General Dentistry DENTISTRY November/December 2012 ~ Volume 60 Number 6

PROSTHODONTICSSPECIAL SECTION GENERALPeer-Reviewed Journal of the Academy of General Dentistry DENTISTRY November/December 2012 ~ Volume 60 Number 6

PROSTHODONTICS n ENDODONTICS TRAUMA IN PRIMARY/YOUNG TEETH IMPLANT RESTORATIONS n WWW.AGD.ORG

CONTENTS

Special section on prosthodontics

466 Guest Editorial In the best interest of our patients Lily T. Garcia, DDS, MS, FACP

467 Complete Dentures Denture adhesive use in complete dentures: Clinical recommendations and review of the literature Ibrahim Duqum, BDS, MS Kendall Ann Powers, BS Lyndon Cooper, DDS, PhD, FACP David Felton, DDS, MS, FACP 480 Implant Restorations Accelerated treatment protocols: Full arch treatment with interim and deﬁnitive prostheses Carl Drago, DDS, MS

494 Removable Prosthodontics Impact of tooth loss on oral and systemic health S. Offenbacher, MS, DDS, PhD S.P. Barros, MS, DDS, PhD S. Altarawneh, DDS J.D. Beck, MS, PhD Z.G. Loewy, MS, PhD

503 Complete Dentures Removable partial denture assisted by implant-retained ﬁxed prosthesis opposing implant-retained overdenture Hyun-seok Nam, DDS, MS Kwang-yeob Song, DDS, MS, PhD Ju-mi Park, DDS, MS, PhD Won-suk Oh, DDS, MS 508 Implant Restorations Sequential provisional implant prosthodontics therapy Ira D. Zinner, DDS, MSD Stanley Markovits, DDS, MAGD Curtis E. Jansen, DDS Patrick E. Reid, CDT, MDT Yale E. Schnader, DDS Herbert J. Shapiro, DDS

519 Fixed Prosthodontics Preparing ﬁxed partial denture abutments such that they provide a path of placement free of undercuts John Mamoun, DMD

526 Prosthodontics The impact of obesity on prosthodontic treatment Judy Chia-Chun Yuan, DDS, MS Fatemeh S. Afshari, DMD, MS Damian J. Lee, DDS, MS Cortino Sukotjo, DDS, PhD, MMSc

www.agd.org General Dentistry November/December 2012 441 CDE Departments self 2 HOURS instruction CREDIT 450 Editorial Relationships are powerful Continuing Dental Education (CDE) Opportunities 452 Dental Materials Impression taking: Still the key to great Earn two hours of CDE restorations credit by signing up for and completing these exercises 454 Pharmacology Bleeding risks for older patients taking based on various subjects. warfarin and commonly prescribed antibiotics and antifungals simultaneously 478 Self-Instruction Exercise No. 315 457 Restorative Dentistry Laboratory work for restorative Complete Dentures dentistry: Model pouring and die preparation

492 Self-Instruction 461 Ethics Dental assistant or patient? Can she be both? Exercise No. 316 Implant Restorations 548 Oral Diagnosis Large radiolucency of the mandibular body and Large pericoronal radiolucency 501 Self-Instruction Exercise No. 317 550 Answers Oral Diagnosis and Self-Instruction exercises No. 291, Removable Prosthodontics 292, 293, 294, 295, 296

538 Self-Instruction Exercise No. 318 Clinical articles Dental Materials 534 Endodontics Antimicrobial effect of three new and two e357 Self-Instruction established root canal irrigation solutions Exercise No. 319 Zahed Mohammadi, DMD, MSD Dental Materials Sousan Shalavi, DMD Luciano Giardino, MD, DDS Flavio Palazzi, MD, DDS e378 Self-Instruction Rasoul Youseﬁ Mashouf, PhD Exercise No. 320 Alireza Soltanian, PhD Appliance Therapy 540 Lasers in Periodontics Five-year retrospective study of Instructions for Authors laser-assisted periodontal therapy For General Dentistry’s Edward R. Kusek, DDS Instructions for Authors, Amanda J. Kusek, RDH please visit the journal’s E. Alex Kusek website at www.agd.org/ 544 Trauma in Primary/Young Teeth Tooth embedded in publications/GD/AuthorInfo. lower lip following dentoalveolar trauma: Case report and literature review Antonio Azoubel Antunes, DDS Thiago Santana Santos, DDS, MS Allan Ulisses Carvalho de Melo, PhD Cyntia Ferreira Ribeiro, DDS, MS Suzane Rodrigues Jacinto Goncalves, PhD Sigmar de Mello Rode, DDS, MS

442 November/December 2012 General Dentistry www.agd.org

e346 Dental Materials Antibacterial activity in adhesive dentistry: A literature review Fereshteh Shaﬁei, DMD, MS Mahtab Memarpour, DMD, MS

e359 Appliance Therapy Appliance design and application Keith A. Yount, DDS, MAGD

e380 Oral Diagnosis/Endodontics A case of a benign cementoblastoma treated by enucleation and apicoectomy Aydin Gulses, DDS, PhD Gurkan Rasit Bayar, DDS, PhD Cumhur Aydin, DDS, PhD Metin Sencimen, DDS, PhD e383 Operative Dentistry The effect of pre-warming and delayed irradiation on marginal integrity of a resin-modiﬁed glass-ionomer Maryam Khoroushi, DDS, MS Tayebeh Mansoori-Karvandi, DDS, MS Saeed Hadi, DDS e389 Endodontics Open apex Type III dens invaginatus: A rare case report of an endodontic retreatment with an anatomical redesign Emmanuel Joao Nogueira Leal Da Silva, DDS, MSc Alexandre Augusto Zaia, DDS, MSc, PhD

e393 Dental Materials Microhardness and sealing ability of materials used for root canal perforations Carlos H.R. Camargo, MSc, PhD Manuela B. Fonseca Alessandra S. Carvalho, MSc, PhD Samira E. Camargo, MSc, PhD Flavia G. Cardoso, MSc Marcia C. Valera, MSc, PhD

e398 Implants Esthetic consideration for alveolar socket preservation prior to implant placement: Description of a technique and 80-case series report Ahmad Kutkut, DDS, MS Sebastiano Andreana, DDS, MS Edward Monaco, DDS

444 November/December 2012 General Dentistry www.agd.org

e404 Non-surgical Endodontics Maxillary ﬁrst molar with three buccal roots evaluated with cone-beam computed tomography: A rare case report Jojo Kottoor, MDS Suresh Nandini, MDS Natanasabapathy Velmurugan, MDS e408 Operative (Restorative) Dentistry Effect of curing unit and adhesive system on marginal adaptation of composite restorations Denise Sa Maia Casselli, PhD, MD, DDS Andre Luis Faria-e-Silva, PhD, MD, DDS Henrique Casselli, PhD, MD, DDS Luis Roberto Marcondes Martins, PhD, MD, DDS e413 Dental Materials Bond strength of resin-modiﬁed glass ionomer restorative materials using a no-rinse conditioner Rian W. Suihkonen, DDS, ABGD Kraig S. Vandewalle, DDS, MS, MAGD, ABGD Jon M. Dossett, DMD, MAGD, ABGD

Coming Next Issue In the January/February 2013 issue of General Dentistry UÊ >À}>Êi>>}iÊ>`Ê microhardness evaluation of low-shrinkage resin- based restorative materials UÊ "LiÃÌÞÊ>`Ê«iÀ`ÌÌÃ\Ê A link UÊ "VVÕÃÊVvÕÃ UÊ "ÛiÀÛiÜÊvÊ , Ê É CAM chairside system

In the December 2012 issue of AGD Impact UÊ iÌÃÌÃÊvÊÌ iÊiÀV>Ê Federal Services UÊ >>`>ÊÀViÃÊ iÌ>Ê Services

446 November/December 2012 General Dentistry www.agd.org

Editor General Dentistry Roger D. Winland, DDS, MS, MAGD Email: [email protected] Director, Communications Fax: 312.335.3442 Cathy McNamara Fitzgerald Executive Editor Back Issues and Change of Address Elizabeth Newman Members, call 888.AGD.DENT (toll-free) and ask for a Member Services representative. Nonmembers, call Derria Murphy (ext. 4097). Interim Managing Editor Tiffany Nicole Slade Mailing Lists Associate Editor For information about ordering AGD mailing lists, call Derria Murphy (ext. 4097). Sheila Saldeen Specialist, Communications Reprints Cassandra Bannon To order reprints of any article in General Dentistry, contact Rhonda Brown at Manager, Production/Design Foster Printing Company (866.879.9144, ext. 194) or email your request to Timothy J. Henney [email protected]. Associate Designer Jason Thomas All materials subject to copying and appearing in General Dentistry may be photocopied for the noncommercial purposes of scientiﬁc or educational advancement. Reproduction of any portion of General Dentistry for commercial Advertising purposes is strictly prohibited unless the publisher’s written permission is obtained. M.J. Mrvica Associates 2 West Taunton Ave. Berlin, NJ 08009 Disclaimer 856.768.9360 The AGD does not necessarily endorse opinions or statements contained in essays or [email protected] editorials published in General Dentistry. The publication of advertisements in General Dentistry does not indicate endorsement for products and services. AGD approval for continuing education courses or course sponsors will be clearly stated.

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448 November/December 2012 General Dentistry www.agd.org Advisory Board Dental Materials Oral and Maxillofacial Pathology Pain Management Steve Carstensen, DDS, FAGD, John Svirsky, DDS, MEd, is a board- Henry A. Gremillion, DDS, is in general practice in Bellevue, Washington. certified oral and maxillofacial pathologist at MAGD, is dean of the Louisiana State He is a visiting faculty member of the Pankey Virginia Commonwealth University in Richmond. University School of Dentistry and a professor in Institute and the Pride Institute, and a He currently is a professor of oral and the Department of Orthodontics at LSUSD. Diplomate of the American Board of Dental maxillofacial pathology and maintains a private Sleep Medicine. practice in oral medicine and oral pathology. Pediatrics Jane Soxman, DDS, is a Diplomate Dental Public Health Oral and Maxillofacial Radiology of the American Board of Pediatric Dentistry, Larry Williams, DDS, ABGD, Kavas Thunthy, BDS, MS, MEd, has authored numerous articles in the dental MAGD, is a Captain in the United States Navy has been a professor of oral and maxillofacial literature, and has been recognized as a leader Dental Corps, and is currently stationed at the radiology in the Department of Oral Diagnosis, in continuing education. She maintains a private Great Lakes Naval Training Center as a member Medicine, and Radiology, at the Louisiana State practice in Allison Park, Pennsylvania. of the Great Lakes Naval Health Clinic. Dr. University School of Dentistry in New Orleans Williams is the Public Health Emergency Officer since 1975. He was named a Fellow in the Periodontics for the 16 states of the Navy Region Midwest American Academy of Oral and Maxillofacial Sebastian Ciancio, DDS, is and for the Naval Health Clinic. He also serves Radiology in 1978 and was board-certified by Distinguished Service Professor and Chair, as the co-chair of the Navy’s Tobacco Cessation the American Board of Oral and Maxillofacial Department of Periodontics and Endodontics; Action Team and as a member of the Department Radiology in 1981. Adjunct Professor of Pharmacology; and Director of Defense Alcohol and Tobacco Advisory Council. of the Center for Dental Studies at the University Dr. Williams teaches for the Dental Hygiene Oral and Maxillofacial Surgery at Buffalo, The State University of New York. program at the College of Lake County and as Karl Koerner, DDS, FAGD, is a an assistant clinical professor for the Rosalind general dentist in Utah who performs oral Pharmacology Franklin University for Medicine and Science. surgery exclusively. He lectures extensively Daniel E. Myers, DDS, MS, is a on oral surgery in general practice and has member of the Oral Diagnosis Department, Esthetic Dentistry made articles, books, and video presentations Dental Associates of Wisconsin, Ltd. in Wynn H. Okuda, DMD, is Past National available to general practitioners. Wauwatosa. President (2002–2003) and a board-accredited member of the American Academy of Cosmetic Oral Medicine Prosthodontics Dentistry (AACD). He also is on the Advisory Sook-Bin Woo, DMD, MMSc, Joseph Massad, DDS, is currently the Board of Best Dentists in America and on the is assistant professor of Oral Medicine, Director of Removable Prosthodontics at the Executive Council of the International Federation Infection, and Immunity at Harvard School of Scottsdale Center for Dentistry in Arizona. He of Esthetic Dentistry (IFED). He practices Dental Medicine. She is board-certified in Oral is adjunct faculty at Tufts University School of cosmetic, implant, and restorative dentistry at the and Maxillofacial Pathology and Oral Medicine Dental Medicine in Boston and the University of Dental Day Spa of Hawaii in Honolulu. and practices both specialities in the Boston/ Texas Dental School at San Antonio. Cambridge area in Massachusetts. Endodontics Jack Piermatti, DMD, is a Diplomate Stephen Cohen, DDS, is one of the Orthodontics of the American Board of Prosthodontics, the foremost endodontic clinicians in the country Yosh Jefferson, DMD, FAGD, American Board of Oral Implantology, and the and lectures worldwide on endodontics. is Past President, International Association International Congress of Oral Implantologists. A board-certified endodontist, Dr. Cohen for Orthodontics, a Fellow of the American He is a board-certified prosthodontist in private specializes exclusively in the diagnosis and Academy of Craniofacial Pain, and a member practice in Voorhees, New Jersey. treatment of endodontic infections. of the American Academy of Dental Sleep Medicine. He maintains a general practice in Geriatric Dentistry Mt. Holly, New Jersey. Lea Erickson, DDS, MSPH, is Chief, Dental Service, at VA Salt Lake City Health P. Emile Rossouw, BSc, BChD, Care System and Clinical Assistant Professor, BChD (Child-Dent), MChD University of Utah in Salt Lake City. (Ortho), PhD, is professor and chairman of the Department of Orthodontics, Implantology University of North Carolina at Chapel Hill Wesley Blakeslee, DMD, FAGD, School of Dentistry. He has published and is a general dentist who practices in New lectured on clinical orthodontic research Jersey. He is a Diplomate of both the American nationally and internationally. He maintains Board of Oral Implantology/Implant Dentistry a part-time clinical practice in addition to his and the International Congress of Oral academic responsibilities. Implantologists, and a Fellow of the American Academy of Implant Dentistry.

www.agd.org General Dentistry November/December 2012 449 Editorial

Relationships are powerful

elationships are the Every person we meet shows us how well-connected food of life. Therefore, we are with our unconscious mind, because we notice Rin order to nourish qualities in other people that we either have resolved, or ourselves, we must surround not resolved within ourselves. We can actually feel the ourselves with healthy rela- energy exchange in a relationship because we feel good, tionships. You are respon- or not so good, when we’re in the company of another sible for the success of your person. The value we place on our relationships is re- own relationships. Both our flected in the type of people we surround ourselves with practices and our families at work and at home. Good relationships are like little are the products of a series homes, complete with healing powers and the promise of inherited patterns: the of sanctuary. negative ones that we can Our relationship with our children also holds a key to choose to observe and change, and the positive ones that better relationships with others, especially by showing we can grow and make stronger. Even if you came from a the importance of good communication. By both teach- dysfunctional family (and who didn’t?), the relationships ing and learning the best way to communicate, we can outside of our blood ties, the ones we forge as indepen- ensure healthy relationships at both home and work. dent adults, are 100% of our own choosing. Strong relationships focus on how we can help and In my life, I feel that the most important relationship interact with our partners in the relationship. We must is that of marriage, and an important component of mar- keep in mind that sometimes life can be challenging. riage that we can take into every relationship we have is to Convincing people that the best way to increase the make sure you always keep a sense of humor. Understand quality of their lives is to do something that will enhance that each person has other issues happening in their lives another person’s life can be difficult. that they must deal with outside the relationship you have In the movie An Officer and a Gentleman the prin- with them. The high energy word to keep in mind when cipal character starts out with the “me” attitude and you’re in a relationship is kindness. If we are anything less through a series of events appears to become “human.” than kind, unpleasant emotions will surface faster than He eventually helps a fellow cadet finish an obstacle a flash flood. Good relationships are about giving and course and his superiors feel he had finally earned the receiving warmth, understanding, acceptance, fun, sincer- title an officer and a gentleman. We must all reach out ity, and trust, as well as having respect for ourselves and unselfishly to help others overcome the obstacles that for our partners in every relationship. keep them from being successful in developing as many Although it sounds wonderful, this is no easy undertak- strong relationships as possible. As Ben Sweetland said, ing. I deal with patients from every walk of life—from “We cannot hold a torch to light another’s path without the wealthy to the poor, the highly educated to the deeply brightening our own.” undereducated—and I treat them all with respect. As a professional, it is my duty to maintain positive relationships with my patients even when my warmth and kindness is not reciprocated. However, I find that many of my patients are indeed grateful when I provide them with Roger D. Winland, DDS, MS, MAGD needed care, since these services add value to their lives. Editor

450 November/December 2012 General Dentistry www.agd.org

Dental Materials

Impression taking: Still the key to great restorations

Michael B. Miller, DDS, FAGD

aking an excellent impression is essential for a well- subgingival preparations and impressions are precarious fitting restoration. This column examines several at best. Referring the patient for a graft is the standard Tfactors that must be present for an impression to of care in this situation. be successful. Finally, biologic width goes hand-in-hand with an adequate band of attached gingiva. If a previously placed Healthy tissue restoration has violated the biologic width, it must be re- It is much easier to impress a preparation accurately if the established before you can hope for gingival rejuvenation. gingiva is healthy. This concept should be common sense. However, laboratories receive numerous impressions that Gentle retraction were obviously taken in a sea of blood; such efforts are Even though it is possible to successfully expose margins an exercise in futility. Any inflammation and/or infection using electrosurgery or a laser, most dentists still rely should be resolved before attempting to take an impres- on retraction cord. It’s not high tech, it’s not sexy, and sion for a definitive restoration. If the cause of the soft it’s tedious to place—but it works, and it’s relatively tissue problem is a current restoration that is not tissue- inexpensive. friendly, a well-fitting provisional should be fabricated. Cord is meant to move tissue laterally, away from Once the tissue heals, the impression can be taken. the tooth, not necessarily apically. However, the tissue An exception to this rule occurs when the tissue does typically moves in an apical direction during this lateral not respond positively to a provisional, no matter how movement. One should not jam the cord down deep well it fits. In these cases, you may want to try fabricat- into the sulcus, but rather place it gently without using ing a new provisional from another material, such as much force. One way to refine your cord packing skills switching from a conventional bis-acryl to Tuff-Temp is to perform this procedure on a patient who has not (Pulpdent Products), which is stated by the manufacturer been anesthetized. to be a “rubberized-urethane” and free from bisphenol A The goal of cord placement is not to search for the (BPA). You may proceed with the definitive crown but epithelial attachment. The goal is to expose tooth struc- plan on provisional cementation. This is a riskier option, ture for access during tooth preparation and to expose since once the tissue heals, it may also shrink and expose margins when taking an impression. your margins. Of course, in some cases, no matter how Paste-type retraction materials can be used as an diligent you are, the tissue may never return to absolute alternative to cord when taking an impression. Approxi- health. Patients should be informed of this possibility mately seven years ago, the gingival retraction/hemo- upfront, or they may end up less than satisfied. static paste market was launched with the introduction Another cause of inflamed tissue is haphazard subgin- of Expasyl (Kerr Dental), which had no competition for gival tooth preparation. If you indiscriminately enter a number of years. This monopoly was broken in 2011 the sulcus with a coarse diamond bur without regard with the introduction of Traxodent (Premier Dental for the tissue, the damage you cause may never resolve Products, Co.). 3M ESPE has also entered the field with completely. Subgingival preparation should always be Retraction Capsule, and Centrix just brought out its done carefully. Either place an instrument between the newest product, Access Edge. gingiva and the diamond bur, or use pack cord to move The advantages of these clay-like materials are ease of the tissue away from the tooth. use and speed of delivery, with virtually no trauma to In addition, there should be an adequate width of the tissue. However, while these products are reasonably attached gingiva adjacent to any crown destined for effective hemostatic agents, their tissue retraction func- subgingival placement. Without attached gingiva, tion falls somewhat short of cord.

452 November/December 2012 General Dentistry www.agd.org Margin placement Digital impressions New ceramic materials such as Lava Plus (3M ESPE) and This new world of impression taking will include digital e.max (Ivoclar Vivadent, Inc.) are much less opaque than devices. These items still command a pretty high price; ceramometal or even some of the original metal-free sys- however, it is the author’s belief that the main reason tems such as Inceram Alumina (Vident). This increased they have not taken off is that they appear unable to translucency means you don’t have to bury margins to capture preparations except in pristine conditions. If keep them out of view. When your preparation margins there was a unit that could “read” margins through can be equigingival or just slightly subgingival, the tissue blood and/or saliva, these machines would start selling has a lower chance of being insulted and the impression in a logarithmic trajectory. is easier to capture. Impression taking is a bedrock procedure for the vast majority of dentists. Adhere to these fairly simple prin- Proper impression tray ciples and your success rate is bound to soar. With the wide variety of impression trays on the market, you can probably find one to fit almost any patient. Author information Whichever brand you choose, your success rate will Dr. Miller is the president of REALITY Publishing increase if the tray is rigid rather than flexible. It is also Company and editor-in-chief of its publications. He also important that the tray does not touch the teeth. A custom maintains a general practice in Houston, Texas. tray remains the best choice for multiple tooth impressions; however, a full-arch stock tray also can be successful. References One of the new ones on the market is HeatWave (Cli- 1. Miller MB. Impression materials—Are there really any new ones? Gen Dent 2010;58(2):94-96. nician’s Choice Dental Products, Inc.), a thermoplastic tray that can be modified to fit a patient’s mouth more Manufacturers precisely by heating it in very hot water and molding the Centrix, Shelton, CT 800.235.5862, www.centrixdental.com flanges and the palate if necessary. While the thermo- Clinician’s Choice Dental Products, Inc., New Milford, CT forming property still doesn’t match a custom tray, it is 800.265.3444, www.clinicianschoice.com faster and less of a hassle. Dentsply Caulk, Milford, DE 800.532.2855, www.caulk.com Accurate impression material Ivoclar Vivadent, Inc., Amherst, NY We are blessed to have a wide variety of excellent materi- 800.533.6825, www.ivoclarvivadent.us Th Kerr Dental, Orange, CA als at our disposal. is column reviewed some of the 800.537.7123, www.kerrdental.com 1 crucial properties of impression materials in 2010. Premier Dental Products, Co., Plymouth Meeting, PA Suffice to say that although versatile vinyl polysiloxane 610.239.6000, www.premusa.com materials will perform very well for most dentists, Aqua- Pulpdent Products, Watertown, MA sil Ultra (Dentsply Caulk) remains the only product in 800.343.4342, www.pulpdent.com this category with a REALITY 5-Star rating. On the 3M ESPE, St. Paul, MN 888.364.3577, solutions.3m.com other hand, polyether materials still have their fans; Vident, Brea, CA one such material, Impregum Soft (3M ESPE), has also 800.828.3839, www.vident.com earned a 5-Star rating.

www.agd.org General Dentistry November/December 2012 453 Pharmacology

Bleeding risks for older patients taking warfarin and commonly prescribed antibiotics and antifungals simultaneously

Richard L. Wynn, PhD

ntibiotic and antifungal medications are associated intracranial, and general warfarin toxicity. The event date with an increased risk of bleeding among patients was defined as the date of hospital admission. Controls Ataking warfarin.1-4 A 2012 study by Baillargeon were matched with cases in terms of event date, indica- et al evaluated more than 38,000 patients aged 65 years tion for warfarin use, age, gender, and race/ethnicity. and older who used warfarin continuously.5 Five antibi- Antibiotic exposure was determined by assessing the otic drug classes were examined: macrolides, quinolones, number of days in a given prescription period that fol- sulfonamides, penicillins, and cephalosporins. According lowed the initial prescription date in the Medicare Part to the authors, exposure to any antibiotic agent was D dataset. Patients were considered to be exposed if their associated with a twofold increased risk of bleeding that most recent prescription period for any antibiotic agent required hospitalization.5 In addition, the risk of bleed- overlapped (by a least one day) the 15-day period before ing that would require hospitalization increased fourfold the event date. Among patients with antibiotic exposure, following exposure to azole antifungals (fluconazole, the authors categorized the time between the initiation ketoconazole, miconazole).5 The results of this study are of antibiotic agents and the event date into one of three applicable in the management of dental patients receiv- categories: 0-15 days, 16-60 days, and more than 60 ing antibiotics or antifungals.5 days. The antibiotics were categorized as “all antibiotic For data collection, the authors used data from several medication,” according to the following classes: cepha- sources—including Medicare enrollment files, Medicare losporins, penicillins, sulfonamides (cotrimoxazole, a Provider Analysis and Review (MEDPAR) files, Outpa- combination of trimethoprim and sulfamethoxazole), tient Standard Analytic files, Medicare Carrier files, and macrolides, and quinolones, while antifungals were Prescription Drug Event records—for a 5% national categorized as azole antifungals. sample of Medicare beneficiaries.5 Medicare Part A, The authors also examined patients’ use of potentially which covers hospital expenses, begins automatically at confounding medications known to interact with war- age 65, whereas coverage for outpatient care (Part B) and farin. A prescription for any potentially confounding prescription drugs (Part D) must be purchased. drug that included at least 1 day in the 15 days before The study evaluated a cohort of 38,762 Medicare the event date was defined as presence of a confounding beneficiaries who used warfarin continuously. Presence drug.5 The following classes of drugs were examined: and duration of warfarin use was examined by evaluat- antidepressants, antiplatelet drugs, corticosteroids, and ing prescription data from the Medicare Part D dataset. selected inhibitors of warfarin hepatic metabolism. Continuous warfarin users were followed from January Standard regression analysis was used to calculate 1, 2008, until the end of the study period (December odds ratios and 95% confidence interval (CI) for the 31, 2008) or until the patient was hospitalized for a risk of bleeding associated with prior exposure to anti- bleeding event, whichever occurred first. Reasons for biotic medications. warfarin use included atrial fibrillation, stroke, presence of prosthetic heart valve, and venous thromboembolism. Results Cases were defined as patients who experienced a The authors identified 38,762 patients as continuous bleeding event requiring hospitalization at any time in warfarin users. During 2008, 1,136 (2.9%) of those 2008, based on International Classification of Diseases, patients were hospitalized with a primary diagnosis of ninth revision codes (ICD-9). Four types of bleeding bleeding. Of those, 798 met the definition for a case. were identified: gastrointestinal, non-gastrointestinal, The authors reported that continuous warfarin users

454 November/December 2012 General Dentistry www.agd.org exposed to any antibiotic agent were twice as likely (odds sulfamethoxazole (TMP/SMX).1 A control drug (terazo- ratio = 2.01) to experience a bleeding event that required sin) known to not interact with warfarin was used as the hospitalization compared to those who were not exposed comparator. The incidence of international normalized to an antibiotic. Assessment of bleeding events revealed ratio (INR) elevation and the degree of change and that antibiotic users were 2.5 times more likely to experi- bleeding events after initiation of either medication type ence non-gastrointestinal bleeding and approximately was recorded. twice as likely to experience gastrointestinal bleeding.5 The control drug experienced a mean change in INR The authors searched for an association between the of -0.15 (N = 20), compared to increases of 0.51 for start of a prescription and major bleeding and found azithromycin (N = 32), 0.85 for levofloxacin (N = 27), that those whose prescription began within 60 days and 1.76 for TMP/SMX (N = 16). These mean INR of the event date were more likely to have been hos- changes were significantly different from the control pitalized for bleeding compared with control patients group. INR was elevated beyond therapeutic levels for who never took antibiotics. Exposed patients whose 5% of the control group, compared with 31% in the antibiotic prescriptions began more than 60 days before azithromycin group, 33% in the levofloxacin group, and the event date did not have a statistically significant 69% in the TMP/SMX group. More clinically significant increased risk for bleeding that required hospitalization elevations of INR (defined as elevations beyond an INR in comparison with the control patients. Patients treated of 4) were observed in 0% of the control group, 16% of with azole antifungals were over four times more likely the azithromycin group, 19% of the levofloxacin group, to experience bleeding, while patients treated with mac- and 44% of the TMP/SMX; the latter was the only rolides were almost twice as likely to experience bleed- group with documented bleeding episodes. The authors ing. Patients treated with quinolones were 1.7 times concluded that oral antibiotics (azithromycin, levofloxa- more likely to experience bleeding, while those taking cin, and TMP/SMX) increased the incidence and degree cotrimoxazole were 2.7 times more likely, those taking of anticoagulation among acutely ill outpatients on cephalosporins were 2.5 times more likely, and those warfarin medication.1 taking penicillins were approximately twice as likely to A 2008 study by Schellemen et al reported that experience bleeding compared to the control group.5 patients taking warfarin for whom azole antifungals and Of the confounder medications, the serotonin selective cotrimoxazole were subsequently prescribed demon- reuptake inhibitors and corticosteroids were associated strated the highest risks of hospitalization for gastroin- with statistically significant increased risk of bleeding.5 testinal bleeding.2 The authors evaluated United States Medicaid patients receiving warfarin (N = 580,188) to Discussion determine whether the potential for interaction between Among older continuous warfarin users, exposure to warfarin and orally administered anti-infectives increased any antibiotic agent was associated with a twofold the risk of hospitalization for gastrointestinal (GI) bleed- increased risk of bleeding that required hospitalization. ing. The authors determined an association between GI All five specific antibiotic drug classes were associated bleeding and prior use of ciprofloxacin, levofloxacin, with an increased risk of bleeding.5 Patients who were gatifloxacin, cotrimoxazole, or fluconazole. By compar- prescribed azole antifungals and cotrimoxazole had the ison, there was no association for patients who used highest risks of hospitalization for bleeding, which the cephalexin (which would not be expected to interact authors noted was consistent with previous reports.2,3,5 with warfarin) and no association for patients who were The increased risk associated with antifungals and not exposed to these drugs. All of the anti-infectives cotrimoxazole was attributed to their inhibitory effects examined were associated with elevated risks of bleeding on CYP2C9, one of the liver enzymes that metabolize compared to no exposure. Using cephalexin as the refer- warfarin.5 The results of the study by Baillargeon et al ence, cotrimoxazole and fluconazole demonstrated the are consistent with some previous reports describing highest risk of GI tract bleeding.2 anti-infective drug interactions with warfarin.5 In 2010, Fischer et al published a population-based, nested case control study using health care databases in Related studies Ontario, Canada, between April 1, 1997, and March 21, Glasheen et al conducted a retrospective analysis of 2007.3 The study identified residents 66 years or older patients at a university-affiliated Veterans Affairs medi- who were treated continuously with warfarin. Cases cal center using warfarin before starting antibiotic ther- were hospitalized with upper GI bleeding; for each case, apy with azithromycin, levofloxacin, or trimethoprim/ the authors selected up to 10 age- and gender-matched

www.agd.org General Dentistry November/December 2012 455 control subjects. They calculated adjusted odds ratios synthesis by alteration of gut flora or inhibition of for exposure to cotrimoxazole, amoxicillin, ampicillin, cytochrome P450 enzymes can increase INR and bleed- ciprofloxacin, nitrofurantoin, and norfloxacin within 14 ing within one to two weeks.5 It may be prudent to days before bleeding began.3 monitor anticoagulation status more closely in patients The authors identified 134,637 patients who had treated with a vitamin K antagonist (that is, warfarin) received warfarin, of whom 2,151 cases were hospital- both during concurrent use of an implicated antibiotic ized for upper GI bleeding. It was found that these cases or antifungal and for at least several days after cessation were almost four times more likely to have recently of the antibiotic or antifungal. It also may be prudent to received cotrimoxazole than patients in the control advise these patients to pay particularly close attention to group. Treatment with ciprofloxacin was also associated any signs or symptoms of bleeding. with twice the increased risk; however, no significant association was observed with amoxicillin, ampicillin, Author information nitrofurantoin, or norfloxacin.3 Dr. Wynn is a professor of pharmacology, Department In a 2006 study, Zhang et al found that of 17,895 of Oral Craniofacial Biological Sciences, Dental School, patients who used warfarin, 2,634 (14.7%) were diag- University of Maryland at Baltimore. nosed with a hemorrhagic event within one week after filling a prescription for warfarin.6 One factor associated References with the increased risk of bleeding was the use of warfa- 1. Glasheen JJ, Fugit RV, Prochazka AV. The risk of overanticoagulation with antibiotic use in outpatients on stable warfarin regimens. J Gen Intern Med 2005; rin in addition to either cephalosporins or metronidazole. 20(7):653-656. 2. Schellemen H, Bilker WB, Brensinger CM, Han X, Kimmel SE, Hennessy S. War- Dental patient considerations farin with fluoroquinolones, sulfonamides, or azole antifungals: Interactions and the risk of hospitalization for gastrointestinal bleeding. Clin Pharmacol In the study by Baillargeon et al, many of the antibiotics Ther 2008;84(5):581-588. and antifungals that increase the risk of bleeding in older 3. Fischer HD, Juurlink DN, Mamdani MM, Kopp A, Laupacis A. Hemor- patients on warfarin (including fluconazole, ketocon- rhage during warfarin therapy associated with cotrimoxazole and other uri- nary tract anti-infective agents: A population-based study. Arch Intern Med azole, miconazole, cephalexin, cefaclor, azithromycin, 2010;170(7):617-621. clarithromycin, amoxicillin, penicillin VK, ciprofloxacin, 4. Mercadal Orfila G, Gracia Garcia B, Leiva Badosa E, Perayre Badía M, Reynaldo levofloxacin, moxifloxacin, and the anti-microbial metro- Martinez C, Jodar Masanes R. Retrospective assessment of potential interac- 5,7 tion between levofloxacin and warfarin. Pharm World Sci 2009;31(2):224-229. nidazole) are used in dentistry. 5. Baillargeon J, Holmes HM, Lin YL, Raji MA, Sharma G, Kuo YF. Concurrent use It has been suggested that antibiotic or antifungal of warfarin and antibiotics and the risk of bleeding in older adults. Am J Med medications interact with warfarin to increase the risk of 2012;125(2):183-189. fl 6. Zhang K, Young C, Berger J. Administrative claims analysis of the relationship major bleeding by disrupting intestinal ora that synthe- between warfarin use and risk of hemorrhage including drug-drug and drug- size vitamin K and inhibiting cytochrome P450 isozymes disease interactions. J Manag Care Pharm 2006;12(8):640-648. that metabolize warfarin.2,3,5,8 7. Wynn RL, Meiller TF, Crossley HL. Drug information handbook for dentistry 2010-2011. ed. 16. Hudson, OH: Lexi Comp; 2010:1945-1958. Baillargeon et al suggested frequent monitoring of 8. Glasheen JJ, Fugit RV. How warfarin interacts with common antibiotics. Emerg INR values for patients who are taking warfarin and Med 2004;36:30C-30I. antibiotic agents concurrently. Inhibition of vitamin K

456 November/December 2012 General Dentistry www.agd.org Restorative Dentistry

Laboratory work for restorative dentistry: Model pouring and die preparation

Bruce W. Small, DMD, MAGD

n recent years, dental schools have de-emphasized recommended by the manufacturer. Although the teaching of laboratory skills. Certain restorative impression materials have improved dramatically Itechniques have been de-emphasized and some cur- since the days of plaster and rubber bases, allowing ricula have eliminated the laboratory work required to an impression to sit for too long increases the risk of construct restorations. Pouring models and trimming distortion. When a model is not poured in the office, dies, basic waxing and casting, and finishing and pol- the impression often is boxed up, sent to another ishing methods are a few examples of laboratory pro- location (possibly by air, with a resultant change in cedures that were taught in dental schools in the past atmospheric pressure), and thus, the model is not and used in dental practice today. Unfortunately, these poured for three to five days after the start of the techniques are no longer being taught in all schools; as process. The following simple steps may eliminate a result, fewer graduates will have skills that were com- errors in the fit of a crown while saving both the monplace only a short time ago. dentist and patient time and money. Incorporating even a minimal amount of laboratory work in a dental practice could provide the dentist and Model pouring staff with new challenges, improve the dentist’s prepara- First, a work space where all necessary equipment tion skills, increase efficiency, and reduce laboratory and materials are close at hand must be created expenses. This column presents an example of such in the office (Fig. 1). A laboratory microscope is a laboratory work—specifically, pouring an articulated big advantage, particularly during die preparation. die model and trimming the die for a single crown. Using a sharp knife, remove the impression material beyond the metal flanges of the impression tray. This Pouring impressions allows full seating of the plastic disposable articulator After making an accurate impression, the (W.O.W., Premier Dental Products, Co.) into the model should be poured within the time period impression (Fig. 2).

Fig. 1. An example of an organized work space, with all necessary Fig. 2. A box cutter is used to remove unnecessary impression material instruments and materials within easy reach. from ﬂanges.

www.agd.org General Dentistry November/December 2012 457 Fig. 3. Prior to the placement of dowel pins, a marking pen is used to identify the prepared tooth and adjacent spaces. Fig. 4. The dowel pins in place on the articulator.

Fig. 5. Die stone is weighed on a digital scale. Fig. 6. Using a vacuum mixer, die stone is blended. Fig. 7. Die stone is placed into the impression.

Next, using a marking pen, draw lines on either side Die preparation of where the preparation is and also on either side of the After the setting of the die stone, the die is sectioned, tooth, to ensure that the articulator is placed accurately trimmed, painted, and lubricated. The die can be sec- into the impression and that the dowel pins will seat in tioned by using a die saw in the traditional manner; if the impression without interference (Fig. 3). contact is tight, a laboratory disk in a straight handpiece Using the drawn lines as guides, place the dowel pins can be utilized (Fig. 10). The die is then trimmed using into the plastic frame—one or two in the preparation a laboratory carbide in a straight handpiece (Fig. 11). At and one on either side (Fig. 4). Using an electronic digi- this point, the die spacer should be painted on the die, tal scale, measure the water and the die stone (to 0.01 taking care to stay away from the margins (Fig. 12). g) (Fig. 5). The die stone (Fujirock, GC America, Inc.) Prior to waxing, a lubricant is painted on the die and should be mixed in a vacuum mixer according to the allowed to dry (Fig. 13); if the wax sticks, a second coat manufacturer’s recommendations and placed carefully may be necessary. At that point, the die model is com- into the impression (Fig. 6 and 7). plete and ready for waxing (Fig. 14). Next, place additional die stone onto the plastic top with the dowel pins and place it into the impression, Discussion lining up the drawn lines (Fig. 8). After setting of the Dentists who do even a small amount of laboratory stone is complete, prepare a second mix, place a layer on work in their offices notice advantages for the patients the other part of the articulator, connect it to the first served and the practice’s bottom line. By pouring an section, close it, and allow it to set (Fig. 9). impression and trimming a die in-house, any mistakes

458 November/December 2012 General Dentistry www.agd.org Fig. 8. The top half of the articulator is placed in the impression. Fig. 9. A completed model prior to die preparation.

Fig. 10. A diamond disk separates die from Fig. 11. Die is trimmed carefully with a Fig. 12. Using a camel hair brush, die spacer model. laboratory carbide. is applied.

Fig. 14. An example of a completed, trimmed, lubricated die model for a Fig. 13. Die lubricant is placed. single crown.

during preparation will be noticed long before the tech- preparation visit. Sometimes these errors are corrected nician sees the case. This will save time for the patient as by the technician without informing the dentist; as a well as show the dentist his/her error, which means the result, the dentist gets a restoration back that doesn’t error may not happen a second time. The dentist will fit properly—requiring another appointment for a new clearly see any undercuts, indistinct margins, inadequate preparation and impression—while failing to learn from occlusal space, or other abnormalities soon after the the process.

www.agd.org General Dentistry November/December 2012 459 Another noticeable aspect within offices that pour Author information impressions and trim dies is how such activities affect the Dr. Small is in private practice in Lawrenceville, New dental assistant. As more lab work is done in the office, Jersey, and is an adjunct professor at the University of the dental assistant will become interested in the “new” Medicine and Dentistry of New Jersey. He also is on the procedures and become more knowledgeable about Board of Advisors and a visiting faculty member of the preparations and excellence in restorative dentistry. L.D. Pankey Institute in Key Biscayne, Florida. Some dentists who do the model work for cases in- house have asked their technicians for a reduction in fees Manufacturers since they are doing some of the work. Fulfilling this GC America, Inc., Alsip, IL 800.323.7063, www.gcamerica.com request depends on the relationship between the dentist Premier Dental Products Co., Plymouth Meeting, PA and the lab person, but it can be done. In these challeng- 610.239.6000, www.premusa.com ing economic times, many dentists have more time on their hands due to a lack of patients. That time could be well spent doing a little more lab work.

460 November/December 2012 General Dentistry www.agd.org Ethics

Dental assistant or patient? Can she be both?

Toni M. Roucka, DDS, MA

he following scenario is not an uncommon occur- Harker if she was still up for the extraction that day. She rence in dental offices. Dentists frequently provide said she was and they proceeded. One of the other dental Tdental treatment to their own families, friends, assistants, Ms. White, stayed late to assist Dr. Leonard. and staff. It is probably quite rare that a bad outcome What Mrs. Harker failed to tell Dr. Leonard was that such as the one described below would occur, however, she was a newly diagnosed diabetic, only three weeks it causes one to reflect on how dentists might alter their into treatment. Her medications were being adjusted patient appointment and patient management protocols and she was having some difficulty regulating her blood when treating patients who are “familiar” to them. It sugar. She was also still somewhat in denial over the is important to be cognizant of some of the moral and whole diagnosis, so the information wasn’t intentionally professional pitfalls that may arise when providing dental omitted; she simply forgot to mention it to him. Besides, care to such patients. Let’s examine the case. she didn’t like to mix personal issues with business and was proud of the fact that she had never used a sick day in three years of working for Dr. Leonard. She consid- Mrs. Harker has been a dental assistant at Dr. Leonard’s ered herself “healthy as a horse.” The diabetes diagnosis practice for three years. Dr. Leonard is an excellent was not going to change her lifestyle if she could help it. employer. He offers generous benefits to his staff, Mrs. Harker tolerated the extraction procedure very including free dental care for them and their immediate well. Once it was complete, Dr. Leonard left for the families. He feels it is his duty to do so. Why should they day, with Mrs. Harker and Ms. White chatting in the have to go elsewhere for their dental treatment? With operatory about their plans for the weekend. Everything a total of five full-time employees, he feels this is a very appeared fine until Mrs. Harker went to stand up from easy benefit to offer. the dental chair. As she rose, she unknowingly began to Dr. Leonard has a general dental practice that is quite experience an episode of hypoglycemia and immediately successful. Though he performs all types of dental treat- passed out, hitting her head on the wall of the dental ment, he enjoys oral surgery the most. He rarely refers operatory and then on the floor. Not knowing what any procedures out and feels confident in all aspects of was happening, Ms. White immediately called 911. general dentistry. Paramedics arrived, administered first aid, including IV One day, Mrs. Harker approached Dr. Leonard with a fluids, and as a precaution, transported Mrs. Harker to concern about one of her teeth. Tooth No. 30 was start- the hospital for some head and neck radiographs. Her ing to bother her during chewing and was keeping her up blood sugar was quite low. When all was said and done, at night. Squeezing her in between patients, Dr. Leonard Mrs. Harker was fine except for a chipped tooth (No. 8), examined the tooth and deemed it unrestorable due to two black eyes, and a bruised ego. a vertical root fracture. As such, he devised a treatment Upon hearing what happened, Dr. Leonard was under- plan that entailed placing a 3-unit bridge to replace tooth standably upset. Looking back on the situation, he began No. 30 once the healing after extraction was complete. to question whether he should continue the practice of Because Mrs. Harker had large restorations on both teeth treating his staff and their families and if so, how could No. 29 and 31, and would eventually require crowns or how should he modify this practice? on these teeth, she opted for a bridge over a dental implant. The extraction was scheduled for the end of the The facts next day, after the last “regular” patient was dismissed. t %S-FPOBSEIBTDIPTFOUPPêFSUIFCFOFëUPGGSFF Mrs. Harker was happy to be getting it over with. dental care to his staff and their families. Mrs. Harker The day of Mrs. Harker’s extraction was very hectic in is his dental assistant and in need of some dental care. the office. The staff barely had time for lunch. After the t %S-FPOBSEJTBOBDDPNQMJTIFEHFOFSBMEFOUJTUBOEDPN- last appointment was completed, Dr. Leonard asked Mrs. fortable with providing the care that Mrs. Harker needs.

www.agd.org General Dentistry November/December 2012 461 t %S-FPOBSEiTRVFF[FE.ST)BSLFSJOwCFUXFFOiSFHV- her pain. “Squeezing her in” between “regular” patients lar” patients for an exam and performed the extraction might not seem problematic at first, but did he have after normal business hours. enough time to take a proper medical history or make a t .ST)BSLFSGBJMFEUPUFMM%S-FPOBSEBCPVUIFSSFDFOU proper diagnosis? Even if he did make a proper diagnosis, diabetes diagnosis. we could argue that his interests came first in this cir- t .ST)BSLFSIBEBIZQPHMZDFNJDFQJTPEFBGUFSUIF cumstance; the patient receiving “free care” was given less extraction resulting in a fall, sending her to the hos- scheduled time than paying patients so as not to affect pital for precautionary radiographs. She now has two the dentist’s bottom line for the day. Likewise, schedul- black eyes and a chipped tooth (No. 8) as a result of ing Mrs. Harker for her extraction at the end of a long the fall. day outside of normal business hours was clearly not in her best interest. She may have felt obligated to take the The ethical issues appointment that was offered to her so as not to incon- When a dentist chooses to treat a patient that has another venience the dentist, even if she really did not feel like relationship to them outside the dentist-patient relation- undergoing the procedure that day. On the flipside, some ship, they are essentially engaging in a “dual relationship” may feel that Dr. Leonard was actually going over and with that patient. Some examples of dual relationships above the call of duty by making special accommodations include when the patient is also a student, friend, family to treat Mrs. Harker in an expeditious manner. Either member, employee, or business associate of the care pro- way, the fact is that Mrs. Harker was treated differently in vider.1 In other professions, dual relationships of various this case because she was Dr. Leonard’s dental assistant. kinds are strictly prohibited. In psychology, for instance, Dual relationships are a two-way street. Patients and having a sexual relationship with a patient amounts dentists are both subject to ethical implications when to a criminal act in many states. Dual relationships in engaging in them. For example, the charging and pay- psychology, in general, are to be avoided at all costs.2 The ment of fees may become awkward in a dual relationship. American Medical Association’s Code of Medical Ethics The dentist may feel guilty for charging their “friend” (AMA Code) has also addressed the issue of dual relation- and the patient may feel they either deserve a discount ships in detail. Physicians are advised not to treat their or owe their friend “a favor” for the care provided. An own family members and are prohibited from having employee/patient may have knowledge of office finances sexual relationships with current patients.3 that may influence treatment choices. These choices may In dentistry, however, dual relationships are not directly not always be in the patient’s best interest.2 addressed in the American Dental Association’s Principles In general, dentists drive the doctor-patient relation- of Ethics and Code of Professional Conduct (ADA ship as they possess the professional expertise and Code) other than in Section 2.G. Personal Relationships knowledge. The professional relationship is one based on with Patients, where it states, “Dentists should avoid trust: Patients trust that the dentist is putting their best interpersonal relationships that could impair their profes- interest above his own and will maintain confidentiality, sional judgment or risk the possibility of exploiting the not cause harm, and not abuse sensitive information confidence placed in them by a patient.”4 Although this provided to them.5 Becoming “too familiar” with a was not a case of a “personal relationship” on a social level, patient gives dentists even more power over that patient it certainly was a case of a dual relationship in that Mrs. as they are in possession of sensitive information that Harker was an employee of Dr. Leonard’s who was also they otherwise would not have. This may put the patient being treated as a patient. in a more vulnerable position than normal and does not There are several ethical issues associated with engaging serve their best interest.2,5 in dual relationships in dentistry. According to the ADA Code, dentists are to always put the patient’s best interest The options and course of action above their own. Unfortunately this becomes more dif- The ADA Code offers no formal guidance on the question ficult to do when a dentist is involved in a dual relation- of whether the provision of dental care to employees and ship with a patient. Roles may become blurred and/or their families is ethically permissible other than what is conflict.2 Both parties are subject to acting in ways that mentioned in Section 2.G. (quoted above). The AMA they might not ordinarily, which could jeopardize the Code does not specifically offer guidance in this area either, professional relationship. but it does offer guidance on treating immediate family In this case, for instance, Dr. Leonard did not provide members and on the offering of professional courtesy. Sec- a proper exam appointment for Mrs. Harker to assess tion 8.19 Self-Treatment or Treatment of Immediate Family

462 November/December 2012 General Dentistry www.agd.org Members of the AMA Code, strictly prohibits treatment the right thing to do barring any insurance company of immediate family for all of the stated reasons that make constraints as described above. If she chooses to bill her dual relationships problematic.3 The AMA Code also medical insurance for the costs of her hospital treatment emphasizes the fact that objectivity may be compromised and there is an insurance co-payment for the medical when treating family members and that professional care, should Dr. Leonard offer to reimburse her for judgment may be unduly influenced.3 The same may be that? That would be a decision he would have to make. said for treating a close friend or a staff member. Often, I would argue that under the circumstances, and in the employees develop long-term relationships with their spirit of goodwill, it is probably the right thing to do. employers and this could be a potential problem. I would also like to add that dealing with such insur- Professional courtesy refers to the provision of care ance questions gets complicated and is beyond the scope to co-professionals or their families, free of charge or of this paper. I would encourage anyone who is unsure at a reduced rate. This is ethically permissible in the how to proceed in a particular situation to refer to their AMA Code and it allows physicians to “use their own insurance company contract and/or applicable state and judgment” in deciding whether to waive or reduce their federal laws for further guidance. fees when treating fellow physicians or their families.3 In conclusion, the provision of dental care is a complex Professional courtesy was initially practiced as a way to process. The value of the dentist-patient relationship to discourage physicians from treating their own families.6,7 the successful outcome of dental treatment cannot be It may be a bit of a stretch to call the case above one of overstated. A professional relationship of mutual trust “professional courtesy,” but lacking guidance from the and understanding will foster better patient compliance, ADA and AMA codes in regard to providing professional better communication between dentist and patient, and services to staff, I believe it is relevant. ultimately, better treatment outcomes overall.2 If dentists If professional courtesy is to be granted to an individ- choose to treat their own staff members, families, or ual, providers must be careful not to violate any insurance friends, they must be cognizant of the possible pitfalls contracts or the law. According to AMA Code Section associated with dual relationships and be prepared, if 6.12 Forgiveness or Waiver of Insurance Co-Payments, necessary, to end the professional relationship in order to ADA Code Section 5.B.1. Waiver of Co-Payment and serve the best interests of the patient. other listed sources, it is unlawful to bill insurance companies and waive the patient portion. This is considered Author information overbilling and is illegal.3,4,7,8 There is no law, however, Dr. Roucka received her DDS degree from the University that prohibits professional courtesy. Schulte states, “As of Illinois, College of Dentistry and an MA in Bioethics long as professional courtesy is not precluded by contract from the Medical College of Wisconsin. She is a Navy Vet- or provided in return for referrals, which could violate the eran and a board member at large for the American Soci- Federal Anti-Kick Back Law, it is not illegal.”8 ety for Dental Ethics. She is currently an assistant professor In this case, Dr. Leonard is faced with several deci- and Program Director, General Dentistry, Marquette sions. The fact is he left his office before his “patient” was University School of Dentistry, Milwaukee, Wisconsin. dismissed from the dental chair. Looking back, he real- izes that he has never done this before. If Mrs. Harker References were a “regular” patient, he would have stayed until she 1. Zur O. Dual relationships, multiple relationships & boundaries in psychothera- py, counseling & mental health. Available at: http://www.zurinstitute.com/ was dismissed in stable condition. True, she was not dualrelationships.html. Accessed July 7, 2012. honest with him about her diabetes, but the fact is, she 2. Donate-Bartﬁeld E, D’Angelo D. The ethical complexities of dual relationships fell in his operatory and ended up requiring a hospital in dentistry, J Am Coll Dent 2000;67(2):42-46. 3. American Medical Association. Code of Medical Ethics, 2006-2007: Current visit and further dental work on tooth No. 8. He was the opinions with annotations. American Medical Association; 2006:171,263,311. dentist who provided the care. Is he now obligated to 4. American Dental Association. Principles of ethics and code of professional pay for her hospital ER visit? He knows he will be fixing conduct. Revised 2012. Available at: http://www.ada.org/sections/about/pdfs/ fi code_of_ethics_2012.pdf. Accessed July 3, 2012. her tooth No. 8 as part of her dental bene ts. 5. George L. Is it ethical for a dentist to date a patient? J Am Dent Assoc 2005; These are all questions that have no concrete answers. 136(9):1312-1313. Dr. Leonard will have to decide how far to extend his 6. Burke M, Baum N. Professional courtesy: Can you legally provide it? J Med fi Pract Manage 2010;26(1):57-60. “dental bene t.” Paying for Mrs. Leonard’s hospital visit 7. Jones JW, McCullough LB, Richman BW. Ethics of professional courtesy. J Vasc would be expensive but a nice gesture on his part. Is Surg 2004;39(5):1140-1141. he ethically or legally required to do so? Probably not, 8. Schulte DJ. Waiver of co-payments or deductibles and professional courtesy. Mich Med 2008;107(2):7. but since she is a long-term loyal employee, it may be

www.agd.org General Dentistry November/December 2012 463 The Time You Spend Reading Our Magazines Is Worth It And, here’s why: Our publications recently received three journalism awards…

International College of Dentists, APEX 2012 APEX 2012 Golden Pen, Honorable Mention, Award of Excellence, Award of Excellence, General Dentistry, March/April 2011, AGD Impact, January 2011, AGD Impact, October 2011, “Evaluation of the microbial ﬂora “Missions Abroad: The World “On The Edge: Dentists Fight for found in woodwind and brass of Volunteer Dentistry,” written Their Practices and Patients in Border instruments and their potential by Rick Asa. Towns,” written by Beth Garcia. to transmit diseases,” written by R. Thomas Glass, DDS, PhD; Gerwald A. Kohler, PhD; Robert S. Conrad, PhD; and James W. Bullard, MS.

So, keep reading, and keep the good ideas and feedback coming. Thank you, AGD members, for your support.

Roger Winland, DDS, MS, MAGD AGD Editor [email protected] SPECIAL SECTION GENERALPeer-Reviewed Journal of the Academy of General Dentistry DENTISTRY

PROSTHODONTICS The Academy of General Dentistry and the American College of Prosthodontists bring you this special section on prosthodontics Guest Editorial

In the best interest of our patients

am honored by the invitation to provide the guest My professional background includes a limited private editorial for the Academy of General Dentistry’s practice but primarily, I am an academic-prosthodontist. I(AGD) journal, General Dentistry. A special thank I work as a specialist in my interactions with dental you for the will and vision that both Drs. Fares Elias, students to make them the best general dentists possible 2011 Past President of the AGD, and Jonathan Wiens, within the constraints of an ever-evolving education pro- 2011 Past President of the American College of Prosth- cess. I strive to empower them with the knowledge, skills, odontists (ACP), created to discuss the potential for and values to direct patient care for the best possible out- collaboration between our two organizations. We are comes. Although they may not be able to provide the vast fortunate that they are colleagues in the same Michigan expanse of care for every level of difficulty, it is the focus town, practiced as neighbors (just 14 miles apart!), and on self-evaluation and self-assessment that empowers the started a healthy dialogue on behalf of our members. young general dentist with the ability to decide when and In this day and age, the exponential growth in tech- if partnership with a specialist is needed. I received a great nology and the plethora of scientific, peer-reviewed education in dental school to graduate as a general dentist publications continue to bring challenges for our private with a solid foundation, which in turn has helped me practitioners in their day-to-day care of patients. It when I pursued an advanced education in prosthodontics. requires exceptional time management and resources to I contend that when the decision is made to partner with stay at the top of our abilities, both in thought processes a specialist, in this instance, a prosthodontist, it makes all and skills; in partnership, our organizations can work of us better when serving the needs of our patients. together to excel for the benefit of our members and I hope we will continue the dialogue for greater advo- ultimately our patients. cacy on behalf of our patients and educational partner- Our approximate membership totals for each orga- ships.Toward this end, I encourage your support for nization include ~37,000 for the AGD and ~3,400 having prosthodontist-academicians contribute in dental for the ACP, both of which represent members who school education alongside general dentist-academicians. have committed themselves to reaching professional The strength of dental schools is dependent on having and educational goals beyond those achieved in dental outstanding resources, one of which is a high-quality fac- school. As such, though difficult to receive in the midst ulty. With the growth in clinically-relevant research and of challenge, the following statement is often repeated the influence this research has on our decision-making in multiple iterations to dental students: This is only the processes, it is incumbent on the faculty to remain at beginning; you will be obligated to your own continued the top of their knowledge and abilities to ensure our professional development and lifelong learning. graduating general dentists are ready for the practice of As the AGD provides the recognition to members today, as well as the practice of tomorrow. Together, our who have pursued and achieved professional distinction organizations, as well as our members—both general through extensive professional education, the ACP is dentists and prosthodontists—can work as a team in the the only organization that represents prosthodontists as most complex of oral health care needs to serve in the specialists recognized by the American Dental Associa- best interest of our patients. tion through the Commission on Dental Accreditation Thank you for the opportunity to address your mem- (CODA) processes. Both of our organizations serve bers and I look forward to the possibilities ahead. the interest of our members. Together, our practitioners can work to achieve what is in the best interest Lily T. Garcia, DDS, MS, FACP of the patient. President, American College of Prosthodontists

466 November/December 2012 General Dentistry www.agd.org Complete Dentures CDE 2 HOURS CREDIT Denture adhesive use in complete dentures: Clinical recommendations and review of the literature

Ibrahim Duqum, BDS, MS n Kendall Ann Powers, BS n Lyndon Cooper, DDS, PhD, FACP n David Felton, DDS, MS, FACP

This literature review sought to determine the advantages and relevance could be determined. The selected manuscripts were disadvantages of denture adhesive use among complete denture reviewed using a standardized manuscript review matrix. patients. Manuscripts were obtained by searching the National Although denture adhesives improve the retention and function Library of Medicine’s PubMed database, Cochrane Collaboration of complete dentures, standardized guidelines are needed for Library, ADA Center for Evidence-Based Dentistry website, and the proper use, application, and removal of denture adhesives. EMBASE database. A total of 85 abstracts were reviewed, and Additionally, long-term studies are warranted on the biologic 38 articles that met the inclusion criteria for this review were effects of denture adhesives. There is a need to establish a regular selected. The inclusion criteria included clinical trials and case recall program for complete denture patients. series in which 10 or more patients were treated, as well as Received: May 24, 2012 Cochrane Collaboration reviews and in vitro studies where clinical Accepted: July 12, 2012

ith complete dentures, retention and stability, rendering a denture adhesives to enhance the insufficient denture reten- denture loose and non-serviceable to retention, stability, and functionality Wtion is a powerful determi- the patient.5 Patients with complete of complete dentures. Definitions for nant of patient satisfaction.1 Several dentures require unique consider- specific terms are listed in Table 1.8 factors and complex interactions ations due to their compromised affect the retention and stability of oral anatomy, reduced adaptive Methods complete dentures in the oral cavity, capacity, and systemic conditions In 2009, the American College of including atmospheric pressure, inti- or medications that further affect Prosthodontists (ACP) formed a mate adaptation of both hard and denture retention and stability, all of task force to develop contemporary, soft tissues beneath the denture base which reduce the patient’s ability to evidence-based guidelines for the to the intaglio surface of the pros- successfully wear their prostheses.6 care and maintenance of complete thesis, accurate peripheral extensions In addition to hard and soft tissue dentures. This task force consisted of the denture base (determined by alterations over time, these patients of individuals representing the ACP, physiological movements), and the can be affected by changes in saliva the Academy of General Dentistry, presence of a thin film of saliva (with quality or quantity (due to medica- the American Dental Association acceptable viscosity) between the tions or age), diminished bite force, (ADA) Council on Scientific Affairs, prosthesis and the tissues. Denture and reduced neuromuscular control.7 the American Dental Hygienists’ retention can be jeopardized if any While these biologic and physi- Association, the National Associa- of these factors are compromised. ologic changes compromise denture tion of Dental Laboratories, and Residual ridge resorption (RRR) is function, new techniques have been GlaxoSmithKline Consumer Health- a common, lifelong condition that created to enhance both the retention care. As part of this task force, a plagues complete denture patients and fit of aging prostheses. These comprehensive review about denture after exodontia and subsequent den- techniques include denture rebasing adhesives was performed by the Uni- ture placement. RRR occurs rapidly or relining, denture adhesives, and versity of North Carolina faculty and within 3-12 months after tooth endosseous dental implants. This ACP members.9 Another manual removal, and continues throughout article will review the advantages and search was performed in May 2012 the patient’s life.2-4 Alveolar ridge potential problems associated with to include all relevant recent litera- resorption compromises denture the use of commercially available ture published after 2009.

www.agd.org General Dentistry Special Prosthodontics Section 467 Complete Dentures Denture adhesive use in complete dentures

Table 1. Deﬁnitions of terms used in this review.8 Table 2. Denture adhesive composition.

