attrition; manifested with oral changes too, which makes dentists 10. Vomiting (weekly or more often), chronic and to be the first health care professional to find out these excessive vomits; diseases due to their primary manifestations. Tooth erosion 11. Sports drinks intake (weekly or more often); is defined as a loss of the tooth hard tissues as the result of 12. Citrus fruits intake (more than twice daily) and soft interaction of several chemical, non-bacterial, factors in acidic and alcoholic drinks consumed (4-6 or more the mouth region. Dental erosion is one of the intra-oral per week); symptoms that defines disorders of gastric-oesophageal 13. Bruxism habit and salivary changes; origin. gastro-oesophageal reflux (GER) is the passage 14. Gastric acids regurgitation into mouth or oesophagus; of the gastric contents into the oesophagus and gastro- 15. Eating disorders, like anorexia nervosa or bulimia; oesophageal reflux disease (GERD) is the complication 16. Hiatus hernia; status of GER, being manifested with changes of tooth 17. Gastrointestinal disorders, such as peptic ulcers or hard tissues. gastritis, pregnancy, side effects of some medicaments, Erosion begins as demineralization of the enamel diabetes or nervous system disorders. surface that causes melting of the surface stratums and It is generally accepted that there are 3 erosion grades: loss of the tooth structure. Tooth erosion risk factors could 0 - no detectable erosion; be: intrinsic and extrinsic causes1,2. Clinically, the tooth erosion in patients with GERD 1 - small pots and lightly rounded cuspids, flat fissures, is characterized with: alterations in the occlusal surface (moderated 1. Wide concavities on the enamel smooth surface; grooving); 2. Cupping of the occlusal surfaces (incisal whooling) 2 - ruining of cuspids with heavy grooving, fillings with dentine exposure; margins are erased over the tooth level, flattening of 3. Increasing of the transparency in the incisal margin; the occlusal surface morphology. 4. Wearing of the non-occluding surfaces; It is very important to make the right differential 5. Amalgam fillings on the enamel smooth surface; diagnosis and to decide about the relation of the dental 6. Wearing of the enamel surface in the gingival/cervical erosion process and other possible pathology of tooth area of teeth; structure loss, such as attrition or abrasion. 164 E. Xhemo et al. Balk J Stom, Vol 12, 2008

Material and Methods partner, morning masticatory muscle fatigue or pain, the use of occlusal guard); We examined 60 out-patients, aged 25-38 years, 3. Dietary History (acidic food and beverage at the gastroenterology ward of the University Hospital frequency, the way of ingestion - swish or swallow, oral Centre in Tirana. 13 of them had evident dental erosions. hygiene methods, tooth-brushing method and frequency). Medical and dental control performed in these patients The data were analyzed statistically using Kendal’s followed special protocols, such as: taking medical, dental correlation coefficient in determining the relationship and dietary history, and performed oral hygiene methods, as to define the disease etiological factors. between the change in pH and the change in the oral status The procedure comprised: (r = 0.685; p = 0.013). SPSS 10.0 programme was used in Making diagnosis based on the GERD symptoms, data analysis. signs and fibroscopic tests; Measuring pH of the gastric juice based on a 24 hours monitoring. The pH was monitored before breakfast and lunch; Results Defining grades of dental erosions. Diagnostic protocol for dental erosion comprised: Results are presented in table 1. From the results it 1. Medical History (excessive vomiting, rumination, can be seen that the difference is significant enough (data eating disorder, GERD, symptoms of reflux, frequent use were considered to be significant enough if difference was of antacids, alcoholism, auto-immune disease such as Sjogren Syndrome, oral and/or eye dryness, medication p ≤ 0.05). that causes salivary hypo-function, acidic medication); A t-test was performed on the data received from the 2. Dental History (history of bruxism, grinding or 2 sample groups (t = 0.45, p = 0.63). These results were clenching, grinding sounds during sleep noted by bed not considered to be significant.

Table 1. Evaluation of the gastric juice pH, localization of the dental erosion and the disease time

Case pH 1 pH 2 Oral Status GERD Period

3.741 3.69 + Erosion of 6 teeth, especially the M sides and lower 2 years 2.872 2.37 + Erosion of 6 teeth, especially the M sides, tubercules 2.5 years and lower teeth 3.583 3.17 + Erosion of all teeth, fillings raised up to the eroded 4 years occlusal surface, the majority of teeth extracted 3.384.24 +Erosion still in its 0 Grade 5-6 months 3.405 3.34 + Erosion of all teeth, teeth extracted 5 years 2.496 2.27 + Erosion of all teeth, teeth extracted 4-5 years 3.647 3.47 + Erosion of all teeth, teeth extracted 6 years 4.528 4.42 + Erosion still in its 1 Grade 4 months 7.129 6.62 + Erosion still in its 1 Grade 7 months 2.8710 2.75 + Erosion of 6 teeth, Grade 2; especially the M sides, 1.7 months tubercules and lower teeth 3.5811 3.17 Erosion Grade2 of mandibular premolars 6 months 7.5212 6.42 Erosion Grade1 Maxilar centrals 4 months 5.78.013 Erosion Grade 1 Mandibular molars 5-6 months Balk J Stom, Vol 12, 2008 Dental Erosion in Gastric Oesophageal Reflux Disease 165