Term Definition Material Purpose Denture The resistance to movement of a denture away Methyl vinyl ether-maleic High molecular weight copolymers retention from its tissue foundation, especially in the vertical anhydride copolymer with adhesive and cohesive direction; a quality of a denture that holds it to the properties tissue foundation and/or abutment teeth Karaya gum Thickener Denture The resistance of a denture to movement on its Tragacanth Water-soluble mixture of stability tissue foundation, especially to lateral (horizontal) polysaccharides that absorbs water forces as opposed to vertical displacement; a quality to become a gel of a denture that permits it to maintain a state of equilibrium in relation to its tissue foundation and/or Acacia Preservative abutment teeth Pectin Gelling agent Denture A material used to adhere a denture to the oral Gelatin Gelling agent adhesive mucosa Carboxymethylcellulose Viscosity modifier/thickener Denture The procedures involved in the diagnosis and service subsequent fabrication and maintenance of artificial Mineral oil Suspending and levigating agent substitutes for missing natural teeth and associated Antimicrobial agents Antimicrobial structures (for example, ethanol, sodium Toxicity The adverse reactions (dose-response-time relation- borate, sodium tetraborate, ships) of tissues to selected foreign substances resulting hexachlorophene) in unacceptable in vivo interactions; toxicity can be at Non-toxic additives Wetting agents and plasticizers the local or systemic level depending on the amount, Flavoring agents (for example, Improves taste rate of release, and specific type of substance available peppermint oil, wintergreen oil) to the tissues

This review evaluated literature careful review of the articles, serve a specific function. Table 2 obtained by searches in the additional reference materials were lists the common components National Library of Medicine’s selected from the reference lists of of denture adhesives and their PubMed database, Cochrane Col- each article and similarly reviewed. respective functions. laboration Library, ADA Center for Of the original 85 articles, only Evidence-Based Dentistry website, 38 manuscripts met the inclu- Ideal characteristics of and EMBASE database. Key words sion criteria for this review: eight denture adhesives included, either singularly or in prospective controlled trials, eight The authors believe that an ideal various combinations, the terms cross-sectional cohort studies, seven denture adhesive should be for- “dentures,” “retention,” “stabil- in vitro studies, six multiple arm mulated so that it is not toxic to ity,” “adhesives,” “toxicity,” and cross-over studies, five case series, the systemic or oral health of the “adaptation.” The inclusion criteria three randomized controlled trials, patient (regardless of short- or long- included clinical trials and case and one retrospective study. term use); it is incapable of promot- series in which 10 or more patients ing bacterial or fungal growth; it were treated, Cochrane Collabora- Results improves the dentures’ retention, tion reviews, and in vitro studies for Composition of denture stability, and functionality (that which clinical relevance could be adhesives is, the ability to chew foods); it determined. Based on this criteria, Denture adhesives are available is easy for the patient or primary a total of 85 article abstracts were in various formulations including caregiver to apply and remove; it obtained and reviewed. Selected powders, liquids, creams, or pads/ has an acceptable aroma (or no full-text manuscripts were reviewed wafers. While the exact composition aroma), taste, and consistency; using a standardized manuscript of commercially available denture it does not alter or degrade the review matrix (Fig. 1) and summary adhesives may vary, they all contain intaglio surface of the denture base; information was provided. After a the same generic materials that it does not modify the occlusion of

468 November/December 2012 General Dentistry www.agd.org 1. Journal citation (in JOPR format): 12. Assessment methods used: a. Author's last name, initials:______ Patient satisfaction survey (OHIP or other—specify): ______b. Title of study: ______ Bacteriological tests (specify): ______c. Name of Journal: ______ Level of inflammation (method used): ______d. Year: ______Issue: ______Pages: ______ Other (specify):______2. Purpose (What is the null hypothesis?): ______13. Outcomes measured (what were the results?): Level of patient satisfaction: ______3. What were the treatment groups that were compared (CD/CD, No. of bacterial CFU formed: ______CD/natural teeth, CD/RPD, RPD/RPD, RPD/natural teeth)? Tissue inflammation: ______a. Group A: ___ Group B: ____ Group C: ____ Group D: _____ Other: ______b. Were the treatment groups age/sex matched? Yes No 14. What type(s) of statistical tests were used (specify types): 4. Study participants (N): ______a. Number of participants at start of trial: ______b. Number of participants at conclusion of trial:______c. Reasons for patient drop out: ______15. Results: i. Were dropped patients included in results? Yes No a. Was one intervention superior (statistically significant) to ii. How did the authors rationalize inclusion of dropped patients the others or to the controls? ______in the data analysis? ______b. Rank of the interventions by statistical significance only: d. What was the sample size in each treatment group? (i.e., method a > method b = method c) ______Group A,N =__ Group B,N =__ Group C,N =__ Group D,N =__ 16. Who funded the study? (Identify funding source, or “no source 5. Was there a control group identified? Yes No identified”): ______a. If yes, what was the size of group? N = ______17. Were there potential sources of bias? Yes No b. Was the control group age/sex matched to the experimental If yes, what were they? groups? Yes No Patient randomization or allocation to treatment groups 6. What was the method of patient allocation to the various treatment Examiner bias and control groups? Funding source Random allocation (method used)? ______ Other (please specify): ______ Sequentially assigned? 18. Summary statement (please answer the following questions): Other? ______a. Was the study design adequate? Yes No 7. Type of study (check appropriate response): If not, please indicate possible limitations in design: ______ Cochrane Review Other systematic review or meta analysis ______ RCT Controlled clinical trial b. Were the results accurately reflected in the conclusions? Case series Cross sectional cohort study Yes No Other ______c. Were appropriate statistical tests utilized? Yes No d. Were the results applicable to contemporary prosthodontics 8. Were there defined inclusion/exclusion criteria for patient selection? practice? Yes No Yes No e. Should the manuscript be included as source material for the 9. Was Institutional Review Board approval for the study obtained prior ACP/GSK denture care guidelines project? Yes No to initiation of trial? Yes No f. Were there other articles referenced in the current manuscript 10. Was informed consent obtained from study participants? that were overlooked in our initial literature search that should Yes No be included in our review? Yes No If yes, please provide the reference here (using JOPR format): 11. What types of interventions were utilized in test/control groups? ______TEST CONTROL ______Brushing only ______Brushing with paste ______Ultrasonic cleaning Chemical disinfection (list types of chemicals used) ______Microwave Combination of these (specify) ______

Fig. 1. The manuscript review matrix used in this review.

www.agd.org General Dentistry Special Prosthodontics Section 469 Complete Dentures Denture adhesive use in complete dentures

Table 3. Summary of methods and ﬁndings of studies that evaluated denture adhesives and their effects on denture retention, stability, and bite force.12-30,37

Author Trial type Testing methods Findings Berg In vivo Patient evaluation and preference of four adhesives Denture adhesives positively improved denture retention (1991)17 tested regarding retention and ability to chew and clean and chewing ability; one adhesive (Fittydent paste) was the prostheses and gums. clearly preferred by patients over all others tested. Cheng In vivo Force transducer measured maximum force needed to Maximum biting force was greater with new dentures & Zhao displace dentures or cause pain in patients with new than old dentures, but adhesives improved the biting (2010)30 and old dentures (with and without an adhesive). force more in old dentures than new dentures. Chew In vivo, Kinesiograph measured chewing movements in patients Adhesives improved the retention and stability of both et al case series with ill-fitting and well-fitting upper dentures before ill-fitting and well-fitting dentures, but was greater in (1985)22 and after application of three adhesives. ill-fitting dentures. de Baat In vivo Maximum incisal force to dislodge old and new The adhesive improved the maximum incisal force et al maxillary dentures measured in denture patients with (retention) of old and new dentures but the effect was (2007)23 and without adhesive. greater in old dentures. Figueiral Pragmatic Vertical tensile tests and intraoral resistance transducers All but one adhesive demonstrated a significantly greater et al clinical trial were used to measure maxillary denture retention with retention of maxillary dentures. (2011)26 (PCT) five different adhesives. Lang et al In vivo, random- Mandibular denture movement with and without one Adhesive reduced mandibular denture movement to (2007)19 ized controlled adhesive and after removing adhesive. provide increased retention and stability to the patient. trial (RCT) Gendreau In vivo, Bite force, masticatory efficacy, and food occlusion Adhesives significantly improved patient satisfaction, et al crossover were tested in denture patients with and without three bite force, masticatory efficacy, retention, and stability (2009)29 different adhesives; patients rated confidence, comfort, of dentures. satisfaction, and retention. Ghani & In vivo UCL Retentiometer measured retentive forces at various Powder adhesives were most effective immediately after Picton intervals over 6 hours in denture wearers using three application but least effective six hours later. Liquid and (1994)18 different types of adhesives: liquid, paste, powder. paste adhesives peaked three hours post-insertion. Grasso In vivo, Maxillary denture movements measured during Adhesive significantly improved retention and stability et al case series standardized chewing, swallowing, and speaking during all activities tested; patients produced significantly (1994)21 activities at intervals with and without one adhesive. higher bite forces with use of the adhesive. Hasegawa In vivo Three-dimensional motion capture system recorded Adhesive reduced three-dimensional and rotational et al old and new maxillary denture movements while denture movements and chewing times in old and new (2003)24 patients chewed three different foods with and dentures. without an adhesive. Kapur In vivo, RCT Denture patients using three different adhesives Adhesives improved denture retention but not mastica- (1967)20 were assessed by masticatory performance, taste tory performance; taste thresholds were unaltered; perception, and taste threshold tests. retention declined after the consumption of food or drink.

the dentures; it maintains adhesive not use denture adhesive, as they edentulous patients over a 10-year capabilities for 8-12 hours; and it is believed they satisfactorily managed period and found that only 15% of cost-effective for the patient. their dentures without it. Among the the completely edentulous patients remaining denture wearers, 20.5% with existing complete dentures Prevalence of adhesive usage did not know denture adhesive acknowledged using denture adhe- Little published data exists regarding existed, 32.9% used denture adhesive sive. There was a direct correlation the prevalence of denture adhesive in the past, and only 6.9% use between complete denture dissat- use. An Australian study evaluated denture adhesive on a regular basis.10 isfaction and denture adhesive use, 146 patients wearing dentures More recently, Divaris et al reviewed which the authors attributed to poor and found 52% of the patients did the charts of 2,526 completely fit and function of the dentures.11

470 November/December 2012 General Dentistry www.agd.org Author Trial type Testing methods Findings Kelsey et al In vivo, Patient evaluation of five denture adhesives, in terms Most patients reported minimal to significant improve- (1997)16 RCT of denture retention quality, duration, mastication, and ment in retention with adhesive use; one adhesive was OHR-QOL. rated significantly higher than the others. Kulak et al In vivo, Patient evaluation of two denture adhesive pastes. Both adhesives tested improved retention, but there was (2005)14 RCT not a significant difference between the two types. Ozcan et al In vivo Bite force until denture dislodgement measured with Consistent improvement in bite force until denture (2005)28 gnathometer in denture patients (with and without one dislodgement for up to six hours after adhesive adhesive) at various intervals. application. Pradies In vivo, Gnathometer and dynamometer measured resistance Adhesives improved the retention and stability of et al crossover to denture dislodgements in maxillary and mandibular well-fitted dentures; no significant difference between (2009)13 dentures, both without adhesive and with the use of the two types of adhesives. two adhesives. Psillakis In vivo Patients evaluated speaking, chewing, fit, and comfort Patient perception of denture performance and bite force et al with denture (using one adhesive); gnathometer improved with adhesive use. (2004)27 measured force until dislodgement in patients. Rendell In vivo Multichannel magnetometer tracking system measured Mean chewing rate increased up to four hours after et al mean chewing rates in denture patients with and application to a rate that approximated that of the control (2000)31 without two denture adhesive creams at various group comprised of dentate patients. intervals. Sato et al In vivo, Unilateral bite force measured until denture dislodge- Retention improved in both cream and gel adhesives; gel (2008)12 crossover ment on balancing side occurred to evaluate retention; was significantly easier to remove from the oral mucosa ease of prosthesis removal judged by remaining than cream. colored denture adhesive left on oral mucosa by adhesive gel and cream. Tarbet et al In vivo, Patients evaluated various aspects of denture Adhesive improved chewing ability, comfort, and (1980)37 RCT performance following application of adhesive. confidence while reducing denture wobble and amount of food collecting beneath the prosthesis. Uysal et al In vivo, Patients evaluated four cushion adhesives in terms Two of the four cushion adhesives tested significantly (1998)15 RCT of denture retention, ability to chew, ability to clean improved denture retention and stability. dentures and gums, and overall preference. Zhao et al In vitro Acrylic resin samples were measured on a universal One adhesive had significantly greater bonding strength, (2004)25 testing machine to determine bonding load and ease of but was more difficult to handle and clean; the other removal for two denture adhesives. adhesive was weaker, but easier to manipulate.

Advantages of using the studies were short in duration and without adhesives). In this last denture adhesive (that is, same day evaluation) and group of studies, denture adhesives Twenty studies were identified and examined only maxillary dentures. improved the retention and stability reviewed; nineteen of them were Some trials randomly allocated of the prostheses investigated.12-22 clinical trials that focused on the patients to various experimental A number of studies indicated that use of denture adhesives relative groups (depending on the number the improvement in retention and to denture retention, stability, of adhesives investigated). Other stability was more pronounced in movement, bite force, ability trials lacked a control group, but old or ill-fitting dentures when to chew test foods, and patient were crossover in design (that is, compared to new prostheses.22-25 satisfaction (see Table 3). Most of comparing the same dentures with However, a 1994 study by Grasso

www.agd.org General Dentistry Special Prosthodontics Section 471 Complete Dentures Denture adhesive use in complete dentures

et al reported no difference in Improvements in oral health- tissue beneath maxillary dentures. adhesive-related improvement related quality of life The authors did not find increased between prostheses that fit well and It has been determined that the mucosal irritation in the denture- those that fit poorly.21 In a 2011 quality of life (QoL) is negatively bearing tissues; rather, the sites of study, Figueiral et al used vertical affected by complete edentulism mucosal irritation present at the tensile tests and intraoral resistance and the use of complete dentures.32 beginning of the study were elimi- transducers and reported that den- In a 2010 study, Nicolas et al nated by the end.37 ture adhesives improved retention conducted a 6-month study involv- A study by Scher et al investigated of maxillary complete dentures for ing 14 complete denture patients the combination of an anti-fungal the most part; however, the authors who reported low QoL scores after agent, amphotericin, into a denture did not indicate the fit of the pros- denture insertion. During this adhesive for patients suffering from theses studied.26 longitudinal study, patient QoL was Candida sp. related denture stoma- The literature has reported that assessed at three different times: titis.38 The study did not reveal a denture adhesives significantly denture insertion, three months statistically significant reduction in improve denture-related bite post-insertion, and six months post- fungal levels; however, there was a force.21,23,27-30 Using a multichannel insertion. At three months, patients reduction in the documented cases magnetometer tracking system to were given denture adhesives to of stomatitis. The authors suggested evaluate jaw movements, Rendell use until the six-month assessment. that even though these materials et al evaluated the impact of At each assessment time, patients lubricated the tissues, the adhesive denture adhesives on the chewing completed a Geriatric Oral Health had a more profound, beneficial rates in complete denture patients. Assurance Index questionnaire to effect on denture stabilization than The mean chewing rates increased determine their oral health-related the amphotericin had in terms of immediately after applying the quality of life (OHR-QoL). The reducing inflammation.38 Denture adhesive and continued to increase authors found no improvement in stomatitis remains a primary after two and four hours.31 Ghani masticatory performance, but the concern for the denture-wearing & Picton suggested the retentive adhesives did improve both the population. Additional studies are force for some types of adhesives patients’ OHR-QOL and their warranted to determine if and how do not peak until 2-3 hours after ability to use their dentures.33 carrier devices (either the denture denture insertion.18 These findings are consistent with base or an antimicrobial/antifungal Kulak et al used subjective mea- other studies that could not link adhesive) can reduce the incidence sures to evaluate whether adhesives denture patient satisfaction to of denture stomatitis. improved chewing ability, comfort, masticatory performance.34,35 retention, and patient confidence, Potential cytotoxic effects and and found positive correlations in Adhesives as a direct delivery microbial contamination of terms of improvements following device for medications denture adhesives adhesive use.14 While many studies A longitudinal study by Lo Muzio Eight articles analyzed the micro- indicate that adhesives are effective et al evaluated complete denture bial contamination and potential for up to eight hours, a 1967 study patients with chronic aphthous cytotoxic effects of denture adhe- by Kapur reported that despite ulcerations and erosive lichen planus sives; these studies are summarized showing initial improvements in lesions. Patients were treated with in Table 4. Among these articles retention, mandibular dentures corticosteroids (that is, clobetasol are three in vitro studies that demonstrated significant loss of propionate) alone, in conjunction evaluated the cytotoxic potential retention following the chewing with an ointment, or incorporated of, and irritation induced by, of test foods and imbibing of taste into a denture adhesive. Incorporat- commercially available adhesives solutions.20 Kapur believed the sig- ing the topical corticosteroid into (for example, pads, creams, and nificant loss of retention occurred the denture adhesive treated the oral powders). A 2005 study by Al et because the denture adhesive lesions effectively.36 A 1980 study al examined six denture adhesives material functions by swelling and by Tarbet & Grossman evaluated and found that only one caused gelling upon insertion to fill the 111 patients over a six-month severe cytotoxic effects, according space between the soft tissues and period, to determine if denture to 3-(4,5-dimethylthiazol-2-yl)- the denture base. adhesive caused any changes to soft 2,5-diphenyltetrazoliumbromide

472 November/December 2012 General Dentistry www.agd.org (MTT) and agar diffusion assays.39 cited above. In their in vitro study, layers were collected from the The authors suggested that these Al et al suggested that using saliva, palate, and denture base at results were due to the extended adhesives for extended periods of insertion (baseline), one month use of denture adhesives since time might contribute to the devel- post-insertion, and two months most patients wear their prostheses opment of mucosal inflammation in post-insertion. The authors hypoth- throughout the day. The results denture wearers.39 By contrast, Kim esized that the level of micro-organ- raised concerns that denture adhe- et al conducted a cross-sectional isms would increase and would sives might cause mucosal inflam- study of 12 maxillary complete continue to increase the longer the mation in denture wearers.39 Using denture wearers to quantify the adhesive was used. While there was the hen’s egg test chorioallantonic total viable counts of Candida sp.43 a slight increase in the number of membrane (HET-CAM) method, Samples were collected from den- micro-organisms at baseline com- Dahl performed an in vitro test tures and saliva two weeks prior to pared to subsequent measurements, to evaluate the degree of mucosal adhesive use and two weeks after the microbial levels for adhesive and irritation caused by 27 denture adhesive use had begun. Neither non-adhesive users did not indicate adhesives.40 The author found the the group that used adhesive nor a statistically significant difference.45 majority of adhesives damaged the the control group (whose patients These results suggest that prolonged vasculature of the chorioallantoic received no adhesive) demonstrated use of denture adhesives do not membrane, which indicated that a statistically significant difference increase micro-organisms. denture adhesives have the potential between the Candida sp. counts in Recently, extended and improper to irritate mucous membranes.40 saliva and those found in maxillary use of denture adhesives containing Another in vitro study by Gates dentures. The authors suggested zinc has been linked to negative et al investigated four denture patient home care and compliance side effects. Zinc is an antimicrobial adhesives and found that not only might have contributed to similar agent used in denture adhesives did each one contain fungal and results between the groups.43 and other cutaneous medications; bacterial contaminants, but also In a similar assessment, Oliveira it plays an integral role in cellular that each one could initiate fungal et al compared the number of metabolism, which is necessary for or bacterial growth when plated on Candida sp. and colony forming immune function, wound healing, the appropriate media.41 The authors units (CFUs) in 24 patients wear- DNA and protein synthesis, cell proposed microwaving the adhesives ing dentures.44 Saliva samples were division, and the catalytic activ- in their original containers for 10 collected from a test group of 12 ity of nearly 100 enzymes.46 The minutes to reduce the contaminants; patients using an adhesive denture recommended daily allowances however, this protocol had no effect and a control group of 12 patients for zinc are 8 mg for women, 11 in 5 of the 24 adhesives tested. The not wearing an adhesive denture mg for men, with a tolerable upper results led the authors to caution at insertion, 7 days post-insertion, limit of 12 mg per day.46 Acute against prescribing denture adhesives and 14 days post-insertion. The test zinc overdose can cause headaches, to immunocompromised indi- group was compared to the control cramps, diarrhea, loss of appetite, viduals.41 A third in vitro study, by group, and the authors failed to find nausea, and vomiting; in addition, Ekstrand et al, utilized the agar over- a statistically significant difference two studies have indicated a con- lay technique to assess the microbial between the groups at two weeks.44 nection between zinc toxicity and contamination in 19 commercially Neither of these in vivo studies denture adhesive use or abuse, with available adhesives and found that analyzed extended use of denture progressive neurological symptoms all of the adhesives caused severe adhesives. In 2012, Ozkan et al (myelopolyneuropathy) after exces- cryptologic effects.42 In addition, the examined the microbial effects of sive and prolonged use of denture majority of the test samples—spe- prolonged denture adhesive use in adhesives containing zinc.47,48 cifically those composed of natural the first in vivo study to last more Patient misuse of zinc-containing raw materials—demonstrated than two weeks in duration.45 adhesives caused hyperzincemia and microbial contamination.42 The authors quantified the levels hypocupremia that ultimately led to Interestingly enough, in vivo of C. albicans and α-hemolytic neurological symptoms. In neither studies on the cytotoxic effects of Streptococcus in 30 complete study did the authors elucidate denture adhesives have different denture wearers, with 15 patients whether the patients were using the outcomes than the in vitro studies using a denture adhesive. Smear zinc-containing denture adhesives

www.agd.org General Dentistry Special Prosthodontics Section 473 Complete Dentures Denture adhesive use in complete dentures

Table 4. Summary of methods and ﬁndings of studies that evaluated denture adhesive effects on cytotoxicty and microbial colonization.

Author(s) Trial type Testing methods Findings Al et al In vitro Cytotoxicity and irritation of six denture adhesives were With one exception, none of the adhesives tested caused (2005)39 analyzed using the HET-CAM and three cell culture methods. noteworthy irritation or cytotoxicity. Ekstrand In vitro Microbial contamination and formaldehyde content of All adhesives caused severe cytotoxicity; some had notable et al (1993)42 19 denture adhesives were examined by various cell formaldehyde content; most had microbial growth and culture methods. those with pronounced contamination were adhesives based on natural raw materials. Gates et al In vitro Microbial contamination of four powder denture adhesives Bacterial and fungal growth were found in all of the (1994)41 was determined from samples and the original product adhesive samples and original containers as microwave containers after 10 minutes of microwave irradiation. irradiation did not consistently sterilize the contents of the original containers. Hedera et al In vivo, Four patients using denture creams who had progressive All patients had ill-fitting dentures and used large amounts (2009)48 cohort myelopolyneuropathy, hypocupremia, and hyperzincinemia of denture cream, which was determined to be the source study were studied to determine the origin of high zinc levels. of the zinc levels; copper and zinc levels normalized after use of denture cream stopped. Kim et al In vivo Samples from the saliva and maxillary dentures of Denture adhesives did not significantly alter the oral (2003)43 patients were tested for absolute and proportional microflora during the trial as there was no statistically counts of Candida and total viable counts (TVC). significant difference between the test and control groups in the amount of TVC or Candida. Nations et al In vivo, Zinc content of three denture adhesives was analyzed; All patients had improved serum zinc levels and mild (2008)47 cohort patients using these adhesives were given copper supple- neurologic improvement after discontinuing adhesive use. study ments to determine post-treatment copper and zinc levels. Oliveira et al In vivo Absolute CFU counts of Candida species and other yeasts No significant difference between the test and control groups (2010)44 were obtained from saliva samples of patients using an in terms of the amount of Candida or other yeasts. adhesive tape. Ozkan et al In vivo, Microbial content of saliva, dentures, and palate was Prolonged denture adhesive use up to two months did not (2012)45 PCT analyzed in patients using one denture adhesive for cause any adverse effects nor increase the microbial diversity extended periods of time. in the oral flora; α-haemolytic Streptococci and C. albicans increased at the one- and two-month intervals, but increase was not significant compared to the baseline measurement.

correctly, or whether the dentures the adhesive. Sato et al compared (70°C) for two minutes; each patient possessed acceptable retention, the ability of edentulous patients repeated the technique five times. stability, fit, or occlusion. Both to remove a cream adhesive and Although repeating the process five studies indicated that neurological an experimental gel adhesive from times did not remove the cream detriments resulted solely from the maxillary soft tissues and the adhesive, the experimental gel adhe- excessive zinc consumption found intaglio surface of the maxillary sive was removed successfully using in denture adhesives.47,48 denture.12 The adhesive was colored a single-stage cleaning method.12 with 0.4% indigo carmine to facili- Uysal et al evaluated four adhesives Application and removal of tate visual identification in removal. according to several categories (reten- adhesives from the intaglio The study used a standardized five- tion, function, cleansibility, and so surface of dentures stage method to assess the patients’ forth).15 The authors applied all the To date, no studies have evaluated ability to remove the adhesive from adhesives to a group of 32 patients effective application of denture the maxillary soft tissues. Each stage with newly relined dentures and adhesive on the intaglio surface of utilized an undetermined mouth instructed the patients to use their the denture. However, three studies rinse, followed by the application dentures with the adhesive for 24 have analyzed effective removal of of cotton gauze or a hot water rinse hours and clean the dentures using

474 November/December 2012 General Dentistry www.agd.org Fig. 2. An example of a small increment of Fig. 3. An example of the correct application of Fig. 4. An example of excessive denture denture adhesive. denture adhesive for a maxillary denture. adhesive applied to a maxillary denture.

the patient’s method of choice (which Correct application of denture be removed. To spread the adhesive, was not disclosed in the study). adhesives the patient should bite firmly for Patient perceptions were tallied and Several denture adhesive manu- 20-30 seconds; again, any additional analyzed and the authors reported facturers have encouraged and excess that expresses into the tongue that 20-30% of patients found it dif- recommended specific methods and or cheek spaces should be removed. ficult or extremely difficult to remove instructions for properly applying Dentists should avoid using too the adhesive from the denture base denture adhesive to the denture much denture adhesive or applying and oral tissues; however, the authors base. The denture should be cleaned it incorrectly (Fig. 4). did not assess the degree of cleaning and the intaglio (tissue side) surface performed by the patients.15 of the denture dried. Next, denture Discussion Berg compared the perceptions of adhesive should be applied in small Complete edentulism remains a 32 patients concerning 10 factors increments, each one approximately prevalent health issue.49,50 Although related to one denture adhesive the size of a pea or a pencil eraser contemporary treatment modalities formulated by a pharmacy (contain- (Fig. 2). Three pea-sized increments (such as implant-supported and ing tragacanth powder) and three of denture cream should be placed retained prostheses) improve the commercially available adhesives.17 on the edentulous ridge of the man- treatment outcome for edentulous The four adhesives were applied dibular denture. Next, three to four patients significantly, conventional and used for one day; at that point, increments of denture cream should complete dentures remain the pri- patient interviews were conducted. be placed on the anterior ridge, pos- mary method for restoring edentu- Unfortunately, the authors did not terior border, and the palatal of the lous arches.51 Complete dentures are verify whether or not the patient maxillary denture midline (Fig. 3). retained in the oral cavity by a series could successfully remove the den- When powder adhesives are used, of complex interactions involving ture adhesive from the denture base one should wet the denture base atmospheric pressure, intimate and the tissues underlying the pros- with water, apply a thin film of the adaptation of the underlying den- theses, focusing instead on patient adhesive to the entire intaglio sur- ture-bearing tissues to the intaglio perceptions.17 Only the study by face, and shake off any excess; when surface of the prosthesis, a thin Sato et al evaluated a patient’s ability pad adhesives are used, the correct film of saliva of acceptable viscosity to remove adhesive effectively from size pad should be positioned onto present between the tissues and the denture base and oral tissues.12 the denture and any excess material prosthesis, and accurate peripheral There are no longitudinal studies on that extends beyond the borders extensions of the denture borders the potential consequences of adhe- trimmed. Each denture should be based on physiological movements. sive accumulating on soft or hard seated separately, held firmly in place However, following exodontia, oral tissues, illustrating the need for for 5-10 seconds, and any excess both hard and soft denture-bearing additional research in this realm of material expressed into the tongue or tissues are remodeled constantly via denture adhesive use. cheek space during insertion should the process of RRR. Although they

www.agd.org General Dentistry Special Prosthodontics Section 475 Complete Dentures Denture adhesive use in complete dentures

are fabricated to meet the demands overall function, thus improving the 8. The glossary of prosthodontic terms. J Prosthet of edentulous patients, the reten- edentulous patient’s QoL. There is a Dent 2005;94(1):10-92. 9. Felton D, Cooper L, Duqum I, Minsley G, Guckes tion, stability and functionality of paucity of evidence concerning the A, Haug S, Meredith P, Solie C, Avery D, Chan- complete dentures are affected by effect of long-term (that is, for more dler ND; American College of Prosthodontists; RRR. Multiple methods can be uti- than six months) use of dental adhe- Academy of General Dentistry; American Dental Association Council on Scientific Affairs; Ameri- lized to overcome RRR, including sive. Denture adhesives should be can Dental Hygienists’ Association; National dental implant therapy, overdenture used according to the manufacturer Association of Dental Laboratories; GlaxoSmith- attachments anchored to natural recommendations, following specific Kline Consumer Healthcare. Evidence-based guidelines for the care and maintenance of teeth, denture adhesives, and den- guidelines for application and complete dentures: A publication of the Ameri- ture relines and rebases. removal to prevent potential misuse. can College of Prosthodontists. J Am Dent Assoc Denture adhesive material func- When prescribing and using denture 2011;142 (Suppl 1):1S-20S. 10. Coates AJ. Usage of denture adhesives. J Dent tions by swelling and gelling upon adhesives containing zinc, one 2000;28(2):137-140. insertion to fill the space between should be aware of their potential 11. Divaris K, Ntounis A, Marinis A, Polyzois GL, Poly- the soft tissues and denture base. for adverse systemic effects. Based on chronopoulou A. Patients’ profiles and perceptions of complete dentures in a university dental Removing zinc from denture this literature review, dentists should clinic. Int J Prosthodont 2012;25(2):145-147. adhesive formulations has reduced develop and implement long-term 12. Sato Y, Kaiba Y, Hayakawa I. Evaluation of den- neurological problems related to maintenance and recall programs for ture retention and ease of removal from oral mucosa on a new gel-type denture adhesive. denture adhesive toxicity. Unfor- edentulous patients. Nihon Hotetsu Shika Gakkai Zasshi. 2008;52(2): tunately, no longitudinal studies 175-182. of more than six months’ duration Author information 13. Pradies G, Sanz I, Evans O, Martnez F, Sanz M. Clinical study comparing the efficacy of two have been performed to evaluate Dr. Duqum is a clinical assistant denture adhesives in complete denture patients. patient comfort, tissue changes, professor, Department of Prosth- Int J Prosthodont 2009;22(4):361-367. or denture serviceability. The odontics, School of Dentistry, 14. Kulak Y, Ozcan M, Arikan A. Subjective assessment by patients of the efficiency of two den- short-term functionality of denture University of North Carolina at ture adhesive pastes. J Prosthodont 2005;14(4): adhesives is regarded as beneficial; Chapel Hill, where Ms. Powers 248-252. however, at present there is little is a postgraduate student and 15. Uysal H, Altay OT, Alparslan N, Bilge A. Compari- son of four different denture cushion adhe- information available concerning Dr. Cooper is the Stallings distin- sives—A subjective study. J Oral Rehabil 1998; extended use of these materials, guished professor and graduate 25(3):209-213. particularly in terms of whether program director. Dr. Felton is 16. Kelsey CC, Lang BR, Wang RF. Examining patients’ responses about the effectiveness of five adhesives prevent patients from professor and Dean of the West Vir- denture adhesive pastes. J Am Dent Assoc 1997; seeking routine dental care because ginia University School of Dentistry, 128(11):1532-1538. the adhesives provide a false sense where he is also editor-in-chief of 17. Berg E. A clinical comparison of four denture adhesives. Int J Prosthodont 1991;4(5):449- of security. It is vitally important the Journal of Prosthodontics. 456. that dentists inform patients of 18. Ghani F, Picton DC. Some clinical investigations the advantages and disadvantages References on retention forces of maxillary complete dentures with the use of denture fixatives. J Oral of denture adhesives, instruct and 1. Fenlon MR, Sherriff M. An investigation of factors influencing patients’ satisfaction with new Rehabil 1994;21(6):631-640. demonstrate how to apply and complete dentures using structural equation 19. Lang LA, Garcia LT, Bohnenkamp DM, Zhu CF. remove adhesives correctly, and modelling. J Dent 2008;36(6):427-434. Effects of denture adhesive on retention of 2. Atwood DA, Coy WA. Clinical, cephalometric, mandibular complete dentures. J Dent Res educate patients concerning the sig- 2007;86(Special Issue Research A). fi and densitometric study of reduction of residual ni cance of routine recall appoint- ridges. J Prosthet Dent 1971;26(3):280-295. 20. Kapur KK. A clinical evaluation of denture adhe- ments for a removable prostheses. 3. Atwood D. Bone loss of edentulous alveolar sives. J Prosthet Dent 1967;18(6):550-558. 21. Grasso JE, Rendell J, Gay T. Effect of denture It is indisputable that standard ridges. J Periodont 1979;50(4 Spec No):11-21. 4. Tallgren A. The continuing reduction of the re- adhesive on the retention and stability of maxil- guidelines for denture adhesive sidual alveolar ridges in complete denture wear- lary dentures. J Prosthet Dent 1994;72(4):399- application and removal are needed. ers: A mixed-longitudinal study covering 25 405. years. J Prosthet Dent 1972;27(2):120-132. 22. Chew CL, Boone ME, Swartz ML, Phillips RW. 5. McCartney JE. Prosthetic problems resulting Denture adhesives: Their effects on denture re- Conclusion from facial and intraoral changes in the edentu- tention and stability. J Dent 1985;13(2):152- Based on a detailed review of the lous patient. J Dent 1981;9(1):71-83. 159. 23. de Baat C, van’t Hof M, van Zeghbroeck L, Oz- relevant literature, one can conclude 6. Atwood DA. Reduction of residual ridges: A major oral disease entity. J Prosthet Dent 1971; can M, Kalk W. An international multicenter that when properly used, denture 26(3):266-279. study on the effectiveness of a denture adhesive adhesives improve complete denture 7. Felton DA. Edentulism and comorbid factors. in maxillary dentures using disposable gnatho- meters. Clin Oral Investig 2007;11(3):237-243. retention and stability as well as J Prosthodont 2009;18(2):88-96.

476 November/December 2012 General Dentistry www.agd.org 24. Hasegawa S, Sekita T, Hayakawa I. Effect of den- adhesive: A pilot study. J Prosthodont 2010; 42. Ekstrand K, Hensten-Pettersen A, Kullmann A. ture adhesive on stability of complete dentures 19(6):443-448. Denture adhesives: Cytotoxicity, microbial con- and the masticatory function. J Med Dent Sci 34. Geckili O, Bilhan H, Mumcu E, Tuncer N. The in- tamination, and formaldehyde content. J Pros- 2003;50(4):239-247. fluence of maximum bite force on patient satis- thet Dent 1993;69(3):314-317. 25. Zhao K, Cheng XR, Chao YL, Li ZA, Han GL. Lab- faction and quality of life of patients wearing 43. Kim E, Driscoll CF, Minah GE. The effect of a oratory evaluation of a new denture adhesive. mandibular implant overdentures. J Oral Implan- denture adhesive on the colonization of Candi- Dent Mater 2004;20(5):419-424. tol 2012;38(3):271-277. da species in vivo. J Prosthodont 2003;12(3): 26. Figueiral MH, Fonseca PA, Pereira-Leite C, Scully 35. Bakke M, Holm B, Gotfredsen K. Masticatory 187-191. C. The effect of different adhesive materials on function and patient satisfaction with implant- 44. Oliveira MC, Oliveira VM, Vieira AC, Rambob I. retention of maxillary complete dentures. Int supported mandibular overdentures: A prospec- In vivo assessment of the effect of an adhesive J Prosthodont 2011;24(2):175-177. tive 5-year study. Int J Prosthodont 2002;15(6): for complete dentures on colonisation of Candi- 27. Psillakis JJ, Wright RF, Grbic JT, Lamster IB. In 575-581. da species. Gerodontology 2010;27(4):303-307. practice evaluation of a denture adhesive using 36. Lo Muzio L, della Valle A, Mignogna MD, Pan- 45. Ozkan YK, Ucankale M, Ozcan M, Uner N. Effect a gnathometer. J Prosthodont 2004;13(4):244- none G, Bucci P, Bucci E, Sciubba J. The treat- of denture adhesive on the micro-organisms in 250. ment of oral aphthous ulceration or erosive vivo. Gerodontology 2012;29(1):9-16. 28. Ozcan M, Kulak Y, de Baat C, Arikan A, Ucankale lichen planus with topical clobetasol propio- 46. Dietary supplement fact sheet: Zinc. Available M. The effect of a new denture adhesive on bite nate in three preparations: A clinical and pilot at: http://ods.od.nih.gov/factsheets/Zinc- force until denture dislodgement. J Prosthodont study on 54 patients. J Oral Pathol Med 2001; HealthProfessional/. Accessed July 2012. 2005;14(2):122-126. 30(10):611-617. 47. Nations SP, Boyer PJ, Love LA, Burritt MF, Butz 29. Gendreau L, Shanga G, Munoz C, Fernandez P, 37. Tarbet WJ, Grossman E. Observations of den- JA, Wolfe GI, Hynan LS, Reisch J, Trivedi JR. Den- Loewy Z. A study of denture adhesive in well- ture-supporting tissue during six months of denture cream: An unusual source of excess zinc, fitting dentures. Abstract presented at: IADR ture adhesive wearing. J Am Dent Assoc 1980; leading to hypocupremia and neurologic dis- General Session; Miami: April 2, 2009. 101(5):789-791. ease. Neurology 2008;71(9):639-643. 30. Cheng S, Zhao K. Effect of denture adhesive on 38. Scher EA, Ritchie GM, Flowers DJ. Antimycotic 48. Hedera P, Peltier A, Fink JK, Wilcock S, London Z, biting force of complete dentures. Abstract pre- denture adhesive in treatment of denture sto- Brewer GJ. Myelopolyneuropathy and pancyto- sented at: IADR Chinese Division; Zian, China: matitis. J Prosthet Dent 1978;40(6):622-627. penia due to copper deficiency and high zinc 2010. 39. Al RH, Dahl JE, Morisbak E, Polyzois GL. Irrita- levels of unknown origin II. The denture cream 31. Rendell JK, Gay T, Grasso JE, Baker RA, Winston tion and cytotoxic potential of denture adhe- is a primary source of excessive zinc. Neurotoxi- JL. The effect of denture adhesive on mandibu- sives. Gerodontology 2005;22(3):177-183. cology 2009;30(6):996-999. lar movement during chewing. J Am Dent Assoc 40. Dahl JE. Potential of dental adhesives to induce 49. Douglass CW, Shih A, Ostry L. Will there be a 2000;131(7):981-986. mucosal irritation evaluated by the HET-CAM need for complete dentures in the United States 32. Veyrune JL, Tubert-Jeannin S, Dutheil C, Riordan method. Acta Odontol Scand 2007;65(5):275- in 2020? J Prosthet Dent 2002;87(1):5-8. PJ. Impact of new prostheses on the oral health 283. 50. Douglass CW, Watson AJ. Future needs for fixed related quality of life of edentulous patients. 41. Gates WD, Goldschmidt M, Kramer D. Microbial and removable partial dentures in the United Gerodontology 2005;22(1):3-9. contamination in four commercially available States. J Prosthet Dent 2002;87(1):9-14. 33. Nicolas E, Veyrune JL, Lassauzay C. A six-month denture adhesives. J Prosthet Dent 1994;71(2): 51. Cooper LF. The current and future treatment of assessment of oral health-related quality of life 154-158. edentulism. J Prosthodont 2009;18(2):116-122. of complete denture wearers using denture

AGDPODCAST Facelift Dentures™

www.agd.org General Dentistry Special Prosthodontics Section 477 CDE self 2 HOURS instruction CREDIT

Exercise No. 315 Complete Dentures

Subject Code 671 5. Which of the following has been linked to The 15 questions for this exercise are based on the negative side effects in denture adhesives? article, Denture adhesive use in complete dentures: A. Zinc Clinical recommendations and review of the literature B. Calcium on pages 467-477. This exercise was developed by William C. Iron U. Wax, DDS, FAGD, in association with the General D. Potassium Dentistry Self-Instruction committee. 6. All of the following are listed components Reading the article and successfully completing this of denture adhesives except one. Which is exercise will enable you to understand: the exception? UÊÌ iÊ«ÀLiÃÊ>ÃÃV>Ìi`ÊÜÌ ÊìÌÕÀiÊ>` iÃÛiÃÆ A. Mineral oil UÊÌ iÊ>`Û>Ì>}iÃÊvÊÕÃ}ÊìÌÕÀiÊ>` iÃÛiÃÆÊ>` B. Karaya gum UÊ ÜÊÌÊÕÃiÊìÌÕÀiÊ>` iÃÛiÃÊVÀÀiVÌÞ° C. Flaxseed oil D. Carboxymethyl cellulose 1. All of the following are considered factors in denture retention except one. Which is 7. Corticosterioids can be incorporated in denture the exception? adhesives to treat oral lesions. The stabilization A. Atmospheric pressure of the denture by the adhesive is more beneficial B. Quality of saliva than the addition of any antifungals. C. TMD A. Both statements are true. D. Denture adaptation B. The first statement is true; the second is false. C. The first statement is false; the second is true. 2. Residual ridge resorption is a lifelong challenge D. Both statements are false. for the denture patient. Methods have been devised to help cope with this problem. 8. The irritating effects of denture adhesives A. Both statements are true. may result in B. The first statement is true; the second is false. A. improved intersurface contact. C. The first statement is false; the second is true. B. increased fungal growth. D. Both statements are false. C. bacterial accumulation in the adhesive. D. damage to the blood vessels. 3. Denture adhesives improve all of the following except one. Which is the exception? 9. All of the following are symptoms of zinc A. Retention overdosage except one. Which is the exception? B. Appearance A. Jaundice C. Stability B. Cramps D. Function C. Headache D. Nausea 4. All of the following may affect denture retention except one. Which is the exception? 10. Long-term retention of denture adhesives may A. Reduced adaptive capacity cause all of the following except one. Which is B. Compromised oral anatomy the exception? C. Medication side effects A. Severe irritation of the oral tissues D. Increased bite force B. Adhesive solidification C. Increased denture adhesion D. Damage to the denture

478 November/December 2012 General Dentistry www.agd.org 11. Denture adhesives should be applied generously. 14. In the Divaris et al study, what percentage of When applying denture adhesive, the denture patients used a denture adhesive? should always be dry. A. 2% A. Both statements are true. B. 5% B. The ﬁrst statement is true; the second is false. C. 10% C. The ﬁrst statement is false; the second is true. D. 15% D. Both statements are false. 15. Because denture adhesives may become 12. With reference to longitudinal studies, the longest contaminated with fungus and/or bacteria, study of adhesive use on denture serviceability one set of authors suggested restricting usage was ______months. in ______patients. A. two A. xerostomic B. four B. pregnant C. six C. prosthetic joint D. eight D. immunocompromised

13. In the Australian study, what percentage of patients refrained from using adhesive in their dentures? A. 20.5% B. 32.9% C. 48.0% D. 52.0%

Answer form is on page 552. Answers for this exercise must be received by October 31, 2013.

To enroll in Self-Instruction, click here.

www.agd.org General Dentistry Special Prosthodontics Section 479 Implant Restorations CDE 2 HOURS CREDIT Accelerated treatment protocols: Full arch treatment with interim and deﬁnitive prostheses

Carl Drago, DDS, MS

With the advent of titanium, root form implants, and osseointegra- prosthetic treatment. This treatment option is also available for tion, dental treatment has undergone a metamorphosis in recent patients with advanced, generalized periodontal disease. years. These new techniques enable dentists to provide anchorage Computer-assisted design/computer-assisted manufacturing for various kinds of prostheses that improve masticatory function, (CAD/CAM) has transformed how dental prostheses are made, esthetics, and comfort for patients. Implant treatment protocols have offering improved accuracy, longevity, and biocompatibility; been improved relative to implant macro- and micro-geometries, along with reduced labor costs and fewer complications than surgical and prosthetic components, and treatment times. Over the casting technologies. past 20 years, immediate occlusal function (also known as loading) This article reviews the principles associated with immediate has been established as a predictable treatment modality, provided occlusal loading and illustrates one specific accelerated prostho- certain specific criteria are met. In many cases, edentulous patients, dontic treatment protocol used to treat edentulous and partially crippled by the loss of their teeth, can undergo outpatient surgical edentulous patients with interim and definitive prostheses. and prosthetic procedures and return to a masticatory function Received: May 31, 2012 that is near normal—sometimes after only one day of surgical and Accepted: July 2, 2012

riginally, osseointegration their mandibular dentures, yet the Buser et al and Cochrane et al was designed for edentulous fixed implant prostheses were not considered implants to be successful Opatients, specifically those placed until 9-12 months after if they satisfied the following criteria: patients with edentulous man- implant placement. t"CTFODFPGQBJOPSBOZOFHBUJWF dibles who had difficulty managing The literature has demonstrated subjective sensation mandibular complete dentures.1 high survival rates for implants t"CTFODFPGDMJOJDBMMZEFUFDUBCMF Lindquist et al recorded high implant placed (with high primary stability) implant mobility cumulative survival rates (CSRs) into the parasymphysis regions of t"CTFODFPGBOZSFDVSSFOU with two-stage surgical protocols edentulous mandibles, splinted peri-implant mucositis and/or where implants were placed and soft together with some type of rigid peri-implantitis accompanied by tissues were closed.1 During initial interim prostheses, and placed into swelling, redness, or pain of the healing, implants were not exposed immediate functional occlusion.2-6 peri-implant mucosa in the oral cavity. Initially, four to This modality also may be considered t"CTFODFPGDPOUJOVPVTQFSJ six months of unloaded healing was for partially edentulous patients with implant radiolucency necessary for osseointegration prior severe periodontal disease.7 In a 2002 t"CTFODFPGNFTJBMBOEPSEJTUBM to a second surgical procedure. This study, Cooper et al placed man- vertical bone loss of more than second procedure was scheduled dibular implants with high primary 30% of the endosseous part of the to uncover the implants, place stability immediately after extraction implants trans-mucosal abutments and begin of periodontally compromised teeth.7 t/POFFEUPSFQBJSPSSFQMBDFUIF prosthetic procedures. Unfortunately, These implants were rigidly splinted implant-supported prosthesis patients generally had to continue together with acrylic resin prostheses, t4VCKFDUJWFFWBMVBUJPOPGUIFUSFBU- wearing ill-fitting dentures during and placed into fully functional ment outcomes.8,9 this entire time. Ironically, patients occlusion. At evaluations 6 to 18 The average number of implants generally scheduled this type of treat- months after placement, the implants required for implant prostheses has ment because of trouble managing demonstrated a CSR of 100%.7 been discussed in the literature.

480 November/December 2012 General Dentistry www.agd.org In a retrospective chart review, The authors concluded that the for passivity, were larger than the Strietzel et al reported that nine All-on-4 protocol can be considered wax frameworks by between 416 was the median number of implants a viable treatment option for imme- and 477 µ. The authors concluded required for maxillary fixed implant diate rehabilitation of both the that conventionally cast titanium prostheses (SD = 1.6; range = mandible and maxilla.11 frameworks probably could not 6-12), compared to eight implants These studies reported consistent be made to the degree of accuracy for mandibular fixed prostheses clinical results associated with imme- required to fit passively on abut- (SD = 1.4; range = 6-10).6 These diate, interim, acrylic resin prosthe- ments because of the multiple vari- findings were similar to those ses. The treatment approach required ables inherent in casting processes.16 published by Del Fabbro et al fabricating two prostheses: interim By contrast, a 2008 study by Tan et in 2006.10 In 2007, Capelli et al acrylic resin prostheses (made and al reported that waxing and casting studied immediate occlusal loading inserted within one to two days of using the lost wax technique resulted in maxillary and mandibular jaws: implant placement) and definitive in smaller vertical marginal gaps the implant CSR for the maxilla prostheses (fabricated with metal between restorations and abutments was 97.6% for up to 40 months frameworks approximately three to (23.91 ± 9.80 µ) than the CAD/ post-loading, no implant failures six months after implant placement CAM process (79.43 ± 25.46 µ).17 were reported for the mandible; the and occlusal loading). Other proto- However, it should be noted that prosthesis CSR was 100%.11 These cols provide patients with definitive these results referred to individual, results indicated that immediately cast metal frameworks/hybrid pros- single-unit restorations rather than loaded tilted implants achieved the theses within 3-5 days of implant multiple-unit implant frameworks.17 same outcome as upright implants placement.13 These protocols involve In a 2010 laboratory study, Drago in both jaws, suggesting that imme- slightly more coordination among et al determined that CAD/CAM diate rehabilitation of edentulous the surgical, prosthetic, and labora- implant frameworks supported maxillae and mandibles with hybrid tory teams, but have proven to by five mandibular implants fit prostheses (supported by six or four be a viable alternative to previous significantly better than cast frame- implants, respectively) may repre- protocols that included interim and works made on the same patient sent a viable treatment alternative definitive prostheses.13 models.18 That same year, Eliasson compared to more demanding sur- et al measured milled titanium gical procedures, such as grafting.11 CAD/CAM frameworks implant frameworks for two different A 2010 clinical study by Agliardi Recent years have seen continued implant systems, concluding that all et al followed 173 edentulous developments related to the fab- the frameworks presented signs of patients for up to 59 months.12 rication of implant frameworks misfit, no framework actually dem- Four implants (two tilted, two and abutments. Complex castings onstrated a “passive” fit, and clinical vertical), were placed according to involving multiple units are difficult frameworks had greater misfits than BTQFDJëDQSPUPDPM "MMPO /PCFM to fabricate with passive, accurate frameworks fabricated in laboratory Biocare). Provisional, all-acrylic fits.14 There are multiple reasons studies.19 The authors reported that resin prostheses and implants were why conventional castings do not all the frameworks in their study inserted on the same day, with result in accurate fitting frame- demonstrated levels of precision of fit definitive prostheses inserted four works, including the expansion/ within clinically acceptable limits.19 to six months later. A total of 154 contraction of materials (such as In 2012, Ortorp & Jemt followed immediately loaded prostheses impression materials, dental stones, 126 edentulous patients for whom (61 maxillary, 93 mandibular) wax, and casting investments).15 67 prostheses with CAD/CAM functioned for at least one year and Mitha et al studied titanium titanium frameworks (test) had were included in the analysis. Four implant frameworks cast with the been provided (in 23 maxillae and vertical maxillary and one tilted lost wax technique and found verti- 44 mandibles), while 62 prostheses mandibular implant failed within cal gaps in both wax patterns and fabricated with gold-alloy castings six months of occlusal loading; no castings. Significant differences were (control) were placed in 31 maxillae further implant failures were noted. found in distortion between wax and 31 mandibles. Clinical and At one year, the CSR was 98.4% for patterns and castings, which, given radiographic 10-year data were maxillary implants compared with the authors’ criteria for the standard collected and statistically com- 99.7% for mandibular implants. of fit to keep within 150 µ of misfit pared. At 10 years, the prostheses

www.agd.org General Dentistry Special Prosthodontics Section 481 Implant Restorations Accelerated treatment protocols: Full arch treatment

the patient’s dentition was restored using an accelerated prosthetic treatment protocol that utilized definitive screw-retained hybrid prostheses made with CAD/CAM technology.

Case report A 45-year-old woman sought treatment with the chief complaint of “loose teeth” in need of repair (Fig. 1). The patient had not seen a dentist in over 15 years and did not Fig. 1. A clinical preoperative photograph of the patient’s teeth in centric occlusion. want to wear dentures. A complete physical and radiographic examination revealed localized, acute, severe periodontitis (type IV); partially Table 1. Treatment plan options presented to the patient at the edentulous maxillae and mandible; consultation appointment. and Class II malocclusion with poor anterior guidance. Treatment plan No. 1 Treatment plan No. 2 When the teeth were determined to be non-restorable, two treatment Extraction, alveolectomy, implant placement, Extractions, alveolectomy, insertion of immediate ff immediate occlusal presented loading with complete dentures options were o ered to the patient: full arch, fixed interim prostheses at new One involved an immediate load- vertical dimension of occlusion ing protocol with extraction of the Follow-up and osseointegration of dental Tissue conditioning of immediate complete teeth, placement of implants and implants dentures insertion of full arch prostheses Evaluation of osseointegration, vertical Evaluation of retention, stability, function, on the day of implant placement. dimension, centric occlusion, phonetics, esthetics and phonetics. Determination of The definitive treatment included and esthetics definitive treatment plan: conventional or implant prostheses with CAD/CAM frame- supported/retained prostheses works approximately 4-6 months Fabrication of definitive prostheses Determination of fixed or removable implant later. The second option included with CAD/CAM frameworks supported/retained prostheses. Implant placement extraction of the teeth and insertion with or without immediate occlusal loading of immediate complete dentures. If Follow-up care Fabrication of definitive conventional or implant the patient could not adapt to the supported/retained prostheses dentures, implants would then be considered for definitive treatment (see Table 1). After discussing the benefits and limitations of each, the demonstrated a 95.6% CSR for the were registered in each group. The patient decided to proceed with the CAD/CAM group compared to authors also identified that maxillary first treatment option (see Table 2). 98.3% for the gold-alloy castings prostheses required more mainte- group; implants demonstrated a nance appointments than mandibu- Accelerated treatment protocol: 95.0% CSR for the CAD/CAM lar prostheses (P < 0.001).20 Initial diagnostic phase group compared with 97.9% for This case report illustrates the con- To facilitate treatment, all necessary the control group (P > 0.05). No cepts mentioned above: extraction prosthodontic procedures—pre- implants were lost after five years of a severely periodontally involved liminary impressions for diagnostic of follow-up; however, one pros- dentition, immediate implant place- casts, jaw relation records (including thesis in each group was lost due ment with high primary stability, and facebow and centric jaw relation to implant loss, one CAD/CAM immediate occlusal loading with two records), shade selection, and prosthesis failed due to framework fixed, full arch prostheses. Osseoin- initial determination of the new fracture, and two metal fractures tegration occurred uneventfully and vertical dimension of occlusion

482 November/December 2012 General Dentistry www.agd.org Fig. 2. A laboratory photograph of a mandibular diagnostic cast. The Fig. 3. A laboratory photograph of the new articulator settings. tentative location of the new mandibular incisal edges was marked on the Mandibular teeth have been set; restorative volume between the mandibular incisor, while the location of the posterior occlusal plane was mandibular occlusal plane and the crest of the maxillary ridge measured marked at two-thirds of the vertical height of the retromolar pad. approximately 15 mm.

Table 2. Beneﬁts and limitations of the two treatment options presented to the patient.

Treatment plan No. 1: Immediate occlusal loading Treatment plan No. 2: Complete dentures Benefits Limitations Benefits Limitations Patient never has to Somewhat long, initial surgical/ Less invasive Removable dentures with palatal wear complete dentures prosthetic appointment surgery coverage Fixed, non-removable Immediate loading is not guaranteed; Less technique- Adaptations needed for patient prosthesis implants need high insertion torque sensitive to be successful (> 50 Ncm) for immediate occlusal loading to take place No palatal coverage Expense Decreased expense Bone resorption continues beneath the dentures Minimal long-term bone loss Technique sensitive Optimal esthetics Decreased masticatory function Improved masticatory Patient adaptation is required (as Increased office visits for function with all prosthetic procedures) maintenance and adjustments Long-term history of documented success Optimal esthetics

and positions of the teeth—were diagnostic cast; the posterior location rest; however, she did wish to see performed in one day, based on of the occlusal plane was located 50% to 66% of the maxillary inci- discussions with the patient relative at approximately two-thirds of the sors when she smiled. The teeth were to her wishes. (The actual procedures vertical height of the retromolar pad removed from the maxillary cast, will not be described here in detail; (Fig. 2). The incisal guide pin was along with additional stone that cor- numerous sources are available for raised approximately 8 mm from responded to a restorative volume learning step-by-step instructions.) the original vertical dimension of of approximately 12-15 mm. The The casts were mounted in an aver- occlusion (VDO); this developed the author measures restorative volume age value articulator (Stratos 100, restorative space required to place as the space from the crest of the Ivoclar Vivadent). The tentative loca- the teeth in their correct positions. alveolar ridge to the location of the tion of the new mandibular incisal The patient did not want to see maxillary central incisor incisal edge edge position was marked on the the maxillary incisal edges while at (Fig. 3). Maxillary and mandibular

www.agd.org General Dentistry Special Prosthodontics Section 483 Implant Restorations Accelerated treatment protocols: Full arch treatment

Fig. 5. A clinical image of the patient with the cotton tip applicator aligned with the nasal dot. The middle dot Fig. 4. A laboratory image of the completed denture setup for the ﬁxed interim indicated the planned location of the incisal edges of the screw-retained prostheses. maxillary interim prosthesis.

Fig. 6. The patient with the interim prosthesis Fig. 7. Left: A metal abutment cylinder in place on the right anterior maxillary implant conical abut- in place. The restorative volume (crest of ment. The screw access opening was to exit near the cingulum of the right maxillary lateral incisor. alveolus to maxillary incisal edges) measured Right: The 30° angled posterior abutment that demonstrated the screw access opening would exit approximately 20 mm in this location. within the occlusal surface of the left maxillary premolar.

denture teeth (Mondial, Heraeus (Sanitary Color Transfer Applica- of restorative volume between Kulzer) were set in Class I occlusion tors, Great Plains Dental). The the alveolar crest and the planned with a horizontal occlusal plane. marks were transferred to a wooden locations of the maxillary central Group function was developed for cotton applicator; the middle mark incisal edges (Fig. 6). The maxillary right and left working movements represented the planned location of canines and lateral incisor segments and the prostheses were processed the maxillary central incisal edges had been removed from the interim and polished (Fig. 4). in the interim prosthesis; the lower prosthesis, which allowed the sur- dot was transferred consistent with geon complete visual access relative Accelerated treatment the tentative increase in the vertical to restorative volume and anterior/ protocol: Second treatment dimension of occlusion planned for posterior implant positioning. phase (surgery and conversion the new prostheses (Fig. 5). At that Visual access could also have been of the interim prostheses) point, the patient was sedated and accomplished with a clear surgical The patient was sitting upright prepared for maxillary surgery. The duplicate of the interim prosthesis. with her head unsupported. Prior maxillary teeth were removed, a full Implants were placed (NobelAc- to anesthesia and sedation, dots thickness mucoperiosteal flap was tive, Nobel Biocare) with insertion were placed on the patient’s nose elevated, and an alveolectomy was torques in excess of 70 Ncm as and chin with an indelible marker performed that provided 12-15 mm measured on a manual torque

484 November/December 2012 General Dentistry www.agd.org Fig. 8. Clinical image of abutment impression copings in place; light cure composite resin was used to initially hold orthodontic wire segments in place on each impression coping. These impression copings were designed with concavities that hold the orthodontic wire segments in place during this procedure. Fig. 9. The intaglio surface of the maxillary stabilizing impression.

driver. The two distal, tilted luted with Triad® Gel (Dentsply midline. In order to consistently seat implants were placed parallel to International) (Fig. 8). The locations the prosthesis in its correct position, the anterior walls of the maxil- of the impression copings were quick setting polyvinyl siloxane lary sinuses; the anterior implants identified and corresponding holes impression material (Imprint 3 were placed relatively vertical in were made in a stock impression Quick Step Light Body, 3M ESPE), the lateral incisor areas. Straight tray (Crystal Disposable Impression was injected onto the intaglio sur- internal connection conical abut- Trays, Henry Schein Inc.) such that face of the maxillary prosthesis; the ments were placed on the anterior the copings did not touch the tray prosthesis was seated paying careful implants (with abutment screws or splinted impression copings. attention to the dental midline, torqued to 35 Ncm) such that the Polyvinyl siloxane impression mate- occlusal plane, and anterior/poste- screw access openings were lingual rial (Imprint 3 Quick Step Light rior positioning (Fig. 9). After the to the anterior teeth. Next, multi- Body and Imprint 3 Penta Quick stabilizing impression was removed, unit abutments (at 30° angles) Step Heavy Body, 3M ESPE) was a rubber dam was cut and placed were placed on the distal implants used to make the definitive impres- onto the anterior temporary cylin- so that the screw access openings sion. A master cast was fabricated ders; at that point, the prosthesis were located within the occlusal using vacuum-mixed dental stone was re-seated, with careful attention surfaces of the posterior teeth per the manufacturer’s instructions paid to the facial midline, orienta- (abutment screws torqued to 15 (Coe Cal, GC America Inc.). Two tion of the occlusal plane, and lip Ncm) (Fig. 7). The flap was closed sections of teeth (canines and lateral support. While the author held the with a combination of bone and incisors) were removed from the prosthesis in position, a dental assis- soft tissue sutures that repositioned maxillary prosthesis prior to the tant injected autopolymerizing resin the peri-implant soft tissues on and surgical phase of treatment; this (Secure Hard Pick-Up Material, 3M to the alveolar ridge. The patient facilitated complete visualization of ESPE) around the cylinders to com- was discharged to the doctor for the temporary cylinders relative to pletely attach them to the denture the prosthodontic procedures. the denture base. Metal temporary base. The resin set and the prosthesis Abutment impression copings abutment cylinders (Temporary were removed (Fig. 10). (Impression Coping Open Tray Coping Multi-unit Titanium, Nobel Locations of the posterior abut- Multi-unit, Nobel Biocare) were Biocare) were placed on the two ments were identified in the stabiliz- placed onto the abutments. Next, anterior implants. The maxillary ing impression. In the laboratory, 30-gauge orthodontic wire was sec- prosthesis was adjusted to fit around holes were drilled through the den- tioned, placed within the concavities the cylinders; the dental midline was ture base and the Mondial posterior of the impression copings and made to be consistent with the facial denture teeth. Using laboratory

www.agd.org General Dentistry Special Prosthodontics Section 485 Implant Restorations Accelerated treatment protocols: Full arch treatment

Fig. 10. The intaglio surface of the interim Fig. 11. The maxillary interim prosthesis in Fig. 12. The occlusal surface of the completed screw-retained prosthesis. place on the master cast. maxillary interim prosthesis.

concavities were placed into the posterior portions of the maxillary denture base. This facilitated treatment by eliminating the need for an interocclusal record to orient the mandibular prosthesis to the maxillary prosthesis. The surgeon was free to concentrate on obtaining Fig. 13. Left: The mandibular interim prosthesis with two sets of ball clasps luted to the denture base the correct jaw position relative to in the right and left posterior segments. Right: The ball clasps retain the mandibular prosthesis to the the prostheses and judge the amount maxillary prosthesis in a Class I occlusal relationship. Concavities (using a 6 round bur) were placed of restorative volume created by the into the maxillary denture base to retain the ball clasps. mandibular alveolectomy. The doctor used 12-15 mm as the baseline for the total restorative volume. Restor- ative volume must take into account abutment and cylinder heights, as screws, the denture base was seated contoured, finished, and polished well as the thickness of the denture on the two anterior cylinders and for use as the maxillary interim base for strength and rigidity. The the base was adjusted so that no prosthesis (Fig. 12). surgeon completed the alveolectomy, part of the denture base touched the By this time, the surgeon had placed four mandibular implants master cast (Fig. 11). Metal, multi- anesthetized the patient’s mandible, (with insertion torques of at least unit temporary cylinders were placed removed the teeth, and started the 70 Ncm) and sutured the flap. The onto the posterior abutment analogs alveolectomy. The surgeon placed the two distal implants were tilted; the and the anterior metal temporary completed, maxillary interim pros- two anterior implants were relatively cylinders were re-positioned onto the thesis onto the anterior abutments vertical. This arrangement provided master cast with laboratory screws. with retaining screws and attached a clinically acceptable anterior/pos- The maxillary interim prosthesis was the mandibular prosthesis to the terior spread. The canine and lateral placed (with the mandibular interim maxillary prosthesis by using poste- incisor segments were removed from prosthesis) into Class I occlusion, rior vertical ball clasps (Ball Clasps the mandibular prosthesis before so that the tooth segments were re- .032, Henry Schein Inc.) (Fig. 13). mandibular clinical procedures were oriented into their proper positions. The ball clasps were attached to the performed. Removing the denture Secure Hard Pick-Up Material was posterior portions of the mandibular teeth from the denture base made used to attach the posterior cylinders denture base after processing. To it possible to visualize implant and anterior tooth segments to the retain the ball clasps into the maxil- placement relative to tooth locations denture base. The prosthesis was lary prosthesis, two corresponding within the interim prosthesis.

486 November/December 2012 General Dentistry www.agd.org Fig. 14. The interim mandibular prosthesis during the application of stabilizing Fig. 15. The patient, just prior to leaving the ofﬁce on the impression material. ﬁrst day of surgery with the interim prostheses in place.

Table 3. Treatments performed at The mandibular procedures Accelerated treatment each appointment for fabrication duplicated the maxillary procedures protocol: Third treatment of the definitive prostheses with as described above with one excep- phase (definitive prostheses) CAD/CAM frameworks, using the tion: The anterior cylinders and Osseointegration occurred unevent- accelerated treatment protocol. the mandibular denture base were fully. Approximately four months connected with the mandibular after extraction, implant placement, Appointment No. 1 prosthesis attached to the maxillary and immediate occlusal loading, Evaluation of esthetics, jaw relation records prosthesis via posterior ball clasps. the patient was ready to receive the (facebow and centric jaw relation records). As a result, the doctor only had to definitive prostheses. (During this Abutment level impression using the interim concentrate on maintaining the cor- time, the patient had a hemangioma prostheses as the verification indexes. rect jaw position (Fig. 14); to make removed from her upper right lip.) Articulator mounting of the master sure the VDO was consistent, this The patient was questioned about casts (with the interim prostheses). position was checked against the the esthetics, tooth display, lip Mounted diagnostic casts of the interim cotton tip applicator and the marks support, phonetics, and hygiene prostheses (cross-mounted against the interim prostheses and master casts). on the nose and chin. The mandib- allowed by the interim prosthesis. Th Wax dentures were set in the laboratory, ular prosthesis was removed and the e patient was very pleased with with plastic temporary cylinders. conversion to the interim prosthesis the results of the interim prostheses Optimal tooth positions and jaw was completed in the laboratory and basically wanted no changes for relations were transferred to the master (including removal of the ball the definitive prostheses. casts via cross mounting the casts of clasps from the denture base). The The traditional prosthodontic the interim prostheses. mandibular prosthesis went into protocol typically includes some The wax dentures and master casts place with prosthetic screws torqued combination of the following: pre- were then sent to a milling center for to 15 Ncm and the access opening liminary impressions for construc- fabrication of the CAD/CAM frameworks. restorations were completed with tion of custom impression trays, Appointment No. 2 Th fi fi light cure resin. e patient left the de nitive impressions, veri cation Framework and wax try-in, evaluation office approximately seven hours index, initial jaw relation records, of the esthetic results and jaw relation after arriving. She now had two wax try-in, metal framework try- records, remount mandibular cast (if fixed, implant-retained interim in, wax try-in with teeth on the needed), and second wax denture setup prostheses in Class I occlusion, at frameworks, and insertion. These for esthetic modifications per patient request (if needed). an appropriate VDO with improved procedures typically require up esthetics (Fig. 15). One of the pri- to eight separate visits; however, Insertion of interim prostheses. mary benefits of immediate occlusal the accelerated treatment protocol Appointment No. 3 loading is that patients never have used in this case combined all of Insertion of definitive prostheses. to go through an edentulous stage the above visits into three appoint- wearing complete dentures. ments (see Table 3).

www.agd.org General Dentistry Special Prosthodontics Section 487 Implant Restorations Accelerated treatment protocols: Full arch treatment

Fig. 17. Intaglio surface of the deﬁnitive Fig. 16. The peri-implant soft tissues and abutments at the impression appointment four months mandibular impression; the mandibular interim after placement of the implants. prosthesis was contained within the impression as the veriﬁcation index.

Fig. 18. The maxillary master cast was mounted onto the upper member of the articulator, using the Fig. 19. The mandibular master cast articulated face bow record, with the maxillary interim prosthesis in place. against the diagnostic cast of the maxillary interim prosthesis. Plastic temporary cylinders were placed onto laboratory abutment analogs as a means to attach and remove the wax dentures prior to scanning.

technique when making the impressions. To make the definitive impressions, Imprint 3 Quick Step Light Fig. 20. The wax dentures are attached to the master casts with plastic temporary cylinders. Body was used in, under, and around the prostheses, while Imprint 3 Penta Quick Step Heavy Body was used in the tray (Fig. 17). The impressions were poured to fabricate master casts. Appointment No. 1 healthy, and abutments and implants After the dental stone had set, the The patient was extremely pleased were stable (Fig. 16). The interim master casts (with the interim pros- with the results of treatment and did prostheses passed the one-screw test theses in place) were mounted in the not want any changes made to the for passivity; the interim prostheses Stratos 100, using the facebow and definitive prostheses. Prior to remov- was contained within the impres- centric jaw relation records (Fig. 18). ing the interim prostheses, facebow sion as the verification index. Long A diagnostic cast of the maxillary and jaw relation records were made impression coping screws were used interim prostheses was mounted at the existing VDO; the dental mid- to seat the interim prostheses/verifi- with the centric jaw relation record line was consistent with the facial cation indexes onto the abutments. against the mandibular interim pros- midline and was so recorded. The A Crystal Disposable Impression thesis/master cast, while a diagnostic interim prostheses were removed. Tray was adjusted to fit around the cast of the mandibular interim pros- The peri-implant soft tissues were screws for use with the open tray thesis was mounted with the centric

488 November/December 2012 General Dentistry www.agd.org jaw relation record against the maxillary interim prosthesis/master cast. This step allowed the dental laboratory technician to set denture teeth for the CAD/CAM prostheses without forcing the patient to wait. The interim prostheses were returned to the patient, who was discharged. These procedures took approximately two hours of chairtime. Fig. 21. Images of the CAD/CAM frameworks received from the milling center. Left: The mandibular Temporary Coping Multi-unit framework was designed as an L-shaped beam. Right: The maxillary framework was designed as an plastic cylinders were placed onto I-bar for a wraparound acrylic resin design. the abutment analogs in the master casts (Fig. 19), and Mondial teeth (of the appropriate size and shade) were set against the casts of the respective interim prostheses (Fig. 20). Since the patient wished to maintain the esthetics of the interim prostheses, a clinical try-in was not needed, as the denture setup was to be used only to design the frameworks. The wax dentures were finished and sent to Fig. 22. Left: The wax/framework try-in with the patient in CO. Right: The try-in with the patient smiling. an implant milling center to design and mill the CAD/CAM frameworks (Bella Tek CAM StructSURE Precision Milled Bars, Biomet 3i). The wax dentures and master casts relationships were confirmed. The were scanned and frameworks were patient had a thorough chance to designed and milled (Fig. 21). evaluate the esthetics of the definitive The frameworks were returned to prostheses (Fig. 22); she was pleased the doctor; at that point, the den- with the esthetic results and wanted ture teeth were removed from the no changes. The wax prostheses scanned, wax dentures and set on were removed and the interim pros- Fig. 23. Anterior view of the deﬁnitive the frames (using the cross-mounted theses were reinserted. The patient prostheses in place, with the patient in CO. diagnostic casts described in Table 3) was discharged and scheduled to prior to the next clinical appoint- return for insertion of the definitive ment. The occlusion was developed prostheses. The appointment lasted as bilateral Class I, with group approximately one hour. function in right and left working function was developed for right movement. Anterior guidance was Appointment No. 3 and left working movements, while developed as anterior disclusion with At this appointment, the interim anterior guidance was established the central and lateral incisors. prostheses were removed, and the with the incisors. The prostheses abutment screws were re-torqued were removed and denture bases Appointment No. 2 (15 Ncm for the angled posterior were finished and polished. They At the second appointment, the abutments; 35 Ncm for the straight went back into place with new pros- interim prostheses were removed and anterior abutments). Initially, the thetic screws, torqued to 15 Ncm. abutments and implants were stable. definitive prostheses were placed Access openings were blocked out The frameworks (with denture teeth) with laboratory try-in screws; even with cotton and restored with light were tried in and both frameworks occlusal contacts were established cured composite resin. The patient passed the one-screw test. The jaw throughout the prostheses. Group was very pleased with the esthetic

www.agd.org General Dentistry Special Prosthodontics Section 489 Implant Restorations Accelerated treatment protocols: Full arch treatment

results and was discharged with technology to mill titanium alloy prostheses at implant placement. Int J Oral written and verbal post-operative frameworks and combines multiple Maxillofac Implants 1997;12(4):495-503. Th 4. Jaffin RA, Kumar A, Berman CL. Immediate instructions (Fig. 23). is appoint- short prosthodontic visits into loading of implants in partially and fully ment took approximately one hour. fewer, longer visits that, in the edentulous jaws: A series of 27 case reports. author’s experience, have proven to J Perio-dontol 2000;71(5):833-838. ffi 5. Grunder U. Immediate functional loading of im- Summary be more e cient in clinical practice mediate implants in edentulous arches: Two- Numerous short- and long-term (and better received by patients) year results. Int J Periodontics Restorative Dent clinical studies, using multiple than conventional appointment 2001;21(6):545-551. 6. Strietzel FP, Karmon B, Lorean A, Fischer PP. Im- implant systems, have documented scheduling with multiple, shorter plant-prosthetic rehabilitation of the edentulous successful cases involving immedi- appointments. That is not to say maxilla and mandible with immediately loaded ate occlusal loading with full arch, that the more conventional meth- implants: Preliminary data from a retrospective fi Th study, considering time of implantation. Int xed prostheses. e keys for suc- ods of performing these treatments J Oral Maxillofac Implants 2011;26(1):139-147. cessful clinical treatment include are incorrect; rather the treatment 7. Cooper LF, Rahman A, Moriarty J, Chaffee N, thorough radiographic and physical described in this article is simply Sacco D. Immediate mandibular rehabilitation with endosseous implants: Simultaneous extrac- examinations, accurate diagnoses quicker and more patient-friendly. tion, implant placement, and loading. Int J Oral and careful, complete treatment Dental implant treatment will con- Maxillofac Implants 2002;17(4):517-525. planning. Ideally, treatment tinue to evolve in terms of materials, 8. Buser D, Mericske-Stern R, Bernard JP, Behneke A, Behneke N, Hirt HP, Belser UC, Lang NP. planning should involve surgical, procedures, protocols, and so forth. Long-term evaluation of non-submerged ITI im- prosthodontic, and laboratory The accelerated treatment protocol plants. Part I: 8-year life table analysis of a pro- personnel. All clinicians need to illustrated in this article is one group spective multi-center study with 2359 implants. Clin Oral Implants Res 1997;8(3):161-172. be involved to obtain optimal, practice’s adaptation to the continued 9. Cochran DL, Buser D, ten Bruggenkate CM, We- consistent restorative volumes evolution of dental implant therapy. ingart D, Taylor TM, Bernard JP, Peters F, Simp- during the surgical phases of treat- son JP. The use of reduced healing times on ITI Th implants with a sandblasted and acid-etched ment. e author recommends Disclaimer (SLA) surface: Early results from clinical trials on making 12-15 mm of vertical space The author has no financial, ITI SLA implants. Clin Oral Implants Res 2002; available for implant restorative economic, commercial, and/or 13(2):144-153. 10. Del Fabbro M, Testori, T, Francelli L, Taschieri S, components and prostheses to professional interests related to Weinstein R. Systematic review of survival rates ensure that the tooth positions and topics or products presented in this for immediately loaded dental implants. Int strength of the prostheses will not manuscript. J Periodontics Restorative Dent 2006;26(3): 249-263. be compromised. High implant 11. Capelli M, Zuffetti F, Del Fabbro M, Testori T. Im- placement insertion torque values Author information mediate rehabilitation of the completely eden- (at least 50 Ncm) are needed for Dr. Drago is clinical director, Eon tulous jaw with fixed prostheses supported by either upright or tilted implants: A multicenter implant primary stability prior to Clinics, Waukesha, Wisconsin, clinical study. Int J Oral Maxillofac Implants fabricating fixed, interim prostheses and was an associate professor, 2007;22(4):639-644. and immediate occlusal loading. Department of Restorative and 12. Agliardi E, Panigatti S, Clerico M, Villa C, Malo P. Th Immediate rehabilitation of the edentulous jaws Fabrication of interim prostheses Prosthetic Dentistry, e Ohio State with full fixed prostheses supported by four im- follows the basic prosthodontic University College of Dentistry in plants: Interim results of a single cohort pro- principles associated with conven- Columbus, Ohio. spective study. Clin Oral Implants Res 2010; 21(5):459-465. tional and immediate dentures in 13. Tames R, McGlumphy E, El-Gendy T, Wilson R. determining the location of teeth, References The OSU frame: A novel approach to fabricating orientation of the occlusal plane, 1. Lindquist LW, Carlsson GE, Jemt T. A prospective immediate load fixed-detachable prostheses. 15-year follow-up study of mandibular fixed J Oral Maxillofac Surg 2004;62(9)(2 Suppl): esthetics, phonetics, vertical dimen- prostheses supported by osseointegrated im- 17-21. sion of occlusion, and lip support. plants. Clinical results and marginal bone loss. 14. Tan KB, Rubenstein JE, Nicholls JI, Yuodelis RA. Once osseointegration has been Clin Oral Implants Res 1996;7(4):329-336. Three-dimensional analysis of the casting accu- fi 2. Tarnow DP, Emtiaz S, Classi A. Immediate load- racy of one-piece, osseointegrated implant-re- achieved, de nitive prostheses can ing of threaded implants at stage 1 surgery in tained prostheses. Int J Prosthodont 1993;6(4): be constructed. The best material to edentulous arches: Ten consecutive case reports 346-363. use for this process involves CAD/ with 1- to 5-year data. Int J Oral Maxillofac Im- 15. Guichet DV, Caputo AA, Choi H, Sorensen JA. plants 1997;12(3):319-324. Passivity of fit and marginal opening in screw- CAM technology for milling tita- 3. Schnitman PA, Wöhrle PS, Rubenstein JE, DaSil- or cement-retained implant fixed partial denture nium alloy frameworks. The accel- va JD, Wang NH. Ten-year results for Brånemark designs. Int J Oral Maxillofac Implant 2000;15(2): erated treatment protocol illustrated implants immediately loaded with fixed 239-246. in this paper uses CAD/CAM

490 November/December 2012 General Dentistry www.agd.org 16. Mitha T, Owen CP, Howes DG. The three-di- AGDPODCAST mensional casting distortion of five implant- Controversies in supported frameworks. Int J Prosthodont Implant Dentistry 2009;22(3):248-250. 17. Tan PV, Gratton DG, Diaz-Arnold AM, Holmes DC. An in vitro comparison of vertical marginal gaps of CAD/CAM titanium and conventional cast restorations. J Prosthodont 2008;17(5): 378-383. 18. Drago C, Saldarriaga RL, Domagala D, Almasri R. Volumetric determination of the amount of misfit in CAD/CAM and cast implant frameworks: A multicenter laboratory study. Int J Oral Maxillofac Implants 2010;25(5):920-929. 19. Eliasson A, Wennerberg A, Johansson A, Ortorp A, Jemt T. The precision of fit of milled titanium implant frameworks (I-Bridge) in the edentulous jaw. Clin Implant Dent Relat Res 2010;12(2):81-90. 20. Ortorp A, Jemt T. CNC-milled titanium frameworks supported by implants in the edentulous jaw: A 10-year comparative clinical study. Clin Implant Dent Relat Res 2012;14(1):88-99. Manufacturers Biomet 3i, Palm Beach Gardens, FL 800.342.5454, www.biomet3i.com Dentsply International, York, PA 800.877.0020, www.dentsply.com GC America Inc., Alsip, IL 800.323.7063, www.gcamerica.com Great Plains Dental, Sioux Falls, ND 605.339.2955, www.gplainsdental.com Henry Schein Inc., Melville, NY 800.372.4346, www.henryschein.com Heraeus Kulzer, South Bend, IN 800.431.1785, www.heraeus-dental-us.com Ivoclar Vivadent, Inc., Amherst, NY 800.533.6825, www.ivoclarvivadent.us Nobel Biocare, Mahwah, NJ 714.282.4800, www.nobelbiocare.com 3M ESPE, St. Paul, MN 888.364.3577, solutions.3M.com

www.agd.org General Dentistry Special Prosthodontics Section 491 CDE self 2 HOURS instruction CREDIT

Exercise No. 316 Implant Restorations

Subject Code 616 4. Adequate space for restoration in this case was The 15 questions for this exercise are based on the article obtained by Accelerated treatment protocols: Full arch treatment A. increasing the vertical dimension of with interim and definitive prostheses on pages 480-491. occlusion (VDO) and alveolectomy of the This exercise was developed by Steven E. Holbrook, DMD, maxilla and mandible. MAGD, in association with the General Dentistry Self- B. increasing the VDO and alveolectomy of Instruction committee. the maxilla only. C. alveolectomy of the maxilla and mandible Reading the article and successfully completing this without increasing the VDO. exercise will enable you to: D. increasing the VDO and alveolectomy of UÊÀiV}âiÊÌ iÊ>`Û>Ì>}iÃÊvÊi`>ÌiÊVVÕÃ>Ê the mandible only. >`}ÊvÊ«>ÌÃÆÊ UÊìÌvÞÊÌ iÊ«ÀV«iÃÊ>ÃÃV>Ìi`ÊÜÌ Êi`>ÌiÊ 5. In this case, the fit of the final frameworks was VVÕÃ>Ê>`}ÊvÊ«>ÌÃÆÊ>`Ê checked using UÊÕìÀÃÌ>`ÊÌ iÊ>VViiÀ>Ìi`Ê«ÀÃÌ `ÌVÃÊ A. a verification jig. protocol for the restoration of edentulous and B. the one screw test. partially edentulous patients. C. radiographic verification. D. abutment scanning. 1. In the Agliardi study using the “All-on-4” protocol, the definitive prostheses were placed 6. The accelerated protocol used in this case refers to A. on the day of implant placement. A. the elimination of the interim prosthesis to B. one week following implant placement. shorten treatment time. C. one to three months following implant B. the placement of an interim prosthesis to placement. allow immediate occlusal loading. D. four to six months following implant C. the use of a CAD/CAM generated stent to placement. speed implant placement. D. longer prosthodontic visits that were well 2. The vertical space recommended by the author for received by patients. implant restorative components and prosthesis is A. 5 to 8 mm. 7. The study by Ortorp & Jemt found a 10-year B. 9 to 11 mm. prosthesis cumulative survival rate (CSR) for the C. 12 to 15 mm. CAD/CAM group of 95.6% compared to a CSR of D. 16 to 19 mm. ____% for the casting group. A. 88.7 3. To ensure primary stability for immediate B. 92.3 occlusal loading, the author recommends that C. 96.5 implants are placed with a minimum insertion D. 98.3 torque of ____ Ncm. A. 20 8. The VDO was verified at the time of surgery by B. 35 the use of a C. 50 A. phonetic examination. D. 70 B. CAD/CAM generated appliance. C. cotton tip applicator. D. prefabricated stent.

492 November/December 2012 General Dentistry www.agd.org 9. According to Cooper et al, mandibular implants 13. A laboratory study by Drago et al determined that placed with high primary stability, immediately the fit of CAD/CAM implant frameworks were after extraction of periodontally compromised significantly better than the fit of cast frameworks teeth, rigidly splinted together with acrylic resin made from the same models. Eliasson et al prostheses, and placed into fully functional measured the precision of fit of milled titanium occlusion exhibited a post-implant placement CSR frameworks and concluded that no framework of _____% at 6 to 18 months. actually had a passive fit. A. 100 A. Both statements are true. B. 98 B. The first statement is true; the second is false. C. 88 C. The first statement is false; the second is true. D. 50 D. Both statements are false.

10. Strietzel reported that the median number of 14. The treatment time to remove the teeth and to implants in their retrospective chart review for place the implants and the interim prostheses maxillary fixed implant prostheses was ____. for the accelerated protocol used in this case was A. 4 approximately ____ hours. B. 6 A. two C. 9 B. four D. 12 C. six D. seven 11. One of the benefits of immediate occlusal loading is that the patient never has to wear a complete 15. The benefits of immediately loaded prostheses denture. Another benefit of immediate occlusal placed with the accelerated prosthodontics loading is that no patient adaptation is required. protocol compared to conventional dentures A. Both statements are true. include all of the following except one. Which is B. The first statement is true; the second is false. the exception? C. The first statement is false; the second is true. A. Minimal long-term bone loss D. Both statements are false. B. No palatal coverage C. Improved masticatory function 12. A clinically acceptable anterior-posterior spread D. Removable by patient was achieved in the mandible by A. placing two anterior implants, two implants in the canine areas, and two implants in the molar areas following nerve repositioning. B. the placement of six parallel implants anterior to the mental foramen. C. placing two distal tilted implants and two anterior implants relatively vertical. D. placing two short implants in the retromolar areas in addition to four implants anterior to the mental foramen.

Answer form is on page 552. Answers for this exercise must be received by October 31, 2013.

To enroll in Self-Instruction, click here.

www.agd.org General Dentistry Special Prosthodontics Section 493 Removable Prosthodontics CDE 2 HOURS CREDIT Impact of tooth loss on oral and systemic health

S. Offenbacher, MS, DDS, PhD n S.P. Barros, MS, DDS, PhD n S. Altarawneh, DDS n J.D. Beck, MS, PhD Z.G. Loewy, MS, PhD

Periodontitis is a primarily bacterial infection that is common in patterns for a number of genes. It appears that down-regulated dentate individuals, while denture stomatitis is a predominantly genes (whose functions are thereby diminished) are associated fungal infection that is common among denture wearers. Both with reduced epithelial barrier integrity. By contrast, there infections may increase a patient’s risk for chronic systemic infec- appears to be an association between up-regulated genes tion dissemination, and may in turn increase the risk of chronic, (which have enhanced function) and inflammatory responses inflammatory-based systemic diseases. Systemic diseases for that facilitate the ability of C. albicans to bind with and penetrate which chronic oral infections are believed to confer attributable the oral mucosa. risk include atherosclerotic and coronary disease, stroke, chronic Molecular biological approaches suggest that future therapeutic obstructive pulmonary disease, diabetes, and hypertension. It development could target reducing either the local inflammatory appears that invasive oral pathogens trigger a systemic inflamma- processor, the binding and attachment of C. albicans to the tory response via mediators released by the cardiovascular system oral mucosa, or both. Ongoing investigations are attempting to and liver, putting the patient at increased risk for these diseases. incorporate interventions into matrices, to provide a local and Data comparing gene expression between denture wearers with sustained presence to therapeutic interventions. and without denture stomatitis (and associated Candida albicans Received: June 6, 2012 infections) has demonstrated unique up- and down-regulation Accepted: June 26, 2012

eriodontal disease is character- obstructive pulmonary disease, and systemic disease, and the implica- ized as a localized chronic adverse pregnancy outcomes.1,3-6 tions for denture wearers. Pinflammation of the gingival While definitive causal associations and periodontal tissues that leads to with periodontitis have not been Periodontitis as a model the gradual and progressive destruc- proven clearly to date, a chronic of an oral-systemic tion of connective tissue and loss systemic inflammatory process has infection pathway of bone structure that supports the proven to be a common underlying Periodontal disease provides a model teeth; it is considered to be bacte- principle for these associations.7-9 of infectious and inflammatory rial in origin.1 Up to 50% of the This article examines the poten- processes that can affect oral and U.S. population has been affected tial for similar associations in terms systemic health. Periodontal disease by mild-to-moderate forms of of edentulism and denture wearers. involves localized bacterial infection periodontitis.2 Its prevalence can be While the specific microbiology of and inflammation, as a number even higher in developing countries, dental and denture plaque differ— of commonly observed mediators where individuals have reduced the former is primarily bacterial of the innate immune response— access to routine dental care and may while the latter is more influenced including interleukins (for example, practice less effective dental hygiene. by yeast microbes—both can lead IL-1 and IL-6), tumor necrosis Over the past 20 years, extensive to sustained inflammatory tissue factor alpha (TNF-α), and prosta- research has demonstrated associa- responses. Denture stomatitis is glandins (for example, PGE2)—are tions between periodontal disease the common oral microbial-related released. The inflammatory response and an increased risk of such inflammatory condition among results in a loss of tissue integrity, illnesses as coronary heart disease, denture wearers, while periodontitis which appears clinically as increased atherosclerosis, acute vascular is most common among dentate probing depth and a loss of both diseases (such as stroke and myocar- individuals. This article focuses on bone-tooth periodontal attachment dial infarction), diabetes, chronic how these conditions can link to and alveolar bone structure. The

494 November/December 2012 General Dentistry www.agd.org loss of epithelial integrity allows sICAM-1) are significant risk factors periodontal disease (defined as bacterial pathogens within the oral for coronary disease.11 For com- 10 < 30%; n = 4,769), and mild biofilm to enter the systemic circula- parison, elevated cholesterol levels to no periodontitis (< 10%).16 This tion, promoting a further systemic (measured as total cholesterol, LDL- study used ultrasound to measure inflammatory response. cholesterol, or the ratio of total to intra medial wall thickness (IMT) In what can be seen as an expand- LDL cholesterol) show an increased of the carotid arteries. This study ing sequential cascade response, the risk for CVD by 200-300%, but found that subjects with severe orally derived inflammatory challenge elevated cholesterol levels have lesser periodontitis had 1.3 times the odds (together with the invasion of oral predictive value for risk than CRP. risk ratio (OR) significantly greater pathogenic bacteria) triggers systemic These findings indicate that the risks thickening of arterial walls (carotid inflammatory responses. One for cardiovascular events and the IMT ≥ 1 mm) among adults with response is the release of soluble intra- onset of Type 2 diabetes involve not severe periodontal disease compared cellular adhesion molecules (sICAMs) only abnormal lipid or carbohydrate to those with less severe periodontal by vascular endothelial cells. These metabolic pathways, but also include disease (OR = 1.31; 95% CI: sICAMS produce an inflammatory inflammatory conditions.12,13 At 1.03 - 1.66), after adjustment for activation of the entire vascular tree, present, there is insufficient evidence other atherosclerosis risk factors such which is a major part of the circula- to support the claim that periodontal as age, race/study center, gender, tory system in the human body. disease is a cause of CVD, diabetes, body mass index, LDL-cholesterol, A second response is the hepatic and so forth; however, it is clearly diabetes, hypertension, education, acute phase, in which the liver a risk factor or an effect modifier.14 smoking, and waist-to-hip ratio.16 In releases inflammatory mediators, The presence of periodontitis alters addition to increased risk of arterial including IL-6 and C-reactive pro- the cumulative lifetime trajectory wall thickening among subjects who tein (CRP). This hepatic response is path, increasing the risk of these dis- have not been diagnosed with CVD, designed to clear invasive organisms eases and affecting the severity of the periodontal disease also significantly (or their derived products, such as disease in the presence of other risk increases the risk of recurrent stroke. endotoxins) from the circulatory factors such as obesity and smoking. Sen et al examined stroke patients by system.10 These various hepatic The risk of chronic inflammation performing periodontal examinations inflammatory mediators have been leading to the development of CVD during hospitalization and assessing proven to further damage the vascu- is not trivial; more than 50% of all their medical status over a 20-month lature tree, especially the major elas- heart attacks occur in persons having follow-up period. Stroke patients tic vessels; IL-6, CRP, and systemic normal lipid profiles.15 In addition with a low percentage of diseased pathogenic bacteria all promote to recommending the monitoring periodontal sites had a much lower atherogenesis and arterial deposition of blood lipids, the American Heart likelihood of stroke recurrence than of oxidized low density lipoprotein Association recently recommended those with a high percentage of sites (LDL) cholesterol and enhance measuring plasma CRP as an affected by periodontitis. Perio- vascular plaque formation. The sys- important and independent predic- dontal disease had a hazard ratio temic inflammatory mediators target tor for risk of heart attack.15 of 3.69 (95% CI: 1.01 – 13.46) for multiple organ systems, exacerbate Periodontal disease not only stroke recurrence, even after adjust- chronic inflammatory diseases, and increases the risk for CVD and ing for confounding factors such as can increase risk for cardiovascular other diseases, it also is associated diabetes, hypertension, cholesterol, disease (CVD), insulin resistance and with the thickening of arterial and smoking.17 diabetes, renal disease, and complica- walls (atherosclerosis). Carotid tions associated with pregnancy. artery intima-media wall thickness Associations between Ridker reported that an elevation (IMT) has been associated with edentulism and denture in CRP (measured as high-sensitivity coronary heart disease and stroke. wearing for risk of CRP) increased the risk of cardiovas- A large study involving more than systemic disease cular events (including myocardial 6,000 persons with no prior his- Periodontitis is a disease which infarction and stroke) more than tory of coronary heart disease used requires the presence of dentition, as fourfold.11 It was also reported that standardized measures of attachment it is not observed among edentulous the elevation of other inflamma- loss to define severe periodontitis individuals, regardless of denture tory mediators (such as IL-6 and ( ≥ 30%; n = 1,248), moderate use. Among adults age 65 or older,

www.agd.org General Dentistry Special Prosthodontics Section 495 Removable Prosthodontics Impact of tooth loss on oral and systemic health

systemic organic disease, since poor denture hygiene produces a pathogenic denture plaque that could lead to local and systemic inflammatory responses. The literature has demonstrated an association between edentulism and chronic obstructive pulmonary disease (COPD). A recent study assessed the severity of COPD among 11,378 dentate and 2,087 edentate individuals by using standardized guidelines developed by the Global Initiative for Chronic Obstructive Lung Disease in 2006 (“GOLD Stages”), which rank COPD into four stages of increas- Fig. 1. Clinical photo of a Type III denture stomatitis case. ing severity (Stage I–IV) based on spirometry.29 The authors reported a positive association between edentulism and a significant increase in risk for severe COPD. By logistic periodontal disease is a greater risk In this population sample, the most regression analysis the OR for stage factor for tooth loss than caries; frequently observed oral lesion was 2 (moderate) COPD was increased however, the relative contribution of denture stomatitis (Type I—III), 2.1-fold (95% CI: 1.79–2.38) periodontal disease versus the relative with an overall prevalence of 6.0% and the OR for stage 3-4 (severe) contribution of caries in the terminal (see Figure 1).24 COPD was increased 3.4-fold (95% dentition leading to incident com- Like biofilm on natural teeth, CI: 2.61–4.69) among edentate plete edentulism is not known.18,19 denture biofilm is complex due versus dentate individuals. When Although periodontal disease is a to its organized structure and the the analysis included adjustments major cause of edentulism, reli- types and numbers of organisms for known COPD risk factors able estimates of how great a role present. A 2010 study by Glass et al (that is, race, gender, age, diabetes, periodontitis plays in edentulism identified more than 900 individual hypertension, CVD, smoking are elusive, as many factors (such as species of aerobic and anaerobic and tobacco use, alcohol use, and access to care) can affect tooth loss bacteria, yeasts, and amoebae within low sociodemographic status), the and rates of edentulism. Clearly, denture biofilm.20 Others have risk association was slightly lower most edentate individuals have a reported similar findings concerning (although still significant). The risk history of chronic exposure to oral the complex microbial content of of severe COPD is lowest among infections. The use of dentures does denture plaque.25 It has also been those with periodontally healthy not abrogate the potential for oral long recognized that unlike dental teeth, while dentate individuals with infection, as dentures have been biofilm, the biofilm that forms on periodontal disease are at higher risk, shown to be a major reservoir of denture materials harbors a much and edentulous individuals are at microbes and therefore a chronic larger population of yeasts. There even greater risk. After adjusting for source of infection and potential is a strong pathogenic association age, it would appear that edentulism inflammatory responses.20 Epide- between Candida yeasts (specifically is associated with risk of COPD for miological data suggest that denture C. albicans) and the presence of reasons that extend beyond a history stomatitis occurs in approximately denture stomatitis.21,23,26-28 of periodontal disease.29 50% of denture wearers.21-23 A six- It is likely that denture-associated Other studies have demonstrated year survey included a cohort of over microbes have effects similar to those associations between an increased 17,000 U.S. adults (both dentate associated with the dental plaque risk of diabetes mellitus and eden- and edentulous) who underwent a microflora, and the potential to tulism (or factors associated with comprehensive oral examination. contribute to (or increase the risk of) edentulism, such as C. albicans

496 November/December 2012 General Dentistry www.agd.org infection or denture stomatitis). risk is independent of associations using the Kapur index) did not In an uncontrolled observational with elevated cholesterol or triglyc- differ between subjects, regardless of study, Aly et al reported isolating erides, as there is no association in whether or not they had stomatitis.33 C. albicans from two-thirds of 439 terms of risk between edentulism Oral palatal punch biopsies were patients with diabetes mellitus.30 A and these parameters changing. The obtained from each subject. For 2000 study by Guggenheimer et al pattern for increased risk associations healthy subjects, samples were taken compared 405 insulin-dependent of major disease with edentulism from one ridge site; for subjects with diabetes mellitus patients and 268 is similar to that reported for denture stomatitis, one biopsy was non-diabetic controls, reporting that associations of systemic disease with taken from an area of mucosa which 15.1% of diabetic patients (com- periodontitis, as they both appear appeared healthy, and the other pared to 3.0% of control patients) to be risk factors or modulators from an inflamed ridge area. The had clinical candidiasis, including for the same diseases. However, for analysis of gene expression was car- median rhomboid glossitis, denture some diseases—especially congestive ried out using whole transcriptome stomatitis, and angular cheilitis. heart failure and coronary artery Affymetrix chips (Affymetrix, Inc.). Among those with diabetes, there disease—the risk may be greater Using a microchip array approach, was a significant association between among edentulous individuals than the Affymetrix analysis allows for C. Albicans pseudohyphae and smok- among those with natural teeth and simultaneous rapid screening of over ing (OR = 2.4), denture use (OR periodontal disease. 30,000 genes. Essentially, the tech- = 2.3), and elevated glycosylated nique can quantitatively identify hemoglobin (OR = 1.9).31 Dorocka- Denture-associated specific genes which are expressed Bobkowska et al found a high stomatitis as an inﬂammatory (at elevated or decreased levels) in incidence of Candida colonization mechanism a non-biased manner by searching among denture wearers with non- The authors of this article evalu- across the entire genome to identify insulin dependent diabetes, suggest- ated the inflammatory response in which mRNA species are being ing that patients with diabetes have denture stomatitis by comparing the expressed differentially to reflect the an increased risk of oral pathogenic patterns of mucosal gene expression activation or suppression of specific yeast infection, or perhaps a predis- in oral mucosa with the presence of genes. Comparing results of tissue position to these infections.32 inflammatory mediators in saliva, as biopsy samples from individuals Soon to be published data from a measure of candidate biomarkers. with healthy mucosa against those the Atherosclerosis Risk in Com- Subjects were edentulous, but other- from patients with denture stoma- munities study, conducted in part wise healthy adults 45 years of age or titis can provide insights regarding by the authors of this article, has older. All used at least a full maxil- the changes in gene expression and shown positive and significant risk lary denture, but did not have to use the cellular and biological processes associations between edentulism denture adhesive daily for retention occurring in the disease state. and congestive heart failure (more or comfort. Exclusion criteria An assay of the gene array expres- than a 2-fold increase in risk), included significant organic disease, sion profiles identified 3,034 genes coronary artery disease (a 1.5-fold chronic disease with oral manifesta- expressed differentially when healthy increase in risk), diabetes and tions other than denture stomatitis, denture wearers were compared to obesity (both demonstrating a 1- to conditions requiring antibiotic use those with C. albicans-associated 2-fold increase). Whether these prior to dental examinations, use of denture stomatitis. It is significant associations involve a causal or antibiotics or antifungals within the that among those with denture casual relationship is not understood month prior to and/or having initi- stomatitis, there was no difference at present. However, each logistic ated new medication(s) within three in the pattern of gene expression, model is independently adjusted for months prior to screening, and use regardless of whether the biopsies relevant confounders or risk factors, of tobacco products within the past were taken from inflamed or including age, race/center, gender, six months. Seventeen subjects had healthy-looking mucosa. In addi- smoking, hypertension, body mass no signs of denture stomatitis, while tion, there was no significant asso- index, blood lipid levels (cholesterol, 15 had Candida-associated denture ciation for age, gender, or race in HDL, LDL), and education, sug- stomatitis (confirmed by culture) terms of the patterns of differential gesting that these are specific asso- of Newton Stage 2 or 3 severity. gene expression in healthy denture ciations. Furthermore, the increased Denture fit and retention (assessed wearers and subjects with denture

www.agd.org General Dentistry Special Prosthodontics Section 497 Removable Prosthodontics Impact of tooth loss on oral and systemic health

Chart 1. An Affymatrix microchip analysis comparing the relative level of stomatitis, 71 genes displayed sig- gene activity between healthy denture wearers and denture wearers with nificant down-regulation of expres- conﬁrmed C. albicans-associated denture stomatitis. Change in gene activity sion, including several genes which is reported as the relative-fold decrease in activity among patients with encode proteins associated with the denture stomatitis compared to healthy controls. structure and integrity of the epithelial barrier (Chart 1). The reduced 2.5 expression of the genes and reduc- 0 tion in synthesis of the proteins they encode could alter epithelial barrier structure and increase its permeability. The increased amount of -5 hyphae inserted by C. albicans into underlying epithelial layers (and its submucosal penetration and colo- -10 nization) increases in subjects with

Numeric fold change in activity denture stomatitis. A correlation appears to exist between the expres- -15 desmocollin-1 repetin loricrin corneodesmosin keratin-10 liver arginase sion of genes and the structure of ﬁlaggrin keratin-2 hornerin keratin-1 keratin-76 the epithelial barrier with respect to Down-regulated gene permeability. The pattern of down- regulation observed in the patients with increased insertion of hyphae Chart 2. Affymatrix microchip analysis comparing the relative level of by C. albicans into the epithelial bar- gene activity between healthy denture wearers and denture wearers riers may provide some understand- with conﬁrmed C. albicans-associated denture stomatitis. Change in gene ing toward a mechanism that could activity is reported as the relative-fold increase in activity among patients be a factor in denture stomatitis. with denture stomatitis compared to healthy controls. Denture stomatitis is also associated with increased up-regulation (more 12 than 2-fold), reflecting the increased expression of 235 genes. Among patients with denture stomatitis, 9 genes with the greatest levels of up- regulation included those associated fl 6 with expression of in ammatory mediators (IL-1β and IL-8), che- mokines (for example, chemokine 3 ligand-1), and alarmin molecules

Numeric fold change in activity (for example, SERPIN-B1). As shown in Chart 2, two genes having 0 the highest level of up-regulation are lactotransferrin mucin-21 chemokine/ligand-1 selectin E interleukin-1β cell surface-associated serpin peptidase inhibitor-B1 interleukin-8 lactotransferrin (which is involved Up-regulated gene in the epithelial uptake of C. albicans) and mucin-21, which serves as a putative receptor for mucosal attachment of C. albicans. Genetic stomatitis. These results indicate that associated with denture stomatitis up-regulation in cases of denture the changes between dental wearers include both up- and down-regula- stomatitis reflects an increase in with healthy mucosa and those sub- tion. Charts 1 and 2 provide exam- the inflammatory response and the jects with denture stomatitis appear ples of genes undergoing changes in enhanced ability for C. albicans to be a disease-related response. response to denture stomatitis. For to bind to and penetrate the oral Changes in gene expression instance, in patients with denture epithelial mucosa.

498 November/December 2012 General Dentistry www.agd.org Denture stomatitis is associated of C. albicans on denture surfaces, Current therapeutic intervention with an increased (4- to 9-fold) up- implying that the denture is the in denture stomatitis often relies on regulation of endocytosis markers, source of the infection. use of antifungal agents to eliminate receptor molecules for C. albicans the fungal infection on denture mucosal binding, and inflamma- Summary surfaces and the oral mucosa. How- tory mediators; in addition, this Denture stomatitis is a common ever, as observed in the genetic and condition produces an increased condition that affects a large percent salivary analyses described above, (4- to 12-fold) down-regulation of denture wearers, and is associated inflammation is also a critical com- of both adhesion and epithelial with candidal infection and mucosal ponent in the activation response disruption markers. Typical inflammation. The source of the observed in denture stomatitis. activation pathways in stomatitis infection is the denture itself, which Incorporating an appropriate anti- include neutrophil, lymphocytic, provides a matrix that allows for the inflammatory therapeutic agent into and monocytic activation; and toll- development of a biofilm plaque a matrix could allow dentists to treat like receptor-2 (TLR-2)-mediated containing high levels of these yeasts denture stomatitis. innate immune responses, which and other infectious organisms release inflammatory mediators. which contribute to inflammation, Author information These patterns are consistent with a increased levels of mediators of Dr. Offenbacher is a Distinguished host-response that serves predomi- inflammation, and oral ridge resorp- Professor and Chair, Department of nantly as a defense against fungal tion observed in denture stomatitis. Periodontology, University of North infection rather than bacterial Patients who wear dentures are at Carolina School of Dentistry, infection; however, the denture- increased risk for several systemic Chapel Hill; where Dr. Barros is associated microbiome clearly pres- diseases, including COPD, heart a Research Associate Professor, ents a mixed infectious challenge. disease, atherosclerosis, hyperten- Department of Periodontology; and In addition to the genetic sion, congestive heart failure, and Dr. Beck is Executive Associate analysis, saliva samples were ana- diabetes. The increased risk for sys- Dean, Dental Research and Distin- lyzed (using standard analytical temic disease among denture wear- guished Professor, Department of approaches) to determine differ- ers is present even after adjusting Dental Ecology. Dr. Altarawneh is ences between healthy individuals for other relevant risk factors such an Assistant Professor, Department and stomatitis patients, in terms of as smoking, body mass, serum lipid of Prosthodontics, University of the levels and expression of inflam- levels (for example, cholesterol), Jordan. Dr. Loewy is Professor and matory mediators and other pro- education, age, race and gender. Chair, Department of Pharma- teins. This analysis demonstrated The role of unclean dentures as a ceutical and Biomedical Sciences, a direct activation of the inflam- chronic source of microbial infec- Touro College of Pharmacy, New matory process, as reflected by the tion contributing to systemic disease York City, and Professor of Micro- levels of inflammatory mediators has long been overlooked. Unclean biology and Immunology, New (such as interleukins and TNF-α) dentures may represent a previously York Medical College. increasing 2- to 5-fold. Differential unrecognized risk factor for systemic salivary proteins expressed in C. diseases and may explain why References albicans-associated denture stoma- people who have lost their teeth and 1. Friedewald VE, Kornman KS, Beck JD, Genco R, Goldﬁne A, Libby P, Offenbacher S, Ridker PM, titis include salivary gland products wear dentures have much poorer Van Dyke TE,Roberts WC, American Journal of as well as immunoglobulins and overall health and increased mor- Cardiology, Journal of Periodontology. The neutrophils; epithelial and tissue/ bidity and mortality compared to American Journal of Cardiology and Journal of Periodontology editors’ consensus: Periodontitis plasma proteins. Interestingly, those with healthy teeth and gums. and atherosclerotic cardiovascular disease. the patterns of the inflammatory Dentures are an important source of J Periodontol 2009;80(7):1021-1032. response observed in denture sto- sepsis and must be treated daily with 2. Eke PI, Dye BA, Wei L, Thornton-Evans GO, Gen- ff co RJ, CDC Peridontal Disease Surveillance matitis in the tissues are consistent e ective antifungal/antimicrobial Workgroup. Prevalence of periodontitis in adults with a fungal infection rather than agents. Additional study is needed in the United States: 2009 and 2010. J Dent a bacterial one. In addition, there to determine the potential benefits Res 2012; 91:914-920. 3. Beck JD, Offenbacher S. Systemic effects of peri- was a correlation between the of improved denture hygiene and odontitis: Epidemiology of periodontal disease levels of inflammatory mediators disinfection in terms of preventing and cardiovascular disease. J Periodontol 2005; observed in this study and the level adverse systemic diseases. 76(11 Suppl):2089-2100.

www.agd.org General Dentistry Special Prosthodontics Section 499 Removable Prosthodontics Impact of tooth loss on oral and systemic health

4. Boehm TK, Scannapieco FA. The epidemiology, Peripheral Vascular Disease, and Council on factors—A large cohort. J Oral Rehab 2007; consequences and management of periodontal Clinical Cardiology. Periodontal disease and 34(6):448-455. disease in older adults. J Am Dent Assoc 2007; artherosclerotic vascular disease: Does the evi- 24. Shulman JD, Beach MM, Rivera-Hildago F. The 138;(Suppl):26S-33S. dence support an independent association? A prevalence of oral mucosal lesions in U.S. 5. Scannapieco FA, Dasanayake AP, Chhun N. scientific statement from the American Heart adults: Data from the Third National Health and “Does periodontal therapy reduce the risk for Association. Circulation 2012; 125:2520-2544. Nutrition Examination Survey, 1988-1994. J Am systemic diseases?” Dent Clin North Am 2010; 15. Pearson TA, Mensah GA, Alexander RW, Ander- Dent Assoc 2004;135(9):1279-1286. 54(1):163-181. son JL, Cannon RO 3rd, Criqui M, Fadl YY, Fort- 25. Campos MS, Marchini L, Bernardes LA, Paulino 6. Xiong X, Buekens P, Fraser WD, Beck J, Offen- mann SP, Hong Y, Myers GL, Rifai N, Smith SC LC, Nobrega FG. Biofilm microbial communities bacher S. Periodontal disease and adverse preg- Jr, Taubert K, Tracy RP, Vinicor F, Centers for of denture stomatitis. Oral Microbiol Immunol nancy outcomes: A systematic review. BJOG Disease Control and Prevention, American Heart 2008;23(5):419-424. 2006;113(2):135-143. Association. Markers of inflammation and car- 26. Vanden Abbeele A, de Meel H, Ahariz M, Perrau- 7. Willerson JT, Ridker PM. Inflammation as a cardiovascular disease: Application to clinical and din JP, Beyer I, Courtois P. Denture contamina- diovascular risk factor. Circulation 2004;109(21 public health practice: A statement for health- tion by yeasts in the elderly. Gerodontology Suppl 1):II2-10. care professionals from the Centers for Disease 2008;25(4):222 -228. 8. Ridker PM. C-reactive protein and the prediction Control and Prevention and the American Heart 27. Ramage G, Tomsett K, Wickes BL, López-Ribot of cardiovascular events among those at inter- Association. Circulation 2003;107(3):499-511. JL, Redding SW. Denture stomatitis: A role for mediate risk: Moving an inflammatory hypothe- 16. Beck JD, Elter JR, Heiss G, Couper D, Mauriello Candida biofilms. Oral Surg Oral Med Oral sis toward consensus. J Am Coll Cardiol 2007; SM, Offenbacher S. Relationship of periodontal Pathol Oral Radiol Endod 2004;98(1):53-59. 49(21):2129-2138. disease to carotid artery intima-media wall 28. Dorko E, Jenca A, Pilipcinec E, Danko J, Svicky E, 9. Ridker PM, Silvertown JD. Inflammation, C-reac- thickness: The Atherosclerosis Risk in Communi- Tkacikova L. Candida-associated denture sto- tive protein, and atherothrombosis. J Periodon- ties (ARIC) study. Arterioscler Thromb Vasc Biol matitis. Folia Microbiol 2001;46(5):443-446. tol 2008;79(8 Suppl):1544-1551. 2001;21(11):1816-1822. 29. Suruki R, Loewy Z, Beck JD, et al. Chronic ob- 10. Sander LE, Sackett SD, Dierssen U, Beraza N, 17. Sen S, Poole R, Akhavan O, et al. Periodontal structive pulmonary disease (COPD) association Linke RP, Müller M, Blander JM, Tacke F, Traut- disease associated with recurrent vascular with edentulusm in community study. Presented wein C. Hepatic acute-phase proteins control events in stroke/TIA patients. Presented at: In- at: IADR/AADR/CADR 89th General Session & innate immune responses during infection by ternational Stroke Conference, Honolulu, HI, Exhibition, San Diego, CA, March 16-19, 2011. promoting myeloid-derived suppressor cell 2010. Abstract No. 2475. Abstract No. 148292. function. J Exp Med 2010; 207:1453-1464. 18. Beck JD, Elter JR. Analysis strategies for longitu- 30. Aly FZ, Blackwell CC, MacKenzie DA, Weir DM. 11. Ridker PM. Clinical application of C-reactive dinal attachment loss data. Community Dent Identification of oral yeast species isolated from protein for cardiovascular disease detection and Oral Epidemiol 2000;28(1):1-9. individuals with diabetes. Mycoses 1995;38(3-4): prevention. Circulation 2003;107(3):363-369. 19. Beck JD, Lawrence HP, Koch GG. Analytic ap- 107-110. 12. Pradhan AD, Manson JE, Rifai N, Buring JE, Rid- proaches to longitudinal caries data in adults. 31. Guggenheimer J, Moore PA, Rossie K, Myers D, ker PM. C-Reactive protein, interleukin 6, and Community Dent Oral Epidemiol 1997;25(1):42- Mongelluzzo MB, Block HM, Weyant R, Orchard risk of developing type 2 diabetes mellitus. 51. T. Insulin-dependent diabetes mellitus and oral JAMA 2001;286(3):327-334. 20. Glass RT, Conrad RS, Bullard JW, Goodson LB, soft tissue pathologies: II. Prevalence and char- 13. Schmidt MI, Duncan BB, Sharrett AR, Lindberg Mehta N, Lech SJ, Loewy ZG. Evaluation of acteristics of Candida and Candidal lesions. Oral G, Savage PJ, Offenbacher S, Azambuja MI, Tracy microbial flora found in previously worn pros- Surg Oral Med Oral Pathol Oral Radiol Endod RP, Heiss G. Markers of inflammation and theses from the Northeast and Southwest 2000;89(5):570-576. prediction of diabetes mellitus in adults (Ath- regions of the United States. J Prosthet Dent 32. Dorocka-Bobkowska B, Budtz-Jorgensen E, erosclerosis Risk in Communities study): A co- 2010;103(6):384-389. Wloch S. Non-insulin-dependent diabetes as a hort study. Lancet 1999;353(9165):1659-1652. 21. Budtz-Jorgensen E, Stenderup A, Grabowski M. risk factor for denture stomatitis. J Oral Pathol 14. Lockhart PB, Bolger AF, Papapanou PN, Osin- An epidemiologic study of yeasts in elderly den- Med 1996;25(8):411-415. bowale O, Trevisan M, Levison ME, Taubert KA, ture wearers. Commun Dent Oral Epidemiol 33. Kapur KK. A clinical evaluation of denture adhe- Newburger JW, Gonik HL, Gewirtz MH, Wilson 1975;3(3):115-119. sives. J Prosthet Dent 1967;18(6):550-558. WR, Smith SC Jr, Baddour LM., American Heart 22. Arendorf TM, Walker DM. Denture stomatitis: A Association Rheumatic Fever, Endocarditis, and review. J Oral Rehab 1987;14(3):217-227. Kawasaki Disease Committee of the Council on 23. Figueiral MH, Azul A, Pinto E, Fonseca PA, Bran- Manufacturer Cardiovascular Disease in the Young, Council co FM, Scully C. Denture-related stomatitis: Affymetrix, Inc., Santa Clara, CA on Epidemiology and Prevention, Council on Identification of aetiological and predisposing 888.362.2447, www.affymatrix.com

500 November/December 2012 General Dentistry www.agd.org CDE self 2 HOURS instruction CREDIT

Exercise No. 317 Removable Prosthodontics

Subject Code 670 5. The C-reactive protein (CRP) response from the The 15 questions for this exercise are based on the article liver is designed to Impact of tooth loss on oral and systemic health on pages A. clear invasive organisms. 494-500. This exercise was developed by Daniel S. Geare, B. reduce the inﬂammatory response. DMD, in association with the General Dentistry Self- C. activate liver enzymes. Instruction committee. D. reduce blood pressure.

Reading the article and successfully completing the 6. CRP has also been shown to affect all of the exercise will enable you to understand: following except one. Which is the exception? UÊÌ iÊÀÃÃÊ>`Ê>ÌÕÀiÊvÊ«iÀ`Ì>Ê`Ãi>ÃiÆ A. Atherogenesis UÊÌ iÊ>ÌÕÀiÊvÊìÌÕÀiÊÃÌ>ÌÌÃÆÊ>` B. Insulin resistance UÊÌ iÊ i>Ì ÊÀÃÃÊvÊìÌÕÀiÊÃÌ>ÌÌÃ° C. Development of coronary disease D. Blood clotting 1. Periodontitis affects up to ______of adults in the United States. 7. Approximately ______of denture wearers A. 50% experience denture stomatitis. B. 55% A. 25% C. 67% B. 33% D. 72% C. 50% D. 75% 2. Periodontitis is characterized as A. generalized chronic inflammation. 8. The predominant infectious agents on denture B. gradual destruction of connective tissue. biofilms are C. predictable loss of bone. A. bacterial. D. having multiple infectious causes. B. viral. C. fungal. 3. Periodontitis is presently associated with all D. protozoan. of the following conditions except one. Which is the exception? 9. There is an increased risk of COPD in edentate A. Diabetes individuals. This is because the organisms of B. Oropharyngeal cancer periodontal disease have been associated with C. Acute coronary syndrome the development of COPD. D. COPD A. Both statements are true. B. The first statement is true; the second is false. 4. Periodontal bacterial infection results in a C. The first statement is false; the second is true. sequential cascading response. Aspects of this D. Both statements are false. response include the soluble intracellular adhesion molecule response as well as the hepatic acute 10. According to the ARIC study, edentulism is phase response. associated with increased risk of all of the A. Both statements are true. following except one. Which is the exception? B. The first statement is true; the second is false. A. Coronary artery disease C. The first statement is false; the second is true. B. Elevated lipid levels D. Both statements are false. C. Elevated body fat D. Elevated blood sugar levels

www.agd.org General Dentistry Special Prosthodontics Section 501 11. In cases of denture stomatitis, gene expression 14. Unclean dentures can contribute to all of the of oral mucosa can following except one. Which is the exception? A. increase epithelial permeability. A. COPD B. increase susceptibility of Candida infections. B. Chronic infection C. track the similarity patterns of age, gender, C. Peripheral neuropathy and race. D. Atherosclerosis D. make the patient more susceptible to oral cancer. 15. Historically, treating denture stomatitis involved eliminating the fungal infections on the denture 12. Identified genes associated with epithelial uptake surface. It is important to now include anti- of Candida albicans include all of the following inflammatory agents as part of the treatment except one. Which is the exception? modality. A. Lactotransferrin A Both statements are true. B. Interleukin 1β B. The first statement is true; the second is false. C. Liver arginase C. The first statement is false; the second is true. D. Chemokine D. Both statements are false.

13. “Up-regulation” of genes is associated with A. increased permeability of epithelium. B. increased inﬂammatory response. C. controlling bacterial byproducts. D. controlling tissue uptake.

Answer form is on page 552. Answers for this exercise must be received by October 31, 2013.

To enroll in Self-Instruction, click here.

502 November/December 2012 General Dentistry www.agd.org Complete Dentures

Removable partial denture assisted by implant-retained ﬁxed prosthesis opposing implant-retained overdenture

Hyun-seok Nam, DDS, MS n Kwang-yeob Song, DDS, MS, PhD n Ju-mi Park, DDS, MS, PhD n Won-suk Oh, DDS, MS

Restoring an edentulous mouth is a challenge when the patient extension-base removable partial denture opposing a mandibular has both high esthetic expectations and ﬁnancial limitations. implant-retained overdenture. The patient’s clinical outcome after This case report describes the prosthodontic management of 30 months is presented. an elderly edentulous patient with a maxillary anterior implant- Received: October 31, 2011 supported ﬁxed partial denture in conjunction with a distal Accepted: February 13, 2012

ndosseous dental implants are main problems with IODs are mandibular IOD. The implants used frequently to provide eden- continuous resorption of the bone were found to be stable with no Etulous patients with support, underneath the denture base and prosthetic complications after 30 stability, and retention for dental the patient’s lack of self-esteem, months of follow-up evaluation, prostheses.1,2 The patient’s comfort since removing the denture often and met the patient’s demands for and function are enhanced by secur- leaves patients with no teeth present esthetics and function. ing a prosthesis to the implants.3-7 in the mouth.16-19 The prosthesis often is firmly con- Currently available implants have Case report nected to the implants to satisfy the moderately rough surfaces, which A 68-year-old woman complained patient’s esthetic demands and to appear to accelerate tissue healing, of difficulty with her conventional avoid an unpleasant experience with withstand stresses, and enhance the maxillary and mandibular remov- removal of dentures.1,8-10 However, remodeling capacity of the bone.20-22 able dental prostheses and sought a many edentulous patients cannot With the development of this fixed dental prosthesis in the ante- afford a fixed prosthesis that may enhanced surface, the clinical appli- rior portion of the maxilla. Her past require a large number of implants, cation of the implant treatment has medical history was not specific. additional surgical procedures, and been widely expanded to support, An intraoral examination controlled systemic conditions.10-12 stabilize, and retain a removable revealed complete edentulism of the Restoring an edentulous mouth partial denture (RPD) where the maxilla and the mandible (Fig. 1) with implant-retained overdentures anterior portion of the edentulous with moderately compromised (IODs) is a practical approach for mouth is restored with an implant- reducing the cost of treatment while supported fixed partial denture satisfying the patient’s need for (FPD).23-25 An RPD is subsequently esthetics and function.2-4,10,13,14 Using designed to restore a posterior por- IODs also eliminates the need for tion of the edentulous arch. The additional surgical procedures, such patient’s comfort and esthetics are as augmentation of the enlarged maintained as the anterior teeth sinus, lateral displacement of the remain in the mouth even after the inferior alveolar nerve, and distrac- denture is removed.23-25 tion osteogenesis.2,10,13 The dentures This case report describes a patient are secured by implants placed in whose edentulous maxilla was the anterior portions of the maxilla restored with an anterior implant- and the mandible and acrylic resin supported FPD and a distal exten- Fig. 1. The edentulous mouth at estimated restores the lost tissues.2,10,14,15 The sion-base RPD against an opposing vertical dimension.

www.agd.org General Dentistry Special Prosthodontics Section 503 Complete Dentures RPD assisted by implant-retained ﬁxed prosthesis

residual ridges of both arches. material (Exafine Regular Type, The patient preferred to avoid the GC America Inc.) and poured in a extensive surgical intervention and Type IV dental stone (Fujirock, GC high cost of treatment. Several America Inc.) to create the master treatment options were proposed, casts. The casts were mounted on including no treatment, complete an articulator to arrange artificial dentures (CDs), implant-supported denture teeth (Endura Anterio, FPDs, IODs, implant-supported Shofu Dental Corp.) in the occlu- Fig. 2. A panoramic radiograph demonstrating FPDs in conjunction with RPDs, sion rims. The wax-trial dentures dental implants in maxilla and mandible. Note and combinations of the above. were evaluated intraorally and two-stage implants in maxilla and one-stage The patient chose an anterior indexed with a silicone putty implants in mandible. implant-supported FPD and a distal impression material to duplicate the extension-base RPD for the maxilla position of the teeth and aid in sub- and an IOD for the mandible. sequent prosthodontic procedures. Using stock trays, diagnostic casts The maxillary implants were were made from irreversible hydro- placed under function by means colloid materials (Aroma Fine DF of an anterior provisional implant- III, GC America Inc.). Impressions supported FPD made of tooth- of the edentulous arches were made colored autopolymerizing acrylic and mounted on an articulator resin (Tokuso CureFast; Tokuyama (PROTAR evo 7, KaVo Dental) for Dental) that used temporary abut- diagnostic waxing. Using surgical ments (RN synOcta, Straumann) Fig. 3. A maxillary interim implant-supported guides, eight regular-neck endosse- (Fig. 3). The posterior occlusion FPD with interim RPD. ous dental implants (SLA Implant, was established with a maxillary Straumann) were placed: four interim RPD against a mandibular two-stage implants in the maxilla at interim CD to evaluate esthetics the right canine and left first molar and function. (4.1 mm x 10 mm) and right second Four separate individual custom premolar and left first premolar abutments were waxed (using non- (4.1 mm x 12 mm) sites, and four segmented cast abutments with a one-stage implants in the mandible silicone index), milled, and cast in a at the right and left lateral incisor Type III gold. A full-contour waxing (4.1 mm x 12 mm) and right and was performed over the custom left first premolar (4.1 mm x 10 mm) abutments (to create an anterior, Fig. 4. Metal framework of the implant-supported sites (Fig. 2). Two weeks following resin-veneered, implant-supported FPD placed on maxillary implants by means of the implant placement, the existing fixed partial denture metal frame- individual custom abutments. Note screw access dentures were relined with a resilient work) and surveyed to create guiding holes over abutments for retrieving the prosthesis. material (Visco-Gel, Dentsply planes, rest seats, and undercut areas DeTrey), which was replaced every and to design a distal extension-base other week for six months. RPD. A mandibular implant-reten- After the second-stage surgery, tion bar was designed to connect the an open-tray technique was used mandibular implants as a one-unit to make impressions of the maxil- and to present Hader bar segment lary and mandibular arches.26 The (Hader-EDS Bar System, Attach- impression copings were placed on ments International) in the middle the implants and connected to each and extra-coronal resilient attach- other with an acrylic resin (Pattern ments (ERA Attachment, Sterngold Resin LS, GC America Inc.). Using Dental) at each end. To ensure the Fig. 5. Mandibular implant-retention bar con- border-molded custom trays, the health of the gingival tissue and nected to implants demonstrating attachment impressions were made with a vinyl allow for an esthetic arrangement elements for IOD. polysiloxane (VPS) impression of artificial denture teeth, a waxing

504 November/December 2012 General Dentistry www.agd.org Fig. 6. Distal extension-base RPD Fig. 7. The completed maxillary implant- Fig. 8. A periapical radiograph taken 30 with anterior resin-veneered implant- supported FPD and RPD opposing mandibular months after treatment, demonstrating stable supported FPD. IOD placed intraorally. implants and precise implant-abutment ﬁts.

was performed using non-segmented abutments. The screw access holes screwed and torqued to 35 Ncm castable abutments with the silicone were filled with a composite resin to the implants. The occlusion was index. The wax bar was milled (Filtek Z250, 3M ESPE). first adjusted with the prostheses and the attachment elements were Using border-molded custom mounted on an articulator, then secured in line by placing the IOD trays, final impressions for a maxil- refined intraorally using a computer- with a dental surveyor (Ney Dental lary RPD and a mandibular IOD ized occlusal analysis system (T-scan Surveyor, Dentsply Prosthetics). were made with a VPS impression III, Tekscan Inc.) to harmonize with The waxed implant-supported material (Exafine Regular Type, GC the patient’s oral function (Fig. 7). FPD framework was invested and America Inc.). The implant-reten- The patient was provided with cast using a nickel-chrome alloy tion bar was taken in the impression post-insertion instructions and (T-3 C&B Alloy, CMP Industries), for constructing the IOD. returned for regular follow-up while the bar was cast using a A distal extension-base maxillary appointments. Using an acrylic resin, Type III gold alloy. The finished RPD was designed to restore the the plastic matrices of the attach- metal frameworks were fitted posterior occlusion of the maxilla ment elements were connected intra- intraorally using a screw test and with the maxillary major connector orally to the IOD at the three-week a silicone material (Fit Tester, GC of a modified palatal strap, occlusal recall appointment. Thirty months America Inc.) to ensure a passivity rests over the implants, and wrought after placement of the prostheses, the of the frameworks.27 The fit of the wire clasp retainers. The cast and fin- patient showed no signs or symp- implant-supported FPD framework ished metal framework (made from toms of biologic and mechanical was evaluated over the custom a chrome-cobalt alloy) was fitted complications, although the plastic abutments placed on the implants intraorally and adjusted to avoid a matrices of the attachment elements (Fig. 4 and 5). binding against the abutment tooth are replaced at every six-month recall The fitted implant-supported under occlusal function (Fig. 6).28 appointment (Fig. 8). FPD metal framework was veneered The maxillary and mandibular using an acrylic resin (Vertex SC, master casts were mounted on an Discussion Vertex Dental) and artificial den- articulator and artificial denture teeth The edentulous mandible com- ture teeth (Endura Anterio, Shofu were arranged in the occlusion rims. monly receives two or four implants Dental Corp.) from the right first Following an intraoral evaluation, for an IOD in its anterior portion premolar to the left first premolar the wax dentures were processed with where the prosthesis is either across the arch. The custom abut- a heat-polymerized acrylic resin (SR- retained by means of individual ments were screwed and torqued to Ivocap, Armstrong Laboratory, Inc.), attachments or an implant con- 35 Ncm to the implants, and the finished, and polished. necting bar.2,3,10,13,15 The design of processed and finished implant- The RPD and IOD were fitted the prostheses does not appear to supported FPD was luted with a intraorally using a silicone material be critical to the success of man- resin cement (Premier Implant and a tungsten carbide bur, with the dibular IODs with modern implant Cement, Premier Dental) on the mandibular implant-retention bar surfaces; however, the prosthetic

www.agd.org General Dentistry Special Prosthodontics Section 505 Complete Dentures RPD assisted by implant-retained ﬁxed prosthesis

complications appear to be lower prostheses, where complication The occlusion was equilibrated to when bar-retained IODs are used rates with fixed restorations were centralize the masticatory forces with rather than ball-retained IODs.3,4,29 not recurrent incidents and did not a lingualized occlusion scheme and In the present case, the implants increase over time.29 eliminate interferences in eccentric were placed bilaterally in the lateral The abutment fit to dental positions.33 The anterior guidance incisor and premolar sites that were implants should be passive to avoid was minimal to reduce a lever action to be connected with a metal bar, biologic and mechanical complica- on the implants. The patient was where the bar conformed with the tions.5,6,30 To eliminate potential instructed not to use the anterior patient’s arch shape and aligned the strain at the abutment-implant teeth in mastication and encouraged axis of rotation of the prosthesis interface due to an improper fit, the to return for regular recall appoint- with the patient’s transverse hori- individual custom abutments of a ments. A 30-month follow-up evalu- zontal axis.2,10,13,15 In general, the high-noble alloy were connected ation indicated that the implants bar design appears to enhance the to the implants with screws before were stable; however, the validity of patient’s comfort by guiding the the FPD was cemented over the this treatment mode has yet to be path of denture placement, increas- abutments.8 This cement- and screw- determined scientifically in terms ing the stability and support of a retained prosthesis is retrievable; the of ensuring long-term success and denture, and promoting a uniform screw access holes prepared in the promoting the patient’s oral health. stress distribution to the support- denture were in line with those in ing structure of the tissue.3,4,29 The the abutments.9 This method may Summary denture retention does not appear to be a viable option for satisfying a Restoring an edentulous maxilla diminish significantly over time.3,4 patient’s demands for affordable with a combination of an anterior Restoring an edentulous maxilla esthetics and function. However, implant-supported fixed partial using dental implants can be chal- care should be taken to avoid using denture and a distal-extension RPD lenging because of the configuration a base metal alloy on patients experi- against a mandibular IOD may of the residual ridge, quality of the encing hypersensitivity, particularly benefit some patients by eliminating bone, and the patient’s expectation in the U.S., where the prevalence of the psychological discomfort associ- for esthetics.11,18 In general, four nickel allergy is relatively high.31 ated with the lack of the maxillary implants are placed in the anterior The maxillary posterior segments anterior teeth once a denture is portion of the maxilla to support were restored with a conventional removed. This article examined the an IOD when a patient’s systemic distal extension-base RPD to oppose clinical outcome of an elderly eden- and anatomic conditions make the mandibular IOD, support the tulous patient who received a maxil- constructing an implant-supported position of the condyle, provide lary implant-supported fixed partial FPD unsuitable.12,19 However, bilateral loading in centric, and denture and a distal-extension the patient’s oral health can be harmonize with the patient’s oral RPD against a mandibular IOD to compromised by failing to comply functions.23-25 Support for the RPD maximize comfort and esthetics. with denture removal at night. The was obtained from the implants, the Additional studies are necessary mucosa may become inflamed; pos- residual ridges, and the palate by to determine the validity of this sible parafunctional activities may means of the occlusal rests, the den- prosthodontic treatment for restor- induce biologic and prosthetic com- ture bases, and the maxillary major ing an edentulous mouth. plications such as peri-implantitis, connector of a modified palatal strap. bone loss, and loosening of the The rests were designed to direct the Disclaimer attachment elements.14,19 forces along the implants and con- The authors have no financial, An anterior implant-supported trol the RPD’s rotation, keeping the economic, commercial, and/or pro- FPD may provide better esthetics axis of rotation over the rest seats.28 fessional interests related to topics and enhance the patient’s psycholog- The wrought wire clasp retainers presented in this manuscript. ical comfort without compromising were soldered to the retentive mesh speech in a relatively well-preserved area to maintain flexibility without Author information maxilla.12,24 According to Nedir et recrystallizing the wire. In addition, Dr. Nam is a former graduate stu- al, implants with fixed prostheses minimum undercuts (0.01 in) were dent, Department of Prosthodon- demonstrated significantly lower utilized to avoid lateral forces on the tics, Chonbuk National University, complication rates than removable implants under function.32 Chonju, Korea. Dr. Song and

506 November/December 2012 General Dentistry www.agd.org Dr. Park are professors, Depart- 12. Lewis S, Sharma A, Nishimura R. Treatment of 27. McDonnell T, Houston F, Byrne D, Gorman C, ment of Prosthodontics, Chonbuk edentulous maxillae with osseointegrated im- Claffey N. The effect of time lapse on the accu- plants. J Prosthet Dent 1992;68(3):503-508. racy of two acrylic resins used to assemble an National University, Chonju, 13. Attard N, Wei X, Laporte A, Zarb GA, Ungar WJ. implant framework for soldering. J Prosthet Korea. Dr. Oh is a clinical associate A cost minimization analysis of implant treat- Dent 2004;91(6):538-540. professor, Department of Biologic ment in mandibular edentulous patients. Int J 28. Kratochvil FJ, Caputo AA. Photoelastic analysis Prosthodont 2003;16(3):271-276. of pressure on teeth and bone supporting re- and Materials Sciences, Division 14. Naert I, Gizani S, Van Steenberghe D. Rigidly movable partial dentures. J Prosthet Dent 1974; of Prosthodontics, University of splinted implants in resorbed maxilla to retain a 32(1):52-61. Michigan School of Dentistry in hinging overdenture: A series of clinical reports 29. Nedir R, Bischof M, Szmukler-Moncler S, Belser for up to 4 years. J Prosthet Dent 1998;79(2): UC, Samson J. Prosthetic complications with Ann Arbor. 156-164. dental implants: From an up-to-8-year experi- 15. Sadowsky SJ. The implant-supported prosthesis ence in private practice. Int J Oral Maxillofac References for the edentulous arch: Design considerations. Implants 2006;21(6):919-928. 1. Lindquist LW, Carlsson GE. Long-term effects on J Prosthet Dent 1997;78(1):28-33. 30. Kano SC, Bonfante G, Hussne R, Siqueira AF. Use chewing with mandibular fixed prostheses on 16. Jacobs R, Schotte A, Van Steenberghe D, Qui- of base metal casting alloys for implant frame- osseointegrated implants. Acra Odontol Scand rynen M, Naert I. Posterior jaw bone resorption work: Marginal accuracy analysis. J Appl Oral Sci 1985;43(1):39-45. in osseointegrated implant overdentures. Clin 2004;12(4):337-343. 2. Thomason JM. The McGill Consensus Statement Oral Implants Res 1992;3(2):63-70. 31. Thyssen JP, Menne T. Metal allergy—A review on Overdentures. Mandibular 2-implant over- 17. Fiske J, Davis DM, Frances C, Gelbier S. The emo- on exposures, penetration, genetics, prevalence, dentures as first choice standard of care for tional effects of tooth loss in edentulous people. and clinical implications. Chem Res Toxicol edentulous patients. Eur J Prosthodont Restor Br Dent J 1998;184(2):90-93; discussion 79. 2010;23(2):309-318. Dent 2002;10(3):95-96. 18. Hutton JE, Heath MR, Chai JY, Harnett J, Jemt T, 32. Brudvik JS,Wormley JH. Construction techniques 3. Naert I, Quirynen M, Hooghe M, Van Steenber- Johns RB, McKenna S, McNamara DC, van for wrought-wire retentive clasp arms as related ghe D. A comparative prospective study of Steenberghe D, Taylor R, et al. Factors related to to clasp flexibility. J Prosthet Dent 1973;30(5): splinted and unsplinted Branemark implants in success and failure rates at 3-year follow-up in 769-774. mandibular overdenture therapy: A preliminary a multicenter study of overdentures supported 33. Phoenix RD, Engelmeier RL. Lingualized occlusion report. J Prosthet Dent 1994;71(5):486-492. by Branemark implants. Int J Oral Maxillofac revisited. J Prosthet Dent 2010;104(5):342-346. 4. Naert I, Gizani S, Vuylsteke M, Van Steenberghe Implants 1995;10(1):33-42. D. A 5-year prospective randomized clinical trial 19. Mericske-Stern R. Treatment outcomes with im- Manufacturers on the influence of splinted and unsplinted oral plant-supported overdentures: Clinical consider- Armstrong Laboratory Inc., Louisville, KY implants retaining a mandibular overdenture: ations. J Prosthet Dent 1998;79(1):66-73. 502.583.7631, www.armstronglab.com Prosthetic aspects and patient satisfaction. 20. Ogawa T, Nishimura I. Genes differentially expressed in titanium implant healing. J Dent Res Attachments International, San Mateo, CA J Oral Rehabil 1999;26(3):195-202. 888.649.6425, www.implantdirect.com 5. Drago C, Saldarriaga RL, Domagala D, Almasri 2006;85(6):566-570. CMP Industries, Albany, NY R. Volumetric determination of the amount of 21. Huang HL, Hsu JT, Fuh LJ, Lin DJ, Chen MY. Bio- 800.833.2343, www.cmpindustries.com misfit in CAD/CAM and cast implant frame- mechanical simulation of various surface rough- works: A multicenter laboratory study. Int J Oral nesses and geometric designs on an Dentsply DeTrey, Konstanz, Germany Maxillofac Implants 2010;25(5):920-929. immediately loaded dental implant. Comput 49.0.7531.583.0, www.dentsply.de 6. Karl M, Graef F, Heckmann S, Taylor T. A method- Biol Med 2010;40(5):525-532. Dentsply Prosthetics, York, PA ology to study the effects of prosthesis misfit over 22. Abrahamsson I, Berglundh T, Linder E, Lang NP, 800.786.0085, www.prosthetics.dentsply.com time: An in vivo model. Int J Oral Maxillofac Im- Lindhe J. Early bone formation adjacent to rough and turned endosseous implant surfaces. GC America Inc., Alsip, IL plants 2009;24(4):689-694. 800.323.7063, www.gcamerica.com 7. Winter W, Mohrle S, Holst S, Karl M. Bone load- An experimental study in the dog. Clin Oral Im- ing caused by different types of misfits of implants Res 2004;15(4):381-392. KaVo Dental, Charlotte, NC plant-supported fixed dental prostheses: 23. Pellecchia M, Pellecchia R, Emtiaz S. Distal ex- 888.275.5286, www.kavousa.com A three-dimensional finite element analysis tension mandibular removable partial denture Premier Dental, Plymouth Meeting, PA based on experimental results. Int J Oral Maxillo- connected to an anterior fixed implant-support- 888.670.6100, www.premusa.com ed prosthesis: A clinical report. J Prosthet Dent fac Implants 2010;25(5):947-952. Shofu Dental Corp., San Marcos, CA 2000;83(6):607-612. 8. Baig MR, Rajan G. Full-arch metal-resin cement- 760.736.3277, www.shofu.com and screw-retained provisional restoration for 24. Starr NL. The distal extension case: An alterna- Sterngold Dental, Attleboro, MA immediately loaded implants. J Oral Implantol tive restorative design for implant prosthetics. 508.226.5660, www.sterngold.com 2010;36(3):219-223. Int J Periodontics Restorative Dent 2001;21(1): 9. Patel D, Invest JC, Tredwin CJ, Setchell DJ, Moles 61-67. Straumann, Andover, MA DR. An analysis of the effect of a vent hole on 25. Chronopoulos V, Sarafianou A, Kourtis S. The use 978.747.2500, www.straumann.com excess cement expressed at the crown-abut- of dental implants in combination with remov- Tekscan Inc., South Boston, MA ment margin for cement-retained implant able partial dentures: A case report. J Esthet Re- 800.248.3669, www.tekscan.com crowns. J Prosthodont 2009;18(1):54-59. stor Dent 2008;20(6):355-364; discussion 365. 26. Sorrentino R, Gherlone EF, Calesini G, Zarone F. Tokuyama Dental Co., Encinitas, CA 10. DeBoer J. Edentulous implants: Overdenture ver- 760.942.7211, www.tokuyama-us.com sus fixed. J Prosthet Dent 1993;69(4):386-90. Effect of implant angulation, connection length, 11. Beumer J 3rd, Hamada MO, Lewis S. A prostho- and impression material on the dimensional Vertex Dental, Zeist, Netherlands dontic overview. Int J Prosthodontics 1993; accuracy of implant impressions: An in vitro 30.697.6749, www.vertex-dental.com 6(2):126-130. comparative study. Clin Implant Dent Relat Res 3M ESPE, St. Paul, MN 2010;12 (I Suppl) 1:e63-e76. 888.364.3577, solutions.3m.com

www.agd.org General Dentistry Special Prosthodontics Section 507 Implant Restorations