Discussion Further examination and studies would help to get better understanding of GERD and its relation to teeth When dentists diagnose tooth erosive lesions, they erosive lesion. have to consider the possibility of theirs systematic origin. Especially patients that suffer from GERD have to be examined continually to prevent erosive lesions. They should keep a good hygiene of their oral cavity and they References should also use local fluoride paste. In the short term the goal in the treatment of dental 1. Barron RP. Dental Erosion in Gastroesophageal Reflux erosion resulting from GERD is making differential Disease. J Can Dent Assoc, 2003; 69(2):84-89. 2. Gandara BK, Truelove EL. Diagnosis and Management of diagnosis between GERD, other mechanical forces effects Dental Erosion. J Contemp Dent Pract, 1999; 1(1):016-023. (attrition, abrasion) and etiopathogenetic factors. However, 3. Cameron A, Widmer R. Handbook of Pediatric Dentistry. it is always advisable to decrease abrasive forces (the use 1998; pp 66-72. of soft toothbrushes and dentifrices low in abrasiveness 4. Eccles JD. Dental Erosion and Diet. J Dent, 1974; 2:153- in a gentle manner, not to brush teeth immediately after 159. an acidic challenge to the mouth, as the teeth will abrade 5. Shaw L, Smith A. Erosion in Children: An increasing clinical easily, and rinse with water immediately after an acidic problem? Dental Update, 1994; 21:103-106. challenge), provide mechanical protection (application 6. Jarvinen V, Meurman JH, Hyvarinen H, et al. Dental erosion of composites and direct bonding where appropriate and upper gastrointestinal disorders. Oral Surg Oral Med Oral Pathol, 1988; 65:298-303. to protect exposed dentin, construction of an occlusal 7. Nunn JH. Prevalence of dental erosion and the implications guard is recommended if a bruxism habit is present), and for oral health. J Oral Sci, 1996; 104:156-161. monitor stability (regular recall examinations should be 8. Xhonga FA, Valdmanis S. Geographical comparisons of the done to review diet, oral hygiene methods, compliance incidence of dental erosions: A two centre study. J Oral with medications, topical fluoride and splint usage). Rehab, 1983; 10(3):269-277. GERD is an important etiologic factor in the erosive 9. Khan F, Young WG, Daley TJ. Dental erosion and bruxism. lesion of teeth hard tissue. Our studies are consistent with A tooth wear analysis from southeast Queensland. Aust Dent other studies carried in other countries1-10. Mandibular J, 1998; 43:117-127. molars had the highest wear out and damage in our cases. 10. Clark DC, Woo G, Silver JG, et al. The influence of frequent The part of the teeth that had been affected the most was ingestion of acids in the diet on treatment for dentin sensitivity. J Can Dent Assoc, 1990; 56:1101-1103. the mesio-lingual surface. Exposure of the dentinal tubules results in hypersensitivity to hot, cold, sweet and tactile stimuli. We have to emphasize that the demineralization occurs faster Correspondence and request for offprints to: in dentin than it does in enamel In diagnosing and curing erosion cases caused by Prof. Diana Brovina Klinika Stomatologjike Universitare GERD, a tight collaboration between several specialists, Fakulteti i Mjekesise-Departamenti i Stomatologjise especially dentists and gastroenterologists, is required. Tirana, Albania

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Histo-Pathological Evaluation of Drug Allergy Observed With Gingival Overgrowth Induced by Phenytoin: A Case Report*

SUMMARY Hakan Develioglu1, Özgür Özgören1, Mert Gingival overgrowths are lesions which can be seen due to diffe rent Nalbantoglu1, Kaya Eren1, Fahrettin Göze2 reasons. Phenytoin (PHT), the drug used in the treatment of epilepsy, is 1Cumhuriyet University, Faculty of Dentistry probably one of the commonest causes of gingival overgrowth. In the pre- Department of Periodontology sented case, a male patient aged 23, who has been taking PHT for the treat- 2Cumhuriyet University, Faculty of Medicine ment of epilepsy, subsequently manifested by the enlarged gingival tissue, Department of Pathology which was cut out using gingivectomy procedure. The biopsy samples, which Sivas, Turkey were taken during surgery, were assessed histo-pathologically. Histo-pathological evaluation showed that there were deepened rete-peg structures, and a connective tissue rich in collagen substance. Moreover, a dense plasmocyte cell infiltration was observed. This fact was interpreted as an allergic effect in gingival tissue caused by PHT. CASE REPORT (CR) Keywords: Overgrowth, gingival; Phenytoin; Drug Allergy Balk J Stom, 2008; 12:166-169

Introduction Epilepsy is a condition in which a person has recurrent seizures due to a chronic underlying process. A seizure is a Gingival enlargement or overgrowth has been paroxysmal event, due to abnormal central nervous system associated with multiple factors including inflammation, activity, that can have various manifestations ranging side effects of drugs, and neoplastic conditions. Chronic from dramatic convulsive activity, with or without loss inflammation due to accumulation of dental plaque of consciousness, to phenomena not discernible by an frequently causes gingival overgrowth1. Drugs associated observer17. Currently available anti-epileptic drugs act by with gingival enlargement include anti-epileptics, like depressing the neuronal activity in the focus of origin or by phenytoin2-5, cyclosporin6,7, and calcium antagonists, such blocking the spreading mechanisms. as dihydropyridines8,9, verapamil10,11, and diltiazem. Phenytoin (PHT, 5,5-diphenylhydantoin) was first The clinical and pathologic features in drug- introduced as an anti-epileptic drug, in 193818. It is slowly induced gingival overgrowth are independent of the absorbed from the gastrointestinal trackt, and shows drug administered, which suggests a common pathway marked inter individual variation19. PHT is known to 12 of induction . The pathogenic mechanisms of gingival concentrate in the brain, at levels 5 to 10 times that found enlargement involve different factors, such as dental in the serum20. The drug is extensively metabolized in the plaque, presence of genetically predetermined gingival liver by microsomal enzymes, with the major metabolite fibroblasts (named responders), and effect of the drug (50-5% of the PHT dose) being 5-(p-hydroxypenyl)-5- itself, with all compounds affecting the trans-membrane phenylhydantoin (p-HPPH)21. The drug has been proposed flow of calcium13,14. This in turn changes the metabolism to act via stabilization of the neuronal cell membranes and of connective tissue fibroblasts, causing an increase in through suppression of synaptic transmissions. Depending the components of the extra-cellular matrix, i.e. collagen on the membrane conditions, drug concentration and fibres and/or ground substance15,16. timing, it appears that PHT acts by affecting the (Na+ K) ++ * Presented at the 37th National Periodontology Congress, pump, Ca transport, or the sodium influx at a cellular May 2007, Antalya, Turkey level22. Balk J Stom, Vol 12, 2008 Gingival Overgrowth Induced by Phenytoin 167

Gingival overgrowth is one of the most common side treatment of other teeth is continuing. After medical history effects associated with the administration of PHT, the most and clinical examination, a treatment phase I (periodontal frequently used anti-epileptic drug. Gingival overgrowth, treatment) was performed. 3 weeks after the treatment in relation to PHT, was first described in 1939, with phase I, periodontal tissues were evaluated again and it several other subsequent authors reporting the overgrowth was decided to perform a gingivectomy operation and associated with phenobarbital, valproic acid and remove gingival enlargements. The biopsy samples were vigabatrin. Gingival overgrowth has not been associated taken during the operation and were subsequently assessed with carbamazepine, a useful alternative medication in the histo-pathologically. Histo-pathological evaluation showed treatment of patients with seizures that have, or are at risk that there were deepened rete-peg structures, thickened of, gingival enlargement23,24. epithelial zone and a connective tissue rich in collagen substance. Moreover, a striking plasmocyte cell infiltration was observed (Fig. 3). Oral hygiene applications were instituted at each Case Report appointment due to achieve an adequate plaque control; and it was achieved. The patient is still being followed-up, A male patient aged 23 with gingival enlargements and is under control (Fig. 4). was referred to the Department of Periodontology, Faculty of Dentistry at the University of Cumhuriyet. In the first step, his dental and medical history was taken and he was clinically examined. The patient had not received any prior dental therapy. In his medical history, it was determined that he has been taking medicaments (Phenytoin sodium 100mg; 2x2, and Barbexaclone 100 mg; 2x1) for the treatment of epilepsy for 3 years, which was diagnosed in the department of neurology. There were severe gingival overgrowths in all quadrants and in both buccal and oral sides of the mouth (Fig. 1). A mild inflammation and bleeding on probing were also recorded. It was thought the gingival overgrowth was due to PHT usage. However, it was not possible to stop or decrease the drug dosage for our patient.