Sequential provisional implant prosthodontics therapy

Ira D. Zinner, DDS, MSD n Stanley Markovits, DDS, MAGD n Curtis E. Jansen, DDS n Patrick E. Reid, CDT, MDT Yale E. Schnader, DDS n Herbert J. Shapiro, DDS

The fabrication and long-term use of first- and second-stage with late failures and/or for the necessity to repair the definitive provisional implant prostheses is critical to create a favorable prosthesis. In addition, the screw-retained provisional prosthesis is prognosis for function and esthetics of a fixed-implant supported used if and when an implant requires removal or other implants to prosthesis. The fixed metal and acrylic resin cemented first-stage be placed in a sequential approach. The creation and use of both prosthesis, as reviewed in Part I of this article, is needed for first- and second-stage provisional prostheses involve a restorative prevention of adjacent and opposing tooth movement, pressure dentist, dental technician, surgeon, and patient to work as a team. on the implant site as well as protection to avoid micromovement If the dentist alone cannot do diagnosis and treatment planning, of the freshly placed implant body. The second-stage prosthesis, surgery, and laboratory techniques, he or she needs help by reviewed in Part II, should be used following implant uncovering employing the expertise of a surgeon and a laboratory technician. and abutment installation. The patient wears this provisional This team approach is essential for optimum results. prosthesis until maturation of the bone and healing of soft Received: October 21, 2011 tissues. The second-stage provisional prosthesis is also a fail-safe Final revisions: January 30, 2012 mechanism for possible early implant failures and also can be used Accepted: March 15, 2012

mong the various prosthodon- explained to the patient prior to any The rationale and technique for tic procedures employed in treatment. Alternative treatments utilization of provisional prostheses Athe creation of an implant- with risks and benefits may also be will be presented in two parts. supported prosthesis, the two least presented. The restorative dentist understood yet quite important must explain why implant dentistry Part I. Technique for fabrication phases are the fabrication of first- is the preferred course and the stan- of ﬁrst-stage ﬁxed provisional and second-stage provisional pros- dard of care for prosthetic problems prostheses: Fixed metal and theses. These provisional prostheses rather than utilizing conventional acrylic provisional prostheses enable the patient and restorative prosthodontic treatment. Diagnostic casts are made and dentist to predictably create a The patient will wear the fabri- mounted with a facebow transfer cosmetic and functional result.1 The cated transitional prostheses from and verified intraoral maxillo- diagnostic wax-up is a requirement first-stage through the insertion of mandibular records. The team prior to any treatment and the basis the definitive prosthesis. This allows should then perform a diagnostic for the proposed prosthesis. This the patient to become accustomed to analysis of the patient and in wax-up is then duplicated and casts the esthetics, contours, and occlusion particular note any parafunctional of the wax-up are poured. They of the restoration that is created from habits that would tend to complicate are used for case presentation to the first day of treatment. Whether the selected treatment. A diagnostic the patient to explain and illustrate it is created by a dentist alone or analysis should aid the practitioner in the proposed definitive result. The a technician and surgeon working determining the presence of an even wax-up is also used to create the together, the first-stage provisional and harmonious occlusal plane, cemented fixed first-stage provisional prosthesis and then the second-stage both inter-arch and intra-arch. The prosthesis, a surgical template, which provisional prosthesis should be used dentist should then be able to deter- is the basis for the retrievable screw- as the architectural design of the mine where any deflective occlusal retained second-stage provisional definitive prosthesis, so as to help contacts are and correct them. The prostheses.2-5 The risks and benefits the patient visualize and become practitioner should relate to the of implant prosthodontics should be accustomed to the end result. patient the clinical diagnosis and

508 November/December 2012 General Dentistry www.agd.org Fig. 2. Completed wax-up sprued for casting in a non-precious alloy Fig. 1. Wax-up for maxillary metal and acrylic ﬁxed posterior ﬁrst-stage casting. Salt or retention beads are placed on the facial and palatal provisional prosthesis. surfaces for mechanical retention as an aid in cementation.

treatment plan, and explain using the diagnostic wax-up.2 The patient should be informed the diagnostic wax-up is the restorative template for the design of the provisional prostheses and serves as an aid in predicting a positive patient outcome Fig. 3. Non-precious metal casting fitted to the cast. The occlusion is refined on the articulator. in the definitive prosthesis. After completion of the diagnostic wax-up, the restorative dentist should design a fixed-metal and acrylic-resin provisional prosthesis.3 The extent of the proposed metal framework is dependent upon the patient’s occlusal contacts, the functional forces of occlusion, as well as such habits as bruxism, clenching, the patient’s typical diet, pipe smoking, Fig. 4. The area of the missing tooth No. 3 is processed in heat-cured acrylic resin of the selected and alcoholism. The proposed metal shade. The provisional prosthesis is then fitted back on the full arch mounted cast. The occlusion and acrylic-fixed provisional pros- is refined. The completed provisional prosthesis is then ready to be cemented to place following thesis is then fabricated by the dental the planned surgical procedure. Tooth No. 3 was extracted, a graft and membrane placed, and the technician prior to any surgical or provisional prosthesis was cemented with Multilink cement on the same day. prosthetic treatment (the surgical template is fabricated at the same time from a duplicate cast). Accurate full arch casts are made and then mounted on an articulator. If there needed (Fig. 1-5).4 Recontouring are enough teeth present, the casts is performed only if the abutment can be hand articulated. If this is not teeth are in premature occlusal con- the case, an interocclusal record is tact or tilted so as to interfere with made in the centric relation position. the implant placement and path of This prosthesis is designed and draw of this prosthesis. The techni- Fig. 5. Facial view of maxillary incisor area then waxed on an unprepared cast. cian and practitioner should examine following extraction of teeth No. 8 and 9. A Usually, no preparations or reshaping the mounted casts in order to bone graft, collagen membrane, and resorbable of the patient’s existing teeth are incorporate occlusal, palatal, and/or sutures were used.

www.agd.org General Dentistry Special Prosthodontics Section 509 Implant Restorations Sequential provisional implant prosthodontics therapy

Fig. 6. Posterior view of mounted maxillary and mandibular casts to analyze the space available for the planned metal and acrylic provisional prosthesis. Note the design of the prosthesis is drawn on the cast. No rest seats are prepared on abutment teeth. Room for Fig. 7. Cast and processed maxillary first-stage Fig. 8. Completed maxillary provisional rests is determined on the articulator and can provisional prosthesis to replace teeth No. 8 prosthesis after fitting the prosthesis to the be placed where there is interocclusal room. and 9. This is ready for cementation on the cast, polishing, and processing acrylic resin The pontic area is relieved gingivally so that it day of surgery. Note the retention areas on the artificial teeth to the framework for replace- does not impinge upon the surgical area. metal of the palatal clasp arms. ment of teeth No. 8 and 9.

Fig. 9. Intraoral palatal view of provisional prosthesis cemented to place Fig. 10. Intraoral facial view of cemented provisional prosthesis on on the day of surgery with Multilink cement. day of surgery.

lingual rests as needed. Posterior wax-up with the sprues attached is cool completely on the laboratory buccal cast clasps should be included weighed, and that weight number bench. After cooling, the metal cast- in the design of the metal framework is multiplied by the density of the ing is removed from the investment (Fig. 6). No facial clasps are designed selected non-precious metal. The and cleaned. Sprues are removed or waxed for a prosthesis that will be result is the amount of metal to be and then the casting is cleaned in used in the esthetic zone. used in grams. This is then weighed an ultrasonic cleaner. The casting Retention beads are created from out on a scale, while the investment is accurately fitted to the master salt or manufactured retention is hardening. cast, and then the metal facing the beads (Zahn Dental) and are incor- The technician should then soft tissues is highly polished. The porated in the wax-up on the side wax the design for the metal- occlusal contacts are refined and the facing the selected teeth to become fixed provisional prosthesis. After prosthesis is processed to the desired an integral part of the nonpre- completion, the wax-up is invested shade. After the prosthesis is fitted cious casting as an aid in retention in a phosphate-bonded investment accurately to the cast, facial clasp after cementation. To determine and cast with a non-precious alloy. arms (if used) are covered with heat- how much metal to use, the The metal is cast and allowed to cured acrylic resin by sandblasting

510 November/December 2012 General Dentistry www.agd.org the buccal clasp arm; opaque it, then heat cure the appropriate acrylic resin (Fig. 7). The missing teeth are then created on this framework using heat-cured acrylic resin. It is easier to use facial and incisal silicone or plaster indices, as well as a heat and pressure machine, such as the Ivomat (Ivoclar Vivadent, Inc.) machine, to cure the resin in 20 minutes, rather than investing, boiling out wax, Fig. 11. Maxillary diagnostic cast. The existing Fig. 12. Maxillary cast with full arch non- packing, curing, and deflasking the posterior fixed prostheses were to be removed precious metal framework fitted to the cast. acrylic resin in a flask (Fig. 8). on the cast prior to intraoral extractions, Note the posterior fixed prostheses scheduled After surgery (usually on the day grafting, and implant placement. for removal have been cut off the cast. of surgery, but maybe the next day) the completed provisional prosthesis is fitted intraorally and the occlusion adjusted where needed (Fig. 9, 10). The clinician should verify the occlusion and ensure that the acrylic resin on the pontic areas does not touch the surgical area. The prosthesis is cemented into place with resin- bonded cement, such as Multilink cement (Ivoclar Vivadent, Inc.). After set, excess cement is removed. The Fig. 13. Gingival view of processed metal and Fig. 14. Occlusal view of completed first-stage patient wears this prosthesis until acrylic provisional prosthesis. provisional prosthesis. the implant or implants are ready for uncovering. This also is used in a bilateral posterior first-stage fixed provisional prosthesis (Fig. 11-16).

Transitional implants for ﬁxed ﬁrst-stage provisional prostheses Transitional implants allow the clini - cian to fabricate a fixed provisional prosthesis that may be temporarily cemented to place in a partially Fig. 15. Maxillary arch on the day of edentulous case, without attaching it surgery following removal of teeth bilaterally, Fig. 16. Intraoral occlusal view of the cemented to the patient’s teeth.6 The advantage placement of implants, bone grafts, collagen provisional prosthesis that was inserted on the of using transitional implants such membranes, and suturing. day of surgery. as Immediate Provisional Implants (IPIs) (Nobel Biocare), especially in the fixed partially edentulous situations is that it avoids the cementation of a metal framework to the teeth adjacent to the edentulous areas (Fig. 17). If there is sufficient bone, the transitional implants may be Fig. 17. IPI. This implant is 14 mm long and 2.8 mm wide. The gingival end may be cut shorter if used when the posterior sections of needed. It is placed a minimum of 3.0 mm from the submerged endosteal implant bodies.

www.agd.org General Dentistry Special Prosthodontics Section 511 Implant Restorations Sequential provisional implant prosthodontics therapy

Fig. 18. Left: Left posterior view of the partially edentulous maxilla. The patient lost the maxillary bicuspids and molars bicuspids bilaterally. Implants, bone grafts, and IPI implants were placed bilaterally. Right: Right posterior view of the partially edentulous maxilla.

Fig. 19. Occlusal view of maxillary cast with 6 IPI provisional implants in the bicuspid and Fig. 20. Close-up of maxillary cast with metal immediate molar areas, but without encroaching on the not-yet-uncovered posterior implant bodies. provisional implant copings in place.

the dental arch are edentulous, thus a noneugenol, acrylic/urethane-based of the bone and covers it with soft avoiding a removable prosthesis. The temporary cement, such as Improv tissue. It can also be trephined out partially edentulous provisional pros- (noneugenol, acrylic/urethane-based and a bone graft placed. thesis is usually cemented only to the temporary cement) (Alvelogro). The transitional implants, which makes it patient wears this prosthesis until the First-stage provisional easier to clean the remaining teeth in implant(s) are ready for uncovering. prostheses supported by the dental arch. This ease of cleaning The fixed first-stage prosthesis can transitional implants is important for a patient that has a be used to replace one tooth and The first-stage fixed metal and high caries rate, as no part of the pro- up to five or six teeth missing in the acrylic provisional prosthesis can visional prosthesis attaches to teeth. four quadrants of the dental arch. be used in conjunction with tran- It will permit the patient to practice When restoring a maxillary lateral sitional implants for a partially or good oral hygiene procedures.7 incisor, cuspid, and bicuspid with a completely edentulous situation.8-11 The missing teeth are created on steep vertical overlap, there should It can also be used alone to fabri- this framework using heat-cured be anterior and posterior abutments cate a fixed first-stage provisional acrylic resin. It is easier to use facial as well as posterior occlusal and/ prosthesis, usually in the partially and incisal silicone indices, as well as or anterior rests, with a cast non- edentulous situation. For partially a heat and pressure machine, such as precious framework. edentulous patients, IPIs may be the Ivomat, to cure the resin in 20 The problem with transitional used for a cemented fixed restora- minutes. On the day of surgery, the implants is that because they can tion. They are 2.8 mm in diameter completed provisional prosthesis is fuse to bone, they may not always and 14 mm long. The gingival fitted intraorally and the occlusion be removed from the bone. If that length of the implant can be reduced adjusted where needed. Then the happens, then the surgeon cuts the to create different lengths. This is prosthesis is cemented into place with top off the implant body at the level done by the surgeon at the time of

512 November/December 2012 General Dentistry www.agd.org Fig. 21. The metal copings are joined with autopolymerizing acrylic resin, first on the cast and then verified intraorally. If there is a discrepancy, the joined copings should be cut, inserted intraorally, reattached with Fig. 22. Maxillary cast with joined metal copings in place after intraoral autopolymerizing acrylic resin, and then altered to cast. verification and alteration of the analogue positions, when needed.

surgery. These implants are placed a minimum of 3 mm from the endosteal submerged implant bodies. The surgeon must use a surgical template for their placement, which is done at the same time as placement of the definitive implant bodies (Fig. 18). Fig. 23. Maxillary metal and acrylic first-stage A cast made from the diagnostic provisional prostheses with metal copings that Fig. 24. Gingival view of processed first-stage wax-up is used to fabricate a thick are used in conjunction with the IPIs, after fixed IPI with metal copings incorporated into heat-cured acrylic resin shell of processing with heat-cured acrylic resin. the prosthesis. the area being treated. Following surgery, metal copings are seated over the occlusal ends of these transitional implants (Fig. 19). The dentist must ensure that there is correctly on the implants, and then placed inside the metal copings of sufficient occlusal room between the reconnecting with autopolymerizing the provisional implants and this occlusal ends of the metal copings acrylic resin (Fig. 21, 22). Any interim prosthesis is cemented with that are seated on the mini implants, undercuts below the occlusal por- Improv cement. Thus, the prosthesis and then an impression is taken and tion should be blocked out. The can be retrieved without torquing a cast is poured. Metal analogues of positions of the analogues in the cast the provisional implants. This the IPI implants are used and are should be corrected. The previously methodology permits the implant seated into the copings. The cast is processed acrylic resin shell should team to sequentially change a failing poured and once set, the full arch be fitted over the joined metal cop- dentition into a transitional implant- maxillary and mandibular casts are ings and connected with acrylic resin supported prosthesis without the mounted on an articulator (Fig. 20). of the same shade. The prosthesis patient wearing a completely muco- After the casts are articulated, the should then be removed from the sal-supported removable prosthesis or metal copings are cleaned and placed cast after processing in the Ivomat. preparing or cementing a prosthesis over the occlusal ends of the implant The processed prosthesis is then to the remaining teeth. This protocol analogues. They are connected with corrected occlusally. The contours are becomes a practice booster in how auto polymerizing acrylic resin. refined and polished (Fig. 23, 24). not to interfere with a patient’s daily After set, they are tried intraorally. A try-in is performed intraorally to life. The method usually avoids a loss Any discrepancy in fit is corrected verify the occlusion and ensure that of vertical dimension of occlusion, intraorally by cutting the acrylic the acrylic resin does not encroach which the patient needs for comfort- resin connection, seating the copings upon the surgical sites. Cement is able speech and mastication.

www.agd.org General Dentistry Special Prosthodontics Section 513 Implant Restorations Sequential provisional implant prosthodontics therapy

Fig. 26. Maxillary right central incisor after Fig. 25. Maxillary right central incisor prior to uncovering and a healing abutment placed by Fig. 27. Facial view of gingival contour following uncovering and installation of an abutment. the surgeon. installation of the selected abutment.

Fig. 29. Gingival view of the provisional cylinder. Note the hexes that provide for non- Fig. 30. The metal provisional cylinder is rotational provisional single tooth prosthesis. painted with opaque that is compatible with Fig. 28. Occlusal view after installation of the The hexes are compatible with the hexes on the shade that is selected. It is allowed to dry abutment. the previously installed abutment. completely prior to use intraorally.

Fig. 31. Gingival view of the screw-retained Fig. 32. Provisional prosthesis at insertion on provisional prosthesis installed in the mouth. the same day as implant uncovering. Fig. 33. Provisional prosthesis after healing and keratinization of the soft tissues. This can take up to a year and the deﬁnitive prosthesis is not made and inserted before this time. Part II. Technique for (Fig. 25-28). An impression is fabrication of second-stage taken, abutment replicas attached, provisional prostheses and a cast poured. Appropriate Before uncovering the previously metal provisional cylinders are placed implant bodies (Part I), attached intraorally to abutments, the provisional cylinder. The cast impressions should be taken using guide pins or prosthetic is then altered, using a fast-setting and the casts mounted on a screws (Fig. 29). These cylinders stone. The processed screw-retained semi-adjustable articulator. The are painted with the appropriate second stage provisional prosthesis technician should fabricate a shell shade of opaque (Fig. 30). Once is installed (Fig. 31). The hexes of of heat-cured acrylic resin of the dry, they are luted together with the abutment and the inside of the appropriate shade and shape. The autopolymerizing acrylic resin of metal provisional cylinder prevent guide for this is the cast made from the selected shade. The accuracy of rotational movement of this pros- the diagnostic wax-up. the impression is verified with these thesis (Fig. 32). As the soft tissues On the day of implant uncover- luted provisional cylinders. When heal, the prosthesis is altered for cos- ing, abutments are installed either an error is noted on the cast, the metics so as to match the adjacent by the surgeon or restorative dentist replica is removed and screwed to central incisor (Fig. 33).

514 November/December 2012 General Dentistry www.agd.org Fig. 36. Left: Contour of provisional screw- retained prosthesis with the metal provisional cylinder and heat-cured acrylic resin. Right: Fig. 34. Facial view of a bicuspid single tooth Fig. 35. Occlusal view of the maxillary bicuspid Gingival view of processed provisional implant after uncovering and insertion of the single tooth implant after installation of the prosthesis with hexed provisional cylinder for a selected abutment. selected abutment on the day of implant. single tooth implant to prevent rotation.

Fig. 38. Intraoral buccal view of Fig. 37. Intraoral gingival view of processed provisional prosthesis inserted on provisional prosthesis using a metal cylinder day of implant uncovering and Fig. 39. Occlusal intraoral view of the maxilla following uncover- with anti-rotational hexes. abutment installation. ing of bilateral posterior implants and abutment installation.

When fabricating a second stage be difficult to change one or more provisional cylinders. After curing, screw-retained provisional pros- abutments due to bleeding following the provisional prosthesis is carved thesis for a maxillary first bicuspid implant uncovering. Usually, the and polished. A try-in of the pro- implant, after ensuring that the bleeding is reduced or stops prior to visional prosthesis should be done hexes of the abutment and metal the patient’s arrival in the restorative intraorally. With one screw at either provisional cylinder are compatible, dentist’s office. Most times when the end, right-angled bite-wing radio- the contour of the facial surface is patient needs a change of the abut- graphs are taken to verify the fit. The critical for cosmetics and for the ment, they still have the effects of the entire provisional prosthesis must fit optimum contour of the dental local anesthetic used by the surgeon, with this one screw test regardless arch. The length of the buccal cusp or the restorative dentist, whoever of the extent of the prosthesis. The should blend in with the adjacent uncovers the implant bodies. one screw test means that when the cuspid anteriorly and second bicus- Management of bilateral pos- prosthesis is being evaluated, the cli- pid posteriorly (Fig. 34-38). terior screw-retained provisional nician observes if there is a rocking If an abutment requires changing prostheses requires that impressions motion, just as with a conventional to an angulated abutment for either are taken on the day of implant prosthesis. Then a prosthetic screw esthetics or a shorter one, or to a uncovering (Fig. 39) and casts is inserted into the posterior casting direct connection to the implant (Fig. 40, 41) are mounted on a and screwed to place. (UCLA connection) due to limited semi-adjustable articulator, and Radiographs are taken with the interocclusal space, it should be the previously made heat-cured film being held parallel to the long accomplished at this point. It may acrylic resin shell is attached to the axis of the implant. The titanium

www.agd.org General Dentistry Special Prosthodontics Section 515 Implant Restorations Sequential provisional implant prosthodontics therapy

Fig. 40. Maxillary cast made on the day of Fig. 42. Gingival view of the heat-cured acrylic second-stage surgery and abutment instal- resin baked to the metal provisional cylinders. lation. A soft tissue cast is used so that the Fig. 41. Close-up of right and left sides of the dentist and technician observes the contours maxillary cast. Note that the implants are not of the provisional restoration and does not placed on a straight line on order to avoid over- or underbuild the restoration. rotation around the sagittal axis during function. prosthesis is needed for incremental loading.14,15 The acrylic resin occlusal surfaces with metal centric occlusal stops from the provisional cylinders are needed to maintain vertical dimension of occlusion and the desired centric occlusal contacts.16 The prosthesis is polished and inserted into the patient’s mouth. The screw access channels are provisionally sealed with cotton and dental stopping (Hygenic Corp.), or Fig. 43. Occlusal intraoral view of maxillary arch with bilateral retrieval provisional prostheses in Cavit (3M ESPE) or Fermit (Ivoclar place at time of insertion and after healing. Vivadent AG). The patient is seen one week later, and the fit of the components and occlusion is verified. Vertical dimension of occlusion must be confirmed prior to inser- alloy provisional cylinders of the ensuring the fit of the cylinders to tion of the prosthesis. The vertical provisional prosthesis should all the abutments intraorally, the repli- dimension should not be increased fit accurately without any space cas on the cast are altered. inadvertently since problems that between the cylinder and the abut- The prosthesis should be rein- may occur are loss of bone; difficulty ment. In addition, the contact areas forced with metal to avoid breakage in speech and with mastication; are verified with unwaxed extra-fine and distortion. After the provisional and temporomandibular joint dental floss. Once the fit is verified, prosthesis has been fitted and pol- complications.17,18 This provisional the occlusion and contours are ished, the technician or dentist cuts prosthesis is worn until the gingiva refined.12,13 If there is an error in a lingual or palatal groove from one has keratinized and stabilization of the fit of one or more provisional end of the restoration to the other. bone levels is seen on radiographs. cylinders, the provisional prosthesis A braided gold plated stainless steel Soft tissues should not bleed when is sectioned, the cylinders attached wire (Keystone Industries) is cut and the prosthesis is unscrewed, and the to the abutments intraorally, and fitted to that groove. The wire is then area around the abutment should the sections luted together with luted in place with autopolymer- not close over. Keratinized and autopolymerizing acrylic resin of izing acrylic resin of the appropriate healed soft tissues should remain in the same shade. After curing and shade and polished. Rigidity of the the position held by the provisional

516 November/December 2012 General Dentistry www.agd.org desired goals are. The surgeon, restorative dentist, and technician cannot work independently from each other. After completion of treatment, it is the restorative dentist who will receive all the complaints and problems if there is no understanding among team members. The Fig. 44. Buccal views of the provisional prostheses after insertion on the day of second-stage surgery creation of a functional and cosmetic and abutment installation. prosthesis that satisfies the patient requires complete interdependence between the team members. The use of fixed provisional prostheses enables the team to create the desired prosthesis. The provisional prosthesis of a definitive prosthesis to allow esthetics and function. The patient is thus used to create a non-surgical time for maturation of the grafted will retain and preserve the second- cosmetic gingivoplasty of the soft sinus. This gradual loading has also stage provisional prosthesis after tissues (Fig. 42-44). The provisional been termed progressive loading insertion of the definitive prosthesis prosthesis supports the development because the occlusal contacts should in case there is a need for repairs or if and maturation of the dento- be in minimal contact at first, and an implant is lost or added at a later gingival complex and acts as a fail- then over a period of two to three stage. It is the fail-safe mechanism safe for the practitioner. Therefore, months, the amount of centric that prevents the patient from ever if there is an early failure, such as occlusal contact is increased in a going without teeth. loss of implant(s) or bone grafts, it vertical direction, only along the can be corrected prior to definitive long axis of the implants.12,13,18,19 Summary prosthesis fabrication. If breakage After insertion of the prefabricated The team approach to implant or loss of an implant occurs, or the definitive prosthesis, the patient dentistry is most prominently noted implant body cannot be restored should be given possession of the sec- when everyone collaborates in the because of its position and/or other ond-stage provisional prosthesis and diagnosis and treatment planning, surgical errors, this problem should be informed that it must be saved. diagnostic wax-up, and fabrication be corrected prior to construction of If repairs to the definitive prosthesis of first- and second-stage provisional the definitive implant prosthesis. have to be made at a later date, this prostheses. This becomes most evi- The use of a second-stage pro- secondary provisional prosthesis can dent when an entire arch of a maxilla visional prosthesis is important be reinserted so that the patient is and a mandibular reconstruction is to avoid implant and graft losses, never without a prosthesis.20-23 done sequentially, so that the patient especially with a sinus bone graft.9-11 is never without teeth and he or she These areas need gradual loading Discussion can function from the day of surgery to allow for graft maturation and The uses of a fixed cemented first- without any interruption in lifestyle. to reduce implant body loss; thus, stage provisional prosthesis followed The authors have described the ratio- requirements of occlusal loading by a screw-retained second-stage nale and technical steps required are in a vertical direction (along the provisional prosthesis has been from the treatment planning phase, long axis of the implant bodies), and described from the single tooth up the use of cemented first-stage provi- cast metal reinforcements are used to and including a full arch implant sional prostheses and the fabrication to provide rigidity. There should not prosthesis. The success of this treat- and use of a retrievable second-stage be occlusal contact in eccentric posi- ment depends first upon the patient’s provisional prosthesis. tions, and the occlusal table should understanding of the treatment be narrowed and the cuspal angula- protocol and the need for the sur- Disclaimer tion shallow. The second-stage pro- geon, restorative dentist, and dental The authors have no financial, visional prosthesis fabricated over a technician to work as a team. The economic, commercial, and/or pro- sinus bone graft should be worn for optimum result can only be achieved fessional interests related to topics at least 1 year prior to fabrication if everyone understands what the presented in this manuscript.

www.agd.org General Dentistry Special Prosthodontics Section 517 Implant Restorations Sequential provisional implant prosthodontics therapy

Author information 6. Babbush, CA. Provisional implants: Surgical and 19. Kinzer, GA. Comprehensive reconstruction using Dr. Zinner is a clinical professor, prosthetic aspects. Implant Dent 2001;10:113- sequential extraction and implant placement. 120. Adv Esthet Interdisciplin Dent 2006;2(1): 17-22. Department of Prosthodontics, 7. Petrungaro PS. Transitional phase: Patient man- 20. Balshi SF, Wolfinger, GJ, Balshi, TJ. A protocol for New York University, College of agement with transitional implants. In: Bab- immediate placement of a prefabricated screw- Dentistry, New York, New York, bush, CA (ed). Dental Implants: The Art and retained provisional prosthesis using computed Science. St Louis: Mosby; 2001:403-420. tomography and guided surgery and incorporat- where Dr. Reid is an adjunct associ- 8. Shatkin, TD, Shadtin, S, Oppenheimer, AJ. Mini ing planned alveoplasty. Int J Periodontics Re- ate professor and Dr. Schnader is a dental implants for the general dentist: A novel storative Dent 2011;31(1):49-55. clinical associate professor, and Dr. technical approach for small-diameter implant 21. de Almeida EO, Filho HG, Goiatto MC. The use placement. Compend Cont Educat Dent 2003; of transitional implants to support provisional Markovits is a clinical professor, 24:(1 Suppl): 26-34. prostheses during the healing phase: A litera- Division of Cariology and Com- 9. Minsk, L. Interim implants for immediate load- ture review. Quintessence Int 2011;42(1):19-24. prehensive Care. Dr. Jansen is the ing of temporary restorations. Compend Contin 22. Drago, C, del Castillo, R, Peterson, T. Immediate Educ Dent 2001;22(3):186-190. occlusal loading in edentulous jaws, CT-guided former director, Implant Dentistry, 10. Ahn, MR, An, KM, Choi, JH, Sohn, DS. Immedi- surgery and fixed provisional prosthesis: A max- University of Southern California, ate loading with mini dental implants in the illary arch clinical report. J Prosthodont 2011; College of Dentistry, Los Angeles, fully edentulous mandible. Implant Dent 2004; 20(3):209-217. 13(4):367-372. 23. Suarez-Feito JM, Siciliua A, Angulo J, Banerji S, California. Dr. Shapiro is chief 11. Sendax, VI. Mini-implants as adjuncts for transi- Cuesta, I, Millar B. Clinical performance of provi- emeritus, Department of Dentistry, tional prostheses. Dental Implantol Update sional screw-retained metal-free acrylic restora- White Plains Hospital, White 1996;7:12-15. tions in an immediate loading implant protocol: 12. Schwartz H. Anterior guidance and aesthetics in A 242 consecutive patients’ report. Clin Oral Plains, New York. prosthodontics. Dent Clin North Am 1987;31(3): Implants Res 2010:21(12):1360-1369. 323-332. References 13. Lang BR, Razzoog ME. Lingualized integration: Manufacturers 1. Zarb GA, Harle T, DeGrandmont P, Caro S, Zarb Tooth molds and an occlusal scheme for eden- Alvelogro, Snoqualmie, WA FL. Use of provisional prostheses with osseoin- tulous implant patients. Implant Dent 1992; 888.268.3286, www.alvelogro.com tegration. Dent Clin North Am 1989;33(3):423- 1(3):204-211. 14. Roberts WE. Bone tissue interface. Int J Oral Im- Hygenic Corp., Akron, OH 433. 800.321.2135, www.hygeniccorp.com 2. Zinner ID, Schnader, YE. Diagnosis and treat- plantol 1988;5(1):71-74. Ivoclar Vivadent AG, Liechtenstein ment planning for implant-supported fixed 15. Binon, PP, Sullivan DY. Provisional fixed resto- 0042.235.35.35, www.ivoclarvivadent.com/en prosthodontics. In: Implant Dentistry: From Fail- rations technique for osseointegrated im- ure to Success. Hanover Park, IL; Quintessence plants. J Calif Dent Assoc 1990;18(1):23-30. Ivoclar Vivadent, Inc., Amherst, NY Publishing Co.: 2004:21-27. 16. Skalak R. Aspects of biomechanical consider- 800.533.6825, www.ivoclarvivadent.us 3. Zinner ID, Panno FV, Pines MS, Small SA. First- ations. In: Branemark PI, Zarb GA, Albrektsson T Keystone Industries, Cherry Hill, NJ stage fixed provisional restorations for implant (eds). Tissue-Integrated Prostheses: Osseointe- 856.663.4700, www.keystoneind.com prosthodontics. J Prosthodont 1993;2(4):228- gration in Clinical Dentistry. ed 1. Chicago: Quintessence Publishing; 1985:117-128. Nobel Biocare, Yorba Linda, CA 232. 800.993.8100, www.nobelbiocare.com 4. Zinner ID, Landa LS, Small SA, Panno FV. Provi- 17. Parel SM, Sullivan DY. Esthetics and Osseointe- sional screw-retained fixed prostheses for im- gration. Dallas, TX: University of Texas Health Zahn Dental, Melville, NY plant prosthodontics. QDT 1994;17:37-44. Science; 1989:97-112. 800.496.9500, www.henryschein.com 5. Drago C. Stage I surgical indexing: Clinical and 18. Misch CE. Density of bone: Effect on treat- 3M ESPE, St. Paul, MN laboratory procedures. J Dent Technol 2000; ment plans, surgical approach, healing and 888.364.3577, solutions.3m.com 17(3):16-21. progressive bone loading. Int J Oral Implantol 1990;6(2):23-31.

518 November/December 2012 General Dentistry www.agd.org Fixed Prosthodontics

Preparing ﬁxed partial denture abutments such that they provide a path of placement free of undercuts

John Mamoun, DMD

The abutments of a fixed partial denture (FPD) should provide “path of placement” and “undercut” and explains concepts such a path of placement, so that the denture may be seated onto as “parallelism of multi-unit fixed partial denture abutments” the abutment without the tooth structure blocking the margin and also what a dentist means when the dentist says that an or intaglio surface. This article presents a literature review abutment “is undercut.” The author suggests that dentists concerning the path of placement (also referred to as the path of use high magnification loupes (6-8X magnification or greater) insertion or the path of draw). In addition, the article presents or a surgical operating microscope to examine abutments for clinical techniques for verifying an undercut-free path of place- microscopic undercuts and to ensure that bridge abutments are ment for a prepared abutment and describes how to determine aligned with a path of placement. if a laboratory technician can fabricate a clinically acceptable Received: August 9, 2011 FPD for an abutment that features undercuts within the path Final revisions: November 11, 2011 of placement. The article provides definitions of terms such as Accepted: January 16, 2012

he creation of a path of place- when the dentist attempts to view, abutment(s) to the point where it ment that is free of undercuts with one eye closed, all points that seats onto the abutment(s), each Tamong the abutment(s) of are on a perimeter that is located atom (or element of mass) of the a fixed partial denture (FPD) slightly lateral to the outer perimeter FPD moves in three-dimensional facilitates fabrication of an FPD that of the margin of the abutment when space along its own respective axis. accurately fits the abutment(s) and using a set of visual axes for viewing The atoms of the FPD collectively seals the abutment margin(s). This the perimeter points such that all move along multiple axes as the article defines the concept of an of those visual axes are of the same FPD is moved onto and is seated FPD undercut and provides a sum- angle in three-dimensional space.1-4 onto the abutment(s). Some of these mary and a literature review of the An abutment is undercut relative imaginary axes pass longitudinally concept of the crown or bridge path to a specified path of placement through the body of the abutment, of placement. Other sources offer a of an FPD that is made for that while some pass slightly lateral to comprehensive summary of the gen- abutment while being seated onto the outermost perimeter of the eral criteria for shaping abutments the abutment. Two representative abutment’s margin(s). Since the prior to the placing of various FPD opinions on the definition of an axial aspect of an FPD is positioned prostheses (including all-metal, FPD path of placement that appear lateral to the axial aspect of the all-porcelain, and porcelain-fused- in the dental literature define it as abutment(s) when the FPD is seated to-metal).1,2 “the specific direction in which a on the abutment, it follows that the An FPD undercut is a line seg- prosthesis is placed on the abutment atoms of the axial aspect of the FPD ment on the axial surface of an teeth or dental implant(s),” and also must follow axes that are located FPD abutment, where one point as “an imaginary line along which slightly lateral to the axial aspect of of the line segment is located more the restoration will be placed onto the abutment(s). occlusal than the other, such that or removed from the restoration.”1-4 Accordingly, an FPD path of the more gingival point appears to The path of placement for an placement is defined as a set of be more axially located compared FPD may also be described as a set axes that are parallel in three- to the more occlusal point; this line of parallel axes or directions. While dimensional space, such that if each segment becomes visually apparent an FPD is being moved onto its atom of an FPD, respectively, travels

www.agd.org General Dentistry Special Prosthodontics Section 519 Fixed Prosthodontics Preparing FPD abutments such that they provide a free path of placement

of the abutment(s), when it can Interproximal tooth structure follow an obstruction-free path of obstructions to seating an FPD placement such that the perimeter along a path of placement of this path of placement is located When an abutment is prepared just lateral to the perimeter of the next to an unprepared tooth that abutment margin(s). tilts toward the abutment, there When assessing if a path of should appear to be no overlap placement is free of undercuts, the of the occlusal-interproximal line dentist views the abutment(s) and angle of the tilted tooth on the side Fig. 1. An illustration of an abutment undercut tries to locate a set of the visual axes, of the unprepared tooth facing the conﬁned to the axial wall without obstructing all parallel to one another, that allow abutment tooth, with the margin of visibility of the abutment margin. a dentist to see all points that are the abutment on the side facing the located slightly lateral to the perim- tilted tooth, when the dentist views eter of the abutment(s) at the most the abutment using visual axes paral- apical aspect of the abutment(s), if lel to the imaginary axes of a poten- the dentist viewed the margins using tial path of placement, the perimeter along one of these axes within this visual axes from this set. These axes of which is “ideal” (that is, located set, then the FPD will seat onto its would be parallel to the axes of the slightly lateral to the perimeter of the abutment(s); that is, the margin(s) path of placement of the FPD made abutment margin). If such overlap of the FPD will be level with the for the abutment(s). In other words, is visually apparent, the tilted tooth margin(s) of the abutment(s), and the dentist is visualizing how the should be modified so that it does no tooth structures will obstruct intaglio surface of the FPD made not obstruct the seating of an FPD complete seating of the FPD. for an abutment would move along and will achieve a more ideal embra- An FPD path of placement may this path of placement. When all sure space contour in this area.1,5 be described mathematically using such margin points are visible to two parameters. One parameter is the the dentist, it means the abutment The role of the dental location at the gingiva of the perim- would be free of undercuts with that laboratory in managing eter of the path of placement that path of placement. abutment undercuts circumscribes each respective abut- If the dentist cannot locate any set If a laboratory technician fails to ment of the FPD. The points along of visual axes that make it possible notice and block out an undercut the perimeter are the origin points of to view all points along the slightly abutment, the wax pattern used to those axes of the path of placement lateral perimeter, then the abut- make the FPD may fill this under- that are positioned laterally to the ment is undercut. By definition, cut, which may result in an FPD axial aspect of the abutment(s). A an abutment “is undercut” when with a protrusion on its intaglio second parameter is the angle in a dentist, after arbitrarily choosing surface, or with a margin that has three-dimensional space of the axes of the perimeter of the path of place- an axial inclination which may the path of placement. The common ment of this abutment to be located prematurely contact the axial wall of angle of the path of placement slightly lateral to the perimeter of the abutment and prevent complete axes helps determine whether tooth the margin of the abutment at the seating of the prosthesis. structure obstructions will be present most apical aspect of the abutment, along the path of placement. cannot visualize a specific set of par- Evaluating the clinical Typically, a dentist shapes a fixed allel axes that originate from points acceptability of undercuts partial denture abutment such that along this slightly lateral perimeter, on FPD abutments the perimeter of the path of place- such that an FPD with a margin An abutment may feature a visually ment that the abutment provides is perimeter that was the same as the apparent but minor undercut that located slightly lateral to the perim- perimeter of this path of placement, allows a laboratory technician to eter of the margin of the abutment would not encounter obstructions fabricate a clinically acceptable at the gingiva. This is because located on the axial wall of the FPD. Figure 1 is an example of an an FPD seals the margin(s) of abutment(s), to its complete seating undercut that appears to be entirely abutment(s), and its intaglio surface onto its abutment(s) if it moved confined to the axial wall of the most closely hugs the axial walls along this set of parallel axes. abutment, so that the undercut does

520 November/December 2012 General Dentistry www.agd.org not block the view of any points a shoulder margin, where the axial along the abutment margin perim- wall of the abutment extends gingi- eter. The FPD can seat fully onto vally to the margin and continues the abutment and seal the abutment horizontally along the chamfer or margins, provided the undercut on shoulder to the outer edge of the the master cast is blocked out prior abutment—it will also have an to fabricating the FPD. Microscopes inner margin perimeter. may be necessary to detect the undercut on the master cast of the Undercuts on margins of abutment and to confirm that the abutments with no horizontal undercut has been blocked out. The margin component intaglio surface of the FPD made For an abutment margin that has for that abutment may not hug the no horizontal component to be free Fig. 2. An example of how magniﬁcation axial wall of the abutment at the of undercuts when viewed along a (approximately 8X) allows veriﬁcation points where the blockout material candidate path of placement, the that both inner (partly outlined in green) was applied; however, the FPD complete outer perimeter of the and outer (partly outlined in red) margin may still seal the abutment margin abutment at the level of the margin perimeters of this abutment are visible along completely and offer clinically must be fully visible to the dentist the viewing axis. (Photo courtesy of Dr. Donato acceptable retention. using visual axes that are parallel Napoletano.) with the axes of the potential path Paths of placement that of placement. feature undercuts contiguous If an abutment margin has no with margins horizontal component, and the When the dentist views the abut- abutment appears to have an ment with a visual axis that is paral- undercut that blocks visibility of a lel with the path of placement, an point on the outer perimeter of the undercut may block visibility of a margin, a dental laboratory techni- point on the margin. The character- cian may attempt to block out the istics of such an undercut determine undercut and extend the margin of whether a clinically acceptable FPD the FPD gingivally to the vertical can be fabricated. level of that point. However, the Fig. 3. An illustration of an abutment undercut Undercuts that block visibility resulting FPD that is fabricated for contiguous with the margin for an abutment of a point on the abutment margin that abutment may not completely with only an outer margin perimeter. also may block visibility of a point seal the outer perimeter of the on the outer margin or the inner margin at that point and may be margin perimeter. All abutment clinically unacceptable (Fig. 3). margins have an outer margin Alternatively, the lab technician perimeter. The inner margin perim- may create an FPD margin that is Undercuts on margins of eter consists of the perimeter or line superior to that undercut. The FPD abutments with a horizontal angle formed at the intersection of may be clinically acceptable if it fits margin component the axial wall of the abutment and snugly on the abutment, seals the Both the outer and the inner the most axial aspect of the hori- entire abutment along the prosthe- perimeters of the margin should be zontal component of the margin sis margin, and features a sufficient fully visible when the dentist views (Fig. 2). An abutment with either amount of ferrule coverage and the abutment. If the abutment has a knife edge or feather edge (a aggregate retention. There may be an undercut that blocks visibility margin with an extremely minimal some exposed tooth structure infe- of a point on the inner perimeter horizontal component)—or with no rior to the fixed prosthesis margin of the margin (Fig. 4), a laboratory margin—will have an outer margin at the undercut point, but it may technician may be able to block perimeter only.1,2 If an abutment be convex enough that it doesn’t it out on a cast of the abutment, has a margin with a horizontal constitute a gap or result in a future so that the resulting FPD can still component—such as a chamfer or plaque trap. fully seal the outer perimeter of

www.agd.org General Dentistry Special Prosthodontics Section 521 Fixed Prosthodontics Preparing FPD abutments such that they provide a free path of placement

This method of verifying a path of placement free from undercuts only works if the abutment of the FPD is tapered enough to allow a dentist to view its entire margin using a single viewing axis. How- ever, if the abutment has a minimal taper or is a perfect cylinder, the dentist may not be able to locate a Fig. 4. An illustration of an abutment undercut Fig. 5. An illustration of an abutment single viewing axis with complete contiguous with the inner margin perimeter undercut contiguous with the inner margin visibility of the margin(s). Instead, that does not obstruct visibility of the outer perimeter that obstructs visibility of the outer the dentist must verify the vis- margin perimeter. margin perimeter. ibility of all points along all margin perimeters using multiple visual axes, all of which must be at the same angle in three-dimensional space. When all margin points are ideal path of placement. Instead, the visible on parallel viewing axes, the laboratory technician would need to abutments provide a path of place- add blockout material to the master ment free from obstructions. cast of the abutment, expanding Dentists shape the abutments the perimeter of the FPD’s path of of an FPD so that the axial wall placement beyond the range of this of the abutment converges from undercut (Fig. 6). The resulting the gingival to the occlusal direc- FPD would have a margin perime- tion; however, the axes of the path ter wider than the margin perimeter of placement are parallel to one Fig. 6. An illustration of an undercut abutment of the abutment, and may not seal another, forming a cylinder that that would provide obstruction for an FPD. The the margin of the abutment at the circumscribes the tapered abutment blue represents the ideal perimeter located point where the blockout material (Fig. 8). The side of this cylinder slightly lateral to the outermost perimeter was applied to a degree that would does not necessarily form a right of the abutment margin at its most gingival be clinically acceptable. angle with the base, particularly if aspect. Green represents blockout material Alternatively, the technician may the abutment is tilted. that could be added to the tooth structure finish the FPD margin so that the To view each respective path of inferior to the obstruction, which would margin was superior to that under- placement axis so that the dentist expand the perimeter of the path of placement cut point. However, the horizontal is viewing the axis parallel to the (in red) beyond the range of the obstruction. component of the margin inferior path of placement that the axes to that point would become an form, the dentist must view each exposed ledge of margin surface and path of placement axis, respec- could become a clinically significant tively, using a visual axis that is 180 plaque trap, which may result in a degrees with respect to that axis. In the margin. Such an FPD may be clinically unacceptable FPD. this viewing perspective, all points clinically acceptable. of the line segment that make up If an abutment has a margin Verifying a single-unit FPD that axis appear to be superim- that has a horizontal component, path of placement posed onto each other, so that the and the abutment has an undercut To verify that a path of placement axis appears to be a point instead of that blocks visibility of a point on for a single unit FPD is free of a line segment (Fig. 3). the outer perimeter of the margin undercuts, the dentist must view the The dentist must view all axes (Fig. 5), a laboratory technician abutment and try to find a visual from the same angle as the one used would not be able to fabricate an axis that allows the dentist to view to view the first axis, so that the FPD that could fully seat onto its the entire perimeter of the abutment other axes appear to be points in the abutments by moving along the margin (Fig. 7). same perspective.

522 November/December 2012 General Dentistry www.agd.org Fig. 7. A lateral view of an abutment model, with toothpicks (all parallel Fig. 8. An occlusal view of an abutment model. The entire margin of the to each other and arranged around the perimeter of the abutment margin) abutment is fully visible, which veriﬁes that it has an obstruction-free path representing the imaginary axes of the path of placement. of placement.

If the dentist views all imaginary views this abutment along this Basic clinical technique for axes of the path of placement using visual axis. In addition, the dentist verifying a path of placement the same angle of viewing, so that must be able to identify a set of for a multi-unit FPD each individual axis appears as a such individual visual axes, such When using direct vision to assess point when it is viewed, and such that all of those individual visual if a path of placement exists among viewing enables the dentist to see axes are parallel to one another. the abutments of the multi-unit all points along the margin perim- That is, the dentist must be able to FPD, the dentist finds a visual axis eters of all abutments, then the sense intuitively that all of the visual that allows the dentist to com- abutment(s) will provide a path of axes within this set of axes intersect pletely see the margin of the first placement that is free of undercuts a single imaginary plane in three- abutment. The dentist then must for the FPD that will be made for dimensional space at the same angle. keep his or her eye steady so as to the abutment(s). This is the general Dentists commonly state that continually look along a visual axis way of verifying that an abutment(s) a path of placement for a multi- that is parallel in three-dimensional provides an undercut-free path of unit FPD exists when a dentist space with the axis used to view the placement for a future FPD (Fig. 3). determines that its abutments “are first abutment.1,6 While keeping parallel with one another.”1,3,6-9 The the eye steady, the dentist moves Verifying the existence author believes that there is some his or her head in a direction that of a multi-unit FPD path ambiguity in conceptualizing how is parallel with the imaginary plane of placement abutments, which are essentially that intersects with the visual axis To verify that a path of placement conical shapes that converge in a used to view the first abutment. free of undercuts exists among gingival-occlusal direction, can be When the second abutment comes multiple abutments of a multi-unit “parallel” with one another. More into view, the dentist will hopefully FPD, the dentist first must be able precisely, to establish the existence be looking at it using a visual axis to identify a path of placement for of a multi-unit FPD path of place- that is parallel with the one used each individual abutment of the ment, what must be parallel are to view the first abutment, so that multi-unit FPD. That is, for each the respective visual axes of each the second visual axis intersects individual abutment, the dentist abutment so that the entire margin the same imaginary plane as the must be able to locate a visual axis of each abutment is visible when the first visual axis intersects at the such that the entire margin of the dentist views each abutment along same angle of intersection. If the abutment is visible when the dentist its respective visual axis.1 margins of the second abutment

www.agd.org General Dentistry Special Prosthodontics Section 523 Fixed Prosthodontics Preparing FPD abutments such that they provide a free path of placement

are also fully visible, with both material from the interproximal show a double-image of the object at visual axes that were used to view aspects of the provisional restora- certain angles. This distortion may the abutments being parallel with tion, the abutment should be exam- prevent clear visibility of abutment each other, then the abutments ined again for undercuts. margins when margins are viewed at are aligned with a single path During the preparation appoint- microscope-level magnification. of placement. ment, an impression of the Large intraoral mouth mirrors may Examining a final impression abutments can be made (using be helpful for capturing images of of the abutments is another way fast-setting plaster or a polyvi- multiple abutments in a single mirror to verify a path of placement for a nylsiloxane material designed for view.6 The wide mirror functions as multi-unit FPD. The dentist exam- casting chairside models) to create a a viewing plane and helps to ensure ines an impression of one prepara- physical model of the abutments.1,2 that the visual axes that the dentist tion (with one eye closed) and turns The physical model can be assessed uses to view the multiple abutments the impression until discovering a for undercuts; in addition, a digital intersect with a single imaginary visual axis that makes it possible to scan of the abutments can be used plane at the same respective angles. see the entire surface of the axial wall to create a virtual computer model When assessing multiple posterior of the preparation as it appears in of the abutments. maxillary abutments for a path the impression. No point along the of placement, dry angles placed axial wall should appear to be more Optimizing the ability to on the buccal mucosa prevent it axially located compared to a point verify a path of placement from drooping over the mouth directly occlusal to it. While main- As mentioned previously, the mirror and blocking the view of taining the angle of the visual axis dentist should always have only the abutment margins. Dry angles used to view the first preparation, one eye open when assessing if an also improve the dentist’s ability to the dentist moves the impression abutment(s) provides an undercut- retract the buccal mucosa with pas- along an imaginary plane until the free path of placement for a future sive force, using the edge of a mouth next preparation comes into view. FPD.1,2,6 If both eyes were open mirror. In the event of resistance to If the second preparation appears (stereoscopic vision) and one eye saw the placement of the mouth mirror, to be free of undercuts, the dentist a part of the margin that the other pushing against the resistant cheek continues to move the impression eye did not see, the brain may men- muscle may shift the mouth mirror parallel to the same imaginary plane tally combine the viewpoint of both off the imaginary plane used to view until the other preparations come eyes and see the entire margin; as a the initial abutments.10 into view. A path of placement result, the dentist may not notice a Microscope-level magnification exists among the abutments when preparation with an actual undercut. (6-8X magnification or more) allows no point along the impression of Viewing the preparation with only a dentist to detect microscopic the axial aspect of the abutment(s) one eye allows the dentist to confirm undercuts within individual abut- appears to be more axially located a path of placement for an abutment ments that hinder alignment of mul- compared to a point located directly for which the entire margin is visible. tiple abutments with a single bridge occlusal to it. Impression material In addition, the dentist can view path of placement. Microscopes that flowed sub-gingivally past the the abutment while drying it with allow a dentist to detect undercuts margins of the abutments, which is high-volume evacuation suction. in crown abutments that might known as “flash,” appears in the final Otherwise, air bubbles from liquids appear foreshortened in the viewing impression to curl in an axial direc- (or refraction of light through the axis. Magnification improves a den- tion. However such flash is not part liquid that wets the abutment) can tist’s ability to sense tiny deviations of the impression of the axial aspect obstruct or distort views of the in the visual axis of their eye or in of the abutment. abutment margin or axial wall. the translational movement of their Sometimes, a well-made provi- The dentist should use front- head when the dentist is observing sional restoration can have an inta- surface mouth mirrors to view abut- multiple abutments to determine if glio surface that is precise enough ment margins. Non-front-surface they are aligned with a single path to verify that there are no undercuts mirrors—that is, where the reflecting of placement. Such tiny inadvertent in the path of placement provided surface of the mirror is not external movements of the dentist’s eye or by the abutments.1,2 If any obstruc- but is covered with a thin transpar- head, microscopic in scale, can tions remain after removing excess ent layer of glass or plastic—can alter the eye’s visual axis so that

524 November/December 2012 General Dentistry www.agd.org the current visual axis is no longer with visual axes that are parallel It may be difficult to verify that parallel with the visual axis used to the axes of the potential path of there are no infinitely small under- previously to view other aspects of placement. Unlike head-mounted cuts in an abutment path of place- the abutment margins. Magnifica- illumination, coaxial illumination ment. However, it is not necessary to tion is also useful for sensing devia- helps to ensure that shadows will verify that a path of placement is free tions when the dentist uses indirect only appear on those parts of the of infinitely small undercuts, as long vision (that is, viewing through a axial wall that have undercuts. as any undercuts that are present are mouth mirror) to assess the align- so small that a laboratory technician ment of multiple abutments with a Maintaining an FPD’s path can block them out and still fabricate single path of placement. of placement an FPD with clinically acceptable When examining a final Of course, once an FPD path of retention and seal. impression of the abutments for placement is created, the alignment the presence of undercuts, use of of the abutments must be captured Author information microscope-level magnification with an accurate impression, from Dr. Mamoun is in private practice helps in distinguishing between which the dental laboratory must in Manalapan, New Jersey. the perimeter of the abutment make accurate master casts. Dimen- margin and impression flash from sional distortions in the impressions Acknowledgement material that may have flowed past or the master casts may result in a The author thanks Dr. Donato the margin during the impression discrepancy between the perimeter Napoletano for providing the surgi- process. Microscope-level magni- of the path of placement on the cal operating microscope digital fication improves a dentist’s ability model of the abutment and that photograph used in this article. to tell intuitively if the impression found in the actual abutment. This has inadvertently moved on the discrepancy may result in an FPD References imaginary reference viewing plane. made for a path of placement that 1. Shillingburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE. Fundamentals of fixed prosthodontics. A dentist with unaided vision may does not exist intraorally. ed. 3. Chicago: Quintessence Publishing; 1997. be able to shape abutments so In addition, a provisional restora- 2. Rosenstiel SF, Land MF, Fujimoto J. Contempo- that they provide an unobstructed tion cemented with a strong cement rary fixed prosthodontics. ed. 4. St. Louis: Mos- by;2006. path of placement, but he or she such as polycarboxylate or glass 3. Al-Omari WM, Al-Wahadni AM. Parallelism of will need excellent visual acuity to ionomer helps to ensure retention abutment teeth on fixed partial dentures. Gen detect any microscopic undercuts and that the abutments will not Dent 2009;57(4):444-447. 4. Academy of Prosthodontics. The glossary of in a potential path of placement. shift during provisionalization. prosthodontic terms. J Prosthet Dent 2005;94(1): A dentist using unaided vision can On the day the FPD is inserted, 10-92. prepare the axial walls of abutments the provisional FPD may have to 5. Kaiser DA, Jones JD. Proximal contour modifications for fixed partial dentures: A clinical report. using tapered torpedo-shaped dia- be sectioned and an ultrasonic J Prosthet Dent 2003;89(4):344-345. mond burs that cut into the axial scaler used to remove the cement 6. Dumbrigue HB, Gurun DC. Use of intraoral pho- wall with a pre-set minimum depth from the abutments. tography mirrors as aids for evaluating parallelism of multiple abutment preparations. J Prosthet cut, creating an axial wall that has Dent 2001;85(1):95. sufficient depth of cut and taper to Summary 7. Ayad MF, Maghrabi AA, Rosenstiel SF. Assess- verify that the abutment is free of If an abutment provides a path ment of convergence angles of tooth preparations for complete crowns among dental visually apparent undercuts along of placement that is free from students. J Dent 2005;33(8):633-638. the path of placement. However, it undercuts, and an FPD made for 8. Gold HO. Instrumentation for solving abutment may be difficult to evaluate prepara- that abutment moves along that parallelism problems in fixed prosthodontics. J Prosthet Dent 1985;53(2):172-179. tions with minimal taper. path of placement, the FPD margin 9. el-Ebrashi MK, Craig RG, Peyton FA. Experimen- The use of head-mounted illumi- will vertically reach the level of, tal stress analysis of dental restorations. IV. The nation ensures that all aspects of and seal, the abutment margins. In concept of parallelism of axial walls. J Prosthet Dent 1969;22(3):346-353. the abutment’s axial walls and mar- addition, the FPD made for that 10. Mamoun J, Salamah M. Use of the dry angle gins will be illuminated simultane- abutment will closely hug the abut- isolation adjunct in general dentistry: A clinical ously while the dentist views them ment walls. approach. Dent Assist 2010;79(1):13-4, 36-37.

www.agd.org General Dentistry Special Prosthodontics Section 525 Prosthodontics

The impact of obesity on prosthodontic treatment

Judy Chia-Chun Yuan, DDS, MS n Fatemeh S. Afshari, DMD, MS n Damian J. Lee, DDS, MS Cortino Sukotjo, DDS, PhD, MMSc

Obesity has become a worldwide epidemic and an increasing comorbidities and assist patients in seeking necessary help. It public health concern that has a negative impact on both may be necessary to modify hardware, equipment, techniques, overall systemic and oral health. At the same time, the need treatment positions, and/or prosthodontic protocols to ensure for prosthodontic treatment has increased and has been that these patients receive the proper care and avoid unforeseen projected to be more in demand in the future. It has also been complications. An obese patient with a compromised medical predicted that the need to provide prosthodontic treatment to history and complex dental status may be managed best by a an increasing number of obese patients may become routine. multidisciplinary team approach. However, delivering prosthodontic treatment to obese patients Received: May 31, 2012 may be a challenge due to their anatomy, physiology, and Revised: August 14, 2012 physical characteristics. It is important to recognize the potential Accepted: August 16, 2012

besity is defined as abnormal (approximately 396 million people) It has been projected that the or excessive fat accumulation was obese.7 That number increased demand for prosthodontic treat- Othat may impair health.1 to more than 500 million adults ment will exceed the available It develops from an imbalance in 2008; it has been projected that number of providers by 2020; this between energy intake and expen- 1.12 billion individuals will be unmet need for prosthodontic treat- diture that is affected by genetic, obese by 2030.7,8 ment will continue to increase as environmental, and psychosocial The United States has the highest the baby boom generation matures, factors.1 The World Health Orga- obesity index among high-income despite an estimated decline in the nization (WHO) recommends countries.9 Between 2003 and age-specific rates of edentulism.12,13 body mass index (BMI) as a means 2010, the prevalence of obesity With the high prevalence for obe- of measuring and categorizing in the U.S. adult population sity in the U.S. and its continued obesity for adult men and women. increased from 32% to 37.4%.9 epidemic trends, it can be assumed BMI is calculated by dividing a If this trend continues, 51.1% that prosthodontic treatment patient’s weight (kg) by square of of U.S. adults will be obese by for obese patients will become their height (m2). A patient with a 2030.9 Within the U.S. popula- more prevalent. As a result, it is BMI ≥25 kg/m2 is classified as over- tion, obesity is prevalent among important to understand the topic weight, whereas a BMI ≥30 kg/m2 the baby boom generation (people of obesity, its effects on systemic is defined as obese.1 born between 1946 and 1965), and oral health, and its consequent Obesity has become an epidemic who became obese at younger ages implications for prosthodontic in many developed and develop- compared to their predecessors.10 treatment. Due to the complex ing countries, and its prevalence The impact of this generation’s nature of prosthodontic treatment, is increasing globally.1-6 Since obesity on the health care system oral health care professionals should 1980, the prevalence of obesity is tremendous. The forthcoming understand diagnosis, treatment has more than doubled in North surge of obesity predicted for older planning, and management of America, United Kingdom, East- adults over the next three decades obese individuals. This article ern Europe, Middle East, Pacific will lead to potentially higher provides an overview of the effect of Islands, Australia, and China. In obesity-related comorbidities and obesity on systemic and oral health, 2005, it was determined that 9.8% a higher demand for age-related and discusses how obesity could of the world’s adult population health care treatment.11 affect prosthodontic treatment.

526 November/December 2012 General Dentistry www.agd.org Effect of obesity on Gastroesophageal number of comorbidities (such systemic health reﬂux disease as hypertension, depression, and Comorbidities Gastroesophageal reflux disease stroke) are related to untreated or The impact of obesity on health (GERD) is a common gastrointes- undiagnosed OSA.46 care is enormous and cannot be tinal disorder affecting 15% of the overlooked.2,3,14-18 Based on the U.S. population weekly and 7% Wound healing and bone potential differences in anatomy of this population daily.34 Reflux mineral density and physiology, evidence sug- occurs when the lower esophageal Obese patients are prone to a gests that obese individuals are sphincter (LES) relaxes and cannot higher incidence of postsurgical of a different cohort compared to prevent fluid or solid matter from wound dehiscence, drainage, and the normal-weight population.14 returning to the cervical esophagus, infection.47-49 Many of these com- Obesity is related to a number of pharynx, or the oral cavity. Risk plications may be due to impaired chronic diseases, including type 2 factors for GERD include hiatal immune response, subtherapeutic diabetes, cardiovascular diseases, hernia, pregnancy, and obesity.35 pharmacokinetic mechanism, certain type of cancers (endome- Obesity is associated with increased increased susceptibility to infection, trial, breast, prostate, colon), and LES relaxation, postprandial and impaired wound healing.48-62 sleep-breathing disorders.14,19-26 gastroesophageal reflux, and Wound healing is a multifactorial Obesity also is associated with esophageal acid exposure. The process, which involves complex bio- health-related risk factors such frequency of transient LES relax- logical interactions.58,63,64 Hypovascu- as high cholesterol levels and ation is correlated with increases in larity and hypoperfusion have been asthma.22 As a result, obese patients BMI and waist circumference.36,37 associated with delayed wound heal- are predisposed to comorbidities There is a positive association ing and a decreased ability to combat and increased complications in between GERD and increased infection.56,60 Predisposing factors overall systemic and oral health.14 BMI.38 Individuals with a BMI associated with obesity complicate To provide the most appropriate ≥30 have approximately twice the the healing process, suggesting a poor care for this cohort of patients, it risk of having GERD compared to outcome for wound healing in this may be necessary to modify exist- those with a normal (<30) BMI.39 subset of the population.48,49,56,58,65 ing treatment protocols. Obese individuals are more likely The direct relationship between to experience hiatal hernias, which obesity and bone mineral density Arthritis contribute to GERD symptoms.40,41 (BMD) is controversial.66-70 Obe- Obesity has been identified as a sity can have a detrimental effect strong risk factor for arthritis, the Obstructive sleep apnea on bone and has been shown to most common cause of physical Obese individuals are more prone adversely influence the cortical bone disability in the United States.10,27 to develop obstructive sleep apnea structure and strength.57,59,62,67,70-72 Between 2007 and 2009, one (OSA) than their normal-weight Obese individuals have lower BMD in five U.S. adults reported counterparts.42 OSA is defined as and bone mineral content relative to doctor-diagnosed arthritis.28 an interruption of normal sleep their weight compared to normal- Osteoarthritis (OA), the most patterns. The most common clinical weight individuals.66,68 Relatively common type of arthritis, was signs of OSA include a large neck low bone strength index implies the fourth most frequent cause circumference, a retrognathic reduced capacity to withstand of hospitalization in 2009 and mandible, an excessive amount mechanical load and increases the the leading indication for joint of fat deposition in the palate, an risk for fracture.59,67,72 replacement surgery.29,30 Clinical enlarged tongue and pharynx, a OA includes pain, aching, or long soft palate, tonsillar hyper- Effect of obesity on stiffness affecting hand, knee, trophy, a wider dental arch, nasal oral health or hip joints, which may limit septum deviation, narrow velopha- Anatomy physical activities.31 Obesity is ryngeal airways, and adipose tissue Administering dental treatment strongly linked to OA of the knee, in the upper body.42-45 Common to obese individuals may prove and has been attributed to an signs and symptoms associated with challenging due to the physical increasing need for knee and hip OSA involve xerostomia, GERD, characteristics associated with these joint replacement.32,33 depression, and drooling.46 A high patients, notably the increased

www.agd.org General Dentistry Special Prosthodontics Section 527 Prosthodontics The impact of obesity on prosthodontic treatment

mandibular length, shorter upper disease is adipocytokine and its harder foods in favor of softer face height, and increased total destructive effect on periodontal foods, which may contribute to the facial height.73-75 These patients tend tissue.92,96,99,100 Zeigler et al reported obesity of the patient.111-114 to have decreased oral openings; that the sum of bacterial cells in additional amounts of oral soft subgingival biofilm is higher among Oral wound healing tissue; short, thick necks; and excess obese patients.101 Obesity has been Obesity also has been associated tongue volume.76-80 shown to impair the immune system; with surgical and post-surgical such an impairment could result in complications in dentistry, includ- Xerostomia and dental caries increased alveolar bone loss after oral ing difficulty during third molar Pharmacological treatment of co- bacterial infections such as gingivitis extractions and increased postsurgi- morbidities associated with obesity and periodontitis.102 These data cal extraction complications.115,116 In may lead to some oral side effects. suggest that obesity is a significant addition, predisposing factors asso- For example, xerostomia can result predictor for periodontal disease. ciated with obesity complicate the from many antidepressant medica- healing process, suggesting a poor tions prescribed for OSA-related Edentulism outcome after surgical extraction in depression or from the application Obesity is associated with an this population.48,49,56,58,65 of some types of nasal continuous increased risk of partial and com- positive airway pressure (CPAP).81,82 plete edentulism.103,104 Dental caries, Effect of obesity on Both obesity and dental caries are medication-induced xerostomia, prosthodontic treatment multifactorial diseases and both are periodontitis, and tooth erosion are Technique and hardware related to the individual’s dietary risk factors that may lead to prema- The anatomical and physiological habits.79 The literature suggests ture tooth loss in the obese popula- makeup of obese individuals may a positive relationship between tion. Some contributing causes of pose a challenge to delivering dental sugar-sweetened beverage intake and edentulism in obese patients may treatment. For instance, a standard- weight gain which may also con- be that these patients tend to seek ized blood pressure cuff may result tribute indirectly to caries develop- dental care irregularly, have higher in a false positive reading for an ment.83 Some studies have shown an dental anxiety, and have poor obese individual.79,80,117 To provide increased prevalence of dental caries health-related quality of life.79,105,106 an accurate reading, the width of in obese young adults and the elderly In one Swiss population study, the the blood pressure cuff should be population.79,84-87 In addition, data highest waist-circumference quartile more than one-third the length of from the third National Health and cohort had 19.7 teeth, compared to the upper arm circumference.77,118 In Nutrition Examination Survey dem- 21.5 teeth for their normal-weight addition, a standard dental chair or onstrated a correlation between the counterparts.107 Consequently, the operatory unit may not be suitable decayed missing filled teeth (DMFT) obese cohort was shown to require for obese patients. Armless treatment score and both BMI and waist-to-hip more dentures.107 In a nationwide chairs and armless waiting room ratios among an adult population.88 survey of elderly people in Great chairs have been recommended to Britain, individuals with less than accommodate these individuals.119 Periodontal health 21 teeth were three times more Positioning an obese patient in a The literature has reported significant likely to be obese.108 dental chair may prove challenging associations between obesity and due to their physical attributes, periodontal disease.88-98 It has been Chewing ability as their neck may not extend suggested that obesity is a second Partial edentulism is associated fully.76,77,79,120 Dentists should risk factor (following smoking) for with poor oral health status among exercise caution when placing these inflammatory periodontal tissue the obese, which may contribute patients in a supine or recumbent destruction; in addition, obesity has to a poor dietary selection. Obese position, which may predispose been associated with increased clini- dental patients demonstrate poorer airway obstruction, hypoxemia, and cal attachment loss and deeper perio- masticatory performance, longer intensified metabolic requirements dontal pocket depths.88,89,91-94,97,98 chewing time, increased chewing leading to fainting or dizziness According to the literature, the cycles, and lower bite force.109-111 after long periods of time in a underlying biological mechanism Obese patients tend to chew less supine position.77 Modifications connecting obesity and periodontal when consuming meals and avoid may be necessary to ensure that

528 November/December 2012 General Dentistry www.agd.org these patients are comfortable in and poor visibility and accessibility time should be planned beforehand, the dental chair. Providers may also in the posterior region. and the patient should be monitored need to maintain good posture when Caries, periodontitis, medication- for postsurgical complications. treating obese patients in modified induced xerostomia, and tooth ero- Longer healing time may be chair positions. Prosthodontic sion are common risk factors among necessary for this cohort due to procedures involving full mouth obese patients that could lead to their anatomical, biological, and rehabilitation usually are lengthy and partial or complete edentulism. physiological differences, and their require multiple appointments. Successful prosthodontic treatment greater prevalence for comorbidities; The physical characteristics of depends on early diagnosis of in addition, medications and doses obese patients may limit visibility of xerostomia, knowledge of its causes, should be selected carefully. Recom- and access to anatomical landmarks and proper management. To reduce mended pharmacological agents are when administering local anesthesia the risk of further caries develop- easily titratable, have a short length and performing certain extraoral ment, frequent water consumption, of action, and are not distributed to examinations (for instance, palpat- xylitol use, artificial saliva products, fatty tissues.120 Modified protocols ing lymph nodes in the head and fluoride application, and calcium to avoid the risk of overdose may neck region).44,76-80 Retracting phosphate mouth rinses have been need to be established when pre- increased soft tissue mass and thick recommended.44,79 scribing a weight-based medication cheeks with a normal size mirror At the initial treatment planning dosage for this cohort.124 may prove challenging for oral phase, dentists should recommend Obese patients with arthritis health care providers. dietary counseling and assist tend to have a higher prevalence patients in seeking help (when nec- of xerostomia, which can lead Prosthodontic treatment essary) for obesity and its comor- to the development of caries, Obese complete dentate, partially bidities. It is important for dentists periodontal diseases, and lesions in or completely edentulous patients to understand the consequences the oral mucosa.125 According to with or without additional medi- of obesity on overall dentition and Pokrajac-Zirojevic et al, patients cal conditions may be classified as provide proper prosthodontic treat- with OA or rheumatoid arthritis Prosthodontic Diagnostic Index ment for these patients to regain (RA) are less likely to visit dental Class III or Class IV categories.121-123 function and improve their nutri- professional than their nonarthritic These patients typically present tional intake. Multiple factors (such counterparts.126 As a result, dental challenges due to their physical as a patient’s medical history, dental procedures for OA and RA patients characteristics and possible comor- needs, and potential obesity-related are more likely to involve extrac- bidities; as a result, they may be best risks) should be considered care- tion and prosthodontic treatment. managed by a prosthodontist when fully to avoid unforeseen complica- According to Laurell et al, patients complex care is required. This pro- tions. A well-planned treatment with RA tend to have less satisfac- cess includes diagnosis, treatment sequence and a multidisciplinary tory function of removable dental planning, and potential surgical team approach may be required to prostheses (usually due to unstable and restorative procedures, as well ensure proper management. impaired occlusion) compared to as maintenance or recall. The thick Prosthodontic treatments often their normal-weight counterparts.127 cheeks and enlarged tongue found involve surgical procedures, such OA patients whose hands are in some obese patients may impede as extraction, periodontal surgery, symptomatic of the condition may certain prosthodontic procedures, or implant placement. Surgical have difficulty performing daily oral such as crown preparation and protocols may need to be modified hygiene or even maintaining a pros- impression making, and also may to minimize complications during thesis.128,129 A more frequent recall predispose this cohort to a smaller the healing period. Obesity is program may ensure the proper neutral zone for teeth arrangement associated with a complicated heal- function of the dental prostheses when fabricating complete dentures. ing process and poor postsurgical and should resolve any unforeseen Establishing borders for removable outcomes.48,49,56,58,65 A 2007 study complications among these patients. dental prostheses and fabricating reported that the total amount For obese patients with GERD a final impression can be difficult of time required for extraction symptoms, acid reflux into the oral because of the smaller opening in increased in patients with higher cavity can lead to chemical tooth the oral cavity, large soft tissue mass, BMI.116 The intrasurgical procedure erosion.41,130-136 Chemical erosion

www.agd.org General Dentistry Special Prosthodontics Section 529 Prosthodontics The impact of obesity on prosthodontic treatment

differs from attrition in that one erosions require a multidisciplinary team approach is needed to ensure a may observe the loss of tooth approach to dental rehabilitation, more comprehensive rehabilitation structure not only on the occlusal/ which may require endodontic and for the obese patient population. incisal surfaces of the teeth, but also periodontic therapy in addition to on the buccal and lingual surfaces. prosthodontic treatment. Author information Individuals who experience symp- Treatment for OSA should be Drs. Yuan, Lee, and Sukotjo are toms of vomiting one or more times based on the recommendation assistant professors, and Dr. Afshari a week, heartburn, belching, pain of the physician. Some suggested is a clinical assistant professor, on awakening, an acid taste in the treatments for OSA involve appli- Department of Restorative Den- mouth, or stomach pain are 31 times ances, including CPAP appliances tistry, College of Dentistry, Univer- more likely to experience dental to maintain upper airway flow sity of Illinois at Chicago. erosion than those who do not.137 during sleep and/or oral appliance To ensure the lasting durability and therapy, which usually involves References high survival rate of a prosthesis, it mouth guards or modified retain- 1. Obesity and overweight. World Health Organi- 139,140 zation. Available at: http://www.who.int/ is essential to select the most suitable ers. Surgical treatments such as mediacentre/factsheets/fs311/en/. Accessed: dental materials for this population. uvulopalatopharyngoplasty (either September 28, 2011. For obese patients with OSA, the alone or combined with a genial 2. Flegal KM, Carroll MD, Ogden CL, Curtin LR. Prevalence and trends in obesity among U.S. most common treatment involves advancement) or maxillomandibu- adults, 1999-2008. JAMA 2010;303(3):235- using oral appliances for mandibular lar advancement are both effective 241. advancement. However, occlusal options.141-143 Dental surgical proce- 3. Seidell JC. Obesity: A growing problem. Acta fl fl Paediatr Suppl 1999;88(428):46-50. changes (such as posterior open bite dures, such as re ecting a ap, may 4. James PT. Obesity: The worldwide epidemic. Clin and altered incisor position) have prevent using a CPAP immediately Dermatol 2004;22(4):276-280. been observed when using these postsurgery.139 5. Ogden CL, Carroll MD, Curtin LR, McDowell MA, 44 Tabak CJ, Flegal KM. Prevalence of overweight appliances. When fabrication of and obesity in the United States, 1999-2004. an occlusal appliance is indicated, Summary JAMA 2006;295(13):1549-1555. the prosthodontist may be the best The high prevalence of obesity and 6. 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Estimating the progression and cost of the U.S. obesity epidemic. Obesity and OSA) early and refer these treatment. Treatment protocols (Silver Spring) 2008;16(10):2323-2330. patients to intervention programs should be modified to ensure that 10. Leveille SG, Wee CC, Iezzoni LI. Trends in obesity through medical professionals, such these patients receive appropriate and arthritis among baby boomers and their predecessors, 1971-2002. Am J Public Health as dietary counseling for weight loss dental care. To ensure the proper 2005;95(9):1607-1613. and other lifestyle modifications.138 function of the dental prostheses, 11. Wang YC, Colditz GA, Kuntz KM. Forecasting For example, when severe erosion is both a frequent recall program the obesity epidemic in the aging U.S. population. Obesity (Silver Spring) 2007;15(11):2855- observed in GERD patients, dental and a rigid maintenance program 2865. rehabilitation should be postponed (one which monitors optimal oral 12. Douglass CW, Watson AJ. 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www.agd.org General Dentistry Special Prosthodontics Section 533 Endodontics CDE 2 HOURS CREDIT Antimicrobial effect of three new and two established root canal irrigation solutions

Zahed Mohammadi, DMD, MSD n Sousan Shalavi, DMD n Luciano Giardino, MD, DDS n Flavio Palazzi, MD, DDS Rasoul Youseﬁ Mashouf, PhD n Alireza Soltanian, PhD

This study sought to assess the efﬁcacy of two established and three irrigants demonstrated the most effective antimicrobial activity. relatively new root canal irrigants against ﬁve different microorganisms Received: December 2, 2011 using the agar diffusion method. Sodium hypochloride (NaOCl)-based Accepted: March 14, 2012

he literature has shown that Sodium hypochlorite (NaOCl) is displayed very similar bactericidal microorganisms are major con- the most commonly used endodon- activity against E. faecalis, while Ttributors to the initiation and tic irrigant for chemomechanical a 2007 article demonstrated that perpetuation of pulpal and periapi- preparation of the root canal system, Tetraclean was more effective than cal diseases.1-3 Enterococcus faecalis offering excellent antimicrobial MTAD against E. faecalis and belongs to the genus Enterococci, activity against bacteria, fungi, and polymicrobial biofilms.10,11 which are Gram-positive cocci. E. biofilms.8 Chlorhexidine (CHX) is Hypoclean (Idropan Dell’Orto faecalis plays an important role in another irrigant that is commonly Depuratori, SRL) is a new NaOCl- the failure of root canal treatment. used in endodontics. CHX is a based endodontic irrigant composed It occurs in persistent periradicular cationic biguanide that appears to of 5.25% sodium hypochlorite and lesions nine times more frequently act by adsorbing onto the cell walls two detergents.12 There are very than in primary infections.4 Can- of microorganisms, resulting in few published studies regarding dida albicans is the most prevalent leakage of intracellular components. its antibacterial activity; however, fungal species in the oral cavity. It Although studies comparing the anti- Mohammadi et al demonstrated occurs much more frequently in bacterial effect of CHX and NaOCl that Hypoclean offers substantivity persistent root canal infections than have produced somewhat conflicting for up to four weeks.12 in primary infections.5 The genus results, it seems that when used in Given the paucity of studies Actinomyces consists of a hetero- identical concentrations, their anti- regarding the antimicrobial activity geneous group of non-acid-fast, bacterial effects ex vivo (in infected of Tetraclean and the absence of stud- non-motile, non-spore-forming, dentin) and in vivo (in the root canal ies on the antimicrobial activity of obligately anaerobic, facultatively system) are similar.8,9 Furthermore, Hypoclean and Chlor-XTRA (Vista anaerobic Gram-positive rods.6 CHX is an effective antifungal agent Dental Products), it was decided to Eliminating microorganisms and its efficacy is significantly less assess the antimicrobial activity of from infected root canal systems is a than that of NaOCl.9 these products against E. faecalis, C. complicated task that requires various Tetraclean (Ogna Laboratori albicans, A. israelii, Lactobacillus instrumentation techniques, irriga- Farmaceutici), like MTAD (Dentsply casei, and Pseudomonas aeroginosa tion regimens, and intracanal medica- Tulsa Dental), is a mixture of an using three concentrations of NaOCl ments. Mechanical instrumentation antibiotic (doxycycline), an acid (5.25%, 2.6%, and 1.3%) and two alone does not result in a bacteria-free (citric acid), and two detergents (pro- concentrations of CHX (2.0% and root canal system; indeed, ex vivo pylene glycol and cetrimide); how- 0.2%). Chlor-Xtra contains a wetting and clinical evidence indicates that ever, Tetraclean contains a different agent, proprietary surface modifiers, mechanical instrumentation leaves concentration of doxycycline (50 mg and alkylating agents. significant portions of the root canal mL-1) and different types of detergent Most of the microbial strains walls untouched.7 Therefore, the use (polypropylene glycol and cetrimide) chosen for the present study were of an irrigation solution with antimi- compared to MTAD.7 A 2009 study relevant because they are a part of crobial activity is recommended. reported that NaOCl and Tetraclean the endodontic microflora.

534 November/December 2012 General Dentistry www.agd.org Table 1. Mean measurements (±SD) of microbial growth inhibition (mm).

Irrigant E. faecalis C. albicans A. israelii P. aeroginosa L. casei p value 5.25% NaOCl 29.4333 ± 0.9073 9.5000 ± 0.3605 19.8000 ± 0.4582 31.7000 ± 0.8888 29.7000 ± 0.5567 0.012 2.6% NaOCl 21.3000 ± 0.4358 14.3000 ± 0.6557 15.3000 ± 0.2000 22.5000 ± 0.3605 18.2000 ± 0.2645 0.009 1.3% NaOCl 16.2000 ± 0.4000 16.7000 ± 0.4358 12.7000 ± 0.1000 16.6000 ± 0.2645 14.3000 ± 0.4582 0.002 2% CHX 14.5000 ± 0.5196 14.2000 ± 0.5291 21.3000 ± 0.3464 13.2000 ± 0.1000 19.7000 ± 0.6245 0.011 0.2% CHX 9.4000 ± 0.4582 9.8000 ± 0.9165 13.7000 ± 0.7000 8.1000 ± 0.2000 14.1333 ± 0.1527 0.015 Tetraclean 19.7000 ± 0.6000 10.3000 ± 0.1000 23.2000 ± 0.3605 27.9000 ± 1.8193 24.1000 ± 0.1732 0.009 Hypoclean 17.1667 ± 0.1154 39.7000 ± 1.0538 19.7000 ± 0.6000 34.1333 ± 1.1503 31.2000 ± 0.9848 0.009 Chlor-XTRA 23.1000 ± 0.8000 14.8000 ± 0.2645 27.0667 ± 0.4041 21.4000 ± 0.3605 18.3000 ± 0.2645 0.009

Materials and methods Overnight cultures of microorgan- Table 2. Summary of irrigants that were most and least effective against isms were grown on brain-heart each microorganism tested (P = 0.001). infusion (BHI) agar plates (Becton Dickinson & Company). Petri Microorganism Most effective irrigant Least effective irrigant dishes containing Muller-Hinton E. faecalis 5.25% NaOCL 0.2% CHX (MH) agar were prepared for all C. albicans Hypoclean 0.2% CHX microorganisms except for A. israelii and C. albicans. Brucella A. israelii Chlor-XTRA 1.3% NaOCl agar (Oxoid Microbiology Products) P. aeroginosa Hypoclean 0.2% CHX supplemented with 5% defibrinated L. casei Hypoclean 0.2% CHX sheep blood, 1% vitamin K, and 0.5% hemin was used to grow A. israelii, while Sabouraud dextrose agar was used to assess the efficacy inhibition were measured across two Chlor-XTRA was the most of irrigants against C. albicans. diameters (perpendicular to each effective solution against A. israelii A total of 150 plates were divided other) and recorded. The tests were (P = 0.009) The complete results are into five groups, one for each of the repeated five times for all isolates, listed in Tables 1 and 2. microorganisms tested (n = 30). and the means were then calculated. Thereafter, each group was divided Data were analyzed using a Kruskal- Discussion into eight subgroups according to Wallis test; in addition, a post hoc The agar diffusion test is a well- the irrigation solution used. Three test was used for multiple compari- established, simple method for paper disks were placed in each sons between different groups. studying the antimicrobial activity of plate. Antibacterial susceptibility root canal irrigants. The antibacterial blank test disks (6 mm in diameter) Results activity of each root canal irrigant is were soaked with 30 µL of the test NaOCl-based irrigants demon- dependent on its diffusion into agar. solutions (1.3%, 2.6%, and 5.25% strated the most effective However, there are several disad- NaOCl; 0.2% and 2% CHX; antimicrobial activity, and the vantages to the agar diffusion test. Tetraclean; Hypoclean; and Chlor- 5.25% NaOCl solution was the First, it is impossible to distinguish XTRA) and stored at 4°C until use. most effective irrigant against E. between the agents’ microbiostatic The disks were placed on plates faecalis (P= 0.012). Hypoclean and microbicidal properties; in stored for one hour at 4°C, then was the most effective irrigant addition, the results are easily incubated for 48 hours at 37°C. against C. albicans, P. aeroginosa, affected by diffusion of the materi- Using a transparent ruler, zones of and L. casei (P = 0.009), while als across the medium. Other

www.agd.org General Dentistry November/December 2012 535 Endodontics Antimicrobial effect of three new and two established root canal irrigation solutions

factors that could affect the results demonstrated the weakest anti- Iran, where Dr. Shalavi is a general include good contact between test microbial activity against four (E. practitioner; Dr. Mashouf is a material and agar, inoculum size, faecalis, C. albicans, L. casei, and professor, Department of Bacte- and incubation time. However, if P. aeroginosa) of the five tested riology; and Dr. Soltanian is an these factors are controlled pre- microorganisms. This finding is not assistant professor of Biostatistics. cisely, compatible and repeatable surprising, as most studies recom- Dr. Giardino is in private practice results can be achieved.13-16 mend a 2% concentration of CHX in Crotone, Italy. Dr. Palazzi is an Few studies have been conducted to irrigate the root canal system.9 assistant professor in the Depart- to determine the antimicrobial There is no consensus regarding ment of Odontostomatological and activity of the recently developed the antibacterial activity found Maxillofacial Sciences, Federico II NaOCl-based irrigation solutions in different concentrations of University, Naples, Italy. (Tetraclean, Hypoclean, and Chlor- NaOCl. A 2000 study by Siqueira XTRA) used in the present study. In et al reported no differences in the References 2010, Pappen et al investigated the antibacterial activity of 1%, 2.5%, 1. Kakehashi S, Stanley HR, Fitzgerald RJ. The effects of surgical exposure of dental pulps in ff 19 antibacterial e ect of several prod- and 5% NaOCl. Four years later, germ-free and conventional laboratory rats. Oral ucts against E. faecalis and discov- Vianna et al reported that five con- Surg Oral Med Oral Pathol 1965;20:340-349. ered that Tetraclean and MTAC-2 centrations of NaOCl (0.5%, 1%, 2. Moller AJ, Fabricius L, Dahlen G, Ohman AE, Hey- den G. Influence on periapical tissues of indige- (a variant of MTAD in which the 2.5%, 4% and 5.25%) all eliminated nous oral bacteria and necrotic pulp tissue in detergent is replaced by 0.1% CTR) Porphyromonas endodontalis, Por- monkeys. Scand J Dent Res 1981;89(6):475-484. killed planktonic E. faecalis in less phyromonas gingivalis, and Prevotella 3. Sundqvist G. Ecology of the root canal flora. 17 20 J Endod 1992;18(9):427-430. than 30 seconds. intermedia within 15 seconds. 4. Stuart CH, Schwartz SA, Beeson TJ, Owatz CB. Two years earlier, Neglia et al Other studies have reported Enterococcus faecalis: Its role in root canal evaluated in vitro the efficacy of that the antibacterial activity of treatment failure and current concepts in retreatment. J Endod 2006;32(2):93-98. NaOCl and Tetraclean against E. NaOCl depends on its concentra- 5. Siqueira JF, Sen BH. Fungi in endodontic infec- faecalis, and found that Tetraclean tion. Berber et al found that a tions. Oral Surg Oral Med Oral Pathol Oral Radi- was at least as effective as NaOCl 5.25% concentration was the most ol Endod 2004;97(5):632-641. 6. Siqueira JF. Periapical actinomycosis and infec- 18 ff in its antibacterial activity. In e ective solution, followed by a tion with Propionibacterium propionicum. En- an ex vivo tooth model, the same 2.5% concentration, while a 0.5% dod Topics 2003;6(1):78-95. authors found that only the teeth concentration provided the weakest 7. Mohammadi Z, Abbott PV. On the local applica- 21 tions of antibiotics and antibiotic-based agents irrigated with Tetraclean saw a antibacterial activity. According in endodontics and dental traumatology. Int gradual decrease in bacteria; no to a 2001 study by Gomes et al, Endod J 2009;42(7):555-567. bacteria were detectable three there is an inverse relationship 8. Mohammadi Z. Sodium hypochlorite in endodontics: An update review. Int Dent J 2008; days post-irrigation. For the teeth between the concentration of 58(6):329-341. irrigated with NaOCl, the drop in NaOCl and the time required to 9. Mohammadi Z, Abbott PV. The properties and the bacterial burden was rapid but kill microorganisms.22 applications of chlorhexidine in endodontics. Int Endod J 2009;42(4):288-302. temporary, and 70% of the teeth 10. Giardino L, Savoldi E, Ambu E, Rimondini R, were re-colonized within 48 hours Conclusion Palezona A, Debbia EA. Antimicrobial effect of post-irrigation. The residual antibac- Within the limitations of the MTAD, Tetraclean, Cloreximid, and sodium hypochlorite on three common endodontic patho- terial activity of Tetraclean has been present study, 5.25% NaOCl and gens. Indian J Dent Res 2009;20(3):391. shown to last for up to four weeks.18 Hypoclean were the most effective 11. Giardino L, Ambu E, Savoldi E, Rimondini R, In 2011, Mohammadi et al irrigants against the microorgan- Cassanelli C, Debbia EA. Comparative evaluation of antimicrobial efficacy of sodium hypo- demonstrated that Hypoclean isms tested. Furthermore, 0.2% chlorite, MTAD, and Tetraclean against offered significantly lower residual chlorhexidine solution demon- Enterococcus faecalis biofilm. J Endod 2007; antibacterial activity compared to strated weakest activity against all 33(7):852-855. 12 12. Mohammadi Z, Mombeinipour A, Giardino L, Tetraclean. However, there have tested bacteria. Shahriari S. Residual antibacterial activity of a been no studies regarding the anti- new modified sodium hypochlorite-based end- bacterial activity of Chlor-XTRA. Author information odontic irrigation solution. Med Oral Patol Oral Cir Bucal 2011;16(4):e588-e592. In the present study, the 1.3% Dr. Mohammadi is an associate 13. Spangberg L, Engstrom B, Langland K. Biologic NaOCl solution was the least professor and head, Department of effects of dental materials. 3. Toxicity and antimi- effective irrigant against A. israelii, Endodontics, Hamedan University crobial effect of endodontic antiseptics in vitro. while the 0.2% CHX solution of Medical Sciences, Hamedan,

536 November/December 2012 General Dentistry www.agd.org Oral Surg Oral Med Oral Pathol 1973;36(6): sodium hypochlorite. Oral Surg Oral Med Oral 856-871. Pathol Oral Radiol Endod 2004;97(1):79-84. 14. Cohen S, Burns RC. Pathways of the pulp, ed. 8. 21. Berber VB, Gomes BP, Sena NT, Vianna ME, Ferraz St. Louis: Mosby Co.;2002:293-364. CC, Zaia AA, Souza-Filho FJ. Efﬁcacy of various 15. al-Khatib ZZ, Baum RH, Morse DR, Yesilsoy C, concentrations of NaOCl and instrumentation Bhambhani S, Furst ML. The antimicrobial effect techniques in reducing Enterococcus faecalis of various endodontic sealers. Oral Surg Oral within root canals and dentinal tubules. Int Med Oral Pathol 1990;70(6):784-790. Endod J 2006;39(1):10-17. 16. Cobankara FK, Altinoz HC, Erganis O, Kav K, 22. Gomes BP, Ferraz CC, Vianna ME, Berber VB, Belli S. In vitro antibacterial activities of root Teixeira FB, Souza-Filho FJ. In vitro antimicrobial canal sealers by using two different methods. activity of several concentrations of sodium hy- J Endod 2004;30(1):57-60. pochlorite and chlorhexidine gluconate in the 17. Pappen FG, Shen Y, Qian W, Leonardo MR, elimination of Enterococcus faecalis. Int Endod J Giardino L, Haapasalo M. In vitro antibacterial 2001:34(6):424-428. action of Tetraclean, MTAD and ﬁve experimental irrigation solutions. Int Endod J 2010;43(6): 528-535. Manufacturers 18. Neglia R, Ardizzoni A, Giardino L, Ambu E, Grazi Becton Dickinson & Company, Franklin Lakes, NJ S, Calignano S, Rimoldi C, Righi E, Blasi E. Com- 201.847.6800, www.bd.com parative in vitro and ex vivo studies on the bac- Dentsply Tulsa Dental, Tulsa, OK tericidal activity of Tetraclean, a new generation 800.662.1202, www.biopuremtad.com endodontic irrigant, and sodium hypochlorite. Idropan Dell’Orto Depuratori, SRL, Milano, Italy New Microbiol 2008;31(1):57-65. 39.02.6680.0267, www.hypoclean.it 19. Siqueira JF Jr, Rocas IN, Favieri A, Lima KC. Che- momechanical reduction of the bacterial popu- Ogna Laboratori Farmaceutici, Muggio, Italy lation in the root canal after instrumentation 39.039.278.2954, www.ognalaboratori.it and irrigation with 1%, 2.5%, and 5.25% sodi- Oxoid Microbiology Products, Basingstoke, um hypochlorite. J Endod 2000;26(6):331-334. Hampshire, United Kingdom 20. Vianna ME, Gomes BP, Berber VB, Zaia AA, Fer- 44.0.1256.841144, www.oxoid.com raz CC, de Souza-Filho FJ. In vitro evaluation of Vista Dental Products, Racine, WI the antimicrobial activity of chlorhexidine and 877.418.4782, www.vista-dental.com

www.agd.org General Dentistry November/December 2012 537 CDE self 2 HOURS instruction CREDIT

Exercise No. 318 Endodontics

Subject Code 070 5. The most commonly used root canal irrigant is The 15 questions for this exercise are based on the article A. sodium hypochlorite. Antimicrobial effect of three new and two established root B. CHX. canal irrigation solutions on pages 534-537. This exercise C. Tetraclean. was developed by Merlin Ohmer, DDS, FAGD, in association D. Hypoclean. with the General Dentistry Self-Instruction committee. 6. CHX’s action is thought to be Reading the article and successfully completing the A. penetration of the cell wall. exercise will enable you to: B. destruction of the cell wall. UÊÕìÀÃÌ>`ÊÌ iÊivwV>VÞÊvÊÛ>ÀÕÃÊÀÌÊV>>ÊÀÀ}>ÌÃÆ C. allowing extra-cellular material into the cell. UÊìVìÊÜ V ÊÀÀ}>ÌÊÌÊÕÃiÊÊVV>Ê«À>VÌViÆÊ>`Ê D. allowing intra-cellular material out of the cell. UÊÕìÀÃÌ>`ÊÌ iÊÛ>ÀÕÃÊÀÌÊV>>ÊÀÀ}>ÌÃÊ>Û>>LiÊ for use. 7. CHX is a more effective irrigant than sodium hypochlorite. It is effective against fungi. 1. Which of the following irrigants has been shown A. Both statements are true. to have residual antibacterial activity for up to B. The first statement is true; the second is false. four weeks? C. The first statement is false; the second is true. A. MTAD D. Both statements are false. B. Hypoclean C. Chlor-XTRA 8. Tetraclean is a commercial irrigant that contains D. Tetraclean which of the following ingredients? A. Tetracycline 2. 1.3% Sodium hypochlorite (NaOCl) is the least B. Minocycline effective antimicrobial agent against C. Doxycycline A. A. israelii. D. Chlortetracycline B. E. faecalis. C. L. casei. 9. Specifically, how long were the agar plates D. C. albicans. incubated? A. 12 hours 3. The root canal system is easily cleaned and B. 24 hours disinfected with thorough instrumentation. C. 48 hours Disinfection is easy to accomplish. D. 72 hours A. Both statements are true. B. The first statement is true; the second is false. 10. Which irrigant ingredient was the most effective C. The first statement is false; the second is true. antimicrobial agent? D. Both statements are false. A. CHX B. Sodium hypochlorite 4. Actinomyces have all of the following characteris- C. Antibiotic tics except one. Which is the exception? D. Detergent A. Non-motile B. Non-spore forming 11. The agar diffusion test measures C. Acid-fast A. the spread of bacteria in a culture medium. D. Rod-shaped B. the depth of penetration of bacteria into the tissue. C. the effectiveness of an antimicrobial. D. the virulence of a bacteria.

538 November/December 2012 General Dentistry www.agd.org 12. The agar diffusion test is very easy to conduct. It 14. 5.25% Sodium hypochlorite and ______has very few, if any, disadvantages. were found to be the most effective irrigants. A. Both statements are true. A. CHX B. The ﬁrst statement is true; the second is false. B. Hypoclean C. The ﬁrst statement is false, the second is true. C. Tetraclean D. Both statements are false. D. Chlor-XTRA

13. The Neglia et al study found Tetraclean to be at 15. In the study, which material demonstrated the least as effective as greatest residual anti-microbial activity? A. sodium hypochlorite. A. Sodium hypochlorite B. CHX. B. Hypoclean C. Hypoclean. C. Tetraclean D. Chlor-XTRA. D. CHX

Answer form is on page 552. Answers for this exercise must be received by October 31, 2013.

To enroll in Self-Instruction, click here.

www.agd.org General Dentistry November/December 2012 539 Lasers in Periodontics

Five-year retrospective study of laser-assisted periodontal therapy

Edward R. Kusek, DDS n Amanda J. Kusek, RDH n E. Alex Kusek

This article outlines a ﬁve-year retrospective study involving In 80% of cases, pocket depth of 3 mm or less was maintained. a diode dental laser used on periodontally infected teeth. Received: October 17, 2011 The present study utilized a speciﬁc protocol: scaling and root Accepted: March 15, 2012 planing, light ultrasonic scaling, and the use of a diode laser.

he use of dental lasers for bacterial colonization after perio- the maximum utilization of insur- the treatment of periodontal dontal treatment help to increase the ance for most patients. Tdisease is accepted in some resistance of the microorganism.5 Optimally, patients would return areas of dentistry, while in others it According to the literature, using for a series of subsequent appoint- is thought to be antidotal therapy.1 diode lasers in conjunction with SRP ments to address every pocket that This article seeks to show that accelerates and enhances wound exceeded the healthy 3 mm. For laser-assisted periodontal therapy healing, making it more comfortable, example, a patient whose deepest is a viable, noninvasive method for while decreasing gingival bleeding, pocket measured 7 mm would come treating periodontal disease. inflammation, and pocket depths.6 in for a total of four appointments Periodontal disease is a chronic A 2002 position paper from the every 7–10 days. Each time the laser inflammatory disease caused by a American Academy of Periodontol- was used to treat that pocket, 1 mm bacterial infection. For this reason, ogy stated that gingival curettage of it would heal from the apical to the bactericidal and detoxifying consistently fails to provide any the coronal.5 Using this example, effects of laser treatment are advan- advantage in treating chronic perio- all 7-mm pockets would be treated tageous in periodontal therapy.2 The dontitis compared to SRP alone.7 first, while the 6-mm pockets would effectiveness of this therapy involves The current article challenges this be treated at the second appoint- suppressing certain bacteria such assertion by describing a five-year ment (7–10 days later). This process as Aggregatibacter actinomycetem- retrospective study that shows how would continue for each appoint- comitans, an invasive bacterium laser technology made a consistent ment until all pockets had a healthy associated with aggressive forms of difference in the health of chronic depth of 3 mm. periodontal disease that cannot be periodontal patients. It is the authors’ Each appointment began with treated readily with conventional opinion that the biofilm attaches to ultrasonic scaling at a low setting, scaling and root planing (SRP). This the inner lining of the epithelium applied to all pockets in a slow, bacterium is present on diseased and bony walls exposed to the sweeping motion. This technique is root surfaces; as a result, it can bacteria. That biofilm will continue used to smooth the root surface, in invade the adjacent soft tissues as to destroy sulcular and junctional addition to the regular cleaning or well, making removal by mechanical epithelium if it is not eliminated. SRP that the patient had undergone instrumentation difficult.3 previously. After ultrasonic scaling It is impossible to achieve success Protocol was completed, a strong topical anes- with traditional periodontal meth- Patients with pockets of 5 mm or thetic (Cetacaine, Cetylite Indus- ods of treatment due to the great more and those with bleeding and/ tries) was applied. Although the laser difficulty in terms of completely or suppuration were considered can- is virtually pain-free, some patients removing bacterial deposits and didates for laser-assisted periodontal might feel an uncomfortable amount their endotoxins from deep areas of therapy. SRP was performed three of heat. Dentists might also opt to periodontal pockets.4 In addition, months before the start of laser- use local anesthetics for patients who antibiotics that are used to prevent assisted periodontal therapy, due to have lower pain tolerances.

540 November/December 2012 General Dentistry www.agd.org Fig. 1. An example of an initiated ﬁber-optic tip. Fig. 2. The laser at the gingival margin.

Fig. 3. Debris removed from the diseased pocket. Fig. 4. The laser is used to coagulate the pocket.

Laser setup which indicates that the laser setting After treating the infected To prevent it from stripping the is correct; it might be necessary pocket, the margins of the pocket epithelial attachment, the laser tip to adjust the laser in 0.1 W incre- must coagulate to help the heal- should be measured 1 mm less than ments to achieve this result (Fig. 2). ing process, as going into the the deepest pocket being treated. Once the correct wattage has been pocket repeatedly with the laser Before placing the tip into the pocket, achieved, the clinician should move can leave the borders jagged. The the laser must be “initiated” with the laser into the pocket for 5–10 clinician needs to return to the black articulating tape (Accufilm II, seconds at a time. Each time the lowest possible setting with the Parkell). This initiation pinpoints the laser is removed from the pocket, initiated fiber-optic tip. The laser laser energy to the end portion of the it might carry a small amount of energy should be traced along the fiber-optic tip (Fig. 1), making it pos- debris; wet gauze will remove this margins of the pocket (at a distance sible to emit laser energy only to the debris from the fiber-optic tip of 1–2 mm) for approximately intended areas rather than laterally. (Fig. 3 and 4). The clinician should 20 seconds (Fig. 6). The diode laser should be set at inspect the fiber-optic tip to make Finally, the diode laser is used the lowest possible setting. The sure it is still initiated each time for biostimulation to aid in healing laser’s energy is directed to the before entering the pocket. The the damaged cells that line the margin of the infected pocket with- clinician should continue until wall of the inner epithelium.8-11 In out actually entering the pocket. no more debris can be removed or the authors’ experience, 6 J is the The margin will start to turn white, fresh bleeding occurs (Fig. 5). optimum setting for the diode laser

www.agd.org General Dentistry November/December 2012 541 Lasers in Periodontics Five-year retrospective study of laser-assisted periodontal therapy

Fig. 5. Fresh bleeding in the pocket. Fig. 6. The laser traces along the coagulated margin of the pocket.

Fig. 7. The laser is used for biostimulation of the pocket. Fig. 8. Vitamin E is applied to the pockets.

when it is approximately 4–5 mm procedure. Patients were asked struggle for most patients, this pro- from the treated area (Fig. 7). (This to avoid smoking for at least 24 cedure might need to be repeated is the minimum distance to ensure hours, rinse with warm salt water every 3–24 months, depending on that the laser energy is diffused suf- at least twice daily for three days the patient’s home care regimen. ficiently so that it provides biostim- post-treatment, and avoid flossing ulation only and does no cutting.) and hard brushing for 48 hours Materials and methods Using a microbrush, the clinician post-treatment. If the patient This study examined the use of should apply liquid vitamin E to experienced discomfort after the diode lasers on periodontal pockets the treated pockets (Fig. 8). (The procedure was complete, ibuprofen to determine their bactericidal attri- efficacy of vitamin E has not been or a similar pain reliever could be butes and their ability to improve validated in the literature, but the used, but typically this was not periodontal conditions. authors have experienced positive necessary. After the initial 48 hours, A total of 70 non-smoking tissue response with its use.) patients could brush and floss patients with no implants needed Patients were instructed to according to their normal routine. SRP, and had been under care for avoid certain foods for at least Patients should return three periodontal disease continuously for 24 hours, including crunchy or months after the last appointment at least five years. Using the protocol spicy foods, foods with tiny seeds, so that the dentist can determine described above, 810 nm and 940 and foods that might become the progress of pocket healing. Since nm diode lasers (Biolase Technol- lodged in the space created by the periodontal disease is a lifelong ogy, Inc.) were used. As described

542 November/December 2012 General Dentistry www.agd.org previously, the cases were rescaled at restored to a healthy pocket depth of periodontal disease. Contemp Oral Hyg 2005; the time of laser treatment using a 3 mm after five years of treatment. 5(12):20-21. 3. Moritz A, Schoop U, Goharkhay K, Schauer P, light stroke and the lowest setting. Of the 267 pockets in the anterior Doertbudak O, Wernisch J, Sperr W. Treatment of Some cases were retreated to main- teeth, 240 (90%) had been restored periodontal pockets with a diode laser. Lasers tain healthy pockets. In all cases, to a healthy pocket depth of 3 mm Surg Med 1998;22(5):302-311. fi fi 4. Li J, Helmerhorst EJ, Leone CW, Troxler RF, Yas- 400 µ ber-optic tips were used. As after ve years of treatment. kell T, Haffajee AD, Socransky SS, Oppenheim a starting point for tissue interac- FG. Identiﬁcation of early microbial colonizers in tion, the lasers were set at 0.5 W in Conclusion human dental bioﬁlm. J Appl Microbiol 2004; 97(6):1311-1318. continuous wave mode. In all, 80% of the pockets treated 5. Andreana S. The use of diode lasers in periodon- Fiber-optic tips were cleaved (that using the diode laser were restored tal therapy: Literature review and suggested tech- is, the tip was cut to get a straight to a healthy pocket depth of nique. Dent Today 2005;24(11);130, 132-135. fi Th 6. Gregg RH 2nd, McCarthy D. Laser periodontal ber) and used for 810 nm lasers 3 mm. ese results suggest that therapy for bone regeneration. Dent Today 2002; and both 810 nm and 940 nm this treatment modality should 21(5):54-59. lasers were initiated. Each tooth become an adjunct for treating 7. American Academy of Periodontology. The American Academy of Periodontology statement had six measurable pockets (that periodontal infections. regarding gingival curettage. J Periodontol 2002; is, mesial facial, center facial, distal 73(10)1229-1230. facial, mesial lingual, center lin- Author information 8. Hamajima S, Hiratsuka K, Kiyama-Kishikawa M, Tagawa T, Kawahara M, Ohta M, Sasahara gual, and distal lingual) and teeth Dr. Kusek and Ms. Kusek are H, Abiko Y. Effect of low-level laser irradiation were treated in all four quadrants. adjunct professors, University of on osteoglycin gene expression in osteoblasts. Four hygienists performed the South Dakota Hygiene School in Lasers Med Sci 2003;18(2):78-82. 9. Trelles MA, Mayayo E. Bone fracture consoli- treatments and did probing read- Vermillion. Mr. Kusek is a student dates faster with low-power laser. Lasers Surg ings, while another hygienist did at the University of Nebraska. Med 1987;7(1):36-45. only probing readings. 10. Takeda Y. Irradiation effect of low-energy laser on alveolar bone after tooth extraction. Experi- Acknowledgements mental study in rats. Int J Oral Maxillofac Surg Results The authors would like to acknowl- 1988;17(6):388-391. A total of 2,103 pockets were edge Jeanette Miranda, RDH, and 11. Dortbudak O, Haas R, Mallath-Pokorny G. Bio- stimulation of bone marrow cells with a diode treated among the 70 patients. Cindy Dellman, RDH, for provid- soft laser. Clin Oral Implants Res 2000;11(6): Of the 2,103 pockets, 1,278 were ing treatment in this study. 540-545. found in molars, 556 in premolars, and 269 in anterior teeth. Of the References Manufacturers 1,278 molar pockets, 973 (76%) 1. Dyer B, Sung E. Minimally invasive periodontal Biolase Technology, Inc., Irvine, CA treatment using the Er,Cr:YSGG laser: A 2-year 888.424.6527, www.biolase.com had been restored to a healthy retrospective preliminary clinical study. Open fi Cetylite Industries, Pennsauken, NJ pocket depth of 3 mm after ve Dent J 2012;6:74-78. 800.257.7740, www.cetylite.com 2. Gutierrez T. Diode laser for bacterial reduction years of treatment. Of the 556 pre- Parkell, Edgewod, NY and coagulation: An adjunctive treatment for molar pockets, 466 (84%) had been 800.243.7446, www.parkell.com

www.agd.org General Dentistry November/December 2012 543 Trauma in Primary/Young Teeth

Tooth embedded in lower lip following dentoalveolar trauma: Case report and literature review

Antonio Azoubel Antunes, DDS n Thiago Santana Santos, DDS, MS n Allan Ulisses Carvalho de Melo, PhD Cyntia Ferreira Ribeiro, DDS, MS n Suzane Rodrigues Jacinto Goncalves, PhD n Sigmar de Mello Rode, DDS, MS

One of the most frequent consequences of trauma to the trauma and the primary care team’s awareness of orofacial injuries. maxillofacial region is damage to teeth and supporting structures. Fractured incisors often cause lacerations to the soft tissues at the Such damage can occur either in isolation or in conjunction with time of trauma. During the diagnosis, particular care must be taken other fractures and soft tissue lacerations. In emergency situations, when such a fracture is associated with a soft tissue injury. the harm caused to teeth could go unnoticed during the clinical Received: June 29, 2011 examination, depending on the nature and complexity of the Accepted: August 15, 2011

ne of the most frequent con- more challenging. Fractured incisors Case report sequences of facial trauma is are often the cause of soft tissue A 17-year-old male came to the Odamage to the teeth and sup- lacerations at the time of trauma.7 clinic at the University of Tiradentes porting structures. Such traumas can For this reason, special care must be School of Dentistry complaining of occur as a result of work- or sports- taken in cases of lacerations occur- a firm mass in the lower lip that was related accidents, physical violence, ring with fractured or missing teeth.8 sensitive to the touch. The patient automobile accidents, and, most This report describes a case of had been referred to the faculty with frequently, falls.1-3 Following a trau- trauma to the maxillary incisors in a preliminary diagnosis of a tumor matic injury to the face, a thorough which tooth fragments remained in the lower lip by a general clini- examination of the soft tissues should embedded in the interior of a lower cian. The patient’s history revealed be systematically performed, includ- lip wound after primary care. The that he had fallen from a bicycle one ing an evaluation of the hard tissues authors also review and compare year earlier. At the time, he received (teeth and bone) through a clinical similar cases cited in the literature. primary care at the emergency room inspection and radiographic examination, as well as pulp vitality, percussion, and mobility tests.4,5 When examining soft tissues, both extraoral and intraoral (lips, gums, cheeks, tongue, oral mucosa, and palate) examinations are necessary. X-rays of tissues with signs of bleeding, laceration, or swelling should always be taken to determine the presence or absence of a foreign body.6 Tooth fragments in the lower lip are subject to constant movement due to contractions of the orbicular musculature and can end up distant Fig. 2. Initial examination revealed a ﬁrm from the original site of perforation nodule with normal pink color measuring at the time of trauma which can Fig. 1. Clinical appearance of the fractured approximately 1 cm in diameter on the mucous make the diagnosis of such cases maxillary incisors. portion of lower lip.

544 November/December 2012 General Dentistry www.agd.org Fig. 3. Radiograph revealing tooth fragments embedded in Fig. 5. Periapical radiograph conﬁrming the the lower lip. Fig. 4. Tooth fragments removed. removal of the tooth fragments.

of a public hospital. The wounds, including a laceration of the lower lip, were sutured, and the patient was discharged the same day. The extraoral examination revealed fractured maxillary central incisors and visible scars on the cutaneous portion of the lower lip. Increased volume in the lip was also noted (Fig. 1). The intraoral Fig. 6. Lower lip with satisfactory healing at Fig. 7. Esthetic and functional integrity of the examination revealed an inconspicu- the six-month follow-up. teeth maintained at the six-month follow-up. ous scar on the mucous portion of the lower lip. A firm nodule, measuring approximately 1 cm in diameter with a normal pink color, was palpated in this region (Fig. 2). tissue. No antibiotic treatment was scheduled at two to four weeks and The periapical radiograph revealed prescribed after surgery, as there three to six months to evaluate the radiopaque structures in the lower were no signs of infection. During esthetic-functional integrity of the lip similar to those of the incisal the surgery, a periapical radiograph traumatized teeth. region of the fractured maxillary was taken to confirm the complete At the six-month follow-up visit, central incisors (Fig. 3). The his- removal of the fragments (Fig. 5). the lip exhibited satisfactory healing tory of trauma and the clinical and After suturing, the fragments were and the repaired tooth was estheti- radiological findings eliminated the reattached to the maxillary central cally pleasing (Fig. 6). The vitality preliminary diagnosis of a tumor. incisors using a composite adhesive test on both teeth was positive, and The patient underwent surgical technique. The lingual sides of the neither tooth displayed any signs of excision of the fragments under fragments were perfectly intact, discoloration (Fig. 7). local anesthesia; 1.0 cc of lidocaine although the buccal aspect exhibited in a 2% solution with 1:100,000 a slight loss of enamel. After the Discussion epinephrine was administered to teeth were primed and etched, flow- The damage caused to teeth and the area of tumefaction. The lower able resin was placed to match both supporting structures is one of the lip was incised along the existing tooth fragments. The buccal gap most frequent consequences of max- mucous scar line. The fragments was microfilled with a composite illofacial trauma. Such damage can were identified and carefully resin and polymerized. The teeth occur either in isolation or in con- removed (Fig. 4). A 4-0 black were polished with rubber points junction with other fractures and nylon thread was used to suture the and polishing discs. Follow-up was soft tissue lacerations. In emergency

www.agd.org General Dentistry November/December 2012 545 Trauma in Primary/Young Teeth Tooth embedded in lower lip following dentoalveolar trauma

The bonding of a tooth fragment Table 1. Previous cases of tooth fragments embedded in lips reported after fracture was first described in the literature. by Chosack & Eidelman in 1964; cementing was performed following Time elapsed adequate endodontic treatment.20 Author Cases Age/Sex since trauma Treatment Current methods range from simple 1 Al-Jundi9 1 13/F 18 months Removal bonding, depending only on the type 2 Gill & Fleming10 1 46/M 3 months Removal of adhesive employed, to different

11 3 Schwengber et al 1 8/M 2 months Removal and reattachment preparation methods for the tooth 21-23 Th 12 and fragment. e advantage of 4 Munerato et al 1 14/F 3 days Removal bonding is that it constitutes a more 13 5 Naudi & Fung 1 11/M 1 hour Removal and reattachment conservative restoration of the tooth 6 6 Pasini et al 1 18/F 36 hours Removal and reattachment injury without impeding the use of 8 7 da Silva et al 2 10/M 3 months Removal a subsequent restorative material in 17/M - Removal cases of unsuccessful treatment.24 7 8 Taran et al 1 7/F 18 days Removal Surgical excision is the treatment 25 9 de Santana Santos et al 1 17/M 1 year Removal and reattachment of choice for tooth fragments embedded in the lip.25 Depending on the size of the fragments and the length of time they were embedded in the situations, the harm caused to teeth process increases the risk of infec- tissue, it might be possible to use the may go unnoticed during the clini- tion and triggers foreign-body reac- fragments to restore the remaining cal exam, depending on the nature tions and fibrous scar tissue. When fractured teeth.26 In the present case, and complexity of the trauma and this reaction is chronic, it leads to even one year after the cycling acci- of the primary care team’s awareness fibrosis, which encapsulates the dent, it was possible to restore the of orofacial injuries.6-13 foreign body through the concentra- fractured teeth using the fragments A number of studies have reported tion of macrophages.18 In the pres- removed from the lower lip. a greater frequency of dental trauma ent case, despite the absence of an to the incisors during childhood and active infectious process, fibrous scar Summary adolescence, with the prevalence tissue surrounding the fragments Knowledge of the patient’s injury, ranging from 10–20%, depending was observed during the surgical a thorough clinical examination, on gender and age. These studies removal procedure. and a radiographic examination are attribute the greater vulnerability of The differential diagnosis is of necessary whenever clinical signs of the incisors to their anterior projec- utmost importance, especially dental trauma are observed during tion and a shorter lip.14-17 Fractured when patients are evaluated after primary care for trauma to the max- incisors often cause lacerations the original injury has already illofacial region. For such cases, an to the soft tissues at the time of healed. Radiographic findings of analysis of the intra- and extraoral trauma. It is not difficult to diagnose tooth fragments in the floor of the tissues is critical, especially when tooth fracture, but particular care mouth could indicate sialolithia- there is a laceration in which foreign must be taken when such a fracture sis.8 In some cases, an increase in bodies might be present. These steps is associated with a soft tissue injury, lip volume could suggest the pres- will prevent the patient from having as tooth fragments embedded in soft ence of a tumor during the initial to undergo additional surgical pro- tissue can be overlooked during a evaluation, as originally hypoth- cedures for the subsequent removal clinical examination.8 esized in the present case prior to of remaining fragments. The authors searched for cases in referral to the dental clinic. Lin the literature documenting tooth et al reported a case of a foreign Author information fragments embedded in lips. Nine body embedded in the tongue Drs. Antunes and Santos are oral previous cases were discovered following trauma that was initially and maxillofacial surgeons and (Table 1). considered a tumor mass. That doctoral students in oral and The incorporation of a foreign hypothesis was promptly discarded maxillofacial surgery, Ribeirao Preto body into the wound healing upon surgical excision.19 Dentistry College, Ribeirao Preto,

546 November/December 2012 General Dentistry www.agd.org Sao Paulo, Brazil. Drs. de Melo and tooth fragments in the lower lip. Ann Plast Surg 18. Andersson L, Andreasen JO. Soft tissue injuries. Goncalves are in the School of Den- 1994;32(4):431-433. In: Andreasen JO, Andreasen FM, Andersson L, 8. da Silva AC, de Moraes M, Bastos EG, Moreira eds. Textbook and color atlas of traumatic tistry, University of Tiradentes, Ara- RW, Passeri LA. Tooth fragment embedded in injuries to the teeth, ed. 4. Copenhagen: Black- caju, Sergipe, Brazil. Drs. Ribeiro the lower lip after dental trauma: Case reports. well Munksgaard;2007:577–597. and de Mello Rode are postgraduate Dent Traumatol 2005;21(2):115-120. 19. Lin CJ, Su WF, Wang CH. A foreign body embed- 9. Al-Jundi SH. The importance of soft tissue exam- ded in the mobile tongue masquerading as a students in oral rehabilitation, ination in traumatic dental injuries: A case re- neoplasm. Eur Arch Otorhinolaryngol 2003; University of Taubate, Taubate, Sao port. Dent Traumatol 2010; 26: 509-511. 260(5):277-279. Paulo, Brazil. 10. Gill P, Fleming K. Retained tooth fragment. Br 20. Chosack A, Eidelman E. Rehabilitation of a frac- Dent J 2010;208(8):330. tured incisor using the patient’s natural crown— 11. Schwengber GF, Cardoso M, Vieira Rde S. Bond- Case report. J Dent Child 1964;31:19-21. References ing of fractured permanent central incisor crown 21. Baghdadi ZD. Crown fractures: New concepts, 1. Andreasen JO. Etiology and pathogenesis of following radiographic localization of the tooth materials and techniques. Compend Contin traumatic dental injuries. A clinical study of fragment in the lower lip: A case report. Dent Educ Dent 2000;21:831-836. 1,298 cases. Scand J Dent Res 1970;78(4): Traumatol 2010;26(5):434-437. 22. Reis A, Loguercio AD, Kraul A, Matson E. Reat- 329-342. 12. Munerato MC, da Cunha FS, Tolotti A, Paiva RL. tachment of fractured teeth: A review of litera- 2. Andreasen JO, Andreasen FM. Textbook and Tooth fragments lodged in the lower lip after ture regarding techniques and materials. Oper color atlas of traumatic injuries to the teeth, ed. traumatic dental injury: A case report. Dent Dent 2004;29(2):226-33. 3. St. Louis: C.V. Mosby;1997:170-188. Traumatol 2008;24(4):487-489. 23. Murchison DF, Worthington RB. Incisal edge re- 3. O’Neil DW, Clark MV, Lowe JW, Harrington MS. 13. Naudi AB, Fung DE. Tooth fragment reattach- attachment: Literature review and treatment Oral trauma in children: A hospital survey. Oral ment after retrieval from the lower lip—A case perspectives. Compend Contin Educ Dent 1998; Surg Oral Med Oral Pathol 1989;68(6):691-696. report. Dent Traumatol 2007;23(3):177-180. 19(7): 731-738. 4. McTigue DJ. Diagnosis and management of 14. Galea H. An investigation of dental injuries 24. Worthington RB, Murchison DF, Vandewalle KS. dental injuries in children. Pediatr Clin North Am treated in an acute care general hospital. J Am Incisal edge reattachment: The effect of prepa- 2000;47(5):1067-1084. Dent Assoc 1984;109(3):434-438. ration utilization and design. Quintessence Int 5. Wadhwani CP. A single visit, multidisciplinary 15. Forsberg CM, Tederstam G. Traumatic injuries to 1999;30(9):637-643. approach to the management of traumatic the teeth in Swedish children living in an urban 25. de Santana Santos T, Melo AR, Pinheiro RT, An- tooth crown fracture. Br Dent J 2000;188(11): area. Swed Dent J 1990;14(3):115–22. tunes AA, de Carvalho RW, Dourado E. Tooth 593-598. 16. Hunter ML, Hunter B, Kingdon A, Addy M, Dum- embedded in tongue following ﬁrearm trauma: 6. Pasini S, Bardellini E, Keller E, Conti G, Flocchini mer PM, Shaw WC. Traumatic injury to maxillary Report of two cases. Dent Traumatol 2011;27(4): P, Majorana A. Surgical removal and immediate incisor teeth in a group of South Wales children. 309-313. reattachment of coronal fragment embedded in Endod Dent Traumatol 1990;6(6):260-264. 26. Chu FC, Yim TM, Wei SH. Clinical considerations lip. Dental Traumatology 2006;22(3):165-168. 17. Dearing SG. Overbite, overjet, lip-drape and inci- for reattachment of tooth fragments. Quintes- 7. Taran A, Har-Shai Y, Ullmann Y, Laufer D, Peled sor tooth fracture in children. N Z Dent J 1984; sence Int 2000;31(6):385-91. IJ. Traumatic self-inﬂicted bite with embedded 80(360):50-52.

www.agd.org General Dentistry November/December 2012 547 Oral Diagnosis

Large radiolucency of the mandibular body

Douglas D. Damm, DDS (Case courtesy of Dr. Victor Barresi, Rockford, IL)

A 33-year-old male sought treatment for extensive Which of the following is the most appropriate diagnosis for dental decay and multiple periapical radiolucencies the large lesion of the right mandibular body? associated with a number of residual root tips. A large A. Apical periodontal cyst (periapical cyst) mandibular radiolucency on the right side was noted B. Calcifying odontogenic cyst (calcifying cystic odontogenic tumor) (Fig. 1). Full mouth extractions were performed along C. Inﬂamed odontogenic keratocyst (keratocystic odontogenic tumor) with removal of the associated periapical pathoses. D. Glandular odontogenic cyst (sialo-odontogenic cyst) At that time, the large lesion was removed from the mandibular body and also submitted for histopathologic Diagnosis is on page 550. examination (Fig. 2).

Fig. 2. A cystic structure lined by thickened stratiﬁed squamous epithelium exhibiting heavy exocytosis and Fig.1. Large radiolucency of the mandibular body on the right side. spongiosis (H&E stain, original magniﬁcation 10X).

548 November/December 2012 General Dentistry www.agd.org Large pericoronal radiolucency

(Case courtesy of Dr. Antonia Kolokythas, Chicago, IL)

A 16-year-old male sought treat- Which of the following is the most ment for failure of eruption of the appropriate diagnosis? left mandibular second molar. A A. Chondromyxoid ﬁbroma panoramic radiograph revealed a B. Myxoid chondrosarcoma deep horizontal impaction of the C. Odontogenic ﬁbroma tooth in association with a large D. Odontogenic myxoma radiolucency within the ascending ramus (Fig. 1). An incisional biopsy Diagnosis is on page 550. was obtained (Fig. 2).

Fig. 2. Loose and lightly basophilic connective tissue with numerous spindle-shaped mesodermal cells. (H&E stain, Fig. 1. Large radiolucency within the ascending ramus. original magniﬁcation 10X).

Author information Dr. Damm is a professor, Department of Oral Health Sciences, Division of Oral Pathology, College of Dentistry, University of Kentucky, Lexington.

www.agd.org General Dentistry November/December 2012 549 Answers

Oral Diagnosis

Large radiolucency of the Large pericoronal radiolucency mandibular body Diagnosis: Diagnosis: D. Odontogenic myxoma A. Apical periodontal cyst (periapical cyst) Incisional biopsy revealed a mass of loose and lightly The histopathologic examination of the large lesion basophilic connective tissue (Fig. 2). The tissue is hyper- revealed a cystic structure that was lined by thickened cellular with numerous spindle-shaped mesodermal cells. stratified squamous epithelium which exhibits heavy exo- Odontogenic myxomas appear among a wide age range cytosis and spongiosis (Fig. 2). The cyst wall consisted of of patients, but are discovered most frequently in young fibrous connective tissue that contained numerous small adults with no gender predilection. Although any gnathic vascular channels. A heavy mixed inflammatory cellular site may be affected, the mandible is involved more fre- infiltrate (predominantly neutrophils, lymphocytes, quently than the maxilla. Radiographically, the neoplasm plasma cells, and histiocytes) was present within the wall. creates a radiolucent lesion which may be unilocular or Large zones of red blood cell extravasation were noted. multilocular, often with irregular or scalloped margins. The apical periodontal cyst is the most common Odontogenic myxomas tend to vary in density. Those odontogenic cyst, with most arising from inflammatory with minimal collagenization and abundant ground activation of epithelial rests of Malassez. Although some substance are very loose and difficult to remove. Small clinicians have little concern for this pathosis, the cyst may odontogenic myxomas generally are treated with curet- demonstrate slow but continuous growth and can become tage and close follow-up. Large tumors and those with quite large. Conservative enucleation usually is curative. a gelatinous consistency often are treated more aggres- For large lesions, marsupialization often results in signifi- sively. Although the recurrence rate is approximately cant size reduction, which aids in easier final removal. 25%, the long-term prognosis is good.

Bibliography Bibliography 1. Sapp JP, Eversole LR, Wysocki GP. Contemporary oral and maxillofacial 1. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology, ed. 2. St. Louis: Mosby/Elsevier;2004:86-87. pathology, ed. 3. St. Louis: Saunders/Elsevier;2009:729-731.