Figure 2. Radiographic view at the initial visit

Figure 1. Clinical view of the patient before the treatment PC PC A radiographic examination revealed no supporting bone loss except the area of the tooth 46; however, teeth 11, 17, 21, 26, 27, 35, 36 ,37, 46, and 47 were carious (Fig. 2). First molar on the right lower jaw (46) was extracted due to a serious caries, and teeth 11,12,13,21,22,23 were Figure 3. A dense plasmocyte infiltration in connective tissue treated aesthetically; the conservative and endodontic (H&E, x20) 168 H. Develioglu et al. Balk J Stom, Vol 12, 2008

to resolution of inflammation and reduction in gingival enlargement. But, if there is a serious gingival overgrowth like in our case, a periodontal surgical management is required to remove the excess tissue. In our case, gingiva had almost covered the full portion of the crowns in all quadrants. It was very difficult to achieve an adequate oral hygiene for the patient. And there was a serious aesthetical problem which affected psychological condition of the patient. In cases that have gingival enlargement covering more than about a third of the tooth surface, a consideration should be given to altering the medication. When possible, reducing the dose or changing to another drug may bring about partial or complete regression of the lesion. But this was not possible for our patient, so we warned our patient about the possibility of gingival Figure 4. Clinical view after treatment of the patient enlargement recurring despite periodontal treatment27. The relationship between anticonvulsant drugs and hypersensitivity has been shown in the literature28. Discussion In our case; the histo-pathological evaluation of the specimens has revealed deepened rete-peg structures A gingival overgrowth is a common feature of and a connective tissue rich in collagen substance. These gingival disease. There are many types of gingival findings are classical for some gingival overgrowths, but overgrowth, varying in accordance to etiological factors a dense plasmocyte cell infiltration was also observed. We and pathological processes producing them. Gingival are of the opinion that this finding could be a result of an overgrowth caused by PHT, usually begins as a painless, allergic background caused by PHT. bead-like, and diffuse swelling of the interdental papillae, As a conclusion, in gingival enlargement cases, which enlarge and coalesce, leaving a nodular appearance. plaque control is very important. Treatment required in As the condition progresses, the marginal and papillary accordance to the degree of gingival enlargement must be overgrowths unite; they may develop into a massive performed and the importance of maintaining good oral tissue fold covering a considerable portion of the crowns. hygiene, as a preventive measure, should be emphasized. The overgrowth is chronic, and slowly increases in size, In addition, the possible allergic drug effects should be recurs when surgically removed, and has been reported to known and if possible, the alternative medications may disappear spontaneously soon after the discontinuation of be considered. If there is not a chance of changing the the drug25. A PHT-induced gingival overgrowth begins as medication, the possibility of recurrence should be told to hyperplasia of the connective tissue core of the marginal gingiva, followed by proliferation of the epithelium. The the patient. overgrowth increases by proliferation and expansion of the central core beyond the crest of the gingival margin. There are various risk factors that have been elucidated for a drug-induced gingival overgrowth. References The identifiable factors can be considered under the following headings: age, oral hygiene, daily dose and 1. Carranza FA. Gingival Enlargement. In: Carranza FA (ed). duration of drug therapy26. The role of oral hygiene in the Glickman’s Clinical Periodontology. Philadelphia: WB pathogenesis of gingival overgrowth is also complex. The Saunders; 1990; pp 125-128. 2. Angelopoulos AP, Goaz PW. Incidence of diphenylhydantoin presence of the overgrowth makes plaque control difficult hyperplasia. Oral Surg Oral Med Oral Pathol, 1972; 34:898- by helping the plaque retention, resulting in a secondary 906. inflammatory process, complicating the gingival 3. Brunet LI, Miranda J, Farre M, Berini L, Mendieta C. hyperplasia caused by the drug. Effective plaque control Gingival enlargement induced by drugs. Drug Safety, 1996; may reduce and prevent gingival enlargement. In addition 15:219-231. to plaque control and medical management, periodontal 4. Hassell TM, Hefti AF. Drug-induced gingival overgrowth: surgical treatment and multidisciplinary dental care are a Old problem, new problem. Crit Rev Oral Biol Med, 1991; key strategy in managing gingival enlargement. 2:103-237. Mild gingival enlargement may only require local 5. Perlik F, Kolinova M, Zvarova J, Patzelova V. Phenytoin as management, as improvement in oral hygiene together a risk factor in gingival hyperplasia. Ther Drug Monit, 1995; with professional cleaning of the teeth, which can lead 17:445-448. Balk J Stom, Vol 12, 2008 Gingival Overgrowth Induced by Phenytoin 169