550 November/December 2012 General Dentistry www.agd.org Self-Instruction

Exercise No. 291 Exercise No. 292 Exercise No. 293 November/December 2011, November/December 2011, November/December 2011, p. 429 p. 438 p. 446 1. D 2. B 3. C 4. D 1. A 2. B 3. C 4. D 1. B 2. B 3. A 4. A 5. C 6. B 7. D 8. A 5. A 6. B 7. D 8. C 5. B 6. D 7. C 8. C 9. D 10. B 11. A 12. A 9. A 10. B 11. C 12. A 9. C 10. B 11. D 12. A 13. D 14. A 15. B 13. C 14. A 15. C 13. B 14. C 15. D

Exercise No. 294 Exercise No. 295 Exercise No. 296 November/December 2011, November/December 2011, November/December 2011, p. 463 p. 474 p. 484 1. C 2. D 3. B 4. B 1. C 2. A 3. B 4. C 1. B 2. B 3. D 4. C 5. B 6. A 7. D 8. A 5. D 6. C 7. A 8. B 5. B 6. B 7. B 8. D 9. D 10. A 11. D 12. A 9. B 10. C 11. A 12. A 9. B 10. B 11. D 12. D 13. A 14. B 15. D 13. A 14. A 15. B 13. C 14. D 15. A

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Dental Materials CDE 2 HOURS CREDIT Antibacterial activity in adhesive dentistry: A literature review

Fereshteh Shaﬁei, DMD, MS n Mahtab Memarpour, DMD, MS

This literature review summarizes the published research when used in various bonding situations. regarding the antibacterial agents used in adhesive dentistry. Received: September 15, 2011 This article provides information about the clinical applications, Accepted: January 31, 2012 beneﬁcial effects, and possible disadvantages of antibacterials

dhesive systems are used extent possible.9 Residual bacteria (such as glutaraldehyde) that are extensively in clinical practice can survive for more than a year found in some adhesives.17,18,22-25 Afor bonding to tooth struc- and can proliferate even in the pres- However, photocuring self-etching ture. Adhesive systems are used for ence of a good seal.10 Adjunctive adhesives reduces their antibacterial direct and indirect tooth-colored treatment with antibacterial agents properties significantly. The litera- esthetic restorations, amalgam during dentin bonding could pre- ture has reported on the inability of restorations, crowns and fixed vent the detrimental effects resulting adhesives to inhibit bacterial growth partial dentures, luting posts in from residual bacteria or microleak- or secondary caries.18,19,25-31 root dentin, fissure sealant therapy, age, such as pulp damage, hypersen- and enamel bonding when placing sitivity, and recurrent caries (a major Categorization of orthodontic brackets. cause of restoration replacement).11 antibacterial agents Despite their qualities, adhesive A biologic seal can improve the Antibacterial activity is provided by systems cannot prevent micro-gaps longevity of the restoration. two types of materials: those that from forming at the dentinal mar- release agents and those that do not gins of composite restorations.1,2 Antibacterial effect of (the latter are known as contact anti- Even when immediate complete adhesive systems bacterials).18,32,33 The agent-releasing marginal sealing is established, the Acid etchants used in etch-and-rinse materials are used as a separate dis- resin-dentin interface can degrade adhesives and the acidic monomers infecting material or as antibacterial- rapidly over time.1,3,4 In addition, found in self-etching adhesives with incorporated materials when the more plaque accumulates on the low pH have both demonstrated disinfecting step is eliminated. surface of composites than on antibacterial activity.12-19 According enamel surfaces or other restorative to Harper & Loesche, the pH values Separate disinfecting materials materials.5,6 The accumulation of that completely eliminated bacteria Originally, chemicals such as silver plaque means that microorganisms over a three-hour period were 2.3 for nitrate precipitated with eugenol, are always in contact with the cured Lactobacillus casei and 3.0 for Strep- phenole, and thymol were recom- adhesives via micro-gaps. The lack tococcus mutans.20 However, certain mended for disinfecting cavity of definitive and reliable assess- bacteria are acid-resistant; in addi- preparations prior to placement of ment criteria means that not all tion, the buffering capacity of dentin restorations. These materials are no microorganisms in carious dentin can limit the effects of the acid.16,20,21 longer used due to their irritating can be detected and eliminated.7,8 Some monomers that promote effect on the pulp.32 Cavity dis- The problem of bacteria remaining adhesion, such as N-methacryloyl infectants were initially proposed in a cavity is more pronounced by 5-aminosalicylic acid (5-NMSA) and by Brannstrom & Nyborg.34 They an increasing predilection toward Phenyl-P—particularly methylene recommended Tublicid (Global minimally invasive, tissue-saving diphosphonate (MDP)— slightly Dental Products), a benzalkonium dentistry in which the intact tooth inhibit bacterial growth, due to the chlorite-based disinfectant contain- structure is preserved to the greatest specific antibacterial components ing ethylenediaminetetraacetic

e346 November/December 2012 General Dentistry www.agd.org acid (EDTA) and sodium fluoride chemical charge also allows CHX after etching, then removing (NaF), for cavity disinfection.34 to adhere to oral cavity surfaces and excess moisture prior to applying a Tublicid is a quaternary ammo- tooth structure, which results in hydrophilic adhesive or a rewetting nium compound with no pulpal longer antimicrobial activity (ranging agent.55,58,64-68 CHX could conserve reactions.32,35,36 Other disinfectant from 48 hours to 12 weeks) com- and regulate the structural integrity materials that have been used to pared with other disinfectants.32,36,48,49 of the collagen matrix.65 Further- disinfect cavities include sodium Fardal & Turnbull recommended more, removing the smear layer hypochlorite (NaOCl), hydrogen CHX as a cavity disinfectant in during etching eliminates most of 42 12,37,58 peroxide (H2O2), and iodine-based 1986. CHX, benzalkonium chlo- the bacteria as well. oral disinfectants. EDTA and ride, and cetylpyridinum chloride CHX was applied on the smear NaOCl were used primarily for have been used as additives to layer in association with self-etch their other properties, including phosphoric acid; the latter is capable adhesives that have no separate the ability to serve as a calcium of cross-linking to collagen.50-52 A etching and washing steps; however, chelator, remove the smear layer, considerable decrease in the number it can affect the bonding ability and help to remove collagen. of bacteria in the dentinal tubules of the adhesives.41,56,60,69,70 The Based on evidence from a study was reported following application of adverse effect of CHX on some by Anderson & Charbeneau on 0.2% CHX for five minutes.53 self-etch adhesives is related to residual bacteria in the cavities, At least two solutions containing residual moisture (a 2% CHX solu- cavity disinfectants were recom- 2% CHX are available commer- tion is composed of 98% water), mended.12,36,37 However, adjunctive cially: Cavity Cleanser (Bisco, Inc.) which contaminates the bonded use of disinfectants during bonding and Consepsis (Ultradent Products, surface.71,72 The gel form of CHX procedures could have an adverse Inc.). A 1% CHX gel (Drogsan could have a limited penetration effect on the bonding ability of dif- Pharmaceuticals) is also available. depth and therefore would not ferent adhesive systems.32,36,38-41 These products have been used affect the bond.60 Self-etch adhesives Chlorhexide gluconate (CHX), to disinfect cavity preparations in containing MDP might have been a bisphenol component containing numerous studies and have pro- adversely affected by CHX bonding chlorine, has been used for many duced interactions with the bonding to loose, superficial apatites within years as a safe antiseptic with a ability of adhesive systems used in the smear layer.72 A 1996 study used broad spectrum of action. Studies direct and indirect restorations that SEM analysis and reported that have shown that CHX reduces the appear to be material-specific. These CHX creates a acid-resistant layer, number of microorganisms in plaque results—in addition to results from inhibiting acidic monomers from and saliva and also reduces the level other studies regarding the effects penetrating the dentin.41 of S. mutans in occlusal fissures and of disinfectants on the bonding Even at a very low concentration root surfaces.42,43 CHX has been used efficacy of adhesive systems—are (0.2%), CHX functions as a matrix as an irrigant for the nonsurgical summarized in Table 1. metalloproteinase (MMP) inhibitor treatment of periodontal diseases The CHX binding to phosphate that can prevent both degradation and adjunctively used in endodontic groups might act as a co-surfactant of collagen and disintegration of treatment.44,45 It is bacteriostatic in on the etched surface and increase the bonding interface.73-75 MMPs low concentrations and bactericidal the surface free energy; however, are a class of metal-dependent in higher concentrations.46 These it can also have an adverse effect endopeptidases that remain latent effects have been reported primarily on bond strength to primary in the dentin matrix during tooth on Gram-positive bacteria and less dentin.42,44,47,48,54 CHX has been development and can be activated on Gram-negative bacteria, such as S. applied in different sequences, during dentin demineraliza- mutans and S. sobrinus, both of which including before etching, after tion.74,76,77 CHX can bind to the contribute to initial caries develop- etching (with or without rinsing), dentin matrix; in addition, it can be ment and are more sensitive to the or CHX-containing phosphoric retained in the dentin and covered antibacterial effect of CHX.42,43,47 acid.41,50,54-63 A number of authors or sealed with adhesive.62,78,79 CHX has strong cationic activity, and a manufacturer of a commer- Long-term use of CHX solu- allowing it to be absorbed easily into cial product, Consepsis (Ultradent tion can result in brown staining (and thus disrupt) the negatively Products, Inc.), recommend of the teeth; however, studies that charged bacterial cell wall.36,46,47 This applying CHX for 60 seconds used CHX for a short time during

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Table 1. In vitro studies regarding the interaction of cavity disinfectants and adhesive systems.

Author(s) Cavity disinfectant(s) Experimental design Procedure/adhesive Effect Surmont et al (1989)151 Benzalkonium Root dentin bond strength Before self-etching/Gluma Bond No effect chloride-based (Heraeus Dental North America) Gwinnett (1992)52 CHX Dentin bond strength Before etching/fourth generation bonding No effect Benzalkonium Dentin bond strength Before etching/fourth generation bonding No effect chloride-based Filler et al (1994)155 CHX Enamel bond strength Before etching/Prisma APH (Dentsply Caulk) No effect Perdigao et al (1994)55 CHX Dentin bond strength After etching/All Bond 2 (Bisco, Inc.) No effect Derhami et al (1995)152 Benzalkonium Enamel and Super-Bond D Liner (Sun Medical Company, Ltd.), No effect chloride-based dentin leakage Clearﬁl Liner Bond (Kuraray America, Inc.) Meiers & Kresin (1996)41 CHX Enamel and Before etching/Tenure (Den-Mat) No effect dentin leakage Before self-etching/Syntac (Ivoclar Vivadent Inc.) No effect Iodine-based Enamel and Before self-etching/Syntac Negative effect on dentin leakage Syntac (dentin) Meiers & Shook (1996)56 CHX Dentin bond strength Before etching/Tenure No effect Before self-etching/Syntac Negative effect Cunningham & Meiers CHX Dentin bond strength Before conditioning/resin-modiﬁed glass ionomer No effect (1997)38 (RMGI) Damon et al (1997)153 CHX Enamel bond strength After etching/Transbond XT (3M Unitek) No effect Tulunoglu et al (1998)154 CHX Primary dentin Before etching/Prime & Bond (Dentsply Caulk) Negative effect Leakage Before self-etching/Syntac Negative effect Gurgan et al (1999)50 CHX Enamel and dentin bond Before etching Negative effect strength After etching Negative effect After etching and rinsing/Permagen (Ultradent No effect Products, Inc.) el-Housseiny & Jamjoum CHX Enamel and dentin bond Before etching/Scotch Bond Multi Purpose No effect (2000)156 strength (3M ESPE) Pilo et al (2001)57 CHX Dentin bond strength After etching and rinsing/One-Step Plus Positive effect (Bisco, Inc.) Owens et al (2003)51 CHX Enamel and dentin leakage After etching/PQ1 (Ultradent Products, Inc.) No effect CHX + silicate glass Enamel and dentin leakage After etching/PQ1 Negative effect Cetyl pyridinium Enamel and dentin leakage Incorporated into acid gel No effect chloride Vieira & da Silva CHX Dentin bond strength Before etching Adper/Single Bond (3M ESPE) Negative effect 54 (2003) CHX incorporated into acid gel No effect

restorative procedures reported no Antibacterial–incorporated added to dental resins.81-85 These such staining.59,62 CHX can reduce materials agents can extend the antibacterial postoperative sensitivity and increase Antibacterial components such effect beyond the immediate area bonding durability as an additional as antibiotics, dodecylamine, of the adhesive restoration; how- therapeutic primer, as long as it has bipyridine, tannic acid derivatives, ever, they could also compromise no adverse effect on the adhesive’s polyhexanide, amphilic lipids, the mechanical and bonding prop- immediate bond.80 silver, and fluorides have been erties of the carrier material.18,86

e348 November/December 2012 General Dentistry www.agd.org Table 1 cont’. In vitro studies regarding the interaction of cavity disinfectants and adhesive systems.

Author(s) Cavity disinfectant(s) Experimental design Procedure/adhesive Effect de Castro et al (2003)71 CHX Dentin bond strength After etching No effect Before etching/Prime & Bond, Single Bond No effect Before self-etching/Clearfil SE Bond No effect (Kuraray America, Inc.) Say et al (2004)58 CHX Dentin bond strength After etching/One-Step Optibond Solo No effect (Kerr Corporation) Benzalkonium Dentin bond strength After etching/One-Step Optibond Solo No effect chloride-based Turkun et al (2004)69 CHX Enamel and dentin leakage Before self-etching/Clearfil SE Bond, No effect Prompt L-Pop (3M ESPE) Benzalkonium Enamel and dentin leakage Before self-etching/Clearfil SE Bond, No effect chloride-based Prompt L-Pop Iodine-based Enamel and dentin leakage Before self-etching/Clearfil SE Bond, Negative effect Prompt L-Pop Sung et al (2004)64 CHX Dentin leakage After etching/Optibond Solo No effect NaCl Dentin leakage After etching/Optibond Solo No effect NaOCl Dentin leakage After etching/Optibond Solo No effect Erdemir et al (2004)161 CHX Root dentin Before etching/C&B Metabond (Parkell, Inc.) No effect NaOCl Bond strength Before etching/C&B Metabond Negative effect

H2O2 Bond strength Before etching/C&B Metabond Negative effect Turkun et al (2005)157 CHX; Dentin bond strength After etching/Syntac, Variolink (Ivoclar No effect Benzalkonium Vivadent Inc.), DenTASTIC (Pulpdent No effect chloride-based Corporation), ResiLute (Pulpdent Corporation) Pappas et al (2005)39 CHX, then Dentin bond strength Before etching/All Bond 2 No effect benzalkonium chloride-based, then NaOCl Cacciafesta et al CHX Enamel bond strength Before conditioning/glass ionomer Negative effect (2006)158 (Fuji Ortho LC, GC America, Inc.) Geraldo-Martins et al CHX Enamel and dentin leakage Before self-etching/Clearﬁl SE Bond No effect (2007)159 Soares et al (2008)59 CHX Dentin bond strength Before etching No effect After etching No effect Incorporated into acid gel/Adper Single Bond, No effect Rely X ARC (3M ESPE)

Also, a strict control of release and polymethyl methacrylate-based study by Cadenaro et al demon- kinetics is difficult, and long-term resin cements.18,87,89-92 The literature strated that CHX had an adverse antibacterial effects are not to be has reported that adding CHX effect on the physical property of expected.18,86-88 to self-etching primers did not a primer.96 Furthermore, CHX CHX has been added to restor- compromise bonding ability and release can be affected by water ative materials, provisional and might even preserve bond strength sorption and hydrophilic character- permanent conventional cements, to dentin.93-95 Conversely, a 2009 istics of resin composites.97

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Table 1 cont’. In vitro studies regarding the interaction of cavity disinfectants and adhesive systems.

Author(s) Cavity disinfectant(s) Experimental design Procedure/adhesive Effect Bansal & Tewarsi CHX Dentin leakage Before etching/Prime & Bond; before self-etching/ Positive effect on (2008)160 Xeno III (Dentsply Ltd.) Xeno III Iodine-based Dentin leakage Before etching/Prime & Bond; before self-etching/ Positive effect on Xeno III (Dentsply Ltd.) Xeno III NaOCl Dentin leakage Before etching/Prime & Bond; before self-etching/ No effect Xeno III (Dentsply Ltd.) Erhardt et al (2008)65 CHX Dentin bond strength After etching/Adper Scotch Bond 1 (3M ESPE) No effect Catalbas et al (2009)162 CHX Enamel bond strength Before etching/Transbond XT Negative effect CHX gel Enamel bond strength Before etching/Transbond XT Negative effect Ersin et al (2009)163 CHX Primary dentin bond strength After etching/Prime & Bond No effect After conditioning/glass ionomer No effect (Vitremer, Ketac Molar, 3M ESPE) Hiraishi et al (2009)72 CHX Dentin bond strength After etching/Adper Single Bond-RelyX ARC No effect Before self-etching/ED Primer II, Panavia F 2.0 Negative effect (Kuraray America, Inc.) Before self-adhesive/RelyX Unicem (3M ESPE) Negative effect Siso et al (2009)70 CHX Enamel leakage Before self-etching/Clearfil SE Bond Negative effect on enamel Dentin leakage Before self-etching/Clearfil SE Bond No effect on dentin Ercan et al (2009)60 CHX Dentin bond strength After etching/Prime & Bond NT (Dentsply Caulk); Negative effect before self-etching/Clearfil SE Bond on self-etch NaOCl Dentin bond strength After etching/Prime & Bond NT; before Negative effect self-etching/Clearfil SE Bond on self-etch

H2O2 Dentin bond strength After etching/Prime & Bond NT; before Negative effect self-etching/Clearfil SE Bond on self-etch CHX gel Dentin bond strength After etching/Prime & Bond NT; before No effect self-etching/Clearfil SE Bond Saber & El-Askary CHX Dentin bond strength Before self-etching/Clearfil S3 Bond Negative effect 164 (2009) NaOCl Dentin bond strength Before self-etching/Clearfil S3 Bond Negative effect

To provide cariostatic and Non-agent releasing (contact) comes in direct contact with the antibacterial effects, fluoride has antibacterial materials polymer.87,101,102 In 2008, Xiao et been incorporated into restorative Methacryloyloxydodecyl pyridinium al developed a similar monomer, materials, sealants, and adhesive sys- bromide (MDPB) is a unique methacryloxylethyl cetyl dimethyl tems; however, the beneficial effect monomer that was developed to ammonium chloride (DMAE-CB), a of fluoride has more to do with provide resin-based materials with compound of the antibacterial agent inhibiting demineralization and long-lasting antibacterial activity quaternary ammonium with a meth- enhancing remineralization than without releasing the antibacte- acryloyl group.103 The adsorption of any antibacterial activity.21,85,98,99 rial agent. After curing, MDPB is the positively charged agent onto a According to Francci et al, released covalently bonded to the polymer negatively charged bacterial surface fluoride has little or no effect on the network and acts as a contact can disrupt cell membranes.36,38 inhibition of S. mutans.100 inhibitor against the bacteria that Both of these monomers have been

e350 November/December 2012 General Dentistry www.agd.org Table 1 cont’. In vitro studies regarding the interaction of cavity disinfectants and adhesive systems.

Author(s) Cavity disinfectant(s) Experimental design Procedure/adhesive Effect Campos et al (2009)66 CHX Dentin bond strength After etching/Adper Single Bond No effect Before self-etching/Clearfil S3 Negative effect Mobarak et al (2010)61 CHX Dentin bond strength Before self etching/Clearfil SE Bond No effect Celik et al (2010)145 CHX Dentin bond strength After etching Adper/Single Bond Positive effect Before self-etching/Clearfil SE Bond No effect Sharifian et al (2010)165 CHX Root dentin bond strength Before self-etching/Resilon-Epiphany No effect (Dentsply Caulk) Lindblad et al (2010)166 CHX Root dentin bond strength After etching/All Bond 2, Duolink (Bisco, Inc.), No effect Perma Flow DC (Ultradent Products, Inc.) Before self-adhesive/RelyX Unicem No effect Pelegrine et al (2010)146 CHX gel Root dentin bond strength Before self-etching/Clearfil SE Bond, RelyX ARC No effect NaOCl Root dentin bond strength Before self-etching/Clearfil SE Bond, RelyX ARC No effect Kustarci & Sokucu CHX Enamel leakage After etching/Transbond XT No effect (2010)167 Shafiei & Memarpour CHX Dentin bond strength After etching/Variolink 2 (Ivoclar Vivadent Inc.) No effect 168 (2010) Before self etching /Panavia F2.0 (Kuraray Inc.) No effect Before self adhesive-Relay X Unicem No effect Shafiei et al (2011)169 CHX Enamel and dentin leakage After etching/Nexus 2 (Kerr Corporation) No effect Before self-etching/ Panavia F 2.0 No effect Shafiei et al (2010)170 CHX Enamel and dentin leakage After etching/Scotchbond Multi-Purpose (3M No effect ESPE), Excite (Ivoclar Vivadent Inc.) Before self-etching/Clearfil SE Bond, iBond No effect (Heraeus Kulzer Dental Products)

CHX = Chlorhexidine solution Note: Four other studies (Stanislawczuk et al, Ricci et al, Breschi et al, and Carrilho et al) demonstrated the preservative effect of CHX (after etching) on dentin bonding and showed no adverse effect on immediate bond strength; these studies are not included in Table 1.63, 68, 73, 75

incorporated into resin composite involves disinfecting the cavity and have reported that incorporating and adhesive systems.86,87,101-105 rendering inactive any bacteria antibacterial monomers does not Although studies have demon- that might enter through marginal compromise bonding efficacy and strated the antibacterial effect of microleakage.18 A self-etch primer stability, curing ability, cytotoxicity, the incorporated composite even containing 5% MDPB killed S. or marginal adaptation.18,104,112-116 after a year of water storage, other mutans within 30 seconds of contact MDPB is a more hydrophobic reports have described the loss of before curing.8,104 Following copo- monomer than hydroxyethyl meth- this effect.18,87,106,107 The adsorption lymerization with other monomers, acrylate (HEMA). Incorporation of proteins on the surface could this self-etch primer had an inhibi- of MDPB increases viscosity of the account for the reduced antibacte- tory effect on the growth and adher- adhesive. These properties could rial effect.18 While the antibacterial ence of bacteria on its surface.21,22,102 slightly decrease the infiltration effects of composite restorations MDPB has demonstrated antibac- of MDPB-containing adhesive primarily involve inhibiting terial activity against various bacteria into demineralized smear layer surface plaque accumulation, the isolated from both root and dentin and dentin.112 It has been reported antibacterial effect of adhesives caries.8,9,16,29,31,32,102,108-111 Studies that resins containing MDPB are

www.agd.org General Dentistry November/December 2012 e351 Dental Materials Antibacterial activity in adhesive dentistry

capable of reducing extracellular study placed an adhesive associated the disadvantage of a discoloration polysaccharides in the plaque matrix with sealant and composite resin on problem related to silver ions.141-143 (restricted to plaque over the mar- uncut enamel and reported that the Randomized controlled clinical long- gins); however, these resins have no bond was comparable to that of a term trials should be conducted to effect on biofilm formation or ini- total-etch adhesive.125 confirm the positive effect of these tial adherence of S. mutans.30,117,118 agents on enamel decalcification Clearfil Protect Bond (Kuraray Enamel bonding in orthodontic during orthodontic treatment. America, Inc.) adds 5% MDPB to brackets its self-etching primer adhesive, Demineralization is a major side Antibacterial effect of lasers Clearfil SE Bond. effect of fixed appliance orthodontic A 1997 article by Klinke et al pro- A 2007 study reported that treatments, with prevalence reports posed using lasers to decontaminate Clearfil Protect Bond demonstrated of 50–70%.126,127 Demineralization cavities or root dentin.144 Although satisfactory clinical performance around fixed orthodontic appli- laser pretreatment might not when used in posterior composite ances results from gap formation affect the bonding ability of some restorations.119 Tziafas et al reported due to polymerization shrinkage, adhesives, it does represent a more that Clearfil Protect Bond main- more retention sites, and increased expensive and complex treatment tained pulp vitality but interfered plaque accumulation.127,128 Fluoride modality in respect to getting a with reparative dentin formation and CHX are the most common homogenous laser application with in exposed, infected pulp.120 Other preventive approaches; however, suitable irradiation parameters to all studies have reported that Clearfil their effects are limited in duration parts of the cavity.70,145-147 Protect Bond offers good bonding and are not completely effective. The durability stability and has a a rela- antibacterial-incorporated type could Antibacterial effect of ozone tively high bond strength associated compromise the bonding ability of Acording to the literature, applying to resin cements.33,121,122 the adhesives.86,129,130 Furthermore, ozone for 20 seconds can kill 99.9% Cetylpyridinium chloride is the ability of fluoride-releasing of microorganisms found in primary another antibacterial agent that has adhesives to inhibit demineralization caries lesions.148 Studies have sug- been immobilized in an adhesive is still in doubt, since the low pH gested that ozone gas can disinfect the and showed an inhibitory effect environment created by bacteria cavity prior to performing restorative on bacteria which were in contact prevents remineralization; for this procedures, without affecting the with its surface.123 Recently, the reason, the combination of fluoride enamel or dentin bond strength.149,150 combination of bioactivity and and antibacterial agents has been bacterial effect has been proposed to suggested.131,132 Studies that used Summary create a dental adhesive containing Clearfil Protect Bond have reported According to the in vitro and crystalline titania nanoparticles that promising results in terms of bond limited in vivo data found in the reduces the incidence of secondary strength and sealing ability.133-136 literature, CHX can be used with caries and promotes closure of the The low bond strength reported etch-and-rinse adhesives as a cavity gaps formed at the interface via in some studies could be attributed disinfectant while improving bond- remineralization.124 to an insufficient etching pattern on ing durability; however, long-term unground enamel because Clearfil clinical studies are necessary to Antibacterial activity in Protect Bond is a mild self-etch confirm these advantages. enamel bonding adhesive with a pH of 2.137 Some Clearfil Protect Bond appears Enamel bonding in ﬁssure studies performed enamel etching for to offer long-lasting antibacterial sealants 10 seconds, while others suggested activity in adhesive dentistry; how- Little information is available regard- that etching might not be necessary ever, additional testing is needed ing antibacterial activity in sealants. and did not recommend it.137-140 to determine its effect on bacteria An antibacterial adhesive under a Other antibacterial agents that invading the adhesive interface sealant might exhibit antibacterial have been added to the adhesives in vivo. In addition, long-term in action on the original bacteria in used in bracket bonding include vivo evaluations using standardized pits and fissures and inhibit caries benzalkonium chloride (as a releasing protocols should be conducted to formation following microleakage or agent) and silver nanoparticles (as a determine the practical application a partial loss of the sealant. A 2005 non-releasing agent). The latter has of mechanical and biologic sealing.

e352 November/December 2012 General Dentistry www.agd.org Disclaimer 12. Settembrini L, Boylan R, Strassler H, Scherer W. caries inhibition promoted by self-etching The authors certify that they do not A comparison of antimicrobial activity of adhesive systems containing antibacterial etchants used for a total etch technique. Oper agents. J Biomed Mater Res B Appl Biomater have any commercial interest that Dent 1997;22(2):84-88. 2005;75(1):122-127. represents a conflict of interest in 13. Imazato S, Imai T, Ebisu S. Antibacterial activity 31. Feuerstein O, Matalon S, Slutzky H, Weiss EI. connection with the manufacturers of proprietary self-etching primers. Am J Dent Antibacterial properties of self-etching dental 1998;11(3):106-108. adhesive systems. J Am Dent Assoc 2007; listed in this article. 14. Kitasako Y, Senpuku H, Foxton RM, Hanada N, 138(3):349-354. Tagami J. Growth-inhibitory effect of antibacte- 32. Turkun M, Turkun LS, Ergucu Z, Ates M. Is an Author information rial self-etching primer on mutans streptococci antibacterial adhesive system more effective fi obtained from arrested carious lesions. J Esthet than cavity disinfectants? Am J Dent 2006; Dr. Sha ei is an associate professor, Restor Dent 2004;16(3):176-182. 19(3):166-170. Department of Operative Den- 15. Baseren M, Yazici AR, Ozalp M, Dayangac B. 33. Cal E, Turkun LS, Turkun M, Toman M, Toksavul tistry, Shiraz University of Medical Antibacterial activity of different generation S. Effect of an antibacterial adhesive on the dentin-bonding systems. Quintessence Int 2005; bond strength of three different luting resin Sciences, Shiraz, Iran, where Dr. 36(5):339-344. composites. J Dent 2006;34(6):372-380. Memarpour is an associate professor. 16. Turkun LS, Ates M, Turkun M, Uzer E. Antibacte- 34. Brannstrom M, Nyborg H. 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140. Korbmacher HM, Huck L, Kahl-Nieke B. Fluoride- dentin bonding systems. J Clin Pediatr Dent 169. Shafiei F, Doozandeh M, Alavi AA. Effect of resin releasing adhesive and antimicrobial self-etch- 1998;22(4):299-305. coating and chlorhexidine on the microleakage ing primer effects on shear bond strength of 155. Filler SJ, Lazarchik DA, Givan DA, Retief DH, of two resin cements after storage. J Prostho- orthodontic brackets. Angle Orthod 2006;76(5): Heaven TJ. Shear bond strengths of composite dont. 2011;20(2):106-112. Epub 2011 Jan 24. 845-850. to chlorhexidine-treated enamel. Am J Dent 170. Shafiei F, Memarpour M, Khajeh F, Kadkhoda Z. 141. Othman HF, Wu CD, Evans CA, Drummond JL, 1994;7(2):85-88. The effect of chlorhexidin disinfectant on micro- Matasa CG. Evaluation of antimicrobial proper- 156. el-Housseiny AA, Jamjoum H. The effect of car- leakage of adhesive systems in composite resto- ties of orthodontic composite resins combined ies detector dyes and a cavity cleansing agent rations. Shiraz Univ Dent J 2010;11(3):228-234. with benzalkonium chloride. Am J Orthod Den- on composite resin bonding to enamel and dentofacial Orthop 2002;122(3):288-294. tin. J Clin Pediatr Dent 2000;25(1):57-63. Manufacturers 142. Saito K, Hayakawa T, Kawabata R, Meguro D, 157. Turkun M, Cal E, Toman M, Toksavul S. Effects of Bisco, Inc., Schaumburg, IL Kasai K. Antibacterial activity and shear bond dentin disinfectants on the shear bond strength 800.247.3368, www.bisco.com strength of 4-methacryloxyethyl trimellitate an- of all-ceramics to dentin. Oper Dent 2005;30(4): hydride/methyl methacrylate-tri-n-butyl borane 453-460. Den-Mat, Santa Maria, CA resin containing an antibacterial agent. Angle 158. Cacciafesta V, Sfondrini MF, Stifanelli P, Scrib- 800.445.0345, www.denmat.com Orthod 2007;77(3):532-536. ante A, Klersy C. Effect of chlorhexidine applica- Dentsply Caulk, Milford, DE 143. Ahn SJ, Lee SJ, Kook JK, Lim BS. Experimental tion on shear bond strength of brackets bonded 800.532.2855, www.caulk.com antimicrobial orthodontic adhesives using with a resin-modified glass ionomer. Am J Or- Dentsply Ltd., Addlestone, Surrey, United Kingdom nanofillers and silver nanoparticles. Dent Ma- thod Dentofacial Orthop 2006;129(2):273-276. 44.1932.853422, www.dentsplymea.com ter 2009;25(2):206-213. 159. Geraldo-Martins VR, Robles FR, Matos AB. Drogsan Pharmaceuticals, Ankara,Turkey 144. Klinke T, Klimm W, Gutknecht N. Antibacterial Chlorhexidine’s effect on sealing ability of com- 90.312.287.74.10, www.drogsan.com effects of Nd:YAG laser irradiation within root posite restorations following Er:YAG laser cavity canal dentin. J Clin Laser Med Surg 1997;15(1): preparation. J Contemp Dent Pract 2007;8(5): GC America, Inc., Alsip, IL 29-31. 26-33. 800.323.7063, www.gcamerica.com 145. Celik C, Ozel Y, Bagis B, Erkut S. Effect of laser 160. Bansal S, Tewarsi S. Ex vivo evaluation of dye Global Dental Products, North Bellmore, NY irradiation and cavity disinfectant application on penetration associated with various dentin 516.221.8844, www.gdpdental.com the microtensile bond strength of different ad- bonding in conjunction with different irrigation Heraeus Dental North America, South Bend, IN hesive systems. Photomed Laser Surg 2010; solutions used within pulp chamber. Int Endod 800.431.1785, www.heraeus-dental-us.com 28(2):267-272. 2008;41(11):950-957. Ivoclar Vivadent Inc., Amherst, NY 146. Pelegrine RA, De Martin AS, Cunha RS, Pelegrine 161. Erdemir A, Ari H, Gungunes H, Belli S. Effect of 800.533.6825, www.ivoclarvivadent.us AA, de Silveira Bueno CE. Influence of dentinal medications for root canal treatment on bond- irrigants on the tensile bond strength of an ad- ing to root canal dentin. J Endod 2004;30(2): Kerr Corporation, Orange, CA hesive system used to root dentin. Oral Surg 113-116. 800.537.7123, www.kerrdental.com Oral Med Oral Patho Oral Radio Endod 162. Catalbas B, Ercan E, Erdemir A, Gelgor IE, Zorba Kuraray America, Inc., New York, NY 2010;110(5):e73-e76. YO. Effects of different chlorhexidine formula- 800.879.1676, www.kuraraydental.com 147. Schoop U, Kluger W, Moritz A, Nedjelik N, Geor- tions on shear bond strengths of orthodontic Parkell, Inc., Edgewood, NY gopoulos A, Wolfgang S. Bactericidal effect of brackets. Angle Orthod 2009;79(2):312-316. 800.243.7446, www.parkell.com different laser systems in the deep layers of 163. Ersin NK, Candan U, Aykut A, Eronat C, Belli S. dentin. Lasers Surg Med 2004;35(2):111-116. No adverse effect to bonding following caries Pulpdent Corporation, Watertown, MA 148. Baysan A, Whiley RA, Lynch E. Antimicrobial disinfection with chlorhexidine. J Dent Child 800.343.4342, www.pulpdent.com effect of a novel ozone-generating device on (Chic) 2009;76(1):20-27. Sun Medical Company, Ltd., micro-organisms associated with primary root 164. Saber SE, El-Askary FS. The outcome of immedi- Moriyama City, Shiga, Japan carious lesions in vitro. Caries Res 2000;34: ate or delayed application of a single-step self- 81.77.582.9978, www.sunmedical.co.jp 498-501. etch adhesive to coronal dentin following the Syntac Coated Products, New Hartford, CT 149. Schmidlin PR, Zimmermann J, Bindl A. Effect of application of different endodontic irrigants. Eur 860.738.2600, www.syntacusa.com ozone on enamel and dentin bond strength. J Dent 2009;3(2):83-89. Ultradent Products, Inc., South Jordan, UT J Adhes Dent 2005;7(1):29-32. 165. Sharifian MR, Shokouhinejad N, Aligholi M, Ja- 888.230.1420, www.ultradent.com 150. Cadenaro M, Delise C, Antoniolli F, Navarra OC, fari Z. Effect of chlorhexidine on coronal micro- Di Lenarda R, Breschi L. Enamel and dentin leakage from root canals obturated with 3M ESPE, St. Paul, MN bond strength following gaseous ozone applica- Resilon/Epiphany Self-Etch. J Oral Sci 2010; 888.364.3577, solutions.3m.com tion. J Adhes Dent 2009;11(4):287-292. 52(1):83-87. 3M Unitek, Monrovia, CA 151. Surmont P, Martens L, Mareels S, Moors M. A 166. Lindblad RM, Lassila LV, Salo V, Vallittu PK, 800.634.5300, solutions.3m.com scanning electron microscopic and tensile bond Tjaderhane L. Effect of chlorhexidine on initial strength evaluation of Gluma dentin bond ap- adhesion of fiber-reinforced post to root canal. plication, as a function of dentinal pretreat- J Dent 2010;38(10):796-801. ment. Dent Mater 1989;5(4):224-229. 167. Kustarci A, Sokucu O. Effect of chlorhexidine 152. Derhami K, Coli P, Brannstrom M. Microleakage gluconate, Clearfil Protect Bond, and KTP laser in Class 2 composite resin restorations. Oper on microleakage under metal orthodontic brack- Dent 1995;20(3):100-105. ets with thermocycling. Photomed Laser Surg 153. Damon PL, Bishara SE, Olsen ME, Jakobsen JR. 2010;28 (2 Suppl):S57-S62. Bond strength following the application of 168. Shafiei F, Memarpour M. Effect of chlorhexidine chlorhexidine on etched enamel. Angle Orthod application on long-term shear bond strength of 1997;67(3):169-172. resin cements to dentin. J Prosthodont Res. 154. Tulunoglu O, Ayhan H, Olmez A, Bodur H. The 2010;54(4):153-158. effect of cavity disinfectants on microleakage in

e356 November/December 2012 General Dentistry www.agd.org CDE self 2 HOURS instruction CREDIT

Exercise No. 319 Dental Materials

Subject Code 017 4. Materials that have been used to disinfect the The 15 questions for this exercise are based on the article cavity preparation prior to placing the restoration Antibacterial activity in adhesive dentistry: A literature include all of the following except one. Which is review on pages e346-e356. This exercise was developed the exception? by Gustav Gates, DDS, MAGD, in association with the A. Tubulicid General Dentistry Self-Instruction committee. B. Alcohol C. Hydrogen peroxide Reading the article and successfully completing the D. Eugenol exercise will enable you to: UÊìÃVÀLiÊ`vviÀiÌÊÌÞ«iÃÊvÊ>ÌL>VÌiÀ>Ê>}iÌÃÊÕÃi`ÊÊ 5. Chlorhexidine gluconate (CHX) has been used >` iÃÛiÊìÌÃÌÀÞÆ for years as a safe antiseptic because of all of the UÊÕìÀÃÌ>`ÊÌ iÊVV>Ê>««V>ÌÃÊ>`ÊLiiwV>Ê following properties except one. Which is the ivviVÌÃÊvÊ>ÌL>VÌiÀ>Ê>}iÌÃÆ exception? UÊÕìÀÃÌ>`ÊÌ iÊVV>ÊivviVÌÃÊvÊ>ÌL>VÌiÀ>Ê>}iÌÃÊÊ A. Site-specific action Û>ÀÕÃÊL`}ÊÃÌÕ>ÌÃÆÊ>` B. Bacteriostatic at low concentrations UÊìÃVÀLiÊÌ iÊ`vviÀiViÊLiÌÜiiÊÌ iÊÌÜÊ>Ê C. Bacteriocidal at high concentrations categories of antibacterial agents. D. Effect on gram-positive bacteria

1. Residual bacteria under restorations have 6. The antibacterial effect of CHX is attributed to its been found to survive and proliferate for A. cationic activity. more than ____ months. B. low pH. A. 6 C. high alcohol content. B. 12 D. high solubility in saliva. C. 18 D. 24 7. CHX can lead to longer lasting antimicrobial substantivity compared to other disinfectants. 2. Plaque accumulation on the composite surface This period of time can be from 48 hours is less than that on an enamel surface. This leads to ____ weeks. to fewer microorganisms around the potential A. 6 microgap. B. 8 A. Both statements are true. C. 10 B. The ﬁrst statement is true; the second is false. D. 12 C. The ﬁrst statement is false; the second is true. D. Both statements are false. 8. Most authors and manufacturers of commercial products recommend the use of CHX as a cavity 3. The antibacterial property of self-etching adhesive disinfectant for _____ seconds after etching. was short-lived and less effective A. 30 A. because the self-etching adhesive was B. 40 photocured. C. 50 B. because some bacteria are acid resistant. D. 60 C. due to the buffering capacity of the dentin. D. due to a limited amount of application time. 9. The percentage of CHX in commercially available products for cavity disinfection is ___%. A. 1 B. 2 C. 3 D. 4

www.agd.org General Dentistry November/December 2012 e357 10. Fluoride has been incorporated into restorative 13. Antibacterial agents that have been used to materials for its antibacterial effect on S. mutans. prevent demineralization around orthodontic Another beneficial effect is the inhibition of appliances include all of the following except one. demineralization of the surrounding tooth Which is the exception? structure. A. Methacryloyloxy dodecylpyridinium bromide A. Both statements are true. B. Silver nanoparticles B. The first statement is true; the second is false. C. Benzalkonium chloride C. The first statement is false; the second is true. D. Cetylpyridinium chloride D. Both statements are false. 14. Using One Step Plus as the adhesive in a restorative 11. What is the correct range of prevalence of procedure with CHX as a cavity disinfectant, one demineralization around fixed orthodontic would expect the effect on the bond strength appliances? to be a A. 10 - 30% A. negative effect on etch-and-rinse. B. 40 - 60% B. negative effect on self-etch. C. 50 - 70% C. positive effect on self-etch. D. 70 - 90% D. positive effect on etch-and-rinse.

12. The adverse effect of a 2% solution of CHX 15. CHX gel as a cavity disinfectant had a negative on self-etch adhesives was related to which of effect on the enamel bond strength of Transbond the following? XT. The enamel bond improved when the CHX was A. High alcohol content applied before etching. B. Residual moisture A. Both statements are true. C. Depth of penetration B. The ﬁrst statement is true; the second is false. D. Removal of smear layer C. The ﬁrst statement is false; the second is true. D. Both statements are false.

Answer form is on page 552. Answers for this exercise must be received by October 31, 2013.

To enroll in Self-Instruction, click here.

e358 November/December 2012 General Dentistry www.agd.org Appliance Therapy CDE 2 HOURS CREDIT Appliance design and application

Keith A. Yount, DDS, MAGD

Today’s dental practice can increase patient satisfaction, as well liability; therefore, undergirding selection with accurate informa- as proﬁtability, through the use of emerging technologies in the tion is critical for proper use and quality of care. The aim of this realm of dental appliances. Appliances can aid in an array of article is to serve as a quick reference for the practitioner in his pathologies; however, many dentists struggle in their prescription selection of the appropriate dental device. of appliances due to a lack of scientiﬁc literature on the devices Received: September 21, 2011 themselves. Blindly choosing an appliance can create a legal Accepted: February 6, 2012

fter graduating from dental rely on the one appliance covered in treat a stranger in pain by using irre- school, dentists typically have dental school (the soft nightguard), versible therapies.”1 This statement Agaps in their knowledge of the due to a lack of time or money for applies not only to understanding extensive list of dental services a gen- further exploration of the options the service, anatomy, physiology, eral practice can provide, especially available. Or they rely on the one and the latest research and science, in the area of appliances. At best, guru-driven appliance stumbled but also understanding the patient. the four-year curriculum provides upon in early CE courses and tend Until the purpose of each appliance limited teaching regarding services to use it indiscriminately for all and the science of the pathology that a caring, quality practice can patients in all situations. being treated are understood, much provide. However, in the real world To provide the best service, a of the appliance therapy should be of dentistry, there is a need to pro- doctor must know both the patient referred to a specialist. Each appli- vide an expanded number of services and their pathology. As Dr. Mahan ance has a specific purpose and it is to establish a quality practice. In wrote in 1991, one must “never important to know them well. this regard, an inordinate amount of time and money are spent educating doctors on expanded services not covered in dental school. Dental appliances have become a multimillion dollar industry, including such devices as: Nociceptive Trigeminal Inhibi- tion (NTI) devices (Therapeutic Solutions International, Inc.), soft nightguards, soft/hard appliances, splints, deprogrammers, orthotic and suckdown appliances, retainer- type appliances, neuromuscular appliances, and store-bought mouth guards. These appliances are available for treating parafunction, muscle pain, partial disc displacements, complete disc displacements, and osteoarthritis. However, knowing which appliance to use in a given situation can be challenging (Fig.1). Many postgraduate dentists Fig. 1. A wide variety of dental appliances.

www.agd.org General Dentistry November/December 2012 e359 Appliance Therapy Appliance design and application

Table 1. Appliances and their purposes.

Appliance Design Purpose Orthotic Passive, ﬂat plane, full coverage, shallow anterior guidance Reduce joint and muscle pain, reduce parafunction, decrease loading of the joint in osteoarthritis Emergency Retainers, suckdown, Aqualizer® Reduce muscle recruitment, reduce parafunction, retain teeth Acute trauma appliance Directing appliance, full, hard, used less than one month Trauma, joint effusion Soft appliance Soft, full coverage Parafunction Soft/hard Hard out, soft in, full coverage Parafunction, MPD Deprogrammer (anterior Segmental, anterior, quick, emergency appliance Muscle pain and partially displaced disc, help CR segmental) (NTI & Best Bite Discluder) bite, emergency and episodic treatment Posterior segmental appliance Covers only posterior teeth Parafunction, reduce power ARS-LVI appliance Anterior repositioning design, forward bite, bite set by TENS Relieve retrodiscal pain, change bite OTC nightguard Soft guards, full, heat-adapted athletic guard Reduce tooth damage from parafunction, athletics

Making an informed decision of standardization of outcomes, to understand—as recent scientific Using scientific data as the back- which make the results difficult to studies have made clear—appli- ground for appliance selection is interpret.3 Studies also indicate the ances do have side effects. They are critical to quality of care and practice longer the duration of the pathol- not benign tools and they have the safety. However, for many years there ogy, the more difficult it becomes potential to damage other parts of was a virtual vacuum in scientific to define successful study results. the chewing system. Both scientific knowledge concerning appliances. This is due to outside factors associ- and legal case literature show appli- As recently as 1996, the National ated with long-term chronic pain ances can be and are being used Institutes of Health (NIH) reported such as higher rates of depression, inappropriately or indiscriminately. “little scientific literature exists on somatization, and health care use, The practitioner must properly cri- how appliances work.”2 This vacuum which some patients were not able tique the current literature to make created a fertile ground for promot- to cope with as well as patients in an informed choice. This article ing and selling “magic plastics” that the study group.4,5 offers a review of the literature with would cure everything as an all-in- In a study by Wedel & Carlsson, the goal of indicating the correct one appliance. Thankfully, the 1996 results tend to emphasize the usage for each appliance. NIH paper created a demand for an heterogeneity of patients who have increased number of studies offering differing factors underlying their Reviewing choices insight into how and why dental particular functional disturbance Dental appliances need to be evalu- appliances work, a greater under- of the masticatory system.6 For ated from a scientific perspective. standing of which appliances should example, articular disc disorder An appliance is deemed correct if be used for which pathologies of the can result from multiple factors it fulfills a chosen purpose without chewing system, and the benefits such as clenching, muscle tension, significant side effects. Not only and side effects of each appliance. bite discrepancies, traumas, muscle should the right appliance be used A 2003 retrospective study splinting, dual bites, subluxation, for the right purpose, but the concluded that the problems cited and even cervical muscle hyper- provider should never imply or hint in earlier studies still exist, such function. Three different appliances that an appliance can deliver more as clearly defining both chewing (the nightguard, orthotic, or depro- than it was designed to do. This is system and multifaceted patholo- gammer) may be effective in cases particularly true when dealing with gies, applying uniform descriptions involving pure clenching or grind- dysfunctional patients who often of appliances, using clinical guide- ing at night (that is, with no pain have unrealistic expectations of lines in measuring results, and lack or joint damage). It is important what an appliance can provide.

e360 November/December 2012 General Dentistry www.agd.org The choice of orthotics from a sampling of U.S. general dentists in 1995 included: 14% soft nightguards, 59.4% hard appliances, and 26.1% varied in selection of appliances.7 A 2011 survey reported that 43.04% of dentists chose a stabilization splint for treating bruxism (not including jaw pain or restricted openings), while 8.63% utilized an unadjusted hard splint, 7.28% employed a soft splint, 5.22% utilized an anterior repositioning splint (ARS), and 1.2% used a reflex splint with anterior ramp.8 Table 1 defines the various types of appliances and their purposes. Fig. 2. An example of an orthotic appliance.

Orthotic appliances The orthotic appliance is a passive, hard appliance with a flat plane in the posterior, evenly supported pos- in most orthotic didactic courses or Lundh et al indicated that there was terior contacts, and shallow anterior participation courses. An orofacial no significant benefit of patients guidance (slope). The orthotic was pain resident spends 2-3 years in treated with an orthotic (a flat developed as part of orthopedic training for the appliance use in occlusal splint) over control subjects therapy to treat significant pain and osteoarthritis cases. with no orthotic treatment.9 If dysfunction of partial displaced disc Popular literature promotes the perceived fatigue, pain, sleep dys- cases, complete displaced disc cases, misconception that the orthotic function, and anxiety are primary and osteoarthritis (Fig. 2). Orthotics is the “magic plastic” appliance. targets for muscle-based pain, then can also be used for simpler chewing Simply stated, the orthotic was one management of these factors would system damage cases (such as chew- of the first appliances created to be the primary interventions.10 ing muscle pain and nocturnal brux- protect the joints and muscles from None of these factors are actually ers/clenchers), on destructive bruxers parafunctional damage at night. related to the performance of the for protection, to protect temporary One of the problems in analyzing appliance; this suggests the orthotic crowns and bridges, reduce pain in the effectiveness of orthotics is may not cure all the aspects of pain jaw joint damage, help achieve an determining their main functions associated with articular disc disor- accurate bite, and help with many or benefits. Is the goal pain relief, ders. However, in a 1978 study by chewing system pathologies. reducing parafunction, or fixing the Carraro & Caffesse, the use of only An example of orthotic use is dysfunction? Does it stop clench- an orthotic (full-coverage occlusal with patients who have dystonia of ing? Does it have a positive effect splint) improved both pain and the jaw. Dystonia is a movement on occlusal relationships, tooth dysfunction symptomology.11 disorder that causes the muscles to position (retention), tooth wear, jaw If a patient has jaw pain and is contract and spasm involuntarily. joint loading, and so forth? a significant grinder or clencher at In these cases, an orthotic can Many scientific studies on dental night, the orthotic appliance will be used to protect the teeth. The appliances, especially the early provide some pain reduction. A orthotic is essential in osteoarthritis ones, are unclear in terms of the 2011 study by Badel et al found cases to decrease the muscular definition or design of the appliance that orthotics reduced pain in 83% loading of the joint; however, the used, type of treatment utilized, of the cases examined, which echoes accuracy required in the placement sample size, or the study’s definition the 1998 study by Ekberg et al that of the appliance goes beyond the of success. In a 1992 study of disc reported a reduction in pain due to standard training and skills taught displacements without reduction, orthotic use.12,13

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In restricted opening cases, the pain), jaw dysfunction, dystonia, joint related cases. The studies orthotic has been purposed by some destructive bruxism, and even of occlusion, sleep, and EMG in to recapture the disc.14 In actuality, restorative cases with difficult bite.16 appliances with proper anterior the orthotic may assist with relax- A wide variety of pathologies can guidance of the orthotic produced ing the superior lateral pterygoid affect a specific joint. To achieve the least muscle recruitment.42 muscle, but as stand-alone therapy, usable results, the definition of the Other studies have reported that an it is not likely to provide enough pathology must be clear. orthotic reduces EMG activity in muscle relaxation to recapture the The widespread effectiveness of bruxing patients.43-47 Elsewhere, it disc. It would have to shorten the orthotics for relieving myofascial pain has been reported that an occlusal lateral ligament to the disc and (that is, pain in the chewing muscles) orthotic tends to reduce the level of repair the retro-discal elastin tissue is indicated in two separate reviews of EMG activity in masseter muscles to affect such an outcome, which literature by Clark and by Major & during maximum clenching.28,44,48,49 is unlikely to work as a stand-alone Nebbe.17,18 These reviews show that Different parameters, such as appliance or therapy. In a 1991 many studies report the effectiveness the length of time of a particular study, Kirk observed the orthotic of orthotics in relieving symptoms of study, can affect a study’s results. did reduce inflammation in the joint pain and dysfunction.17-37 Kovaleski & De Boever reported and joint loading, and did improve A 1998 study by Canay et al that orthotics reduced muscle activ- movement (disc condyle transla- reported an orthotic produced no ity, but it took days or even weeks tion), but concluded that, “the con- change in electromyography (EMG) before the reduction in symptoms cept of disc capture is a clinical term from maximum biting but did were apparent.50 To properly evalu- only, and does not indicate that an reduce complaints of pain signifi- ate the success of any one particular actual change in intra-articular ana- cantly. In this study, the defining study, the pathology must be clearly tomic relations has occurred.”14 success via “lower pain perception defined. A 2003 study by Ekberg The challenge in determining reports” was a problem in analyzing et al reported that an orthotic was the effectiveness of an orthotic the effectiveness of orthotics.38 In more effective in myogenous cases appliance comes from the fact that a 2010 meta-analysis, Fricton et al than in disc displacement cases.34 articular disc disorders, myofascial examined 44 random controlled In a critical evaluation, Clark pain dysfunction (MPD), bruxism, trials (RCTs) and found that the reported that orthotics offered and osteoarthritis are different orthotic improved jaw joint/muscle 70%-90% effectiveness in treating multi-factorial pathologies. For pain compared to no treatment joint muscle damage cases.17 More example, a 1984 literature review at all or treatment using non- recently, Kuttila et al reported a reported a 90% success rate when occluding appliances.39 Conversely, reduction in clinical signs when an using orthotics and occlusal therapy Okeson reported that EMG activity occlusal splint was used by individ- to treat temporomandibular joint decreased for most patients wearing uals with osteoarthritis (secondary disorder (TMJ); however, a mixture orthotics.40 Dahlstrom et al found otalgia was reduced as well).51 of treatments were utilized and the that patients who either used an The non-directive, passive, specific role of the appliance in treat- orthotic or underwent biofeedback reversible, flat-planed, and shal- ment was indistinct.15 Even when demonstrated equal reductions in low anterior guidance orthotic is the focus is on a single variable, the terms of EMG activity.41 used to protect muscle and joints actual effectiveness may be hard to The orthotic reduces the power at night, but it can protect other gauge, since some factors (such as of the bite by opening the vertical. structures of the stomatognathic clenching) vary from day-to-night, Maximal clenching on an occlusal system as well, particularly the from night-to-night, and even from splint is significantly lower than teeth and tooth bone. One of the person-to-person. Clenching can the maximum bite in tooth contact great benefits of the orthotic is that occur both day and night. As a result, position.28 The maximum power the units are reversible and conser- an appliance worn only at night may occurs when teeth make maximum vative. The ADA presently recom- not address the complete problem. contact; opening the bite with a mends using reversible therapy for Since the 1980s, science has tried piece of plastic will reduce the joint muscle pathologies. Many to document the effectiveness of the power, which is why different authors using reversible therapy orthotic for treating disc displace- appliance designs may provide place the effectiveness of the ments, osteoarthritis, MPD (jaw some or slight benefits in muscle/ orthotic at higher than 70%.34,52-54

e362 November/December 2012 General Dentistry www.agd.org The orthotic is one of the few joint ranges on open mouth were appliances that require anterior from -10 to +30 mm/Hg, while guidance, which can range from the pressure inside the joint on steep to shallow, rough to smooth, clenching teeth ranged from 20 to and short- to full-range motion, 200 mm/Hg (the highest readings all of which can make assessing the were in females, which could help success of treatment difficult. This explain the considerably higher pro- pattern of equal posterior tooth con- portion of women with TMJ prob- Fig. 3. An orthotic in protrusive guidance. tact and shallow anterior guidance lems); while the maximum pressure on the canines and centrals causes a inside the jaw joint when clenching progressive shutdown of power as it on the orthotic ranged from 0 to goes further into lateral or protru- 40 mm/Hg.61,62 The center of the sion distance (Fig. 3).42,55 The overall TMJ disc has no blood vessels and reported an increase in neuromus- largest percentage of patients (87%) receives its nutrients from diffusion cular activity.66 This result of the had some degree of improvement in via an efficient lubrication system increase in clenching can cause TMD symptoms (joint sounds or involving phospholipids.63 A prob- havoc in determining success when jaw pain) with an orthotic.32 lem arises in dysfunctional TMJs using an orthotic. The increase in Suvinen & Reade found that the after clenching is released, when a clenching occurs in all appliances; stabilization of occlusal patterns sudden rush of oxygen back into the some appliances may cause more of was a good indicator of successful joint space produces free radicals this effect than others.67 This possible treatment in most patients with that cleave the lubricant molecules, increase in clenching reinforces the orthotics.56 Beard & Clayton used which produces friction between the need for multifaceted treatment of a pantographic reproducible index articular disc and the fossa.63,64 This articular disc disorders from several and found that the muscle activity may be a major causative factor in different angles, including the use of in chewing muscles decreased with articular disc displacement.63 an orthotic. These studies reveal that orthotic use.33 A study by Santander In the past, the occlusal splint was the orthotic is not the “magic plas- et al found the orthotic reduced thought to stop parafunction (for tic” appliance because parafunction EMG activity in cervical muscles.57 example, clenching and grinding). activity (clenching is the most preva- A 2008 study by Nascimento et al The orthotic has now been purposed lent type) may occur during the day reported that wearing an orthotic to reduce clenching or grinding or night.65-67 However, by placing an for 60 days significantly decreased at night, as well as offering some appliance that wears quicker than TMD signs and symptoms among protection against damage from enamel, the orthotic offers protec- sleep-bruxing patients.58 Other stud- bruxism, and in most cases this has tion of the teeth.65-67 This is not the ies have reported that orthotic use been proven.45,58,65-67 For example, primary purpose of the orthotic, but reduced EMG activity in the right a 1984 study found that of the is a positive side effect. and left temporalis during maximum subjects wearing orthotics, nocturnal In cases where occlusal trauma clenching, and in the anterior tem- muscle activity was reduced in 52%, is suspected as the reason for tooth poralis by inserting a well-adjusted increased in 20%, and 28% of the pain, the orthotic can provide revers- splint.33,59,60 The literature has indi- subjects reported no change.66 In a ible evidence of the cause and effect cated that the longer symptoms were 1993 study involving 31 patients, (diagnosis and recommended treat- present, the longer it took to achieve Holmgren et al reported that 61% ment). One should avoid the tempta- results with an orthotic.33,35 still clenched or ground teeth at tion to use a bur to make occlusal or It has been discovered that the night after orthotic therapy, indicat- crown/bridge adjustments, as a pro- orthotic can also reduce intra- ing the continued need for some sort longed open mouth procedure might articular pressures (IAPs). Nitzan of protection.65 One must remember have been the cause of increased et al found that clenching teeth that the design and accuracy of the pain or discomfort in teeth. creates an increase in pressure inside appliance does affect the outcome. Some doctors find the revers- the jaw joint that stops the flow of In a small percentage of cases, ibility of the orthotic offers some nutrients into the jaw. The author the orthotic can actually increase legal protection in cases of jaw pain measured IAP in 28 females and parafunction activity. Clarke et where a dysfunctional (and possibly 7 males. The pressure inside the jaw al reported that 20% of subjects litigious) patient might otherwise

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Functional Occlusion.68 When the jaw joint, and result in pain. The Table 2. Beneﬁts of orthotic jaw joint is pulled downward/for- teeth are hotwired to the brain appliances. ward to fit the tooth-protected bite, to control the chewing muscles the muscles have to splint the con- and therefore the brain can use its Relieve muscle and joint pain dyle on the slick incline. It is analo- memory in engrams to control the Th Reduce power gous to holding a bowling ball on a tooth-protected bite. e orthotic slanting board with oil on it. When binds the teeth together, intercedes Reduce muscle recruitment the jaw muscles are recruited to hold between contacting teeth, and alters Reduce IAP any position for a period of time, the ability of the teeth to control Stop lubricant destruction the chewing muscles will eventually the muscles. The use of the orthotic Reduce clenching and grinding fatigue, lactic acid builds up, and improves the jaw joint’s ability to Splint teeth together with reduced loading pain results. The value of measuring direct the muscles to the bone- CR against CO seems to be related braced position (that is, CR), which to the size of the difference and the anatomically refers to the most pos- amount of clenching (parafunction) terior superior position of the jaw receive equilibration, orthodontics, in CO (Fig. 1 and 2). A small dif- joint. The anatomical description or reconstruction: If the orthotic ference (0.01 mm) is not significant does not adequately define CR. cannot reduce the pain, the dental enough to cause much muscle The CR position is where the effort is unlikely to resolve it either. splinting, but a large CR=/=CO least muscle activity occurs and the Making this discovery at an early difference (3 mm) will produce a ideal position for the jaw joint to stage stops the dentist from promis- significant amount of muscle splint- reduce muscle recruitment at night. ing relief from alteration of tooth ing. In other words, muscle activity The fifth nerve is much larger than structure that may not be attainable. increases as the difference between the other cranial nerves because The orthotic reduces the damage the ideal jaw joint position and the it contains the bundles of fibers resulting from the prolonged repeti- tooth protected bite (CR and CO) from the plexus of nerves around tive loads of parafunctional activity increases. An ARS or neuromuscular all 28 teeth and combines with the on teeth; such activity can lead to appliance would increase the CR other important head structures it traumatic damage and pain.65 and CO difference, thus making the innervates. The teeth have power The overall interpretation of the problem worse; therefore, a moder- over muscles to control the tooth- scientific literature suggests that the ate to large CR and CO difference protected bite because the teeth are orthotic is an appropriate appliance is definitely a contraindication so important to survival. Therefore, for reducing damage to the joint for a neuromuscular appliance or a person’s teeth being hotwired to muscle complex due to nighttime ARS.16 The multifactorial nature of the brain may be viewed as an evo- parafunctional activity.65-67 The muscle and disc displacement cases lutionary advantage. The orthotic orthotic, along with an NTI (depro- means that a dentist must consider can redirect or deprogram the grammer), appear helpful in achiev- more than jaw joint position and muscles or dissipate muscle activity ing centric relation (CR) (jaw joint the tooth protected position when by allowing the jaw joint to go to bite) in a few rare cases where the determining what aggravates the the position where there is the least jaw joint instability disallows proper chewing system. Again, one factor muscle activity and allows those centric occlusal (CO) position. alone, such as the measurement muscles to be controlled more by Most dentists who challenge of CR against CO, usually needs the jaw joint. CO (that is, tooth bite) by restor- to be combined with other muscle The majority of patients have a ing many cases are familiar with recruiting activities in order to fully difference between CR and CO that measuring CR against CO in a small breach the adaptive capacity of is small enough not to worry about, percentage of cases, yet the subject the chewing system. If the patient but in a few patients, the difference of CO is not covered in most dental experiences tension in chewing is large enough for the case to fail schools. A great deal of literature muscles, clenches, cervical hyper- in terms of patient comfort. If a on CR=/=CO is found in the post- contraction, muscle splinting, or crown and bridge case succumbs dental school education of Spears, bite inefficiencies, measuring CR to jaw pain, it must be managed Pankey, and Dawson, especially the against CO may overstimulate appropriately with an orthotic and latest edition of Dawson’s book, the chewing muscles, overload the orthopedic therapy.

e364 November/December 2012 General Dentistry www.agd.org Fig. 4. An orthotic demonstrating equal posterior contacts and shallow anterior guidance. Fig. 5. An example of a deprogrammer.

Orthotics can be used for other Emergency appliances can be pro- deprogrammers primarily involves purposes, such as: allowing dentists duced quickly and inexpensively for case reports such as the 2010 report to test patient comfort following treating sudden onset muscle pains, concerning a 61-year-old whose an increased vertical dimension; simple partial disc displacements, short-term jaw pain was relieved by removing occlusion from a cracked or minor traumas. The primary using the deprogrammer.71 tooth (thus relieving pain); deter- purpose of emergency appliances In cases involving osteoarthritis mining if parafunctional activity is to decrease muscle activity or or completely displaced discs, emer- has injured a tooth (thus ruling deprogram muscles. gency appliances will increase joint out occlusal trauma and avoiding loading on the condyle. This loading the need for root canal surgery); Deprogrammers presses on the innervated retrodiscal assessing the patient’s psychological The word deprogrammer refers to an tissue, thus increasing jaw pain.72 stability during the adjustment appliance used to reduce the use or According to McKee, one can test stage; protecting porcelain crowns, recruitment of muscles, leading to a deprogrammer on a completely bridges, or implants from bruxism/ reduced muscle inflammation and displaced disc by load testing the clenching damage at night; resisting pain. The insertion of an NTI in jaw joint to confirm that the con- tooth movements or retaining teeth clenching patients leads to significant dyles are not pressing on retrodiscal after braces (especially in cases reduction in EMG activity of the tissue.72 One dilemma is that load where bruxism/clenching exists or jaw-closing muscles.69 The depro- testing a jaw joint is not part of the in jaw damage cases); managing grammer is an anterior segmental formal training in dental school. To tension headaches; tracking condy- appliance or piece of plastic placed in avoid failure with a deprogrammer, lar bone loss in osteoarthritis cases; the front of the mouth to keep back practitioners should initially inform and protecting teeth in dystonia. teeth apart (Fig. 4). Deprogram- the patient it is a diagnostic device Table 2 summarizes the benefits mers have been used for years in to differentiate the partial displaced provided by an orthotic. orofacial therapy for emergency cases disc from the complete displaced involving muscle pain. In orofacial disc. A deprogrammer will fulfill its Emergency appliances pain therapy, the use of the depro- purpose if it increases the pain in Some appliances may serve as an grammer in emergency pain cases the joint pain case, helping diagnose emergency tool for acute jaw pain is preferred to the orthotic for long- a completely displaced disc. (that is, joint or muscle patholo- term care (Fig. 5). In a study by Van The deprogrammer can also help gies). Like medications, these Eijden et al, clenching on the incisor define the proper bite to manufacture emergency appliances have specific teeth resulted in significant decline in and deliver the large bridge in mod- purposes (primarily to deprogram EMG activity as compared to clench- erate difficult bite cases. For instance, muscles and decrease muscle ing in maximum contact of teeth.70 if the lateral pterygoid is not relaxed activity) along with side effects. Published research concerning enough to give the proper bite for

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Deprogrammer (Aztec Orthodontic reported that NTIs reduced the Laboratory, Inc.), use plastic on severity and frequency of migraine the front teeth to disclude poste- pain from a score of 6.6 to 3.3 on rior teeth, which deprograms the the Visual Analog Scale (VAS).82 chewing muscles while preventing There are few studies concerning clenching and grinding.74 Both of deprogrammers (especially in terms these appliances allow full range of of testing specific deprogrammers) motion and any particular closure on reduction of headaches. By pattern as does their cousin, the understanding the contribution Fig. 6. An example of an NTI splint. NTI. According to a 2001 study of muscle inflammation in the by Shankland, the NTI and the pathophysiology of headaches, it orthotic were equally beneficial at makes sense that the deprogrammer reducing clenching, which in turn could help in some of these cases. It reduces headache symptoms.75 is naive to think the deprogrammer manufacturing a second molar The NTI and the other depro- would completely alleviate some crown/bridge, a deprogrammer may grammers can help deprogram the headaches, especially as a stand- be enough to relax the muscles. chewing muscles to reduce muscle alone therapy, due to multifaceted When a deprogrammer is used pain. In a 2005 study by Jokstad sources of the inflammation and 24 hours a day for extended periods, et al, two splint designs were many different types of headaches. one side effect is the separated produced: an ordinary stabilization Deprogrammers reduce muscle posterior teeth can supererupt. This (Michigan type) and an NTI. The recruiting, especially in the lateral happens when the patient fails to splint and the NTI were equally pterygoid, which allows the condyle follow directions on the proper successful at reducing muscle, joint, to seat more in its fossa. In a small times to wear the device. A recently and head pain.76 percentage of cases where CR does disclosed side effect of a specific Muscle inflammation is created by not equal CO, the jaw joint seats deprogrammer, an NTI device, is its over-use, over-recruitment, or over- more superior and posterior in ability to relax the lateral pterygoid stimulation of the chewing muscles. the fossa, which causes the second in cases where the jaw joint bite By reducing clenching, reducing molars to pivot off second molars and tooth bite are different enough power of muscles, and deprogram- and sets up an anterior open bite to measure setting up open bite ming muscles, the NTI has a great (Fig. 6). For moderate to difficult by contact on second molars.73 effect on muscle pain. bite cases, the deprogrammer helps Relaxing the lateral pterygoid may Deprogrammers are best for cases determine the proper bite so that a create the illusion that the bite has involving excessive muscle recruit- large bridge can be manufactured changed: It really is just highlighting ment and simple partially displaced and delivered accurately. The the difference between the jaw joint discs. According to Helkimo, the deprogramming of muscles by the and the tooth bite (CR against CO), NTI is superior to other appliances deprogrammer makes the Dawson in which the majority of individuals when treating MPD, only because bimanual technique of load testing do not have a measureable differ- of its ease of fabrication.3 and getting CR bite easier to per- ence. The inexpensive nature of the There are always psychosocial form. It is well known that errors appliance and its ease of learning are issues that can cause compliance in recording the terminal transverse important considerations in its use. issues or NTI failure. Several studies horizontal axis can lead to signifi- The former deprogrammer was have reported that a deprogram- cant errors in occlusion.83-85 Enough developed into a prefabricated mer such as an NTI significantly patients present with muscle tight- deprogrammer called an NTI reduced muscle activity.77-80 The ness, tenderness, or overcontrac- (Fig. 6). The prefabricated depro- NTI and other deprogrammers have tion to warrant consideration of grammer is realigned chairside to been marketed for treating bruxism, MPD/TMD as pathologies in the perfect the fit in relatively little TMD, tension headache, and even patients’ population.86,87 time. Two other prefabricated migraines. However, a 2004 study If a disc is in proper position deprogrammers, the Best Bite Dis- was unable to find evidence for all with the joint, and the joint can cluder (Whip Mix, Contemporary these claims.81 A study of Best Bite be loaded, the deprogrammer can Product Solutions) and the Kois Discluders by Goldstein & Gilbert help to relax chewing muscles by

e366 November/December 2012 General Dentistry www.agd.org Fig. 8. An example of an Aqualizer®.