6. Adams D, Davies G. Gingival hyperplasia induced by 19. Gugler R, Manion C, Azarnoff D. Phenytoin: Pharmaco- cyclosporin A. A report of two cases. Br Dent J, 1984; cinetics and bioavailability. Clin Pharmacol Ther, 1976; 157:89-90. 19:135-142. 7. Bennett JA, Christian JM. Cyclosporine-induced gingival 20. Houghton G, Richens A, Toseland P, Davidson S, Falconer hyperplasia. Case report and literature review. J Am Dent MA. Brain concentrations of phenytoin, phenobarbital and Assoc, 1985; 111:272-273. primidone in epileptic patients. Eur J Clin Pharmacol, 1975; 8. Bullon P, Machuca G, Martinez-Sahuquillo A, Rios JV, Rojas 9:773-781. J, Lacalle JR. Clinical assessment of gingival hyperplasia in 21. Dudley K. Phenytoin metabolism. In: Hassell T, Johnston patients treated with nifedipine. J Clin Periodontol, 1994; M (eds). Phenytoin-induced Teratology and Gingival 21:256-259. Pathology. New York: Raven Pres; 1980; pp 13-21. 9. Lederman D, Lummermann M, Reuben S, Freedman PD. 22. Maclean M, McDonald R. Multiple actions of phenytoin on Gingival hyperplasia associated with nifedipine therapy. mouse spinal cord neurons in cell culture. J Pharmacol Exp Oral Surg, 1984; 57:620-622. Ther, 1983; 227:779-789. 10. Miller CS, Damm DD. Incidence of verapamil-induced 23. Kimball OP. Treatment of epilepsy with sodium gingival hyperplasia in a dental population. J Periodontol, diphenylhydantoinate. JAMA, 1939; 31:336-344. 1992; 63:453-456. 24. Panuska HJ, Gorlin RJ, Bearman JE, Mitchell DF. The 11. Pernu HE, Oikarinen K, Hietanen J, Knuuttila M. Verapamil Effect of anticonvulsant drugs upon gingiva: a series of induced gingival overgrowth. A clinical, histologic and analysis of 1048 patients. J Periodontol, 1960; 31:336-344. biochemic approach. J Oral Pathol Med, 1989; 18:422-455. 25. Carranza FA. Gingival enlargement. In: Carranza FA, 12. Akimoto Y, Tanaka S, Omata H, Shibutani J, Nakano Y, Newman MG (eds). Clinical Periodontology. 8th ed. Kaneko K, et al. Gingival hyperplasia induced by nifedipine. Philedelphia: WB Saunders Company, 1996; pp 233-249. J Nihon University Sch Dent, 1991; 33:174-181. 26. Seymour RA, Ellis JS, Thomason JM. Risk factors for drug- 13. Sooriyamoorthy M, Gower DB. Drug induced gingival induced gingival overgrowth. J Clin Periodontol, 2000; overgrowth. Clinical features and possible mechanisms. Med 27:217-223. Sci Res, 1989; 17:881-884. 27. Hallmon WW, Rossmann JA. The role of drugs in the 14. Atilla G, Kutukculer N. Crevicular fluid interleukin-1β, pathogenesis of gingival overgrowth. A collective review of tumor necrosis factor-α, and interleukin-6 levels in renal current concepts. Periodontol 2000, 1999; 21:176-196. transplant patients receiving ciclosporine A. J Periodontol, 28. Baba M, Karakaş M, Aksungur VL, Homan S, Yücel A, Acar 1998; 69:784-790. MA, Memışoglu HR. The anticonvulsant hypersensitivity 15. Newell J, Irwin CR. Comparative effects of cyclosporin syndrome. Journal of the European Academy of on glycosaminoglycan synthesis by gingival fibroblasts. J Periodontol, 1997; 68:443-447. Dermatology and Venereology, 2003; 17(4):399-401. 16. Hassell T. Evidence that cyclosporine, phenytoin and dihydropiridines elicit overgrowth by different mechanisms. J Dent Res, 1990; 69:164. (Abstract 447) 17. Lowenstein DH. Seizures and epilepsy. In: Fanci AS, Correspondence and request for offprints to: Braunwald E, Isselbacher KJ, Wilson JD, Martin JB, Kasper Dr. Hakan Develioglu DL, et al (eds). Harrison’s Principles of Internal Medicine. University of Cumhuriyet New York: McGraw-Hill, 1998; pp 2311-2325. Faculty of Dentistry, Department of Periodontology 18. Merrit H, Putman T. Sodium diphenyl hydantoinate in Sivas, 58140 the treatment of convulsive disorders. JAMA, 1938; Turkey 111:1068-1103 E-mail: [email protected]

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Postextraction Inferior Alveolar Nerve Injuries - Prevention and Treatment

SUMMARY A. Delantoni, P. Papademitriou-Delantoni, Several sensory disturbances may occur to the inferior alveolar nerve K. Antoniades postoperatively. They are usually associated with lower third molar sur- Aristotle University of Thessaloniki, gery, and even then they are rare. The aim of this study was to evaluate and Thessaloniki, Greece describe the radiological aspects of sensory disturbances after an attempted tooth extraction, and present their preoperative and postoperative treatment. The cases demonstrated are presented with symptoms of facial pain; radiological and clinical situation are given preoperatively and postoperatively. A small comparison is also made to a case without symptoms, although the inferior alveolar nerve was in close relation to the tooth, and to which a proper operative approach was taken. CASE REPORT (CR) Keywords:Inferor alveolar nerve, injury; Impacted lower third molars. Balk J Stom, 2008; 12:170-173

Introduction lower right second molar, though clinically no tooth was present. The panoramic radiograph, which patient had There are several sensory disturbances that may with him, showed a residual root (Fig. 1) indicated for occur to the inferior alveolar nerve during an extraction extraction. The position of the root was confirmed with attempt. They most often occur when the tooth involved an intraoral radiograph. The residual root was removed. is an impacted lower third molar1-7 and include complete During the postoperative follow-up, 3 and 8 months after anaesthesia, hypoesthesia, hyperaesthesia and the most the initial surgery, the paresthesia was limited to the area common one, paresthesia. of 41 and 42 at the time of the first follow-up, and ceased Paresthesia is attributed to nerve injury being of completely at the time of the second follow-up. either odontogenic or iatrogenic origin8,9. It is expressed as numbness, burning sensation and/or electric type stimuli. The cause of paresthesia is often odontogenic, though it can be of systemic origin, such as viral or bacterial infections, or local neoplasms. Of the mentioned causes, those of odontogenic origin are of special concern to general dentists, which can be an attempt to extract molars and, most often, wisdom teeth, cysts, odontomas and periapical inflammations8,9. Figure 1: panoramic radiograph of the patient revealing the root The aim of this paper is to present 4 patients who remnant that caused the patient’s paresthesia were referred to our clinic with symptoms of sensory disturbances of the trigeminal nerve. Case 2 A 52 years old patient was referred to our clinic Report of 4 Cases after a long history of pain and misdiagnosed trigeminal neuralgia. According to the patient’s history, he initially Case 1 showed symptoms of pain about 2 years ago, when he A 57-year-old patient was referred to our clinic with visited a hospital with acute pain at the lower mandibular intense symptoms of pain and numbness at the area of area that reflected to the ear and eye. Since then he had Balk J Stom, Vol 12, 2008 Postextraction Inferior Alveolar Nerve Injuries 171 visited numerous clinics from E.N.T. to Neurological and had been given medication (carbamazepine) for treatment of trigeminal neuralgia. The symptoms persisted, and about a year ago, he was referred to our clinic from a neurologist. After making an OPG (Fig. 2), we noticed a strongly inflamed wisdom tooth that was removed. The patient was re-examined 6 and 12 months after surgery and paresthesia he initially had was at the first follow-up restricted to the area between 31 and 34, and gone at the second follow-up.