Fig. 7. An example of a suckdown appliance. One benefit of the suckdown is separate the posterior teeth, cushion the ease of making the appliance the bite, and reposition the jaw to and the ease of insertion to the produce a more adaptive bite. The patient. Another benefit is the lower appliance was designed to achieve cost. Patients also readily accept it even pressure on both sides of the changing the terminal hinge posi- due to its thin nature and its similar arch. For muscle cases, this helps tion.88 Even though cases in which contours to teeth. to reduce uneven muscle activity CR and CO do not match are rare, Suckdown appliances are good due to even posterior contacts; the they occur often enough to need as tooth protectors and retainers. even pressure from side-to-side and deprogrammers to assist at bite deter- By molding an appliance to the tooth-to-tooth helps to reduce the mination in the evolving world of position where the teeth should be irregular muscle activity. Like the reconstruction (crowns and bridges). positioned, the suckdown device will soft splint, the Aqualizer® still has In reconstructive dentistry, a few help to keep the teeth in place. The posterior lateral interference that patients are assumed to have a dis- reduction in power due to opening increases chewing muscle activity. crepancy between CR and CO that bite is minimal since the appliance is Like a soft appliance, it increases a deprogrammer may reveal during very thin. The suckdown appliance joint loading and produces some the course of managing TMD/MPD can be converted into an orthotic increase in muscle activity. or large reconstruction cases. by adapting acrylic precisely to the Practitioners and patients should For cases of emergency muscle appliance, but the cost of conversion be aware that the Aqualizer® will pain, emergency appliances such is not cost effective. The suckdown increase pain in complete disc dis- as suckdown (Fig. 7), Aqualizer® appliance may be ineffective as par- placement. In addition, it can rupture (Fig. 8), and other prefabricated tial disc displacement therapy due in cases of destructive bruxism. Its emergency appliances may be to its duplicaton of lateral guidance use is limited due to its ability to help acceptable. The suckdown appliance interference, its duplication of poor only in muscle cases and also due to is made on a model of the patient anterior guidance patterns, and its the difficulty of patient retention, with all the cusp and fossa relation- continuation of clenching; thus, the particularly in cases where the patient ships and interferences reproduced muscle recruitment deprogramming has an anxious or nervous tongue. in the appliance. The primary has not been accomplished.56 purpose for the suckdown is tooth Athletic guards protection in parafunctional situa- Aqualizer® Some medical doctors and young tions, but many orthodontists use Aqualizer® is a self-contained, dental graduates with a limited these for retainers. The side effect, disposable splint filled with fluid knowledge of jaw problems may due to reproducing interferences that can shunt from one side to recommend that a patient purchase (walls of fossa), is increased muscle the other for equalization. It is a a soft over-the-counter (OTC) ath- activity in clenching. If the bite ready-to-use, prepackaged appliance letic guard for joint muscle patholo- inefficiencies are a small factor for for treating MPD/TMD pathologies; however, they were created excessive muscle use, the suckdown gies and for emergency situations primarily for tooth protection. The will not be effective in reducing involving mostly muscular jaw pain athletic guard is also bulky, which muscle activity. (Fig. 8). A layer of fluid is used to can irritate gums, the tongue, and

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Fig. 9. En example of an OTC sports guard. Fig. 10. An example of an anterior repositioning splint.

cheeks. Besides the production ensuring less dependence on pain appliance is not stepped back fast errors found in any OTC product, medicines, and the convenience enough or is left in the anterior posi- an athletic guard may be difficult of a fast approach. Emergency tion too long, causing overgrowth of to keep in place or may not fit appliances are quick (used on the retrodiscal tissue (permanent poste- the patient’s bite properly. One of same day), effective (on muscle- rior open bite) making it impossible the primary benefits of an OTC based pain), acute (usually used to return to CR. athletic guard is its low cost. One for only brief periods of time), Many patients with acute pain of its potential negative side effects and cheap (as compared to full in their jaw joints will go to an is relying on patient-directed care, coverage appliances). emergency room for relief of the using a tool that may not target pain. However, most ER doctors do the real problem due to incomplete Acute trauma appliance not fully understand acute trauma diagnosis. The soft and compress- The emergency appliance used for to jaw joints and may fail to refer ible athletic guards introduce significant acute trauma to the the patient to a specialist in a timely interferences that increase muscle jaw joint is a short-term anterior manner, setting the stage for limited activity and loading of joints repositioning appliance. Its primary use of emergency appliances. A (Fig. 9). Whether due to mass pro- purpose is to manage pain associated trauma to the jaw causes acute fluid duction manufacturing errors, the with pressure on retrodiscal tissue retention in retrodiscal tissue that increase in clenching, or the patient in part due to swelling (significant pushes the disc and condyle down- acting as doctor with self-directed inflammation) in the temporo- ward and forward, so an indication treatment, the soft athletic guard mandibular joint, similar to the of jaw trauma requires the need for has a high failure rate as a jaw joint treatment of a swollen ankle. The not only timely referrals but also the pain appliance. The waste of money purpose of an acute trauma appli- use of an acute trauma appliance. and the frustration for the patient is ance is to reduce pain without using definitely one of the athletic guard’s opioids (Fig. 10). This anterior repo- Soft appliances most negative attributes. Occasion- sitioning appliance pulls the condyle Another group of appliances are soft ally in an acute muscle pain case, down and away from inflamed ret- full-coverage appliances (Fig. 11). the soft athletic guard interferes rodiscal tissues. When incorporating The majority of dentists use the word with the trauma to teeth enough steroids, muscle relaxants, and physi- nightguard to refer to these profes- for the patient to perceive a reduc- cal therapy, the emergency anterior sionally made appliances; however, tion in discomfort. repositioning device can effectively the term has been overused to refer The favorite reasons for using reduce acute trauma pain in the jaw. to OTC or Internet-ordered soft emergency appliances are in The biggest side effect of the anterior appliances. True nightguards are helping reduce urgent care pain, repositioning device occurs when the full-coverage appliances made with

e368 November/December 2012 General Dentistry www.agd.org soft material that can be fabricated by a dental office or laboratory. The grinding of teeth at night is a highly destructive behavior and there is a great need for recommending tooth protection or preventive dental services to this group of patients.89 Studies have estimated that 15%-90% of the population suffers from destructive forms of parafunction (such as clenching, grinding, tooth brace, and so forth).90-92 Bite Fig. 11. An example of a soft nightguard. forces are much greater during nocturnal activity compared to daytime mastication.93 The initial benefit of the soft appliance is its ability to interfere with the power of the grind- In a study of soft appliances such appliances reduce delivery ing of teeth at night. The second versus medications, the soft appli- time and hassles for the doctor. The benefit of the soft nightguard is to ances reduced tenderness of muscles occlusal surface of the appliance is protect the teeth from the destruc- and improved mouth opening hard plastic that allows for adding tive wear caused by parafunctional more than medications.100 The soft acrylic to the surface to perfect habits.94 In 2000, Halachmi et al nightguard may have a periodontal the contact of the teeth in order to reported that soft splints were more benefit as well, by reducing the achieve muscle recruitment reduc- efficient than hard splints in protect- lateral forces that could lead to tion and decrease loading of jaw ing teeth against damage, despite an cervical erosion, recession, mobility, joint. The inner surface (adjacent to increase in compressive force.95 or cracking of teeth.100 teeth) is firm thermoplastic material As with comparable dental appli- The biggest complaint about pro- that allows for ease of delivery due ances, the soft nightguard can inter- fessional soft nightguard appliances to its heat-adaptive quality. This rupt muscle activity by interfering is that they are hard to wear due to appliance is designed to combine with occlusal contacts.96 In most their bulky nature. The biggest side the best of both worlds of soft and cases, the soft nightguard increases effect is their inability to disclude hard appliances. lateral interferences due to its com- the posterior surfaces in lateral The downfalls of soft/hard appli- pressibility, which in turn increases and protrusive movements, which ances include the following: muscle activity in lateral movement. increases muscle recruitment.55 t"UIJO IBSEPVUFSTVSGBDFUIBU In addition, a 1987 study reported Soft appliances can be problematic does not have much room for that a soft nightguard did increase as severe grinders or bruxers can reducing plastic in cases of adapt- EMG activity in the majority of the chew through the soft full coverage ing to opposing tooth contacts patients.40 The soft nightguard was appliance in a short period of time. that are not even or equal. The more effective for palliative treatment On the plus side, soft nightguards only way to get somewhat ideal of muscle pain.97 In a 1998 study, are easy to insert and were one of contacts in the posterior is to add Pettengill et al found that both soft the first appliances used in den- acrylic. Therefore, this limitation and hard appliances were effective at tistry. This is the best appliance for reduces versatility in perfecting the reducing muscle pain.98 According parafunction teeth protection due occlusion on the appliance. to Quayle et al, a soft nightguard to low cost, ease of production, and tɨFQFSGFDUJPOPGUIFPDDMVTJPO can even help to reduce tension ease of delivery. is more difficult due to the slight headaches. When the soft nightguard compressibility of the soft inside of reduces parafunction power, it could Soft/hard appliances the appliance. in turn reduce most of the inflamma- The recently introduced soft/hard t"OPUIFSQSPCMFNXJUIBTPGUIBSE tion in the temple muscle, reducing appliance has a hard top and a soft appliance is if the first insertion of the pain from tension headaches thermoplastic inside surface. Due the appliance reveals an instabil- while increasing EMG activity.99 to ease of delivery to the patient, ity (pivoting or rocking), it must

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Fig. 13. Long-term wear of ARS produces posterior open bite that must have the occlusion corrected post-ARS. In this case, they have used a partial to restore the occlusion that was changed with ARS. Fig. 12. An example of a segmental appliance. Left: A patient with a posterior open bite wearing an ARS. Right: The same patient without the appliance.

be remade because it cannot be the micro-movements of the teeth soft/hard appliances can be used for relined. Skilled impressions and and the appliance still fits. The hard parafunctional cases, muscle-based proficient lab work reduce the material on the outside means a cases, and even some simple early chances of this happening, but at longer life for the appliance due to partial displaced discs. times it does occur. its resistance to the grinding forces t"GPVSUIQSPCMFNUIBUPDDVSTJT of the chewing system. In addition, Segmental appliances when the patient bites in maxi- this appliance is less compressible Segmental appliances only cover a mum intercuspation when the goal than a soft nightguard, increasing its partial aspect of the occlusal table is to deliver the appliance in cen- ability to be more accurate on the (Fig. 12). The segmental appliance tric relations (jaw joint bite). If the occlusion, which could help in some can be divided into anterior and opposite arch occlusion is too far muscle cases. Another benefit of posterior segmental devices. The off, the thin hard surface and the soft/hard appliances over soft appli- anterior segmental devices are also need for major additions are too ances is their improved adaptability known as deprogrammers. difficult to overcome. In this case, for changes to the anterior guidance, The posterior segmental appliances the appliance has to be remade. which occur in a small percentage cover both sides of the arch, but The management of fit and of cases that have CO and CR only posterior teeth. The posterior occlusion on a completely hard discrepancies large enough to increase segmental creates the bite-reducing splint is an accomplished skill that chewing muscle activity. In these power with an increase in vertical requires major training in order cases, there is a need to add acrylic from the acrylic. These appliances for the appliance to achieve all to the front aspect of the appliance. allow for posterior interferences due its purposes, but on an appliance The main drawback to soft/ to the lack of anterior guidance while with some compressibility it can be hard appliances is that, like soft increasing muscle recruitment in lat- nearly impossible. It is believed the appliances, they aid in some muscle eral and protrusive movements. The degree of accuracy needed on the cases but are not very effective in combination of reducing power and appliance goes up as the instabil- joint damage cases. The posterior increasing muscle activity may equal ity in the jaw joint goes up. This disclusion on movement would not small improvement in patients with might indicate that the soft/hard be adequate enough in all cases for muscle pathologies. The posterior appliance is not well-suited for the significant jaw joint instabilities segmental appliance increases joint complete displaced disc or osteoar- such as osteoarthritis or complete loading, making it inappropriate for thritis. No studies are available to disc displacements. Unless the exact compromised joint tissue pathologies confirm this proposition. status of the disc position is known, (that is, completely displaced discs The beauty of the soft/hard the concern for the soft/hard appli- or osteoarthritis). They could be appliance is that in patients with ance would be using it on a joint used as posterior retainers, provided irregular wear of the appliance, the muscle case that is more complex the anterior teeth are stable and adaptable inner surface allows for than it appears at first. However, the the posterior teeth are not involved

e370 November/December 2012 General Dentistry www.agd.org periodontally. A posterior segmental recapture failure.105 As Joondeph anterior displacement of disc tissue appliance worn constantly (that is, pointed out in his study on the long- loses its biconcave shape over time. 24 hours a day, seven days a week) term stability of ARS, there is high The Gelb appliance, one of the origi- can change a patient’s bite by ante- potential for relapse in relieving the nal ARS appliances, was marketed rior tooth eruption or posterior tooth click.106 A 1988 study reported that and dispensed before the NIH paper intrusion. The bite changes occur 65% of patients who had originally of 1996.2 The Gelb appliance sur- most often when the patient falls lost the click relapsed.107 Moloney & vived for a number of years by clinical out of care and “forgets” instructions Howard examined 241 patients who marketing pressure and the fact that to wear it only at night or for short wore ARS appliances constantly appliances do not have to be studied periods of time. This is especially true for four months and found 70% of before entering the market (that in psychologically challenged patients patients had no click one year after is, they do not go through double- who are not able to listen to or follow the conclusion of treatment, with blinded, randomized, scientific instructions, and as a result may be 53% success at two years, and 36% experiments). The Gelb appliances surprised and angry when their bite success at three years, which sug- had a negative effect on posterior changes. The posterior segmental can gests that the success was temporary open bite and redundant retrodiscial serve as an acceptable parafunctional and fails over time.108 A 1984 study tissue. Extended wear of the ARS appliance (Fig. 13). However, clinical treated 25 patients with ARS appli- over time resulted in permanent bite observation indicates the posterior ances; however, in only one case was changes (positioning condyle down- segmental is usually less effective at the click removed.109 That same year, ward and forward), new condylar reducing muscle pain than an ante- Manzione et al found that only 26 position, increased posterior superior rior segmental appliance. of 56 discs responded positively to joint space, and redundant retrodiscal ARS therapy.110 tissue.113,114 The reasoning behind Anterior repositioning The ARS appliance can reduce the use of the Gelb appliances was appliance pressure on retrodiscal tissue. A 1990 that recapturing the disc was a higher The ARS (anterior repositioning study reported significant reduc- priority than the other symptoms, splint) reduces pain by repositioning tions in patients’ jaw pain, temporal especially long-term pain. the condyle downward and forward headaches, and ear pain in disc dis- The ability to recapture a partially past the maximum intercuspa- placements with reduction; however, displaced disc depends on the extent tion.101 In a 1985 study by Lundh 40% of patients experienced joint of joint damage, how much of the et al, the ARS was compared with a symptoms after ARS treatment.111 lateral ligament is torn, or how soon flat occlusal splint and the control In addition, while ARS devices the click occurs on opening. A 2002 group found that the ARS removed can be used to treat partial disc study reported that the ARS was the “click” (that is, the sound made displacements, these constitute only effective 83% of the time at recaptur- when the posterior band of the disc a percentage of MPD/TMD cases. ing a lateral pole displaced disc, com- moves rapidly over the condyle), In a study by Hoffman & Cubillos, pared to 50% success in recapturing decreased joint pain, and reduced they found 67% were disc displace- a middle displaced disc and no muscle tenderness while the flat ment with reduction, 22% were disc success in recapturing a completely occlusal splint reduced joint discom- displacement without reduction, and displaced disc.115 In fact, in the Kai fort.102 The problem with that study 10% were osteoarthritis.112 et al study of 15 ARS cases, of the was that the variability of the appli- Using an arthrogram study, Tallents 10 patients reviewed post-treatment ance design did not provide anterior et al found that 15% of cases contin- with arthroscopic evaluation, only guidance, nor was the clicking reduc- ued to experience displaced discs even 4 actually completely recaptured.114 tion an appropriate symptom guide. after ARS treatment.105 One must Interestingly, the theory to recapture In the past, the literature has consider that the failure of ARS may as a success criteria was incorrect suggested that the purpose of TMD be due to inadequate understanding and the ability of the ARS to treatment was to reposition the of disc status due to the lack of a recapture disc was wrong. In 1988, condyle back under the center of the clinician’s examination before treat- Lundh et al chose 63 patients with lateral pole of the disc, thus stopping ment, inadequate management of an anthrographic diagnosis of disc the click.88,103,104 In a 1985 study by the two most prominent causalgia replacement with reduction to carry Tallents et al, 18% of cases treated of articular disc disorder (parafunc- out their ARS study; they found that with an ARS had a click and disc tion and tension in muscles), or the not all discs were recaptured.116

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Fig. 14. Upper ARS device inserted into mouth. Note the ramp used to reposition the mandible forward. Fig. 15. ARS end-to-end bite.

ARS devices were designed to appropriately might help decrease system, which is approximately half remove the click in cases with lateral the indiscriminate use of the ARS of the opening distance. If, in fact, pole partially displaced discs. If the on all types of disc displacements the displaced part of the disc at disc was only partially displaced in and osteoarthritis. The biggest the lateral portion or even middle the anterior and medial direction, mistake in the use of the Gelb or disc area has turned into a blob the ARS might recapture the lateral ARS appliance is the one-size-fits-all shape, the disc cannot be recaptured pole portion of disc; using the ARS treatment without the ability to because the three convex surfaces alone will not eliminate the problem determine the severity of displace- do not fit together (Fig. 14 and 15). unless the factors that caused the ment. The amount or degree of Using MRI, Eberhard et al reported lateral ligament tear in disc displace- displacement and the amount of that the ARS appliance could not ment are eliminated also. The use of time the displacement was present recapture a non-reducing disc or a this appliance alone seems doomed are critical factors in how Gelb or severely degenerated disc.115 to failure. However, in an ARS ARS therapy could be considered a appliance study by Williamson & success (which most studies define Neuromuscular appliance Sheffield, the patients in that study as removal of clicking). Despite its side effects, lack of self-reported improvement of 90% A second problem exists regarding research (science), and potential success in three years.117 the severity of displacement. If the for lawsuits, the ARS appliance is In the complete displaced disc, degree of disc displacement is all still being used today as the neuro- the longer the disc is displaced, the the way to the medial pole (disc is muscular appliance of choice. The more likely it will lose its biconcave completely displaced), the distance neuromuscular dentist uses a trans- shape (in other words, it turns to move the condyle forward to cutaneous electrical neural stimula- into a blob). This change makes it recapture the disc by the ARS is too tion (TENS)-induced outside difficult to recapture the disc, as great. In other words, if it is neces- chewing muscle-fatigued bite.52 The the three convex surfaces do not fit sary to move the mandible forward TENS-induced bite moves the con- together or have stability. The ARS so much that the lower incisors are dyle downward and forward so that is not realistic for treating complete near or past end-to-end, all anterior the neuromuscular bite is forward to displaced discs or osteoarthritis, but guidance (overjet and overbite) will the patient’s tooth bite (maximum the science in Gelb’s day did not be removed, which helps reduce intercuspation). In this way, the allow for differentiation of partial muscle recruitment. If you move neuromuscular appliance becomes versus complete displaced disc the condyle downward and forward, an anterior repositioning appliance. cases. We presently have enhanced so that the condyle is at or past The high cost of neuromuscular MRIs and are able to see the disc, the eminence, you remove all the therapy is due to the need to crown position and shape, which if used translational ability of the chewing or orthodontically reposition

e372 November/December 2012 General Dentistry www.agd.org posterior teeth to the new bite. Not to diagnosis and treat jaw joint of scientific literature is where most even considering the significant cost problems.120 A 2008 study by Tecco doctors are able to see past the of ARS therapy, the side effect of et al reported that ARS reduced “smoke and mirrors” of this indis- the posterior open bite makes ARS the EMG activity in masseter and criminate treatment concept. a less likely consideration due to the temporalis muscles over a 10-week ADA’s position of more reversible period; however, clenching increased Summary and conservative approaches. EMG activity.121 In a study by In a 2003 study, nearly 27.2% of As with the ARS or Gelb appli- Cooper & Kleinberg, the success the Sardinian population were ance, the neuromuscular appliance criteria (using self-reported improve- grinding their teeth and destroy- relieves pain initially in joint-related ments in jaw related pain) resulted ing their chewing structures.122 In cases by pulling the condyle away in flawed data.101 A 2008 case study studies using a broader definition from inflamed tissues, thus decreas- involving left internal derangement of destructive habits, the percent- ing blood flow.31 A study by Lundh (partial disc displacements) with a age of the population that has et al reported better results with significant discrepancy between CR parafunctional habits would be neuromuscular appliances than flat and CO reported that the ARS was much greater. Many of the current plane splints using arthroscopically not effective.16 The irreversible side studies have focused specifically on chosen disc displacement with effect of pulling the condyle forward grinding or clenching. However, reduction cases.116 However, the is the production of posterior open there are more destructive oral ARS group was given counseling.116 bite, creating a need for more work habits, such as muscle or tooth Choosing the ARS appliance only on the patient. bracing. Similarly, there are factors for cases of partial disc displacement The creation of a TENS-induced besides bruxism, such as tension with reduction and specifically not bite makes no economical sense, even in muscles (stress-induced contrac- for all joint-related cases is a subject when considering the initial pain tion of muscles) that can damage selection bias. In addition, there is reduction, when other conservative, the jaw joint and lead to muscular the bias of using counseling on only reversible, and scientifically proven inflammation. If one wants to be one group of subjects.116,117 Another methods exist to manage the pain. successful in managing pain from study by Mazzetto et al in 2009 Moving the condylar muscle down- the chewing system, one cannot get found that ARS appliances better ward and forward on a slick incline too focused on just one aspect of reduced joint vibrations in internal ignores the good anatomy and physi- care, such as “magic plastic.” derangements (disc displacements ology of the chewing system. In 1990, it was reported that with and without reduction) than There is little doubt that the 48% of women and 38% of men did stabilization appliances.118 It short-term benefit of using an ARS suffered from tension headaches.123 makes sense that recapturing of the (neuromuscular) device to reduce As the majority of tension head- disc by the lateral pole in partial disc pain of a partially displaced disc ache patients were also found to displacements would have a reduc- (lateral pole disc displacement) gives suffer from parafunctional habits, tion in joint sounds. Most of every it some appeal. The fact that most parafunctional protection can help study cohort is comprised of partial chewing system pathologies are reduce pain for these patients.123 disc displacement cases due to its partial disc displacements increases a Kemper & Okeson found that high prevalence in pain groups. neuromuscular device’s initial success occlusal splint therapy reduced The theory of TENS-induced rate in reducing pain. However, the headaches by 30.3% and reduced bite is that by fatiguing the outer appliance is indiscriminately used tension headaches by 63.6%.124 chewing muscles, a proper bite will on complete disc displacements The type of appliance used will be determined. This TENS-induced and osteorarthritis, which have depend on the structure that is bite is downward and forward to shown poor success rates with ARS being damaged and the amount maximum intercuspation. Multiple appliances. In many clinical cases, of damage involved. For instance, studies indicating the use of surface the neuromuscular dentist does not to protect teeth, a nightguard is a electrodes to accurately evaluate examine the chewing structures to good choice, but not an OTC-type muscles and bite position are reveal differentiation of the different sports guard due to its 90% failure flawed.119 A 2006 review by Klasser damage levels before implementa- rate as related to pain. The orthotic & Okeson provided more information of the TENS or ARS; they often is best for those patients trying to tion on the use of surface EMG tend to be used in all cases. Review protect the jaw joints. Based on

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Table 3. Appliance types and their effects.

Appliance Tooth load Parafunction Joint load Periodontal Muscle Bite change Orthotic Decrease Decrease Decrease Decrease Decrease No Deprogrammer Decrease posterior Decrease Increase Decrease posterior Decrease Yes NTI Decrease posterior Decrease Increase Decrease posterior Decrease Yes Suckdown Decrease Increase Increase Decrease Increase No Aqualizer® Decrease Increase Increase Neither Increase No Soft appliance Decrease Increase Increase Neither Increase No Soft/hard Decrease Increase Increase Neither Increase No Posterior segmental Decrease Slight increase Neither Decrease anterior Slight increase Yes LVI Anterior teeth Decrease Increase Anterior teeth Decrease Yes Gelb/ARS Anterior teeth Decrease Increase Anterior teeth Decrease Yes

the literature, the NTI is appropri- of science, common sense, and pain management: A practitioner’s handbook. ate for cases involving short-term empathy. Prepare for the world of New York: Guilford Press; 1996:33. 6. Wedel A, Carlsson GE. Factors inﬂuencing the pain, small amounts of damage, clinical dentistry with the shield of outcome of treatment in patients referred to a partially displaced discs, and much knowledge and science. Love your temporomandibular joint clinic. J Prosthet Dent muscle inflammation. Table 3 work and care for the patient with 1985;54(3):420-426. 7. Pierce CJ, Weyant RJ, Block HM, Nemir DC. Den- summarizes the various appliances all your skills and heart. tal splint prescription patterns: A survey. J Am and their uses. Dent Assoc 1995;126(2):248-254. In 2010, The National Institute Disclaimer 8. Ommerborn MA, Taghavi J, Singh P, Handschel J, Th fi Depprich RA, Raab WH. Therapies most fre- of Dental and Craniofacial Research e author has no nancial, quently used for management of bruxism by a stated that “reversible treatments economic, commercial, and/or sample of German dentists. J Prosthet Dent such as stabilization appliances are professional interests related to 2011;105(3):194-202. 125 9. Lundh H, Westesson P, Eriksson L, Brooks SL. useful in relief of pain.” topics presented in this article. Temporomandibular joint disk displacement There are various appliances for without reduction. Treatment with ﬂat occlusal treating acute traumatic jaw pain, Author information splint versus no treatment. Oral Surg Oral Med Oral Pathol 1992;73(6):655-658. tooth protection, occlusal trauma, Dr. Yount maintains a private prac- 10. Carlson CR, Reid KL, Curran SL, Studts J, Okeson jaw joint damage, muscle inflam- tice, limiting his care to orofacial JP. Psychological and physiological parameters of mation, osteoarthritis, complete dis- pain in Raleigh, North Carolina. masticatory muscle pain. Pain 1998;76:297-307. 11. Carraro JJ, Caffesse RG. Effect of occlusal splints placed discs, and partially displaced on TMJ symptomology. J Prosthet Dent 1978; discs. The most important aspect References 40(5):563-566. of appliance selection is diagnos- 1. Mahan PE. In: Facial Pain, ed. 3. Philadelphia: 12. Badel T, Lovko SK, Podoreski D, Pavcin IS, Kern J. Fea and Febiger;1991:1-376. Anxiety, splint treatment and clinical character- ing the problem and tailoring the 2. National Institutes of Health. Management of istics of patients with osteoarthritis of temporo- treatment to specifically control the temporomandibular disorders. Available at: mandibular joint and dental students—A pilot major factor that causes that prob- http://consensus.nih.gov/1996/1996Temporoma study. Med Glas Ljek komore Zenicko-doboj ndibularDisorders018PDF.pdf. Accessed June kantona 2011;8(1):60-63. lem. General dentists with limited 2012. 13. Ekberg E, Vallon D, Nilner M. Occlusal appliance diagnostic ability might agree with 3. Helkimo M. Request for expert statement re- therapy in patients with temporomandibular Greene & Laskin in their study’s garding the use of NTI splint. Stockholm: Social- disorders. A double-blind controlled study in a styrelesen. National Board of Health and short-term perspective. Acta Odontol Scand conclusion that the conservative and Welfare. DNR 53-52941-2003;2003. 1998;56(2);122-128. reversible approach yields some of 4. Dworkin SF, Massoth DL. Temporomandibular 14. Kirk WS Jr. Magnetic resonance imaging and the best results.53,126 Dentists should disorders and chronic pain: Disease or illness? tomographic evaluation of occlusal appliance J Prosthet Dent 1994;72(1):29-38. treatment for advanced internal derangement of diagnose and treat patients with the 5. Gatchel RJ. Psychological disorders and chronic the temporomandibular joint. J Oral Max Surg instruments that fulfill the treatment pain cause and effect relationships. In: Gatchel 1991;49(1):9-12. objective based on their knowledge RJ, Turk DC, eds. Psychological approaches to

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Nociceptive trigeminal inhibi- tients with craniomandibular disorders. Cranio py for recapturing the emporomandibular joint tion—Tension suppression system: A method 1989;7(2):119-125. meniscus. Oral Surg Oral Med Oral Pathol 1984; of preventing migraine and tension headaches. 94. Okeson JP. The effects of hard and soft occlusal 57(3):235-240. Compend Contin Educ Dent 2001;22(12): splints on nocturnal bruxism. J Am Dent Assoc 111. Tallents RH, Katzberg RW, Macher DJ, Roberts 1075-1080; quiz 114. 1987;114(6):788-791. CA. Use of protrusive splint therapy in anterior 76. Jokstad A, Mo A, Krogstad BS. Clinical compari- 95. Halachmi M, Gavish A, Gazit E, Winocur E, Bro- disk displacement of the temporomandibular son between two different splint designs for sh T. Splints and stress transmission to teeth: An joint: A 1- to 3-year follow-up. J Prosthet Dent temporomandibular disorder therapy. Acta in vitro experiment. J Dent 2000;28(7):475-480. 1990;63(3):336-341. Odonto Scand 2005;63(4):218-226. 96. Singh BP, Berry DC. Occlusal changes following 112. Hoffman DC, Cubillos L. The effect of ar- 77. Sears VH. Occlusal pivots. J Prosthet Dent 1956; soft occlusal splints. J Prosthet Dent 1985;54(5): throscopic surgery on mandibular range of mo- 6:332-338. 711-715. tion. Cranio 1994;12(1):11-18. 78. Ito T, Gibbs CH, Marguelles-Bonnet R, Lupkie- 97. Wright E, Anderson G, Schulte J. A randomized 113. Farrar WB, McCarty WL. A clinical outline of wicz SM, Young HM, Lundeen HC, Mahan PE. clinical trial of intraoral soft splints and pallia- temporomandibular joint diagnosis and treat- Loading on the temporomandibular joints with tive treatment for masticatory muscle pain. ment. ed. 7. Montgomery, AL: Normandie Study J Orofacial Pain 1995;9(2):192-199. Group for TMJ Dysfunction; 1983:115.

e376 November/December 2012 General Dentistry www.agd.org 114. Kai S, Kai H, Tabata O, Tashiro H. The signifi- neck, and trunk muscles in temporomandibular cance of posterior open bite after anterior repo- joint dysfunction. Eur J Orthod 2008;30(6):592- sitioning splint therapy for anteriorly displaced 597. disk of the temporomandibular joint. Cranio 122. Melis M, Abou-Atme YS. Prevalence of bruxism 1993;11(2):146-152. awareness in a Sardinian population. Cranio 115. Eberhard D, Bantleon HP, Steger W. The efficacy 2003;21(2):144-151. of anterior repositioning splint therapy studied 123. Bailey DR. Tension headache and bruxism in the by magenetic resonance imaging. Eur J Orthod sleep disordered patient. Cranio 1990;8(2):174- 2002;24(4):345-352. 182. 116. Lundh H, Westesson PL, Jisander S, Eriksson L. 124. Kemper JT Jr, Okeson JP. Craniomandibular dis- Disk-repositioning onlays in the treatment of orders and headaches. J Prosthet Dent 1983; temporomandibular joint disk displacement: 49(5):702-705. Comparison with a flat occlusal splint and with 125. The National Institute of Dental and Craniofacial no treatment. Oral Surg Oral Med Oral Pathol Research. TMJ Disorders. Available at: http:// 1988;66(2):155-162. www.nidcr.nih.gov/. Accessed September 2012. 117. Williamson EH, Sheffield JW. The non-surgical 126. Greene CS, Laskin DM. Long-term evaluation of treatment of internal derangement of the tem- conservative treatment for myofascial pain-dys- poromandibular joint: A survey of 300 cases. function syndrome. J Am Dent Assoc 1974; Facial Orthop Temporomandibular Arthrol 1985; 89(6):1365-1368. 2(10):18-21. 118. Mazzetto MO, Hotta TH, Mazzetto RG. Analysis of TMJ vibration sounds before and after use of Manufacturers two types of occlusal splints. Braz Dent J 2009; Aztec Orthodontic Laboratory, Inc., Tucson, AZ 20(4):325-330. 888.744.1588, www.aztecortholab.com 119. Frame JW, Rothwell PS, Duxbury AJ. The standardization of electromyography of the masse- Therapeutic Solutions International Inc., ter muscle in man. Arch Oral Biol 1973;18(11): Oceanside, CA 419-423. 877.468.4877, www.therapeuticsolutionsint.com 120. Klasser GD, Okeson JP. The clinical usefulness of Whip-Mix, Contemporary Product Solutions, surface electromyography in the diagnosis and Virginia Beach, VA treatment of temporomandibular disorders. 888.259.9754 , http://cpsmagazine.com/our- J Am Dent Assoc 2006;137(6):763-771. partners-member/whipmix 121. Tecco S, Tete S, D’Attilio M, Perillo L, Festa F. Electromyographic patterns of masticatory,

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www.agd.org General Dentistry November/December 2012 e377 CDE self 2 HOURS instruction CREDIT

Exercise No. 320 Appliance Therapy

Subject Code 185 5. The orthotic appliance is versatile and may be used The 15 questions for this exercise are based on the article with all of the following conditions except one. Appliance design and application on pages e359-e377. Which is the exception? This exercise was developed by Thomas C. Johnson, DMD, A. Osteoarthritis MAGD, FICOI, in association with the General Dentistry B. Completely displaced disc Self-Instruction committee. C. Nocturnal bruxism D. Joint trauma with effusion Reading the article and successfully completing the exercise will enable you to understand: 6. All of the following design components are UÊÌ iÊii`ÊvÀÊ>`Û>Vi`]ÊiÛ`iViL>Ãi`ÊÌÀ>}ÊÊ characteristic of the orthotic appliance except one. >««>ViÊÃiiVÌÊ>`ÊÕÃiÆ Which is the exception? UÊÌ iÊLiiwÌÃÊÌÊ«>ÌiÌÃÊvÊÌ iÊÛ>ÀÕÃÊ>««>ViÃÆ A. Evenly supported posterior contacts UÊÌ iÊÃ`iÊivviVÌÃÊvÊ`vviÀiÌÊ>««>ViÃÆÊ>` B. Posterior directing ramp UÊÌ iÊ«ÀÌ>ViÊvÊÀi>ÃÌVÊ«>ÌiÌÊiÝ«iVÌ>ÌÃÊÀi>Ìi`Ê C. Flat plane posterior to appliance therapy. D. Shallow anterior guidance

1. Which of the following factors makes 7. A small percentage of patients will have increased interpretation of the results of appliance parafunctional activity with appliance use. This studies difficult? reflects the multifactorial nature of articular A. A homogenous pool of patients disc disorders. B. Standardization of treatment outcomes A. Both statements are true. C. Clear definitions of pathologies B. The first statement is true; the second is false. D. Multifaceted pathologies C. The first statement is false; the second is true. D. Both statements are false. 2. Some appliances may be used for bruxism but not for pain cases. Appliances may have side effects, 8. Which appliance is contraindicated with a damaging parts of the masticatory system. moderate to large discrepancy between centric A. Both statements are true. relation and maximum intercuspation? B. The first statement is true; the second is false. A. Soft/hard C. The first statement is false; the second is true. B. Segmental D. Both statements are false. C. Neuromuscular D. Aqualizer® 3. Which condition will require an orthotic with a design and accuracy that requires 9. Which appliance may be used to decrease muscle advanced training? activity and deprogram muscles? A. Periodontal protection A. Aqualizer® B. Trauma with joint effusion B. NTI C. Clenching and grinding with no pain C. Soft/hard or joint damage D. Suckdown D. Osteoarthritis

4. Which is the most prevalent form of parafunction? A. Clenching B. Bruxism C. Dystonia D. Tongue thrust

e378 November/December 2012 General Dentistry www.agd.org 10. Load testing the jaw joint can help diagnose a 13. All of the following are side effects of long-term completely displaced disc and osteoarthritis. The use of an anterior repositioning splint except one. NTI appliance decreases joint load and will relieve Which is the exception? pain with these cases. A. Permanent posterior open bite A. Both statements are true. B. Redundant retrodiscal tissue B. The ﬁrst statement is true; the second is false. C. An increase in posterior superior joint space C. The ﬁrst statement is false; the second is true. D. Posterior interferences in mandibular D. Both statements are false. excursions

11. Which is a common side effect of soft material 14. Which of the following is synonymous with the appliances? neuromuscular device? A. Posterior interferences in mandibular A. Orthotic appliance excursions B. NTI appliance B. Supereruption of posterior teeth C. Gelb/ARS C. Posterior open bite D. Posterior segmental D. Growth of redundant retrodiscal tissues 15. An anterior repositioning splint (ARS) can be 12. All of the following should be goals of therapy for used as an acute trauma appliance by pulling the MPD/TMD except one. Which is the exception? condyle away from inﬂamed retrodiscal tissue. A. Improve the function How soon should the patient be transitioned out B. Stop the clicking of the ARS to avoid permanent joint changes? C. Stop the progression of the disease A. 1 week D. Reduce the pain B. 1 month C. 90 days D. 6 months

Answer form is on page 552. Answers for this exercise must be received by October 31, 2013.

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www.agd.org General Dentistry November/December 2012 e379 Oral Diagnosis/Endodontics

A case of a benign cementoblastoma treated by enucleation and apicoectomy

Aydin Gulses, DDS, PhD n Gurkan Rasit Bayar, DDS, PhD n Cumhur Aydin, DDS, PhD n Metin Sencimen, DDS, PhD

Cementoblastoma is a rare, benign, odontogenic neoplasm the affected roots were performed. Removal of the tumor while of ectomesenchymal origin, representing less than 6% of all preserving the associated tooth resulted in normal osseous heal- odontogenic tumors. Despite its well-known typical features, there ing and no evidence of recurrence after one year. Based on the are still controversies regarding the management of the condition. ﬁndings of the current report, it can be suggested that, in properly This article presents the case of a benign cementoblastoma in a selected cases, it is possible to remove cementoblastomas that 17-year-old girl. The lesion was typical and associated with the affect molars without extracting the involved teeth. mandibular right ﬁrst molar. Endodontic treatment of the involved Received: July 15, 2011 tooth, enucleation of the cementoblastoma, and apicoectomy of Accepted: September 21, 2011

enign cementoblastoma is Surgical removal of both the tooth to the roots of the mandibular right a relatively rare, benign and tumor is one treatment option. first molar (Fig. 1). No periodontal Bneoplasm of odontogenic Recently, conservative treatment ligament space separated the ectomesenchymal origin that is modalities including the endodontic radiopacity from the root tips. The characterized by the proliferation treatment of the affected tooth and tooth responded negatively to an of the cellular cementum around the surgical removal of the lesion electric pulp test. A provisional the root of a tooth.1-4 Benign have also been advocated.5,8,9 diagnosis of benign cementoblas- cementoblastomas are usually The report presented here toma was made. After consultations slow-growing lesions and develop describes the case of a patient who with the Department of Endodon- more commonly around the root had a benign cementoblastoma that tics, it was decided to perform of a mandibular first molar.2 affected a mandibular first molar. endodontic therapy followed by the Symptoms associated with benign The patient was successfully treated surgical removal of the lesion. cementoblastomas are variable. with endodontic therapy and surgi- The pulp tissue of the affected They can be totally absent or the cal excision of the lesion. tooth was extirpated and the root lesion can present as a painful canals were prepared with K-files, swelling. In any case, localized jaw Case report irrigated with copious amounts enlargement is a typical feature of A 17-year-old otherwise healthy of 2.25% sodium hypochlorite, the condition.3 Radiographically, female was referred to the Depart- and dried with paper points. After benign cementoblastoma appears ment of Oral and Maxillofacial complete instrumentation, a cal- as a radiopaque mass, surrounded Surgery at Gulhane Military Medi- cium hydroxide paste (Vision, FKG by a thin radiolucent line.4 During cal Academy for investigation and Dentaire) was placed in the canals early stages of cementoblastoma, management of pain and tender- with lentulo filler. The intracanal the affected tooth can respond nor- ness affecting the posterior right dressing was changed once. The mally to vitality tests.5-7 However, region of the mandible. Clinical root canals were obturated with during later stages, pulp necrosis examination showed no extraoral gutta-percha (Gapadent Co. Ltd.) can occur. Histologically, the lesion or intraoral abnormalities. The soft and a resin-based root canal sealer is composed of sheets and masses of tissues, bony structures, and teeth (Diaket, 3M ESPE) using the paucicellular cementum that have all appeared to be normal. Radio- lateral condensation technique. variably prominent reversal lines graphic examination revealed the The patient’s symptoms remained with an intervening stroma consist- presence of a radiopaque lesion 1.8 unchanged during this period. ing of loose fibrovascular tissue x 1.5 cm in diameter, surrounded Surgery was performed using an with osteoclast-type giant cells.7 by a thin radiolucent line, attached inferior alveolar nerve block. After

e380 November/December 2012 General Dentistry www.agd.org the lesion was separated from the roots and removed, an apicoectomy was completed. The excisional biopsy specimen was submitted to the Department of Pathology, where histologic examination revealed that the tissue was relatively acellular but contained relatively large cells identified as cementoblasts; therefore, a diagnosis of a benign cementoblastoma was rendered. The healing period was uneventful. The patient reported no symptoms during the follow-up period. After Fig. 1. An orthopantomograph revealed the presence of a radiopaque lesion, surrounded by a thin one year, the tooth and related radiolucent line, that attached to the roots of the mandibular right ﬁrst molar. tissues were symptom-free and the radiograph revealed that osseous healing was almost complete (Fig. 2).

Discussion A cementoblastoma (also known as a true cementoma) can be easily misdiagnosed if the clinical and radiographic findings are not considered.5,10 Therefore, the diagnosis of a cementoblastoma cannot be made based solely on histopatho- logical examination of the biopsy specimen. The differential diagnosis of the condition might include odontoma, ossifying fibroma, osteoblastoma, fibrous dysplasia, or Fig. 2. An orthopantomograph taken one year after surgery revealed that osseous healing was calcifying odontogenic tumour.11 almost complete. Furthermore, cementum- producing lesions such as periapical cemental dysplasia, cementifying fibroma, and gigantiform cementoma can also be confused with cemento- lesion that is part of the root struc- root cementum.10 Brannon et al blastoma.5,12 In addition to the risk of ture of the involved tooth.5 Both suggested that cementoblastomas misdiagnosis, a benign cementoblas- of these features were present in be removed as early as possible, toma can be easily overlooked.5,13,14 the current case. together with the associated teeth.16 However, benign cementoblas- There is some controversy in The same authors also reported toma can be easily distinguished the literature regarding the treat- recurrent cases and found, through from other lesions based on two ment of cementoblastoma. Mader a comparison of the initial treat- clinical characteristics: The pres- & Wendelburg recommended ment methods of those cases, that ence of an opaque core surrounded complete excision and removal of recurrence was more likely when by a radiolucent line is a radio- the associated tooth.15 Jelic et al curettage was attempted without graphical characteristic of a cement- also argued that extraction of the extraction of the associated tooth oblastoma, and cementoblastoma associated tooth is necessary because or teeth. However, recurrence also is the only cementum-producing of the fusion of the lesion to the occurred in nine of 26 cases in

www.agd.org General Dentistry November/December 2012 e381 Oral Diagnosis/Endodontics A case of a benign cementoblastoma treated by enucleation and apicoectomy

which the tumor and tooth were apicoectomy can be a successful 8. Adkins KF, Monsour FN. Benign cementoblasto- initially removed together.16 Adkins treatment for the management of ma in the maxilla. Aust Dent J 1973;18(2):99- 101. & Monsour suggested that a con- cementoblastomas. 9. Keyes G, Hildebrand K. Successful surgical endo- servative approach is justified for dontics for benign cementoblastoma. J Endod functional and aesthetic reasons.8 Author information 1987;13(12):566-569. 10. Jelic JS, Loftus MJ, Miller AS, Cleveland DB. Be- In the current case, the authors Dr. Gulses is in the 2nd Army nign cementoblastoma: Report of an unusual performed enucleation with apico- Corps, Commando Troop No. case and analysis of 14 additional cases. J Oral ectomy to preserve the tooth. The 5, Surgical Infirmary, Gokceada, Maxillofac Surg 1993;51(9):1033-1037. 11. Schafer TE, Singh B, Myers DR. Cementoblasto- conservative approach selected for Canakkale, Turkey. Drs. Bayar and ma associated with a primary tooth: A rare pe- this case was dependent on factors Sencimen are in the Department diatric lesion. Pediatr Dent 2001;23(4):351-353. identified by Keyes & Hildebrand of Oral and Maxillofacial Surgery, 12. Makek M, Lello G. Benign cementoblastoma. Case report and literature review. J Maxillofac in 1987: Gulhane Military Medical Academy, Surg 1982;10(3):182-186. t ɨFTUSBUFHJDOBUVSFPGUIFUPPUI Ankara, Turkey, where Dr. Aydin is 13. Ohki K, Kumamoto H, Nitta Y, Nagasaka H, and the patient’s desire to save the in the Department of Endodontics. Kawamura H, Ooya K. Benign cementoblastoma involving multiple maxillary teeth: Report of a tooth. case with a review of the literature. Oral Surg t "DPSSFDUQSFPQFSBUJWFEJBHOPTJT References Oral Med Oral Pathol Oral Radiol Endod 2004; made by the clinicians to justify 1. Regezi JA, Kerr DA, Courtney RM. Odontogenic 97(1):53-58. tumors: Analysis of 706 cases. J Oral Surg 1978; 14. Ulmansky M, Hjorting-Hansen E, Praetorius F, performing nonsurgical endodon- 36(10):771-778. Haque MF. Benign cementoblastoma. A review tics before periapical surgery. 2. Zaitoun H, Kujan O, Sloan P. An unusual recur- and ﬁve new cases. Oral Surg Oral Med Oral t ɨFMFTJPOXBTJOUFSDFQUFEFBSMZ rent cementoblastoma associated with a devel- Pathol 1994;77(1):48-55. ffi oping lower second molar tooth: A case report. 15. Mader CL, Wendelburg L. Benign cementoblas- enough to allow for a su cient J Oral Maxillofac Surg 2007;65(10):2080-2082. toma. J Am Dent Assoc 1979;99(6):990-992. crown-to-root ratio after surgery. 3. Corio RL, Crawford BE, Schaberg SJ. Benign ce- 16. Brannon RB, Fowler CB, Carpenter WM, Corio t ɨFUVNPSXBTSFMBUJWFMZTNBMM mentoblastoma. Oral Surg Oral Med Oral Pathol RL. Cementoblastoma: An innocuous neoplasm? 1976;41(4):524-530. A clinicopathologic study of 44 cases and re- and localized around the apical 4. Farman AG, Kohler WW, Nortje CJ, Van Wyk CW. view of the literature with special emphasis on end of the molar.5,9 Cementoblastoma: Report of a case. J Oral Surg recurrence. Oral Surg Oral Med Oral Pathol Oral 1979;37(3):198-203. Radiol Endod 2002;93(3):311-320. 5. Biggs JT, Benenati FW. Surgically treating a be- Summary nign cementoblastoma while retaining the in- Cementoblastoma is a relatively volved tooth. J Am Dent Assoc 1995;126(9): Manufacturers rare tumor of the jaws. The early 1288-1290. FKG Dentaire, La Chaux-de-Fonds, Switzerland 6. Zachariades N, Skordalaki A, Papanicolaou S, 032.924.22.44, www.fkg.ch and correct diagnosis of this Androulakakis E, Bournais M. Cementoblasto- Gapadent Co. Ltd., North Vale, NJ condition might allow conserva- ma: Review of the literature and report of a 201.294.4952, www.gapadent.com case in a 7-year-old girl. Br J Oral Maxillofac tive approaches in its treatment. 3M ESPE, St. Paul, MN Surg 1985;23(6):456-461. 888.364.3577, solutions.3m.com Based on the case report presented 7. Huber AR, Folk GS. Cementoblastoma. Head here, enucleation performed with Neck Pathol 2009;3(2):133-135.

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e382 November/December 2012 General Dentistry www.agd.org Operative Dentistry

The effect of pre-warming and delayed irradiation on marginal integrity of a resin-modiﬁed glass-ionomer

Maryam Khoroushi, DDS, MS n Tayebeh Mansoori-Karvandi, DDS, MS n Saeed Hadi, DDS

Recent studies have indicated that the acid-base reactions and capsules were pre-warmed and photocuring was delayed for 2.4 polymerization of resin-modified glass-ionomers (RMGIs) compete minutes. Microleakage scores were determined using the dye with and inhibit each other; however, external energy can also penetration technique; Kruskal-Wallis and Mann-Whitney U tests influence the properties of RMGIs. This in vitro study evaluated were used for statistical analysis (α = 0.05). the effect of pre-warming and/or delayed light irradiation on The enamel groups exhibited statistically significant differ- marginal integrity of RMGIs in cervical restorations. ences (P = 0.036), while the dentin groups did not (P = 0.122); Standard Class V cavities were prepared on the buccal aspects however, in both cases, Group 2 demonstrated the highest of 60 human maxillary premolars. Each cavity was treated with marginal integrity. Based on the results of this study, pre-warming a cavity conditioner for 10 seconds, rinsed, and gently air-dried. could jeopardize the marginal integrity of RMGIs in cervical An RMGI was applied to the prepared cavities as dictated by the restorations, while delaying the curing process might improve it study protocol. Group 1 samples were treated per manufacturers’ (particularly for enamel). instructions. Group 2 samples were photocured after a delay of Received: July 21, 2011 2 minutes. For samples in Group 3, the encapsulated material Final revision: October 3, 2011 was pre-warmed (at 40ºC) for 90 seconds; for Group 4 samples, Accepted: November 7, 2011

he setting of a glass-ionomer (HEMA), which may be grafted polymerization reaction establish- (GI) is mediated through an onto the polyacrylic acid.2,3 ing a polymer network, and an acid- Tacid-base reaction between the Incorporating low-molecular- base reaction yielding a GI polysalt polymers of polyacrylic acid and weight resin monomers—such matrix.4 Setting time in GIs lasts fluoroaluminosilicate bases.1 Dis- as HEMA—into the chemical for some time; nevertheless, further advantages of GI include low early composition of conventional GIs maturation processes continue. strength and moisture sensitivity to initiate the setting reaction However, the resin reaction rate is during the setting reaction. in addition to an acid-base reac- much faster than the acid-base reac- By contrast, resin-modified glass- tion has been described as a dual tion. The complex, photo-initiated ionomers (RMGIs) have the unique mechanism.4 The setting processes polymerization required for RMGIs ability to form a chemical bond of RMGIs are time-dependent eventually produces a diffusion-con- with tooth structures, while dem- and the properties of the material trolled, polymer chain propagation onstrating early strength (greater undergo significant and rapid as the concentration and mobility than that found in conventional changes during the setting.4,5 of monomers decrease concomitant GIs).2 RMGIs were developed to Conventional GIs contain an with the formation of cross-linked improve mechanical properties, ion-leachable glass component matrix networks. The final degree of decrease setting time, and reduce and a polyalkenoic-acid compo- conversion depends upon monomer the moisture sensitivity found in nent, which initiate the acid-base mobility and diffusion.6,7 A prompt conventional GIs.3 The major ingre- reactions to produce the cement curing procedure might retard the dients of RMGIs are fluoroalumi- mass. These components mean acid-base reaction, producing a nosilicate glasses, photoinitiators, that RMGIs have a relatively material with a different structure.6 polyacrylic acid, water, and a water- complex setting reaction chemistry. However, delaying the curing soluble methacrylate monomer RMGIs exhibit a dual setting reac- procedure might prevent complete such as hydroxyethyl methacrylate tion that includes a free-radical polymerization of the resin.6,8

www.agd.org General Dentistry November/December 2012 e383 Operative Dentistry The effect of pre-warming and delayed irradiation on marginal integrity of an RMGI

Table 1. Composition and mode of their applications for Table 2. Scoring system for the materials used in this study determining microleakage

Material Manufacturers’ instructions Chemical composition Score Deﬁnition Cavity Apply with a brush for 10 seconds, Polyacrylic acid (20%), aluminum 0 No microleakage Conditioner rinse thoroughly chloride (3%), distilled water 1 Penetration up to one-third of the Fuji II LC Shake the capsule, push the plunger until Powder: Fluoroalumino-silicate cavity depth (improved it is ﬂush with the main body, place the glass; Liquid: Polyacrylic acid 2 Penetration between one-third to version) capsule into a metal GC capsule applier (20-25%); 2-hydroxyl ethyl two-thirds of the cavity depth and click the lever once, set the capsule methacrylate (30-35%); proprietary in a mixer and mix for 10 seconds, load it ingredient (5-15%); 2,2,4, trimethyl 3 Penetration of more than two- into the applier, inject into the prepared hexamethylene dicarbonate (1-5%) thirds of the cavity depth up to the cavity, cure for 20 seconds axial wall or toward the pulp

Few studies have discussed the under the influence of the amount that pre-heating composite resins effect of the irradiation regimen on of material already cross-linked in could have a negative effect on resto- RMGIs.4,6,9-12 Tonegawa et al used the matrix network by the acid-base ration margins because polymeriza- ultrasound measurements to evalu- reaction. It is, therefore, acceptable tion shrinkage would increase.22 ate the effect of the power density to assume that since one reaction A 2006 study by Daronch et al of the curing unit on the setting influences the extent and pace of showed that rapid setting reactions reaction and behavior of RMGIs.4 the other, if the initiation time of due to heat or ultrasound energies In a 2008 study, Yelamanchili & the photopolymerization reaction shortens the setting time of RMGIs Darvell examined whether changing is modified, the balance of acid- and significantly increases bond the irradiation regimen would lead base versus photopolymerization strength to enamel.7 More recently, to interferences between the com- of the material would be altered.10 O’Brien et al reported that using ponents of an RMGI cement. They Delaying irradiation allowed for a external energy sources on a GI found that competition between more widespread acid-base reaction, cement (including pre-heating network-forming reactions resulted reducing resin polymerization extent the capsules, applying light to the in a delicate balance; that is, delay- and producing an RMGI with a dif- surfaces from a high irradiance ing irradiation and utilizing too ferent structure.6 light source, or using an ultrasonic much light energy both could have Other studies have suggested that scaler) significantly improve upper a deleterious effect.12 Therefore, the increasing the temperature of resin surface hardness during the initial authors recommended following composite leads to a higher degree setting stages.23 the manufacturer’s recommenda- of conversion, increases flow, and RMGIs are a hybrid of GIs and tions concerning the duration of improves adaptation with cavity composite resins. In simple words, exposure.12 A 2010 study by Berzins walls—all of which can be advanta- RMGIs are a combination of tra- et al showed that because the setting geous when placing composite.13-17 ditional GIs and composite resins; process of RMGIs is accomplished Other studies have confirmed that therefore, they are considered through acid-base and polymeriza- pre-heating composite resin before complex materials and the acid- tion reactions, and each mechanism irradiation improved adaptation base and components amenable to depends on reactant diffusion before without altering the mechanical polymerization must exist together gelation, the reaction kinetics and properties and monomer conver- in one formulation. It is, therefore, mechanisms of each setting reaction sion.18-21 Furthermore, pre-heating acceptable to assume that since one influence one another.6 The photo- the resin composite up to 54°C reaction influences the extent and polymerization reaction of the resin and 60°C decreased the means of pace of the other, if the initiation is much faster than the acid-base microleakage values when a quartz- time of the photopolymerization reaction; however, it is dependent tungsten-halogen (QTH) light was reaction is modified, the balance of on the availability of monomer used at low power.18 These findings acid-base vs. photopolymerization and its mobility/diffusion, which is contradict a 2009 study that showed of the material would be altered,

e384 November/December 2012 General Dentistry www.agd.org Table 3. Frequency of marginal microleakage in Table 4. Frequency of marginal microleakage in enamel margins (N = %). dentin margins (N = %).

Scores Scores Group 0 1 2 3 Group 0 1 2 3 1 1 (6.7) 8 (53.3) 3 (20) 3 (20) 1 2 (13.3) 6 (40) 2 (13.3) 5 (33.3) 2 4 (26.6) 9 (60) 1 (6.7) 1 (6.7) 2 3 (20) 7 (46.7) 3 (20) 2 (13.3) 3 2 (13.4) 5 (33.3) 0 (0) 8 (53.3) 3 1 (6.7) 5 (33.3) 3 (20) 6 (40) 4 0 (0) 7 (46.6) 4 (26.7) 4 (26.7) 4 0 (0) 5 (33.3) 3 (20) 7 (46.7)

which is referred to as network Inc.) for 10 seconds, washed and stored in distilled water (at 37°C) for competition.9-11 The concept gently dried according to manu- 24 hours. At that point, the restora- requires evaluation in order to facturer’s instructions (see Table 1). tions were finished with fine dia- determine the marginal integrity The restorative material (Fuji II LC mond drills and polished with disks of RMGIs in cervical restorations. Improved Version, GC America (Soflex, 3M ESPE) under constant This study sought to evaluate the Inc.) was mixed per manufacturer’s and copious water spray. The speci- marginal microleakage of RMGI recommendations in a mechanical mens in all groups were then ther- cervical restorations using two mixer for 10 seconds at 4,000 rpm. mocycled at 5°/55°C for 500 cycles different modalities in which For samples in Group 1 (control with a dwell time of 30 seconds and photocuring began after RMGI group), the material was mixed, 15 seconds for transfer. The apices of mixing and/or pre-heating. It injected into the cavities, and all the samples were sealed using util- was hypothesized that delaying allowed to set; curing light was used ity wax and all tooth surfaces (except the irradiation procedure and/or per the manufacturer’s instructions. for restorative materials) were cov- warming the material would not For Group 2 samples, the material ered with three coats of nail varnish influence the microleakage from was mixed, placed in the cavities, 1 mm from the margins. Each group RMGI cervical restorations. and allowed to set for 2 minutes was immersed in 2% basic fuchsin before it was photocured according solution and incubated at 37°C Materials and methods to manufacturer’s instructions. For for 36 hours; at that point, each Sixty sound human premolars were Group 3 samples, RMGI capsules specimen was bisected longitudinally stored in 0.2% thymol solution for were immersed for 90 seconds in through the center of the restoration 90 days after extraction. After all a water bath (40° ± 1°C); at that in a bucco-lingual direction, using a tooth surfaces were cleaned with a point, RMGI was activated, mixed, cutting machine and diamond discs. brush and pumice/water slurry, a and placed into the cavities. Group All the sections were examined under cylindrical diamond bur (0.8 mm 4 underwent the same protocol as a stereomicroscope (magnification in diameter) was used to create Group 3, except that the samples 16X) and observed by two experi- Class V cavities (3 mm width × 2 were photocured after setting for enced operators in a blind manner. A mm length x 1.5 mm depth) on 2 minutes, as in Group 2. standard scoring system was applied the buccal aspect of each tooth Using a halogen light unit (Col- (see Table 2). at the cemento-enamel junction tolux 2.5, Coltene/Whaledent Inc.), Data was analyzed by SPSS 11.5 (CEJ). The margins of the cavities the Fuji II LC was photocured for software program (IBM) using were butt-jointed, with 50% of the 20 seconds (with a light intensity Kruskal-Wallis and Mann-Whitney margin in the enamel and 50% in of 480mW/cm2). Irradiance was U tests (α = 0.05). the root dentin. The samples were checked daily with a radiometer randomly and equally divided into (Optilux 100, Kerr Dental). All Results four groups (n = 15). restorative procedures were Tables 3 and 4 summarize the All the cavities were treated with performed at room temperature microleakage scores of the study Cavity Conditioner (GC America (22° ± 1°C) and restorations were groups for enamel and dentin

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Chart. Mean scores of marginal leakage at enamel tooth structures and there is no need and dentin margins in study groups (n = 15). for dentin bonding agents prior to material placement.26 However, it 2.5 appears that the use of phosphoric acid and probably placing a small Enamel margin bevel at enamel margins is necessary 2 Dentin margin due to a 3% shrinkage of hybrid GI, resulting in significant microleakage 1.5 at enamel margins. If RMGI is to be photocured immediately after placement in the

Mean scores 1 cavity (similar to the placement and curing of composite resins), the results of this study indicate a 0.5 stronger acid-etching procedure is necessary, especially in the case of enamel substrate. This consideration 0 Group 1 Group 2 Group 3 Group 4 is especially clear when the results of Group 2 are taken into account: In the groups in which the material was treated in the same manner as margins. The mean scores of micro- The mean microleakage scores GI, the acid-base reaction might leakage are shown in the chart. in the control group for enamel have had the opportunity to pro- Group 2 demonstrated the lowest was 1.53, compared to 1.66 for ceed. RMGIs are hybrid versions of microleakage scores at both the dentin. GI cements form chemical GI cements; they are photocured enamel and dentin margins. The bonds with enamel and dentin; the because their chemical composition Kruskal-Wallis test did reveal signifi- amount of heat and material shrink- contains small quantities of resin cant differences in the integrity of age during setting is considered to components, such as HEMA or enamel margins (P = 0.036); how- be insignificant. An ion-enriched bisphenol A-glycidyl methacrylate ever, the integrity of dentin margins layer forms at the tooth structure- (BIS-GMA). In some cases, the did not increase significantly cement interface so that the cement polyacid of RMGIs has been modi- for any group (P = 0.122). The can establish a bond with both fied with side chains that can be Mann-Whitney U test revealed that enamel and dentin without microle- polymerized by light. Different the integrity of the enamel margin akage at the margins. RMGIs form manufacturers use slightly differ- increased significantly for Group 2, similar bonds with dentin in the ent formulations, but the amount while it decreased in Groups 3 and 4. same manner. Secondary ion mass of resin in the final restoration is spectrometry depth profiles have approximately 4.5-6%.25 Discussion exhibited the ion-exchanged process In the present study, the enamel In the present study, an RMGI between the photocured cement and samples of Group 2 demonstrated a was evaluated under two different the dentin surface. significant decrease in microleakage. conditions of warming the material RMGIs have the potential to form Delaying the photocuring procedure before mixing and delaying the direct bonds with resin composite. by 2 minutes allowed the material photocuring procedure. In both They produce a catalyst-rich, air- to undergo more acid-base reaction, experimental conditions, both inhibited layer that is polymerized preventing the rapid formation of enamel and dentin margins of the with the composite, rendering it polymer networks.23 The results cavity were treated using the cavity suitable for GI/composite laminate can be explained by the fact that conditioner of the material itself, restorations.2 Adhesion can be enamel is a highly mineralized tissue, which consisted of 20% polyacrylic increased by etching the enamel which is replete with hydroxyapatite acid and 3% aluminum chloride. with acid.2,24,25 McLean reported and calcium. Based on the results None of the cavity enamel margins that since RMGI contains HEMA, of the present study, the authors were beveled. it has the potential of adhering to believe that etching the enamel with

e386 November/December 2012 General Dentistry www.agd.org phosphoric acid and exposing the degree of conversion, reduced vis- detrimental effect on marginal adap- RMGI to a curing light can produce cosity, and improved marginal adaptation of the material contrary to a proper mechanical interlocking tation of the restoration.18 In the delaying the photocuring procedure. and lead to the formation of more present study, pre-warming RMGI Based on the results of the present resin tags with higher strengths. increased enamel and dentin margin study, pre-warming the RMGI is These conditions are ideal for microleakage. The material was not recommended. the dental practitioner in the oral heated for 90 seconds (up to 40°C) It has been assumed that environment, in which moisture based on a method used by O’Brien polymerization shrinkage results contamination is possible.6,12 et al.23 No previous study has ever in restoration margin defects, Similar results were observed evaluated the effect of RMGI leading to microleakage, margin with dentin samples in Group 2, pre-warming on microleakage. The discolorations, and tooth hypersen- where the mean microleakage scores literature has reported that pre- sitivity. Hygroscopic expansion can decreased from 1.66 to 1.26; warming composite resins increases compensate for the shrinkage to however, the differences with other linear shrinkage (due to an increase some extent.2 Absorption of water dentin groups were not statistically in the degree of polymerization); by RMGI produces an acid-base significant. It appears that as with however, pre-warming composite reaction, hygroscopic expansion, enamel, delaying the photocuring resin up to 60°C has no effect on and decreased cavity margin gaps.25 procedure has a positive effect on cavity microleakage.18-21 Previous studies have noted that the dentin; however, the histologic When the effects of pre-warming bond strength between RMGI and differences of dentin substrates on composite resin and RMGI are enamel or dentin increased at three- (including the nature of dentin, compared, the physical proper- and six-month intervals.28,29 the age of the teeth under study, ties and chemical composition and the type and quality of dentin) of the materials should be taken Conclusion influenced the results. Conversely, into account. Composite resins Under the limitations of the pres- it is probable that acid-etching the have a paste consistency that has ent study, enamel microleakage of dentin surface increased surface been established chemically by the cervical cavities restored with Fuji permeability, which accelerated and coupling agents between the fillers II LC RMGI decreases when pho- facilitated the acid-base reaction due and resin component. With encap- tocuring is delayed. Pre-warming to increased surface moisture.4 sulated RMGI, the powder and the the material before mixing has a When photocuring is delayed, liquid are kept separate from each detrimental effect on the restora- polymerization shrinkage due to other before mechanical mixing and tion’s marginal integrity. This immediate light activation is elimi- the chemical reaction is initiated observation might apply to dentin nated and a better marginal seal after mixing. It is likely that warm- margins as well; however, addi- is achieved. However, additional ing the material increases molecular tional studies are required to verify research is necessary to confirm movement, decreases working time, the results of this study. these results. accelerates the setting reaction, and In the present study, the overall increases the rate of poly-HEMA Author information microleakage at both enamel and formation, which deprives the oper- Dr. Khoroushi is an associate pro- dentin margins was relatively higher ator of the opportunity to properly fessor, Dental Materials Research than previous studies. The literature adapt the material to cavity walls.4 Center and Department of Opera- has reported that using more than In addition, the possibility for the tive Dentistry, School of Dentistry, one operator to place the restora- evaporation of HEMA increases Isfahan University of Medical Sci- tions may affect microleakage; by after injection into the cavity, ences, and editor-in-chief, Journal of contrast, one operator placed all the which results in a brittle restoration Isfahan Dental School, Isfahan, Iran. restorations under identical operat- with poor adaptation. Further, in Dr. Mansoori-Karvandi is a member ing conditions in the present study, Group 4, although noticeable, the of Department of Operative Den- which made it possible to compare deleterious effect of pre-warming on tistry, School of Dentistry, Isfahan the results of various groups.25,27 marginal integrity was less than that University of Medical Sciences, In 2006, Knight et al pre-heated in Group 3 due to a delay in the Isfahan, Iran, and Dr. Hadi is a den- resin composite before placing it photocuring procedure. Therefore, tist, Oral Health Center, Chadegan in the cavity, which improved the it seems that pre-warming has a branch, Isfahan, Iran.