Figure 3: The intraoral radiograph prior to the extraction attempt that does not provide with the necessary information to avoid complications

Figure 2: Panoramic radiograph of the patient showing the impacted Figure 4a: An intraoral radiograph of the same case as in figure 3 the wisdom tooth with the inflammation of the surrounding tissues. way the patient presented to the clinic. We can clearly see the needed information to proceed to further surgery

Case 3 A 67-year-old patient was referred to our clinic after an unsuccessful attempt to remove the wisdom tooth. She came to us with the radiographs her dentist had taken before the attempt (Fig. 3). An intraoral and a panoramic radiograph were taken to gain a better understanding of Figure 4b: Panoramic radiograph of the same case to give us all the the tooth’s position (Fig. 4, a and b). After viewing the information we need for the surgical removal of the root residues radiographs, we ordered a computerized tomography (CT) scan to know with absolute certainty the position of the inferior alveolar nerve (Fig. 5, a and b). In the CT scans we observed the close approximation of the tooth’s residual roots to the inferior alveolar nerve. The correct localization of the inferior alveolar nerve was done, and a more careful approach to the extraction of the roots was taken. The lack of inflammation allowed us to conclude that the atypical paresthesia the patient had upon arrival, was of iatrogenic origin. When the patient came for a recall, 3 months after surgery, paresthesia was restricted in extent, but the symptoms of numbness and pain were more intense. A second recall, 6 months after surgery, was scheduled, when patient showed an improvement. The area of paresthesia was limited in extent, there was sensation at the lip and cheek area and only the anterior lower teeth area was still numb with very short paroxysmal pain involvement. Currently, 10 months after surgery, there are Figure 5a: A C.T. section of the patient giving us the exact position of the no symptoms of paresthesia. inferior alveolar nerve in relation to the root residues 172 A. Delantoni et al. Balk J Stom, Vol 12, 2008

Figure 7b: Panoramic radiograph of the same tooth showing the close relation of the tooth’s roots to the inferior alveolar nerve

Figure 5b: Cross sections of the area of interest for locating the inferior alveolar nerve and obtaining all required information regarding the Discussion position of the root residues Trigeminal paresthesia is not a commonly occurring sensory disorder. In many of the cases it is of odontogenic Case 4 or iatrogenic origin. In cases of difficult tooth extraction, In this case, the patient arrived with no symptoms particularly of lower wisdom teeth, it is one of the most or clinical findings of paresthesia, after referral of an frequently occurring extraction complications. The most orthodontist for a wisdom tooth removal. The case is common cause of its appearance is the improper surgical discussed in contrast to the previous cases to demonstrate procedure performed by the dentist, and underestimation the significance of proper preoperative control and of the difficulty of the operation. the importance of proper surgical moves to avoid any When there is a need to extract a tooth that is in close complications. The orthopantomogram showed a close approximation to the inferior alveolar nerve, one must connection of the inferior alveolar nerve to the wisdom always be aware of the tooth’s position radiologically. tooth’s roots (Fig. 6). We ordered a CT scan prior to the Initially, an intraoral radiograph and a panoramic radio- surgery. At the CT we observed the exact position of the graph should be taken to provide information regarding tooth and its roots, as well as the course of the nerve (Fig. the tooth’s exact position. If a close proximity of the 7, a and b). The surgery was scheduled and the tooth was tooth’s roots to the inferior alveolar nerve is observed, it extracted causing minimal damage to the surrounding should be decided whether additional radiographs, such as tissues and, therefore, after the extraction, there was a CT scan, are needed to best assess the exact anatomical limited paresthesia that lasted only a couple of weeks. relationships between the tooth’s roots and the inferior alveolar nerve. Patient must be informed of the possibility of a complication during surgery, and must be aware of the fact that there is no current treatment if paresthesia is the complication. He must also be informed that paresthesia is a temporary complication in most of the cases, but seldom it is a permanent one. The possibility of this complication during an extraction cannot always be avoided. One should try to limit it, though, by taking every possible measure available Figure 6: Panoramic radiograph of the patient prior to removal of the impacted third molar demonstrating the close relation of the nerve to the prior to surgery. Reference of the patient to an oral tooth’s roots. surgeon should be made when the dentist is not certain of his limitations. The proper radiographic control and the correct clinical movements (e.g. avoiding lingual moves or instrument placement for lower wisdom teeth) during a tooth extraction, when the tooth is in approximation to the inferior alveolar nerve, should be considered in order to avoid complications, such as paresthesia of the nerve.

References

Figure 7a: Cross section of the impacted third molar 1. Malden NJ, Maidment YG. Lingual nerve injury subsequent demonstrating the exact position of all anatomical to wisdom teeth removal - a 5-year retrospective audit from a structures high street dental practice. Br Dent J, 2002; 193(4):203-205. Balk J Stom, Vol 12, 2008 Postextraction Inferior Alveolar Nerve Injuries 173

2. Song F, O’Meara S, Wilson P, Golder S, Kleijnen J. The 7. Gregg JM . Studies of traumatic neuralgias in the effectiveness and cost-effectiveness of prophylactic removal maxillofacial region: surgical pathology and neural of wisdom teeth. Health Technol Assess, 2000; 4(15):1-55. mechanisms. J Oral Maxillofac Surg, 1990; 48(3):228-237; 3. Gulicher D, Gerlach KL . Incidence, risk factors and follow- discussion 238-239. up of sensation disorders after surgical wisdom tooth 8. Yana Y, Boukobza F, Mardam-Bey W, Derycke R. Paresthesia removal. Study of 1,106 cases. Mund Kiefer Gesichtschir, of the inferior dental nerve: clinical signs, etiological diagnosis and prognosis. Rev Odontostomatol (Paris), 1990; 2000; 4(2):99-104. 19(4):307-315. 4. Pogrel MA, Thamby S. The etiology of altered sensation in 9. Lambrianidis T, Molyvdas J. Paresthesia of the inferior the inferior alveolar, lingual, and mental nerves as a result alveolar nerve caused by periodontal-endodontic pathosis. of dental treatment. J Calif Dent Assoc, 1999; 27(7):531, Oral Surg Oral Med Oral Pathol, 1987; 63(1):90-92. 534-538. 5. Commissionat Y, Roisin-Chausson MH. Lesions of the inferior alveolar nerve during extraction of the wisdom Correspondence and request for offprints to: teeth. Consequences - prevention. Rev Stomatol Chir Maxillofac, 1995; 96(6):385-391. Dr. Antigone Delantoni 94 Mitropoleos street 6. Blondeau F. Paresthesia: incidence following the extraction 54622, Thessaloniki of 455 mandibular impacted third molars. J Can Dent Greece Assoc, 1994; 60(11):991-994. E-mail: [email protected]

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Use of Polyethylene Fibre Ribbon Reinforced Composite Resin as Post-Core Build-Up: A Technical Report

SUMMARY Hasan N. Alkumru, Sebnem Begum Turker, Restoration of an endodontically treated tooth is a subject that has been Buket Evren evaluated and discussed widely in the dental literature. Use of polyethylene Marmara University, Dept. of Prosthodontics fibre ribbon reinforced composite resin as post in restoring extensively Faculty of Dentistry, Istanbul, Turkey damaged teeth is something new. This article describes the use of polyethylene fibre ribbon reinforced composite resin as post-core build-up. TECHNICAL REPORT (TR) Keywords: Polyethylene Fibre Ribbon; Reinforced Composite Resin; Post-Core Build-Up Balk J Stom, 2008; 12:174-177

Introduction Technical Report

Teeth that have been endodontically treated often Clinical and radiographic examinations of a 21-year- have little coronal tooth tissue remaining and, as such, old male patient revealed a root canal treatment due to require a post to retain the core and restoration, and the fracture of the maxillary right central incisor, which need to be restored by crowns1,5,9. Metal posts are most was restored with composite resin filling materials 4 commonly used due to their favourable physical properties years ago. The discolouration and secondary caries of the and excellent biocompatibility4,8. With recent advances in related tooth was not satisfactory for the patient (Fig. 1). ceramic technology, the all-ceramic crown has become Polyethylene fibre ribbon reinforced composite resin as more popular. However, restoring a pulpless tooth with a post-core build-up and Empress II crown were planned metal post and core in combination with an all-ceramic is as treatment options to the patient for replacement of a challenge. The underlying metal from the post and core the extensively damaged tooth. The construction of can alter the optical effects of a translucent all-ceramic polyethylene fibre ribbon reinforced post-core restoration crown and compromise the aesthetics7. There has been is not time consuming and provides tooth coloured a significant amount of interest in the development of aesthetic substructure for a complete porcelain crown, non-metallic post systems in recent years. Several tooth- which will satisfy aesthetic requirements of the patient. coloured posts have been developed, such as zirconia coated CFP, all-zirconium posts and fibre-reinforced posts2,10,12. A leno-woven polyethylene ribbon (Ribbond Bondable Reinforcement Ribbon) has been used successfully for a variety of clinical techniques, including tooth splinting, replacement of missing teeth, treatment of dental emergencies and reinforcement of resin provisional fixed prosthodontic restorations, orthodontic retention and other clinical applications11. In recent year, there has been a great deal of interest in the use of resin cement to bond a post into a prepared canal2,10. Some laboratory studies have shown a significant increase in post retention with resin cement3,6,13. This paper describes a treatment alternative for extensively damaged tooth using polyethylene fibre ribbon reinforced composite resin as post-core build-up. Figure 1. Initial view of teeth Balk J Stom, Vol 12, 2008 The Use of Reinforced Composite Resin 175

Polyethylene Fibre Ribbon as Post Material Ivoclar Vivadent, Liechtenstein) was used for luting The root canal filling was removed to the apical polyethylene fibre ribbon. Syntac primer (Ivoclar Vivadent), third by using gates glidden and washed with 5% sodium Syntac Adhesive (Ivoclar Vivadent) and Heliobond (Ivoclar hypochlorite (Fig. 2A and B). After drying procedure with Vivadent) were applied to dentine separately in accordance paper points, 37% phosphoric acid was used to etch the root with the manufacturer’s directions. A piece of fibre ribbon canal wall and remaining tooth surface for 15 seconds, and (Kerr Connect Reinforcement Ribbon; Kerr Corp, Orange, washed thoroughly for 30 seconds (Fig. 3). Retraction cord CA), 3 mm width and 5-6 mm longer than the prepared root (Stay-put; Roeko, Germany) was used to isolate sub-gingival canal length (Fig.4), was cut off and embedded in mixed finish line after anaesthesia. Resin cement (Variolink; Variolink resin cement (Variolink; Ivoclar Vivadent).

Figure 2A. Remaining tooth structure, after removal of composite resin Figure 2 B. Root canal ready for polyethylene fibre ribbon reinforced restoration and caries composite resin post-core restoration

Figure 3. Total etch of the root canal Figure 4. Polyethylene fibre ribbon embedded in resin cement (Variolink II)

Figure 5A. Insertion of polyethylene fibre ribbon into the resin cement Figure 5B. Forming loop by insertion of free end of fibre ribbon into filled tooth canal root canal 176 H.N. Alkumru et al. Balk J Stom, Vol 12, 2008

margin was placed 0.5 mm sub-gingivally to increase the length of preparation as well as aesthetic improvement of the final restoration. Sharp edges or irregularities were corrected to minimize stress concentration. Complete arch impression was made with a silicon impression material (Speedex; Coltene AG, Switzerland) and chair side provisional crown (Dentalon Plus; Heraeus Kulzer, Germany) was constructed. Empress II full ceramic crown (Empress II; Ivoclar, Vivadent) was fabricated. The complete seating, marginal adaptation, aesthetic appearance of crown and occlusion was checked at the first try-in. Any premature contacts of centric occlusion position and /or the Figure 6. Construction of composite resin (Tetric-Ceram) core lateral and anterior movements were eliminated.

The root canal was filled with resin cement. Fibre- Empress II Crown Cementation Procedure resin combination was carefully placed into the canal The internal surface of the crown was etched with by use of titanium nitride coated instruments (Brilliant 5% hydrofluoric acid gel (IPS ceramic etching gel; Esthetic Line Composite Instrument, Coltène AG, Ivoclar, Vivadent) for 20 sec. A silane coupling agent Switzerland), leaving a loop formed 2-3 mm ribbon above (Monobond-S; Ivoclar, Vivadent) was applied for 60 the occlusal surface of the root (Fig. 5A and B). The sec. The preparation was cleaned with pumice slurry combined fibre ribbon and luting resin was light cured for and retraction cord was applied. The core surfaces 40 sec (Optilux; Demetron Inc, Danbury, Conn). Exposed and remaining tooth surfaces were etched with 37% ribbon loop was then filled and covered with composite phosphoric acid (Total Etch; Ivoclar, Vivadent) for resin (Tetric Ceram, Ivoclar Vivadent) incrementally 60 seconds. Tooth was rinsed with water and dried. for fabricating core, and light cured for 40 sec from one Following the manufacturer’s guidelines, Syntac Primer surface, total of 160 seconds (Fig. 6) . and Syntac Adhesive were applied. The bonding agent was brushed on both preparation surfaces and internal surface Core Preparation of the restoration, thinned with air, and cementation was The core preparation was completed with performed immediately by using Variolink II high viscosity circumferential deep chamfer finish line (Fig. 7). Medium resin cement. Excess cement was removed with brush and and coarse diamond burs (Accurata, G+K Mahnhardt dental floss. The restoration was photo-polymerized for 40 Dental, Germany) were used for tooth preparations. The sec. from all surfaces, total of 200 seconds. The occlusion width of the shoulder was kept 1 ~ 1.2 mm. Cervical was controlled to preclude premature contacts (Fig. 8).

Figure 7. Final preparation for full ceramic restoration Figure 8. Full porcelain in-situ

After cementation of Empress II crown, routine recall outcome was successful. Additionally, no functional or visits were performed 4 times over a 1-year period. The aesthetic problems were reported by the patient. evaluation of the polyethylene fibre ribbon reinforced composite resin as post-core build-up at these visits was made with radiographic examination. In each recall, Discussion radiograph was taken from the restored tooth with the standardized long-cone technique. No differences were The purpose of a post and core is to reinforce the observed between the initial and recall radiographs. The remaining coronal tooth structure and to replace missing Balk J Stom, Vol 12, 2008 The Use of Reinforced Composite Resin 177 coronal tooth structure9. Due to the shearing forces that application, the aesthetic goal was achieved and there was act on anterior tooth, anterior endodontically treated teeth functional success over 1 year period. Long-term clinical are restored with posts more often than posterior teeth8. performance of polyethylene fibre ribbon reinforced The metallic colour of metal posts leads to a greyish composite resin as post-core build-up needs to be evaluated. discoloration of the root and consequently of the gingiva. In summary, the polyethylene fibre ribbon can be This may be an enormous aesthetic disadvantage in the used safely with composite resin for post-core build- anterior teeth5 and cosmetic concern has led to development up restorations for endodontically treated teeth. The of aesthetic posts7. The use of polyethylene fibre ribbon translucent quality of fibre ribbon and composite resin reinforced composite resin as a post-core restoration enables complete porcelain crowns to be fabricated material satisfied the aesthetic demands beneath all without compromising aesthetics. ceramic restorations and also provided a level of strength to composite core material replacing the lost tooth structure. Dental cement lute the post to radicular dentin and some properties of cements, such as compressive strength, References tensile strength and adhesion, are commonly described .8 as predictors for success of a cemented post . Cement 1. Bateman G, Ricketts DNJ, Saunders WP . Fiber-based post provides important retention to the post and core; however, systems: a review. Br Dent J, 2003; 195:43-48. no cement can compensate for a poorly designed post7. 2. Fernandes AS, Dessai GS . Factors affecting the fracture Mendoza et al6 showed that resin cements give additional resistance of post-core reconstructed teeth: a review. Int J resistance to fracture compared to brittle, nonbonding zinc Prosthodont, 2001; 14:355-363. phosphate cement, and reported that resin luting agents 3. Goldman M, De Vitre R, White R, Nathanson D. A SEM study of posts cemented with an unfilled resin. J Dent Res, are technique-sensitive and difficult to manipulate. In the 1984; 63:1003-1005. presented study, before the cementation procedure, the 4. Kakehashi Y, Lüthy H, Naef R, Wohlwend A, Schärer P. An canal was washed off and dried after the etching procedure, all-ceramic post and core system: clinical, technical and in ensuring that the post space was free of any residue4. vitro results. Int J Periodont Rest Dent, 1998; 18:587-593. The root canal was filled with resin cement by using 5. Kovarik RE, Breeding LC, Caughman WF. Fatigue life of lentulospiral10 and polyethylene fibre ribbon embedded to three core materials under simulated chewing conditions. J the resin cement was placed to the prepared root canal. Prosthet Dent, 1992; 68:584-590. 6. Mendoza DB, Eakle WS, Kahl EA, Ho R. Root reinforcement Silver amalgam, composite and glass-ionomer are 3 with a resin-bonded preformed post. J Prosthet Dent, 1997; 8 5 basic direct core materials . Kovarik evaluated different 78:10-15. core materials under simulated chewing conditions and 7. Morgano SM, Brackett SE. Foundation restorations in fixed concluded that amalgam core build-ups with metal posts prosthodontics: current knowledge and future needs. J had a significantly higher resistance to chewing forces Prosthet Dent, 1999; 82:643-657. when compared to metal post-composite resin build-ups. 8. Morgano SM, Milot P. Clinical success of cast metal posts In the present study, since exposed ribbon loop was filled and cores. J Prosthet Dent, 1993; 69:11-16. 9. Robbins JW. Guidelines for the restoration of endodontically and covered with composite resin incrementally, fibre- treated teeth. J Am Dent Assoc, 1990; 120:558-566. resin combination with 2-3 mm loop provided adequate 10. Robbins JW. Restoration of the endodontically treated tooth. retention and resistance for the core material clinically. Dent Clin North Am, 2002; 46:367-384. The technique presented in this paper is a chair- 11. Rudo DN, Karbhari VM. Physical behaviors of fiber side procedure, and allows direct core build-up. Therein reinforcement as applied to tooth stabilization. Dent Clin with one visit for the patient, the dentist can fabricate North Am, 1999 43:7-35. post-core, complete the crown preparation and make a 12. Sirimai S, Douglas NR, Morgano SM. An in vitro study of the fracture resistance and the incidence of vertical root final impression for the restoration. Since the endodontic fracture of pulpless teeth restored with six post-and-core enlargement is enough and since there is no need for systems. J Prosthet Dent, 1999; 81:262-269. extra preparation in the canal for the polyethylene ribbon, 13. Wong B, Utter JD, Miller BH, Ford JP, Guo IY. Retention the preservation of residual dentin is possible with this of prefabricated posts using three different cementing technique. Therefore, the risk of root perforation can be procedures. J Dent Res, 1995; 74:181. eliminated and the remaining root dentin to resist fracture is optimized. However, a significant challenge with this technique is the handling of the polyethylene fibre ribbon during embedment of the resin cement. Titanium nitride Correspondence and request for offprints to: coated instruments can be used for better handling of Dr. Hasan N. Alkumru ribbon and resin cement combination. Marmara University Sirimai et al12 reported that the polyethylene fibre Faculty of Denistry Buyukcftlik Sok. No:6 ribbon was effective in reducing the incidence of vertical 34365 Nisantasi, Istanbul root fractures and the failure thresholds were significantly Turkey lower than that of conventional cast posts. In this clinical E-mail: [email protected]

178 Z Balk J Stom, V ol 12, 2008

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Book Review

ORAL CANCER: DIAGNOSIS, MANAGEMENT, AND REHABILITATION 1st Edition Editor: John W. Werning Publisher: Thieme Medical Publishers, New York - Stuttgart, 2007 Hard cover, 368 pages with 350 illustrations and 46 tables Price: $ 129.95

Although there are many reference textbooks that cover oral cancer comprehensively, “Oral Cancer” by JW Werning is a practical, easy-to-read guide to the management of oral cancer. It provides readers with a systematic review of the diagnostic and treatment principles that maximize the outcomes of patients who have been diagnosed with oral cancer. Editor JW Werning, M.D., D.M.D., has brought together contributions from authorities in the fields of head and neck surgical oncology, radiation oncology, reconstructive surgery, dentistry, and oral and maxillofacial surgery. This book provides clinicians with the unified management philosophy firmly based upon the available evidence in the peer- reviewed literature. Unlike more comprehensive texts on head and neck cancer, this text does not address the basic science foundation of cancer biology or medical therapy. Because of its concise format and coverage of key clinical principles, it makes for a good addition to the library of residents or surgeons who manage head and neck cancer. This book is divided onto 31 chapters in a following order: Epidemiology of Oral Cancer - Oral Precancer - Malignant Lesions of the Oral Balk J Stom, V ol 12, 2008 179

Cavity - Evaluation of Oral Premalignant Lesions reconstructive options that are time tested and - Anatomic Consideration - Imaging of Patients effective for restoring form and function. with Oral Cancer - Staging of Oral Cancer - Chapter on reconstruction of the lips exhaustively Pretreatment Dental Evaluation and Management covers a technique published in 1974 by Prof. M. of the Oral Cancer Patient - Cancer of the Lip - Karapandžić from the University of Belgrade, Clinic Cancer of the Buccal Mucosa - Cancer of the Oral of Maxillofacial Surgery. The description of that Tongue and Floor of Mouth - Cancer of the Lower method is concluded with the following statement: Alveolar Ridge and Retromolar Trigone - Cancer „Based on the superior functional and cosmetic of the Hard Palate and Upper Alveolar Ridge - results that can be achieved, the Karapandzic flap is Management of the Neck - Reconstruction of the arguably the flap of choice for most defects“. Lips - Reconstruction of the Cheek - Reconstruction of the Tongue - Reconstruction of the Mandible - Exhaustive coverage was given to the topics Reconstruction of the Maxilla - Radiation Therapy that have until now received limited attention in – Chemotherapy - Oral Rehabilitation with other textbooks devoted to oral cancer, including the Osseointegrated Implants - Dental Implant Imaging evaluation and management of oral premalignant - Oral Prosthetic Rehabilitation - Xerostomia and lesions, osseointegrated implantation and dental Mucositis – Osteoradionecrosis - Speech and implant imaging, and orofacial pain. Swallowing Following Treatment for Oral Cancer - “Oral Cancer” is long on management and Temporomandibular Disorder and Orofacial Pain – short on pathophysiology. This makes it concise and Chemoprevention - Novel Therapeutics for Head and attractive for clinicians or residents accumulating Neck Cancer - Medical/Legal Issues. information specifically about patient management. Those chapters contain in-depth clinical reviews Its lack of pathophysiology and basic science limits of preferred treatment approaches and reconstructive its utility to residents preparing for the in-service techniques for each oral cavity site facilitate the examination. However, it will certainly help students development of effective treatment strategies that are or residents prepare for the next days operation or tailored to the location and extent of the lesion. They case presentation. For more senior clinicians, it also give insightful reviews of controversial clinical serves as a well-referenced, up-to-date review on issues, such as the management of early mandibular management techniques. invasion and the clinically negative neck. As a clinical text, it directs the reader through In addition to covering management of oral difficult subjects; it clearly states which topics are cavity cancer, the book has well-written and concise controversial, outlines the relevant studies, and then chapters on related topics such as osteoradionecrosis, leads the reader to a fair conclusion of acceptable prosthetic implantation techniques, chemoprevention, management practices. In areas in which there is new therapeutic agents (including monoclonal consensus, management options are stated clearly antibodies, tyrosin kinase inhibitors, gene replacement and concisely. Furthermore, it informs the reader therapy, farnesyl transferase inhibitors, etc), legal when introducing a non-standard treatment (such as issues (malpractice litigation, cancer litigation and risk management). For the most part, the book is well radiation therapy for lesions traditionally managed by referenced internally, referring the reader to places surgery). For a text addressing oral cavity cancer, it within the book that are not covered in the current contains significant detail on radiotherapy treatment. chapter. Unfortunately, this is not always the case, Overall, this is a valuable addition to the book, as it and some topics are divided into separate chapters is not always as well covered in traditional textbooks. that might be better grouped together. For example, Although the radiation oncology sections are well the chemotherapy section does not include targeted written with excellent figures, they seem in places therapies, which are appropriately covered within the excessive for the target audience. book, but in a separate chapter. The textbook appropriately concludes with a A key element in the surgical treatment discussion of future directions in cancer therapy, of patients with oral cancer is state-of-the-art novel therapeutics that are on the horizon, and reconstruction, and leaders in the field have options for managing treatment sequelae that can contributed site-specific chapters covering the significantly affect a patient’s quality of life. 180 Balk J Stom, V ol 12, 2008

In what is notably missing for a clinically oriented an essential educational tool for residents and other text, it does not contain an adequate discussion of members of the multidisciplinary oral cancer team. complications related to surgery or radiotherapy Its comprehensive coverage of oral cancer prevention, within each chapter, nor does it contain a separate diagnosis, therapy, reconstruction, and rehabilitation chapter that addresses long-term post-treatment is intended to become an invaluable tool for all who complications. provide a service aimed to improve both therapeutic “Oral Cancer” is an up-to-date and comprehen- outcome and quality of life for all patients treated for sive guide to the clinical management of oral oral cancer. cancer and its rehabilitation. This book is both an indispensable reference for experienced clinicians and Prof. Miodrag Gavrić