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Acknowledgement 7. Daronch M, Rueggeberg FA, Moss L, de Goes composite on restoration microleakage. Oper The authors gratefully acknowl- MF. Clinically relevant issues related to preheat- Dent 2008;33(1):72-78. ing composites. J Esthet Restor Dent 2006; 20. Froes-Salgado NR, Silva LM, Kawano Y, Francci edge that this report is based on a 18(6):340-350. C, Reis A, Loguercio AD. Composite pre-heating: thesis submitted to the School of 8. Algera TJ, Kleverlaan CJ, de Gee AJ, Prahl-An- Effects on marginal adaptation, degree of con- Dentistry, Isfahan University of dersen B, Feilzer AJ. The influence of accelerat- version and mechanical properties. Dent Mater fi ing the setting rate by ultrasound or heat on the 2010;26(9):908-914. Medical Sciences, in partial ful ll- bond strength of glass ionomers used as ortho- 21. Deb S, Di Silvio L, Mackler HE, Millar BJ. Pre- ment of the requirement for DDS dontic bracket cements. Eur J Orthod 2005; warming of dental composites. Dent Mater degree. This study was financially 27(5):472-476. 2011;27(4):e51-e59. 9. Thomas JT, Roberts HW, Diaz L, Bradley TG, Ber- 22. Lohbauer U, Zinelis S, Rahiotis C, Petschelt A, supported and approved by Isfahan zins DW. Effect of light-cure initiation time on Eliades G. The effect of resin composite pre- University of Medical Sciences, polymerization efficiency and orthodontic bond heating on monomer conversion and polymer- Isfahan, Iran. strength with a resin-modified glass-ionomer. ization shrinkage. Dent Mater 2009;25(4): Orthod Craniofac Res 2012;15(2):124-134. 514-519. 10. Lawson NC, Cakir D, Beck P, Ramp L, Burgess 23. O’Brien T, Shoja-Assadi F, Lea SC, Burke FJ, Palin Disclaimer JO. Effect of light activation on resin-modified WM. Extrinsic energy sources affect hardness The authors declare that they have glass ionomer shear bond strength. Oper Dent through depth during set of a glass-ionomer fi 2012;37(4):380-385. cement. J Dent 2010;38(6):490-495. no individual, nancial, or other 11. Khoroushi M, Karvandi TM, Sadeghi R. Effect of 24. Cortes O, Garcia-Godoy F, Boj JR. Bond strength personal interests of any nature or prewarming and/or delayed light activation on of resin-reinforced glass ionomer cements after kind in any commercial product resin-modified glass ionomer bond strength to enamel etching. Am J Dent 1993;6(6):299-301. tooth structures. Oper Dent 2012;37(1):54-62. 25. Toledano M, Osorio E, Osorio R, García-Godoy F. and/or company that is presented in 12. Yelamanchili A, Darvell BW. Network competi- Microleakage of Class V resin-modified glass this article. tion in a resin-modified glass-ionomer cement. ionomer and compomer restorations. J Prosthet Dent Mater 2008;24(8):1065-1069. Dent 1999;81(5):610-615. 13. Rueggeberg FA, Daronch M, Browning WD, De 26. McLean JW. The clinical use of glass-ionomer References Goes MF. In vivo temperature measurement: cements. Dent Clin North Am 1992;36(3):693- 1. Wilson AD, Kent BE. A new translucent cement Tooth preparation and restoration with preheat- 711. for dentistry. The glass ionomer cement. Br Dent ed resin composite. J Esthet Restor Dent 2010; 27. Tulunoglu O, Uctash M, Alacam A, Omurlu H. J 1972;132(4):133-135. 22(5):314-322. Microleakage of light-cured resin and resin- 2. Hse KM, Leung SK, Wei SH. Resin-ionomer re- 14. Hacioglu B, Berchtold KA, Lovell LG, Nie J, Bow- modified glass-ionomer dentin bonding agents storative materials for children: A review. Aust man CN. Polymerization kinetics of HEMA/DE- applied with co-cure vs. pre-cure technique. Op- Dent J 1999;44(1):1-11. GDMA: Using changes in initiation and chain er Dent 2000;25(4):292-298. 3. Mitra SB, Lee CY, Bui HT, Tantbirojn D, Rusin RP. transfer rates to explore the effects of chain- 28. Mitra SB. Adhesion to dentin and physical prop- Long-term adhesion and mechanism of bonding length-dependent termination. Biomaterials erties of a light-cured glass-ionomer liner/base. of a paste-liquid resin-modified glass-ionomer. 2002;23(20):4057-4064. J Dent Res 1991;70(1):72-74. Dent Mater 2009;25(4):459-466. 15. Trujillo M, Newman SM, Stansbury JW. Use of 29. Fritz UB, Finger WJ, Uno S. Resin-modified glass 4. Tonegawa M, Yasuda G, Chikako T, Tamura Y, near-IR to monitor the influence of external ionomer cements: Bonding to enamel and den- Yoshida T, Kurokawa H, Miyazaki M. Influence of heating on dental composite photopolymeriza- tin. Dent Mater 1996;12(3):161-166. power density on the setting behaviour of light- tion. Dent Mater 2004;20(8):766-777. cured glass-ionomer cements monitored by ul- 16. Daronch M, Rueggeberg FA, De Goes MF. Manufacturers trasound measurements. J Dent 2009;37(7): Monomer conversion of pre-heated composite. 535-540. Coltene/Whaledent, Inc., Cuyahoga Falls, OH J Dent Res 2005;84(7):663-667. 330.916.8800, www.coltenewhaledent.com 5. Cardoso MV, Delme KI, Mine A, Neves Ade A, 17. Lucey S, Lynch CD, Ray NJ, Burke FM, Hannigan Coutinho E, De Moor RJ, Van Meerbeek B. To- A. Effect of pre-heating on the viscosity and GC America, Inc., Alsip, IL wards a better understanding of the adhesion microhardness of a resin composite. J Oral Re- 800.323.7063, www.gcamerica.com mechanism of resin-modified glass-ionomers by habil 2010;37(4):278-282. IBM, Armonk, NY bonding to differently prepared dentin. J Dent 18. Knight JS, Fraughn R, Norrington D. Effect of 800.426.4968, www.ibm.com 2010;38(11):921-929. temperature on the flow properties of resin Kerr Dental, Orange, CA 6. Berzins DW, Abey S, Costache MC, Wilkie CA, composite. Gen Dent 2006;54(1):14-16. 800.537.7123, www.kerrdental.com Roberts HW. Resin-modified glass-ionomer set- 19. Wagner WC, Aksu MN, Neme AM, Linger JB, 3M ESPE, St. Paul, MN ting reaction competition. J Dent Res 2010; Pink FE, Walker S. Effect of pre-heating resin 89(1):82-86. 888.364.3577, solutions.3m.com

e388 November/December 2012 General Dentistry www.agd.org Endodontics

Open apex Type III dens invaginatus: A rare case report of an endodontic retreatment with an anatomical redesign

Emmanuel Joao Nogueira Leal Da Silva, DDS, MSc n Alexandre Augusto Zaia, DDS, MSc, PhD

Dens invaginatus is a critical condition for endodontic treatment. months, at which point the anatomical features in the root canal It frequently presents a complex internal anatomy and might be system could be accessed. Adequate periradicular healing was associated with incomplete root and apical development. This observed and regression of the lesion was noted at the two-year article presents one of the few reported cases of endodontic follow-up. This case reinforces the idea that knowledge about retreatment of Type III dens invaginatus. First, the internal anato- the biologic aspects of endodontics, combined with adherence my was modiﬁed using burs under an operating microscope. to technical standards, is helpful in resolving complex cases. Next, conventional chemical and mechanical preparation with Received: June 24, 2011 hand ﬁles and 2.5% sodium hypochlorite was performed. Finally, Accepted: October 3, 2011 an intracanal dressing with calcium hydroxide was used for nine

ens invaginatus (DI) is a commonly accepted classification labiolingual or mesiobuccal diam- developmental anomaly created by Oehlers, who described eter, peg-shaped, barrel-shaped, and Dresulting from invagination of the following three types of DI for conical.13 Dental treatment is often enamel organ into the dental papilla, anterior teeth: required because the invagination beginning at the crown and some- t5ZQF*oinvagination confined allows the access of irritants into the times extending into the root before within the crown; pulp space or into an area connected calcification occurs.1,2 Incomplete t5ZQF**o invagination invading to the periradicular tissues.14 The lateral fusion of two germs has been the root as a blind sac, with pos- literature has reported various tech- described as one of several theories sible connection to the dental niques for the treatment of teeth that explains the morphogenesis pulp; and with DI, including nonsurgical root of invaginated teeth.3 DI seems to t5ZQF***oinvagination penetrat- canal therapy, endodontic surgery, be an appropriate nomenclature, ing through the root to open in and extraction.15,16 because it reflects the infolding of the apical region.10 In the present case, an immature the outer portion (enamel) into the In Type III DI, any infection maxillary lateral incisor was discov- inner portion (dentin), with the within the invagination can lead to ered to have Type III DI associated formation of a pocket space.2 an inflammatory response within with a periradicular lesion and a The incidence of this anomaly is the periodontal tissues, giving rise to normal clinical crown. Endodontic reported to range from 0.04% to a peri-invagination periodontitis.11 retreatment was performed to 10.00%.4 It commonly occurs in Radiographically, DI shows a radi- achieve resolution of a substantial permanent maxillary lateral inci- opaque invagination similar in den- periradicular lesion and apexification. sors, followed by maxillary central sity to dental enamel and extending incisors, premolars, canines, and from the cingulum into the root Case report less often, molars.2,5,6 Occurring in canal. It can be identified easily A 15-year-old girl with no general 43% of all cases, bilateral presence because infolding of the enamel health prob lems was referred by her is common.7 Permanent teeth are lining is more radiopaque than the dentist for the retreatment of her usually involved; however, there are surrounding tooth structure.12 The maxillary left lateral incisor. The reports of this anomaly occurring in clinical appearance of the crown can patient reported that the tooth had primary teeth.8,9 DI can be classified vary, ranging from a normal form to been treated with root canal therapy according to severity, with the most more unusual forms such as greater 18 months earlier. The patient

www.agd.org General Dentistry November/December 2012 e389 Endodontics Open apex Type III dens invaginatus: Endodontic retreatment with an anatomical redesign

Fig. 2. Radiograph after anatomical redesign Fig. 3. Radiograph showing the apical closure Fig. 1. Initial radiograph. and insertion of calcium hydroxide paste. after nine months.

Fig. 5. Radiograph after lateral condensation Fig. 4. Radiograph showing inverted master and vertical condensation with warmed gutta-percha cone positioned in the canal. carriers. Fig. 6. Two-year follow-up radiograph.

complained of painful swelling on complex canal anatomy with a Type unilateral. The patient was informed the mucosa over the maxillary left III DI. Periradicular radiolucency of the diagnosis and the need for anterior teeth. Clinically, the tooth was evident around the root apex. root canal retreatment. was hypersensitive to percussion and The previous endodontic treat- After local anesthesia using palpation, the soft tissues around ment had been performed only in 2% lidocaine with 1:100,000 the tooth were free of pathologic the invagination and was insuf- epinephrine was administered, the signs, and there was a large com- ficient to remedy the condition cavity was accessed using diamond posite filling on the lingual surface. (Fig. 1). Radiographic examination burs in high-speed rotation in an Radiographic examination revealed of the patient’s contralateral teeth attempt to reach the root canal. A a large periapical radiolucency and confirmed that the condition was rubber dam was placed and all of

e390 November/December 2012 General Dentistry www.agd.org the gutta-percha and sealer were the oral cavity. As a result, it is apical formation and achieve dis- removed. In light of the complex- common for the affected tooth infection of canals, which has been ity of the internal anatomy and to require endodontic treatment, reported as a successful approach the challenges it presented for which often is complicated due in the literature. 6,22,23,24 Apical the cleaning and sealing of the to the complex anatomy of teeth closure took nine months in the individual canal spaces, it was with DI. Endodontic treatment of current case, but that time period decided to remove the central teeth with a Type III DI associ- can range from 6 to 14 months.5,21 dentinal core and create a single ated with apical pathosis generally The two-year follow-up radiograph canal space. Under magnification involves complicated procedures demonstrated normal periradicular and illumination, the root invagina- that require accurate diagnosis and bone structure and continued tion was removed using a spherical appropriate treatment planning.18 apical development. diamond bur. Next, the root canal The invagination frequently com- There is no consensus on a post- was prepared using Gates-Glidden municates with the oral cavity, treatment follow-up period for DI burs and manual endodontic files. allowing the penetration of irritants and open apex in the literature; it A 2.5% sodium hypochlorite solu- and microorganisms either directly can range from four months to six tion was used for irrigation and into the pulp tissues or into an area years.5,15 Favorable tissue healing renewed at each change of instru- separated from the pulp by a thin responses have been observed for ment. Following chemomechanical layer of enamel or dentin. For this the treatment of DI in maxillary preparation, the root canal was reason, early diagnosis is critical to lateral incisors, even after long peri- dried with sterile paper points and prevent pulp necrosis and periapical ods of evaluation. All efforts must dressed with a calcium hydroxide inflammation.10,11,15 be made to obtain an adequate paste, which was replaced monthly Few cases of endodontic retreat- apical seal with obturation or to induce apexification (Fig. 2). ment of DI have been described retrofilling, complemented by the Coronal restoration was com- in the literature.19,20 The clinical placement of a definitive coronal pleted with glass ionomer cement. appearance of DI varies consider- restoration to avoid reinfection of After nine months, a radiograph ably. The crowns of affected teeth the root canal system.25 showed apical closure (Fig. 3). can have either normal morphology Obturation was performed using or abnormal forms.6 In the present Summary Sealapex (SybronEndo Corporation) case, the crown had a conoid mor- A lack of knowledge about possible and an inverted master gutta-percha phology. Careful radiographic evalu- root canal anatomical configurations cone, with lateral condensation ation can lead to identification of can be a disadvantage for dentists, followed by additional vertical abnormal anatomical conditions.13 resulting in unsuccessful endodontic condensation with warmed carriers The current case demonstrated treatment outcomes. The present (Fig. 4 and 5).17 At that point, it was that anatomical difficulties can case report showed the importance evident that periapical healing was lead to endodontic failure and the of a correct diagnosis for successful almost complete. development of periapical pathology endodontic treatment. Nonsurgical The patient returned for clinical requiring endodontic retreatment. root canal retreatment of DI proved and radio graphic examinations at Due to the complexity of the root successful in promoting the healing six months and two years following canal system, access cavity prepara- of an associated periradicular lesion. endodontic retreatment. At the tion and all endodontic treatment two-year follow-up, the patient was done under an operating Author information was asymptomatic and reported microscope. Dr. Silva is a postgraduate student, no postoperative pain. A periapi- The treatment of a tooth with University of Campinas (UNI- cal radiograph revealed complete Type III DI, an immature apex, CAMP), Piracicaba, Sao Paulo, periapical healing around the root and an associated large periradicu- Brazil, where Dr. Zaia is a professor, end (Fig. 6). lar lesion is usually complicated.5 Department of Endodontics. Surgical treatment is indicated Discussion only when nonsurgical root canal References DI is an anomaly of dental devel- treatment has failed.3,5,21 In the 1. Lindner C, Messer HH, Tyas MJ. A complex treatment of dens invaginatus. Endod Dent Trauma- opment that could precipitate a current case, the authors used tol 1995;11(3):153–155. connection of the pulp space with calcium hydroxide to induce an

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2. Alani A, Bishop K. Dens invaginatus: Part 1: 16. Jung M. Endodontic treatment of dens invagina- AGDPODCAST Classification, prevalence and aetiology. Int En- tus type III with three root canals and open api- Endodontics dod J 2008;41(12):1123-1136. cal foramen. Int Endod J 2004;37(3):205-213. 3. Ortiz P, Weisleder R, Villareal de Justus Y. 17. Wu MK, de Groot SD, van der Sluis LW, Wesse- Combined therapy in the treatment of dens link PR. The effect of using an inverted master invaginatus: Case report. J Endod 2004;30(9): cone in a lateral compaction technique on the 672-674. density of the gutta-percha fill. Oral Surg Oral 4. Hovland EJ, Block RM. Nonrecognition and sub- Med Oral Pathol Oral Radiol Endod 2003;96(3): sequent endodontic treatment of dens invagina- 345-350. tus. J Endod 1977;3(9):360-362. 18. Sigrist De Martin A, da Silveira Bueno CE, Sand- 5. Pai SF, Yang SF, Lin LM. Nonsurgical endodontic hes Cunha R, Aranha de Araujo R, Fernandes de treatment of dens invaginatus with large perira- Magalhaes Silveira C. Endodontic treatment of dicular lesion: A case report. J Endod 2004; dens invaginatus with a periradicular lesion: A 30(8):597-600. case report. Aust Endod J 2005;31(3):123-125. 6. Tarjan I, Rozsa N. Endodontic treatment of im- 19. Evans DJ, Reid JS. Dens invaginatus: An avoid- mature tooth with dens invaginatus: A case re- able complication. Int J Paediatr Dent 1995; port. Int J Paediatr Dent 1999;9(1):53-56. 5(4):263-264. 7. Grahnen H, Lindahl B, Omnell K. Dens invagina- 20. Silberman A, Cohenca N, Simon JH. Anatomical tus, I: A clinical, roentgenological and genetical redesign for the treatment of dens invaginatus study of permanent upper lateral incisors. Odon- type III with open apexes: A literature review tol Rev 1959;10:115-137. and case presentation. J Am Dent Assoc 2006; 8. Eden EK, Koca H, Sen BH. Dens invaginatus in a 137(2):180-185 primary molar: Report of case. ASDC J Dent 21. Subay RK, Kayatas M. Dens invaginatus in an Child 2002;69(1):49-53. immature maxillary lateral incisor: A case report 9. Holan G. Dens invaginatus in a primary canine: of complex endodontic treatment. Oral Surg A case report. Int J Paediatr Dent 1998;8(1):61- Oral Med Oral Pathol Oral Radiol Endod 2006; 64. 102(2):e37-e41. 10. Oehlers FA. Dens invaginatus (dilated composite 22. Schmitz MS, Montagner F, Flores CB, Morari VH, odontome). I. Variations of the invagination pro- Quesada GA, Gomes BP. Management of dens cess and associated anterior crown forms. Oral invaginatus type I and open apex: Report of Surg Oral Med Oral Pathol 1957;10(11):1204- three cases. J Endod 2010;36(6):1079-1085. 1218. 23. Sathorn C, Parashos P. Contemporary treatment 11. Bishop K, Alani A. Dens invaginatus. Part 2: of class II dens invaginatus. Int Endod J 2007; Clinical, radiographic features and management 40(4):308-316. options. Int Endod J 2008;41(12):1137-1154. 24. Chamberlain TM, Kirkpatrick TC, Rutledge RE. 12. Gotoh T, Kawahara K, Imai K, Kishi K, Fujiki Y. pH changes in external root surface cavities af- Clinical and radiographic study of dens invagi- ter calcium hydroxide is placed at 1, 3 and 5 natus. Oral Surg Oral Med Oral Pathol 1979; mm short of the radiographic apex. Dent Trau- 48(1):88-91. matol 2009;25(5):470-474. 13. Keles A, Cakici F. Endodontic treatment of a 25. Hommez GM, Coppens CR, De Moor RJ. Periapi- maxillary lateral incisor with vital pulp, perira- cal health related to the quality of coronal res- dicular lesion and type III dens invaginatus: A torations and root fillings. Int Endod J 2002; case report. Int Endod J 2010;43(7):608-614. 35(8):680-689. 14. Kulild JC, Weller RN. Treatment considerations in dens invaginatus. J Endod 1989;15(8):381-384. Manufacturers 15. Nallapati S. Clinical management of a maxillary SybronEndo Corporation, Orange, CA lateral incisor with vital pulp and type 3 dens in- 800.346.3636, www.sybronendo.com vaginatus: A case report. J Endod 2004;30(10): 726-731.

e392 November/December 2012 General Dentistry www.agd.org Dental Materials

Microhardness and sealing ability of materials used for root canal perforations

Carlos H.R. Camargo, MSc, PhD n Manuela B. Fonseca n Alessandra S. Carvalho, MSc, PhD Samira E. Camargo, MSc, PhD n Flavia G. Cardoso, MSc n Marcia C. Valera, MSc, PhD

Root perforations may lead to a loss of integrity in the root and assessed; microleakage data were submitted to analysis of periodontium, violations of the biologic periodontal distance, and variance (ANOVA) testing, while microhardness data were injuries to periodontal tissue. This study sought to analyze the submitted to Dunnet and Tukey tests (p < 0.05). Group 4 reported effect of root canal biomechanical preparation on the microhard- the lowest amount of microleakage (0.65 mm), followed by ness and the marginal sealing ability of different materials used Group 3 (1.02 mm), Group 1 (1.14 mm), and Group 2 (1.30 to treat root perforations. Standard root perforations were mm); however, no difference was detected among the groups. performed in 96 bovine incisors. The teeth were divided into four Groups 1-3 demonstrated signiﬁcantly higher microhardness groups (n = 24) based on the material used to treat those teeth: values compared to COB. It was concluded that the chemical and Mineral trioxide aggregate (MTA) (Group 1), MTA protected with mechanical agents used during root canal preparation did not cyanoacrylate (Group 2), MTA protected with glass ionomer (GI) affect the sealing procedures. Administering surface protection to cement (Group 3), and castor oil bean (COB) cement (Group 4). MTA did not improve microhardness or sealing. After root perforations were closed, the root canals were Received: August 29, 2011 prepared biomechanically and teeth were sectioned longitudinally. Accepted: November 8, 2011 Microleakage and microhardness of sealed perforations were

oot perforations may occur Materials such as mineral trioxide as apexification).3,13-16 However, due to pathological processes, aggregate (MTA) and castor oil MTA has no adhesive properties; Rsuch as external and internal bean (COB) cement have been used as a result, its use in treating non- root resorption; caries lesion; iatro- for sealing perforations while avoid- retentive cavities is limited. genic reasons, including excessive ing contamination and promoting COB has excellent structural or improperly performed crown tissue repair.2-5 properties; it is available at a low openings; post and core procedures; MTA cement contains hydro- cost, offering adequate adhesion or root canal preparations. In all philic particles that produce a and biocompatibility to living con- cases, root perforations may result colloidal gel upon contact with nective tissues, without releasing in loss of integrity in the root and water; this gel eventually solidifies toxic substances or radicals within periodontium, violation of the into a hard structure, which causes prepared cavities.17,18 COB can be biologic periodontal distance, and the material to expand, promoting used clinically for prosthesis fixa- injuries to the periodontal tissue due adequate marginal sealing.6-9 In tion, reconstitution of bone defects, to inflammation and infection. Root addition, MTA shows excellent and orthopedic procedures.5,19-22 In perforations that allow root canals biocompatibility and induces hard dentistry, COB cement has been and micro-organisms direct contact tissue barrier formation at pulp used as a root end restoration mate- through the gingival sulcus or root exposure sites.10,11 Its ability to set rial for apicoectomies; it is consid- canal can lead to secondary infection in less than ideal conditions (for ered an excellent candidate for root at the involved areas, epithelium example, in the presence of blood canal restorations.5,23,24 migration, and destruction of adja- and water) has been chronicled.11,12 Additional studies are needed to cent bone.1 The prognosis of per- MTA has been used clinically as determine proper clinical protocols forations depends on size, location a retrofilling material and also for which sealing materials can be (apical and middle thirds present is indicated as an apical barrier used to seal endodontic perfora- better prognoses), and if contamina- for treating open apices and tions. The clinical use of irrigating tion by micro-organisms exists. necrotic pulps (the process known solutions during biomechanical

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preparation might chemically This procedure was standardized Microleakage test influence some characteristics of the using a modified microscope. Large One root was taken from each sub- sealing materials and also the end- gutta-percha points were inserted group and used as a positive control odontic files can displace the sealing into the root canals to seal the (totally sealed) while another root material. According to Lee et al, the access between the perforation and from each subgroup was used as a use of ethylenediaminetetraacetic the root canal. The specimens were negative control (not sealed). For acid (EDTA) affected the hydration divided into four groups (n = 24) each subgroup, the surfaces of the process of MTA, decreasing micro- according to the material used. buccal root hemi-sections were iso- hardness and biocompatibility.9 Group 1 samples were treated with lated with two layers of nail polish, Determining the best time to MTA (MTA-Angelus Industria de leaving a standardized exposed seal a root perforation can be a Produtos Odontologicos). Group buccal area (2 mm). challenge. Sealing perforations 2 samples were treated with MTA The dye solution was prepared by prior to root canal preparation protected with cyanoacrylate dissolving 2 g of rhodamine into may lead to removal of the sealing (Loctite Super Bonder 3G, Henkel 100 mL of water. All specimens material. One might expect that Corporation). Loctite Super Bonder were immersed into a 2% buffer if root perforations previously 3G was applied over the surface rhodamine solution for a period of sealed with MTA or COB undergo of the sealing material inside the 24 hours, and rinsed for 12 hours biomechanical preparation, the root canal, using a microbrush in running water. Specimens were sealing material may be affected by (Microbrush International). Group sectioned with steel discs in dry the action of the endodontic instru- 3 samples were treated using MTA conditions to prevent dye from ments and irrigating solutions. protected with glass ionomer (GI) penetrating into dentin or the The experimental hypothesis cement (Vidrion R, SS White Burs restorative material at the central of the study asserted that surface Inc.), while Group 4 samples were portion of perforation. Microleak- protection materials used for sealing treated with COB cement (Poliquil age was assessed at the tooth-resto- perforations would improve the Araraquara Polimeros Quimicos), ration interface on the internal wall microhardness and microleakage which was placed in the perforation surface of the root. Data were ana- in comparison to non-protected area using a No. 7 wax spatula (SS lyzed by two calibrated evaluators materials. This study simulated root White Burs Inc.). using stereomicroscopy (STEMI perforations and performed biome- Roots were maintained at 37°C 2000, Carl Zeiss Microscopy) at chanical preparation to evaluate the (±10°C) and 100% humidity for 20X magnification at different microleakage and microhardness 24 hours after perforations were periods. Data were recorded (mm) of COB and MTA (on its own and sealed. Root canals were prepared for further evaluation. with surface protection). up to Kerr file #50 (Dentsply Maillefer) followed by step-back Microhardness evaluation Materials and methods technique up to Kerr file #80 Forty buccal hemi-sections (10 from Ninety-six bovine lateral incisors (Dentsply Maillefer) by anatomic each group) were embedded in resin were used. The teeth were cleaned, diameter to the coronal direction. blocks, so that only the external root stored in saline solution (Glico- Roots were irrigated with 3 mL of surfaces were exposed. The exter- labor Industria Farmaceutica), 2.5% NaOCl solution (Bioformula nal surface of the specimens was and frozen prior to the testing Farmacia de Manipulacao) at each polished with silicon carbide sand- procedures. Using double-sided change of instrument, with final papers of 80 grit, 320 grit, 600 grit, diamond discs, the crowns were irrigation performed with 2 mL 800 grit, and 1200 grit (Norton, sectioned 3 mm apically from the sterile saline solution. Following Saint-Gobain Abrasives). Final pol- cemento-enamel junction (CEJ). root canal preparation, all roots ishing was performed with polishing The complete removal of the pulp were sectioned longitudinally; the paste and felt discs. Microhardness tissue was performed with No. buccal hemi-section containing the was assessed (using the indenta- 50 Hedstroen files (Dentsply perforation was used for this study. tion technique) with a Vickers Maillefer). Root perforations were The specimens of each group were microhardness tester (Digital Micro- performed 3 mm below the CEJ subdivided into two groups (n = 12) hardness Tester DL200 FM-ARS, at the buccal surface using a No. to assess microleakage and micro- Future-Tech) under a load of 50 20-94 diamond bur (KG Sorensen). hardness values. kgf for 10 seconds, according to the

e394 November/December 2012 General Dentistry www.agd.org manufacturer’s instructions. Eighty- Chart 1. Graphical representations of microleakage eight data points were obtained values (mm), for each experimental condition. for both investigated variables 3.0 (microleakage and microhardness). Data were submitted to ANOVA and Dunnet’s tests (P < 0.05), using 2.5 Minitab (Version 14.12, Minitab) and STATISTICA (Version 5.5, 2.0 StatSoft Inc.) softwares. 1.5 mm Results Th e microleakage values for the 1.0 COB specimens (Group 4) did ff fi not di er signi cantly from the 0.5 protected MTA specimens in Groups 2 and 3 (P = 0.7466) 0 (Chart 1). In terms of microhard- MTA MTA+C MTA+GI COB fi ff ness values, signi cant di erences Group were observed among the tested materials; Groups 1-3 demonstrated higher microhardness values than Group 4 (Chart 2). The microhard- Chart 2. Graphical representations of microhardness ness values in Group 1 were similar values (mm), for each experimental condition. to those in Groups 2 and 3, showing that there were no differences regard- 140 ing surface protection (P = 0.8937). 120 No sealing material was displaced from any specimen at any time. 100

Discussion 80 To the authors’ knowledge, there are HV no published reports in the litera- 60 ture that have assessed microleakage and microhardness of a filled perfo- 40 ration to determine how mechanical instrumentation and chemical 20 irrigating solutions affect the MTA or tooth interface. 0 MTA+GI MTA+C MTA COB It is common sense that high-qual- Group ity sealing should be an important target to avoid microleakage between sealing materials and dental tissues. Based on the recommendation by The authors are unaware of any treatment. However, Hardy et al Lamb et al, materials used in the previously published reports in the used a microleakage fluid test to present study for quality seal of a per- literature regarding the need to determine perforations in the area foration were placed in thicknesses use MTA to protect the surfaces of of the molar furcation sealed using of at least 3 mm.25 MTA in clinical areas that would come into contact MTA protected with one of two applications, such as sealing root with chemical agents (for example, bonding agents.26 The results showed perforations, is reported to undergo irrigating solutions) and mechani- higher MTA (Group 1) displace- dissolution and misplacement if cal instrumentation (for example, ment compared to the other groups: surface protection is not provided.25 endodontic files) during endodontic MTA protected with cyanoacrylate

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COB cement requires a skilled Table 1. Mean values (mm) of Table 2. Mean values (HV) of operator, as it sets in a short time microleakage. microhardness. (1 minute); as a result, it should be mixed constantly during handling Group Mean value Group Mean value to avoid setting prematurely. When used within the ideal setting 1 (MTA) 1.143 1 (MTA) 94.69 time, this material can be placed 2 (MTA + C) 1.302 2 (MTA + C) 92.25 easily into perforations or cavities. 3 (MTA + GI) 1.029 3 (MTA + GI) 97.68 However, during its setting time, 4 (COB) 0.652 4 (COB) 8.48 the incorporation of voids increases volume and causes material overflow to internal and external areas, which interferes with laboratory tests of (Group 2), MTA protected with GI of a tester under a 50 kgf load for this fast-drying cement. The lowest cement (Group 3), and COB cement 10 seconds. Different load values— microhardness value (8.48 HV) (Group 4). The higher displacement 100 g for 30 seconds and 98.07 mN observed for COB cement might be is due to MTA’s low adhesive prop- for 6 seconds—are also reported in due to air incorporation during set- erty in comparison to One-Up Bond the literature.27,28 The present study ting time, to small amounts of hard (Tokuyama Corporation) or to the evaluated three measurements to particles, or to its flexibility. association of both materials. assess each specimen, compared An ideal material for root canal In the present study, microleakage to other studies that utilized five perforations would include the testing was performed for all groups indentation measurements.27,28 The adhesive properties of COB and (through dye penetration) with no present study employed 10 speci- the microhardness associated with significant differences between the mens per group. MTA. Additional studies are needed four groups (Table 1). The microhardness of cements to certify the minimum MTA thick- According to Leite & Ramalho, depends on their components, the ness needed for maximum retention COB cement is a proven biocompat- particles’ characteristics, the powder/ and to analyze the dimensional ible material, a mixture of fatty acid liquid ratio, and the amount of alterations of COB and MTA when and diphenylmethane diisocyanate, incorporated air. The amount of used for endodontic perforations. and thus not recognized by the tis- potassium can also improve the sues as antigens.20 Camargo et al used hardness of materials, leading to the Conclusions a kristal violet test in human pulp assumption that an MTA structure MTA and COB fillings were not fibroblasts and detected no cyto- might be harder, as detected in the affected by chemical or mechanical toxicity; in addition, no genotoxic present study (the MTA-Angelus agents, suggesting that these materi- activities were detected when using has potassium, while ProRoot MTA als can be used as root perforation the micronuclei test in V79 fibro- does not) (ProRoot, Dentsply Ltd.). sealants. No significant differences blasts.17 Moreover, COB could be a Studies have reported that MTA in microhardness and microleakage promising option for several dental cement might exhibit negative were detected between unprotected procedures, such as retrofilling mate- microhardness changes at a low MTA and MTA with surface protec- rial, as endodontic cement and in pH, which can be observed during tion. Although voids were detected root perforation.5 Despite its porous tissue inflammation.3,28 However, all in the structure of COB, it had surface (which is due to air incor- inflammatory processes should be excellent sealing properties and low poration detected during the setting treated before use of MTA. microhardness values. Additional phase), the lowest microleakage In the present study, Group 1 studies are needed to investigate values observed for the COB group demonstrated a microhardness COB’s long-term sealing properties were not statistically significant, sug- mean value of 94.69 HV, a value when treating root perforations. gesting that COB’s high sealing qual- that is greater than reported dentin ity is due to its adhesive property. values (70 HV) (Table 2).29 By Author information In the present study, the indenta- contrast, a 2006 study by Danesh Dr. C. Camargo is an associate pro- tion technique was used and micro- et al reported a microhardness value fessor, Department of Restorative hardness was recorded by means 39.99 HV for MTA.27 Dentistry and Endodontics, Sao

e396 November/December 2012 General Dentistry www.agd.org Jose dos Campos Dental School, 12. Mitchell PJ, Pitt Ford TR, Torabinejad M, McDon- 26. Hardy I, Liewehr FR, Joyce AP, Agee K, Pashley Sao Paulo, Brazil. Dr. S. Camargo ald F. Osteoblast biocompatibility of mineral tri- DH. Sealing ability of One-Up Bond and MTA oxide aggregate. Biomaterials 1999;20(2): with and without a secondary seal as furcation is a professor, Department of 167-173. perforation repair materials. J Endod 2004; Biosciences, where Ms. Cardoso 13. Torabinejad M, Watson TF, Pitt Ford TR. Sealing 30(9):658-661. and Ms. Carvalho are postgraduate ability of a mineral trioxide aggregate when 27. Danesh G, Dammaschke T, Gerth HU, Zandbi- used as a root end filling material. J Endod glari T, Schafer E. A comparative study of select- students in the PhD program, Ms. 1993;19(12):591-595. ed properties of ProRoot mineral trioxide Fonseca is a postgraduate student in 14. Aqrabawi J. Sealing ability of amalgam, super aggregate and two Portland cements. Int Endod the MSc program, and Dr. Valera is EBA cement, and MTA when used as retrograde J 2006;39(3):213-219. filling materials. Br Dent J 2000;188(5):266- 28. Lee YL, Lee BS, Lin FH, Yun Lin A, Lan WH, Lin a full professor. 268. CP. Effects of physiological environments on the 15. Shabahang S, Torabinejad M. Treatment of teeth hydration behavior of mineral trioxide aggre- References with open apices using mineral trioxide aggregate. Biomaterials 2004;25(5):787-793. 1. Nakata TT, Bae KS, Baumgartner JC. Perforation gate. Pract Periodontics Aesthet Dent 2000; 29. Ryge G FD, Fairhurst CW. Microindentation repair comparing mineral trioxide aggregate 12(3):315-320; quiz 22. hardness. J Dent Res 1961;40:1116–1126. and amalgam using an anaerobic bacterial leak- 16. Witherspoon DE, Ham K. One-visit apexification: age model. J Endod 1998;24(3):184-186. Technique for inducing root-end barrier forma- Manufacturers 2. Ford TR, Torabinejad M, McHenry DJ, Hong CU, tion in apical closures. Pract Proced Aesthet Angelus Industria de Produtos Odontologicos S/A, Kariyawasam SP. Use of mineral trioxide aggre- Dent 2001;13(6):455-460; quiz 62. Londrina, Brazil gate for repair of furcal perforations. Oral Surg 17. Camargo SE, Camargo CH, Hiller KA, Rode SM, 55.43.2101.3200, www.angelus.ind.br Schweikl H, Schmalz G. Cytotoxicity and geno- Oral Med Oral Pathol Oral Radiol Endod 1995; Bioformula Farmacia de Manipulacao, 79(6):756-763. toxicity of pulp capping materials in two cell lines. Int Endod J 2009;42(3):227-237. Sao Jose dos Campos, Brazil 3. Namazikhah MS, Nekoofar MH, Sheykhrezae 55.11.2065.6936, www.bioformula.com.br MS, Salariyeh S, Hayes SJ, Bryant ST, Mohamma- 18. Camargo SE, Rode Sde M, do Prado RF, Carval- Carl Zeiss Microscopy, Dublin, CA di MM, Dummer PM. The effect of pH on surface ho YR, Camargo CH. Subcutaneous tissue reac- 800.442.4020, www.zeiss.com hardness and microstructure of mineral trioxide tion to castor oil bean and calcium hydroxide in aggregate. Int Endod J 2008;41(2):108-116. rats. J Appl Oral Sci 2010;18(3):273-288. Dentsply Ltd., Surrey, England 4. Rosa PC, Mancini MN, Camargo SE, Garrido AD, 19. Laureano Filho JR, Andrade ES, Albergaria-Bar- 44.1932.853422, www.dentsplymea.com Camargo CH, Rode Sde M. Dimensional altera- bosa JR, Camargo IB, Garcia RR. Effects of de- Dentsply Maillefer, Tulsa, OK tions and solubility of new endodontic sealers. mineralized bone matrix and a ‘Ricinus 800.924.7393, www.maillefer.com communis’ polymer on bone regeneration: A Braz Dent J 2010;21(4):301-304. Glicolabor Industria Farmaceutica, 5. de Martins GR, Carvalho CA, Valera MC, de histological study in rabbit calvaria. J Oral Sci 2009;51(3):451-456. Ribeirão Preto, Brazil Oliveira LD, Buso L, Carvalho AS. Sealing ability 55.16.3512.4900, No website of castor oil polymer as a root-end filling mate- 20. Leite FR, Ramalho LT. Bone regeneration after rial. J Appl Oral Sci 2009;17(3):220-223. demineralized bone matrix and castor oil (Rici- Future-Tech, Kanagawa Prefecture, Japan 6. Aminoshariae A, Hartwell GR, Moon PC. Place- nus communis) polyurethane implantation. 81.44.270.5789, www.ft-hardness.com ment of mineral trioxide aggregate using two J Appl Oral Sci 2008;16(2):122-126. Henkel Corporation, Rocky Hill, CT different techniques. J Endod 2003;29(10):679- 21. Fukushima H, Hashimoto Y, Yoshiya S, Kurosaka 860.571.5100, www.henkelna.com M, Matsuda M, Kawamura S, Iwatsubo T. Con- 682. KG Sorensen, Sao Paulo, Brazil duction analysis of cement interface tempera- 7. Al-Hezaimi K, Naghshbandi J, Oglesby S, Simon 55.11.4777.1061, www.kgsorensen.com.br JH, Rotstein I. Human saliva penetration of root ture in total knee arthroplasty. Kobe J Med Sci Microbrush International, Grafton, WI canals obturated with two types of mineral tri- 2002;48(1-2):63-72. 262.375.4011, www.microbrush.com oxide aggregate cements. J Endod 2005;31(6): 22. Nussbaum DA, Gailloud P, Murphy K. The chem- 453-456. istry of acrylic bone cements and implications Minitab, State College, PA 8. Sarkar NK, Caicedo R, Ritwik P, Moiseyeva R, for clinical use in image-guided therapy. J Vasc 814.238.3280, www.minitab.com Kawashima I. Physicochemical basis of the bio- Interv Radiol 2004;15(2 Pt 1):121-126. Poliquil Araraquara Polimeros Quimicos, logic properties of mineral trioxide aggregate. 23. Camargo CH, Camargo SE, Valera MC, Hiller KA, Araraquara, Brazil J Endod 2005;31(2):97-100. Schmalz G, Schweikl H. The induction of cyto- 55.11.3846.9855, www.poliquil.com.br 9. Lee YL, Lin FH, Wang WH, Ritchie HH, Lan WH, toxicity, oxidative stress, and genotoxicity by root canal sealers in mammalian cells. Oral Surg Saint-Gobain Abrasives, Stephensville, TX Lin CP. Effects of EDTA on the hydration mecha- 254.918.2313, www.nortonabrasives.com nism of mineral trioxide aggregate. J Dent Res Oral Med Oral Pathol Oral Radiol Endod 2009; 2007;86(6):534-538. 108(6):952-960. SS White Burs Inc., Lakewood, NJ 10. Bargholz C. Perforation repair with mineral tri- 24. Souza EM, Wu MK, Shemesh H, Bonetti-Filho I, 732.905.1100, www.sswhiteburs.com oxide aggregate: A modified matrix concept. Int Wesselink PR. Comparability of results from two StatSoft Inc., Tulsa, OK Endod J 2005;38(1):59-69. leakage models. Oral Surg Oral Med Oral Pathol 918.749.1119, www.statsoft.com Oral Radiol Endod. 2008;106(2):309-313. 11. Matt GD, Thorpe JR, Strother JM, McClanahan Tokuyama Corporation, Tokyo, Japan 25. Lamb EL, Loushine RJ, Weller RN, Kimbrough SB. Comparative study of white and gray miner- 81.3.3835.701, www.tokuyama.co.jp al trioxide aggregate (MTA) simulating a one- or WF, Pashley DH. Effect of root resection on the two-step apical barrier technique. J Endod apical sealing ability of mineral trioxide aggre- 2004;30(12):876-879. gate. Oral Surg Oral Med Oral Pathol Oral Radi- ol Endod 2003;95(6):732-735.

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Esthetic consideration for alveolar socket preservation prior to implant placement: Description of a technique and 80-case series report

Ahmad Kutkut, DDS, MS n Sebastiano Andreana, DDS, MS n Edward Monaco, DDS

An esthetic restoration supported by dental implant rehabilitation is a may delay surgical implant placement for a few months, and the major challenge to restorative dentists. The ultimate goal of a dental quality of new bone regeneration is questionable. implant is to restore missing or extracted teeth by placing implants in The aim of this report was to describe a minimally traumatic anatomically, esthetically, and long-term functional restorations. extraction socket preservation technique using different types of Alveolar ridge preservation and site enhancement following bone graft as a preserver prior to implant placement applied in 80 tooth extraction has a major impact on the hard and soft tissue consecutive cases. volume. Extraction socket preservation is technique sensitive, not Received: August 8, 2011 100% successful, and at times unpredictable. Current techniques Accepted: October 25, 2011

xtraction socket wound of the alveolar architecture of bone graft as a preserver prior healing is characterized by including cortical bone and soft to implant placement applied in Eresorption of the alveolar bone tissue. Prevention of hard and soft 80 cases.35-46 volume at the extraction site. This tissue collapse can minimize or bone resorption results in esthetic eliminate the necessity for future Materials and methods and restorative challenges that augmentation procedures.13-19 Eighty nonrestorable teeth were reduce the bone volume available The use of resorbable bone fillers extracted and followed by implant for implant placement. have been shown both clinically and placement as documented in the Major changes in an extraction histologically to improve new bone technique described below. The socket occur during the first year formation in intact extraction sockets indications for tooth extraction after tooth extraction with two- before implant placement.20-34 included root or crown fractures, thirds of bone loss occurring within When incorporated as part of the nonrestorable caries, residual roots, the first three months. The literature site preparation for an implant resto- and root resorption (Fig. 1 and 2). documents an average of 0.7 to ration, placing a graft into an extrac- Several types of resorbable bone 1.5 mm vertical bone resorption tion socket provides a scaffold for grafts and fillers were used such as following extraction procedures the in-growth of cellular and vascular calcium sulfate, allograft, xenograft, without any socket preservation graft components to form new bone of and collagen resorbable plug, or performed and an average of 4 to 4.5 acceptable quality and quantity.35-37 a combination of two bone grafts mm horizontal bone resorption.1-5 Extraction socket preservation mixed with platelet-rich plasma Preservation of alveolar bone however, is technique sensitive, not (PRP). The grafts were covered following tooth extraction has a 100% successful, and can at times be with resorbable collagen membrane major impact on the functional and unpredictable. Current techniques or, for limited cases, with polytet- esthetic outcomes of subsequent may delay implant placement for rafluoroethylene (PTFE) barriers prosthetic treatment; this has been months, and the quality of regener- and secured with PTFE reversed long studied yet it remains an unre- ated bone is questionable.38 figure-eight sutures. Follow-ups for solved problem.6-12 This report describes a minimally patients were scheduled at 14 days The extraction socket preserva- traumatic alveolar socket preserva- for the suture removal and at three tion technique implies preservation tion technique using different types months for implant placements.

e398 November/December 2012 General Dentistry www.agd.org Fig. 1. Nonrestorable tooth Fig. 2. Nonrestorable tooth No. No. 8 indicated for extraction and 8 indicated for extraction and Fig. 3. Sulcular incision made with Fig. 4. Tooth luxation and alveolar socket graft (x-ray). alveolar socket graft. surgical blade 15C. extraction using periotomes.

Fig. 6. Resorbable collagen Fig. 5. Minimally traumatic membrane placed over the Fig. 7. Reverse cross mattress extraction with alveolar socket grafted socket just below the free resorbable suture to secure the Fig. 8. Healing after 14 days at bone preservation. gingival margin. membrane in place. the time of suture removal.

Surgical procedure debrided of any granulation tissue (PerioGard®, Colgate) four times Patients’ vital signs were deter- using a curette (Fig. 5). daily for two weeks. mined and assessed prior to com- The bone graft material was Patients returned 14 days after the mencing surgical treatment. After packed in 3-4 bulk amounts until surgical procedure. At this visit, the administration of a local anesthesia the extraction sockets were com- sutures were removed and wound (Xylocaine 2% injection with pletely filled to the gingival margin. healing was evaluated (Fig. 8). 1:100,000 epinephrine, Dentsply In the cases of collagen resorbable Patients returned approximately Pharmaceutical), a sulcular incision plug, the plugs were packed into three months after the surgical was performed using a 15C surgical the sockets. The extraction socket procedure when healing of the blade around the nonrestorable graft was covered with a resorb- bone grafting had been achieved teeth to separate the gingival able collagen membrane (ACE (Fig. 9).43 Vital findings were col- fibers and also coronal periodontal ConFORM™ Membrane 15 mm lected and reported. After local ligaments (Fig. 3). This incision X 20 mm, (ACE Surgical Supply anesthesia was administrated (Xylo- was accomplished carefully to Company) to perform guided bone caine 2% injection with 1:100,000 preserve the attached gingiva and regeneration (GBR) and to protect epinephrine), a papilla-saving papillae. The teeth were carefully the bone graft from the intrusion crestal incision was made and full and gently luxated from the mesial of undesired soft tissue growth and thickness flap reflected (Fig. 10). and distal using periotomes (QC oral debris (Fig. 6). The membrane Osteotomy for implant insertion Orthodontics Lab Inc.) (Fig. 4). was secured using a reverse cross was prepared according to implant Extraction of the luxated teeth was mattress resorbable suture (Fig. 7). manufacturer recommendations performed with surgical forceps Patients were advised to clean and a dental implant (70 cases: (QC Orthodontics Lab Inc.) to the surgical area gently with Nobel Replace, Nobel Biocare; 10 minimize the amount of mechani- a Toothette® Oral Swab (Sage cases: SLActive Bone Level Strau- cal pressure applied to the buccal Products Inc.) saturated with mann Implant, (Straumann USA bone. The extraction sockets were 0.12% chlorhexidine gluconate LLC) was placed (Fig. 11 and 12).

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Fig. 10. Alveolar bone healing with Fig. 9. Healing after three months the papilla saving crestal incision Fig. 12. Healing abutment and flap at the time of implant placement. and full thickness flap reflected. Fig. 11. Implant placed. closure using resorbable sutures.

Fig. 13. Healing after three Fig. 14. Zirconia custom abutment Fig. 15. Provisional (PMMA) crown Fig. 16. Deﬁnitive full ceramic months after implant placement. delivered. cemented with temporary cement. crown delivered.

Healing was uneventful, and that soft tissue closure was almost non-restorable teeth, flapless eleva- at the time of implant placement complete at 14 days postextraction tion, and an application of guided no additional grafting procedures in all cases. After three months of bone regeneration principle using were needed to either improve the healing, when implant placement a resorbable collagen membrane esthetics or cover any implant’s was performed, all examined sock- barrier secured by sutures were body exposure for proper implant ets were completely filled by dense applied to all sites in this technique prosthetic restoration. bone; when the osteotomies were protocol. This may explain why all Healing abutments for one-stage prepared by the pilot drill, bone of the grafted sockets showed mini- surgery or cover screws for two- exhibited a great resistance during mal marginal bone resorption and stage surgery were placed, and the osteotomy preparation. no further soft tissue manipulation flaps were secured with 4-0" PTFE The treatment was considered suc- in the 80 cases with esthetic final sutures. Patients were advised to cessful if sufficient bone was present restorations (Fig. 13-24). clean the surgical area gently with for implants to be placed after three a Toothette® Oral Swab moistened months of healing. Treatment fail- Discussion with 0.12% chlorhexidine gluconate ure was indicated when after three This technique aimed to place four times daily for two weeks. months of healing, there was not different types of graft material enough bone present for implant in fresh extraction sockets and to Clinical outcome placements. Radiographically, the evaluate the clinical healing three Clinical healing was uneventful and bone regenerated in the extraction months postextraction. It has been free of infection or other symptoms sites showed high density in all cases reported that most morphologic in all cases. No patient reported any and the success rate was 100%. extraction socket changes take place postoperative pain or discomfort At the time of implant placement, within this time frame.1-5 Socket nor was any pain medication pre- a complete alveolar bone bridge preservation procedures are effective scribed or used by any patients. Soft formation was observed with a in limiting horizontal and vertical tissue healing of the grafted areas minimal amount of horizontal and ridge alterations in postextraction was visually assessed as quick and vertical bone resorption. Minimally sites and are accompanied by vary- mature in all cases. It was observed traumatic extraction technique of ing percentages of bone formation.

e400 November/December 2012 General Dentistry www.agd.org Fig. 17. Preoperative nonrestor- Fig. 19. Preoperative nonrestorable tooth No. 8 indicated for Fig. 18. Deﬁnitive crown placed able tooth No. 10 indicated for Fig. 20. Deﬁnitive crown placed extraction and socket preservation. after treatment. extraction and socket preservation. after treatment.

Fig. 21. Preoperative nonrestor- Fig. 23. Preoperative nonrestorable tooth No. 12 indicated for Fig. 22. Deﬁnitive crown placed able tooth No. 14 indicated for Fig. 24. Deﬁnitive crown placed extraction and socket preservation. after treatment. extraction and socket preservation. after treatment.

This depends on the materials and was achieved at 14 days when the the key to the successful outcome techniques used. There is no evi- sutures were removed. achieved in this report. dence to support the superiority of The observation of enhanced Tooth position may affect one technique over another.35-46 epithelial wound healing, as well as the amount of horizontal bone This described technique was effec- the observation of complete bone resorption due to the buccal bone tive in enhancing bone maturation fill, would support the clinical use thickness. Forty-two anterior teeth and in minimizing vertical and hori- of this technique in fresh extraction (36 in the premaxilla and six in the zontal alveolar bone resorption within sockets without flap mobilization. symphysis area) and 38 posterior the fresh extraction sockets without This technique has the advantage of teeth (21 in the posterior maxilla further soft tissue managements. avoiding the necessity of soft tissue and 17 in the posterior mandible) In these 80 cases, the operators remodeling. The use of membranes were followed up. More horizontal did not elevate flaps in order to without primary closer may optimize bone resorption was observed in the avoid mucogingival changes and to treatment outcomes. This procedure premaxilla than in other regions. reduce the bone remodeling activ- has been recognized as a necessary One of the most important condi- ity that mediates resorption of the treatment step in order to maintain tions related to socket grafting pro- surface layer of the alveolar bone and restore adequate bone volume cedure is the number and thickness in the exposed area.40, 43 This is of for implant placement.43,47,48 of the bony walls surrounding the particular concern at the buccal This concept is applicable also to extraction site. A thick labial plate (no aspects of the maxillary alveolar the technique of creating a pouch less than 1.5 mm) and completely ridge, where the cortical plate is between buccal and palatal bone intact bony walls will regenerate bone often extremely thin. The present to insert the membrane. This, using almost any resorbable graft operators used resorbable collagen by default, leads to elevation of material.14, 15 However, when the membrane in the majority of cases the periosteum from the alveolar buccal plate is extremely thin, pro- to cover the grafting materials and crest. Elevating the periosteum nounced bone resorption in width is secured the site with a cross mattress leads to bone resorption.40 In this greater than the resorption in height suture during the early healing pro- 80-case series, operators did not after extraction, to a degree that may cess.43 Complete epithelial closure elevate the pouch; this fact may be affect the implant placement.40,43

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These findings demonstrate the References dog. Clin Oral Implants Res 2008;19(11):1111- importance of extraction socket 1. Schropp L, Wenzel A, Kostopoulos L, Karring T. 1118. ff Bone healing and soft tissue contour changes 15. Fickl S, Zuhr O, Wachtel H, Stappert CF, Stein JM, graft technique using di erent types following single-tooth extraction: A clinical Hurzeler MB. Dimensional changes of the alveo- of bone grafts and fillers to regener- and radiographic 12-month prospective study. lar ridge contour after different socket preserva- ate new bone and to reduce the Int J Periodontics Restorative Dent 2003;23(4): tion techniques. J Clin Periodontol 2008;35(10): 313-323. 906-913. amount of bone resorption. 2. Lam RV. Contour changes of the alveolar pro- 16. Hoffmann O, Bartee BK, Beaumont C, Kasaj A, cesses following extraction. J Prosthet Dent Deli G, Zafiropoulos GG. Alveolar bone preserva- Summary 1960;10:25-32. tion in extraction sockets using non-resorbable Th 3. Johnson K. A study of the dimensional changes dPTFE membranes: A retrospective non-random- e 80 cases presented in this occurring in the maxilla following tooth extrac- ized study. J Periodontol 2008;79(8):1355-1369. report indicate that the extraction tion. Aust Dent J 1969;14(4):241-244. 17. Brkovic BM, Prasad HS, Konandreas G, Milan R, socket preservation technique was 4. Fickl S, Zuhr O, Wachtel H, Bolz W, Huerzeler M. Antunovic D, Sandor GK, Rohrer MD. Simple Tissue alterations after tooth extraction with preservation of a maxillary extraction socket successful in preserving the alveolar and without surgical trauma: A volumetric study using beta-tricalcium phosphate with type I col- ridge after extraction for implant in the beagle dog. J Clin Periodontol 2008; lagen: Preliminary clinical and histomorphomet- placement. Any resorbable bone 35(4):356-363. ric observations. J Can Dent Assoc 2008;74(6): 5. Van der Weijden F, Dell’Acqua F, Slot DE. Alveo- 523-528. replacements applied by guided lar bone dimensional changes of post-extraction 18. Misch CE, Silc JT. Socket grafting and alveolar bone regeneration will generate sockets in humans: A systematic review. J Clin ridge preservation. Dent Today 2008;27(10): clinical healing process with favor- Periodontol 2009;36(12):1048-1058. 146, 148, 150 passim. 6. Lekovic V, Camargo PM, Klokkevold PR, Wein- 19. Barone A, Aldini NN, Fini M, Giardino R, Calvo able clinical results when used in laender M, Kenney EB, Dimitrijevic B, Nedic M. Guirado JL, Covani U. Xenograft versus extrac- fresh extraction sockets. Although Preservation of alveolar bone in extraction sock- tion alone for ridge preservation after tooth re- the sample size investigated in this ets using bioabsorbable membranes. J Periodon- moval: A clinical and histomorphometric study. fi tol 1998;69(9):1044-1049. J Periodontol 2008;79(8):1370-1377. case series was small, the ndings 7. Camargo PM, Lekovic V, Weinlaender M, Klok- 20. Guarnieri R, Pecora G, Fini M, Aldini NN, Giardi- are clinically relevant. kevold PR, Kenney EB, Dimitrijevic B, Nedic M, no R, Orsini G, Piattelli A. Medical grade calcium Jancovic S, Orsini M. Influence of bioactive glass sulfate hemihydrate in healing of human extrac- on changes in alveolar process dimensions after tion sockets: Clinical and histological observa- Conclusion exodontia. Oral Surg Oral Med Oral Pathol Oral tions at 3 months. J Periodontol 2004;75(6): Extraction socket preservation is Radiol Endod 2000;90(5):581-586. 902-908. technique-sensitive, not 100% 8. Iasella JM, Greenwell H, Miller RL, Hill M, Drisko 21. Guarnieri R, Aldini NN, Pecora G, Fini M, Giardi- C, Bohra AA, Scheetz JP. Ridge preservation with no R. Medial-grade calcium sulfate hemihydrate successful, and can be unpredict- freeze-dried bone allograft and a collagen (surgiplaster) in healing of a human extraction able. Current techniques may delay membrane compared to extraction alone for socket—Histologic observation at 3 months: A implant placement for months, implant site development: A clinical and histo- case report. Int J Oral Maxillofac Implants 2005; logic study in humans. J Periodontol 2003;74(7): 20(4):636–641. and the quality of regenerated bone 990-999. 22. Walsh WR, Morberg P, Yu Y, Yang JL, Haggard W, is questionable. The aim of this 9. Lekovic V, Kenney EB, Weinlaender M, Han T, Sheath PC, Svehla M, Bruce WJ. Response of report was to describe a minimally Klokkevold P, Nedic M, Orsini M. A bone regen- calcium sulfate bone graft substitute in a con- erative approach to alveolar ridge maintenance fined cancellous defect. Clin Orthop Relat Res traumatic alveolar socket preserva- following tooth extraction. Report of 10 cases. 2003;406:228-236. tion technique using different types J Periodontol 1997;68(6):563–570. 23. Kelly CM, Wilkins RM, Gitelis S, Hartjen C, Wat- of bone graft as a preserver prior to 10. Bartee BK. Extraction site reconstruction for al- son JT, Kim PT. The use of a surgical grade calci- veolar ridge preservation. Part 1: Rationale and um sulfate as a bone graft substitute: Results of implant placement in 80 cases. materials selection. J Oral Implantol 2001;27(4): a multi-center trial. Clin Orthop Relat Res 2001; 187-193. 382:42-50. Author information 11. John V, De Poi R, Blanchard S. Socket preserva- 24. Andreana S, Cornelini R, Edsberg LE, Natiella JR. tion as a precursor of future implant placement: Maxillary sinus elevation for implant placement Dr. Kutkut is an assistant profes- Review of the literature and case reports. Com- using calcium sulfate with and without DFDBA: sor, Department of Oral Health pend Contin Educ Dent 2007;28(12):646-653; Six cases. Implant Dent 2004;13(3):270-277. Practice, Division of Restorative quiz 654, 671. 25. Kutkut A, Andreana S. Medical-grade calcium 12. Keith JD Jr, Salama MA. Ridge preservation and sulfate hemihydrate in clinical implant dentistry: Dentistry, University of Kentucky, augmentation using regenerative materials to A review. J Long Term Eff Med Implants 2010; College of Dentistry, where Dr. enhance implant predictability and esthetics. 20(4):295-301. Andreana is an associate professor Compend Contin Educ Dent 2007;28(11):614- 26. Thomas MV, Puleo DA. Calcium sulfate: Proper- 621; quiz 622-624. ties and clinical applications. J Biomed Mater and Director of Implant Dentistry. 13. Cardaropoli D, Cardaropoli G. Preservation of Res B Appl Biomater 2009;88(2):597-610. Dr. Monaco is an assistant professor the postextraction alveolar ridge: A clinical and 27. Sanchez AR, Sheridan PJ, Kupp LI. Is platelet-rich and Director of the Postgraduate histologic study. Int J Periodontics Restorative plasma the perfect enhancement factor? A cur- Dent 2008;28(5):469-477. rent review. Int J Oral Maxillofac Implants 2003; Program in Prosthodontics, Depart- 14. Fickl S, Zuhr O, Wachtel H, Bolz W, Huerzeler 18(1):93-103. ment of Restorative Dentistry, State MB. Hard tissue alterations after socket preser- 28. Marx RE. Platelet-rich plasma: Evidence to sup- University of New York at Buffalo, vation: An experimental study in the beagle port its use. J Oral Maxillofac Surg 2004;62(4): 489-496. School of Dental Medicine.

e402 November/December 2012 General Dentistry www.agd.org 29. Intini G. The use of platelet-rich plasma in bone 38. Schropp L, Isidor F. Timing of implant placement plasma: A pilot study in a canine model. Int J Oral reconstruction therapy. Biomaterials 2009;30(28): relative to tooth extraction. J Oral Rehabil 2008; Maxillofac Implants 2007;22(4):656-665. 4956-4966. 35 Suppl 1:33-43. 46. Jackson BJ, Morcos I. Socket grafting: A predict- 30. Tozum TF, Demiralp B. Platelet-rich plasma: A 39. Cardaropoli G, Araujo M, Lindhe J. Dynamics of able technique for site preservation. J Oral Im- promising innovation in dentistry. J Can Dent bone tissue formation in tooth extraction sites. plantol 2007;33(6):353-364. Assoc 2003;69(10):664. An experimental study in dogs. J Clin Periodon- 47. Mardas N, Chadha V, Donos N. Alveolar ridge 31. Freymiller EG, Aghaloo TL. Platelet-rich plasma: tol 2003;30(9):809-818. preservation with guided bone regeneration and Ready or not? J Oral Maxillofac Surg 2004; 40. Elian N, Cho SC, Froum S, Smith RB, Tarnow DP. a synthetic bone substitute or a bovine-derived 62(4):484-488. A simplified socket classification and repair xenograft: A randomized, controlled clinical trial. 32. Zechner W, Tangl S, Tepper G, Furst G, Bernhart technique. Pract Proced Aesthetic Dent 2007; Clin Oral Implants Res 2010;21(7):688-698. T, Haas R, Mailath G, Watzek G. Influence of 19(2):99-104; quiz 106. 48. Misch C. The use of recombinant human bone platelet-rich plasma on osseous healing of den- 41. Wood DL, Hoag PM, Donnenfeld OW, Rosenfeld morphogenetic protein-2 for the repair of ex- tal implants: A histologic and histomorphomet- DL. Alveolar crest reduction following full and traction socket defect: A technical modification ric study in minipigs. Int J Oral Maxillofac partial thickness flaps. J Periodontol 1972;43(3): and case series report. Int J Oral Maxillofac Im- Implants 2003;18(1):15-22. 141-144. plants 2010;25(6):1246-1252. 33. Intini G, Andreana S, Margarone JE 3rd, Bush PJ, 42. Bragger U, Pasquali L, Kornman KS. Remodelling Dziak R. Engineering a bioactive matrix by mod- of interdental alveolar bone after periodontal Manufacturers ifications of calcium sulfate. Tissue Eng 2002; flap procedures assessed by means of comput- ACE Surgical Supply Company, Brockton, MA 8(6):997-1008. er-assisted densitometer image analysis (CA- 508.588.3100, www.acesurgical.com 34. Intini G, Andreana S, Intini FE, Buhite RJ, Bobek DIA). J Clin Periodontol 1988;15(9):558-564. Colgate, New York, NY LA. Calcium sulfate and platelet-rich plasma 43. Kutkut A, Andreana S, Kim HL, Monaco E Jr. Ex- 212.752.2357, www.colgate.com make a novel osteoinductive biomaterial for traction socket preservation graft before implant Dentsply Pharmaceutical, York, PA bone regeneration. J Transl Med 2007;5:13. placement with calcium sulfate hemihydrate 717.699.1400, www.dentsplypharma.com 35. Darby I, Chen ST, Buser D. Ridge preservation and platelet-rich plasma: A clinical and histo- techniques for implant therapy. Int J Oral Maxil- morphometric study in humans. J Periodontol. Nobel Biocare, Yorba Linda, CA lofac Implants 2009;24 Suppl:260-271. 2012;83(4):401-409. 800.322.5001, www.nobelbiocare.com 36. McAllister BS, Haghighat K. Bone augmentation 44. Payne JM, Cobb CM, Rapley JW, Killoy WJ, Spen- QC Orthodontics Lab, Inc., Fuquay-Varina, NC techniques. J Periodontol 2007;78(3):377-396. cer P. Migration of human gingival fibroblasts 919.577.2250, www.qcortho.com 37. Anitua E. Plasma rich in growth factors: Prelimi- over guided tissue regeneration barrier material. Sage Products, Inc., Cary, IL nary results of use in the preparation of future J Periodontol 1996;67(3):236-244. 800.323.2220, www.sageproducts.com sites for implants. Int J Oral Maxillofac Implants 45. Shi B, Zhou Y, Wang YN, Cheng XR. Alveolar ridge 1999;14(4):529-535. preservation prior to implant placement with Straumann USA, LLC, Andover MA surgical-grade calcium sulfate and platelet-rich 800.448.8168, www.straumann.us

AGDPODCAST AGDPODCAST Controversies in Mini Implants Implant Dentistry

www.agd.org General Dentistry November/December 2012 e403 Non-surgical Endodontics

Maxillary ﬁrst molar with three buccal roots evaluated with cone-beam computed tomography: A rare case report

Jojo Kottoor, MDS n Suresh Nandini, MDS n Natanasabapathy Velmurugan, MDS

This case report describes the nonsurgical endodontic manage- morphology associated with maxillary ﬁrst molars and the ment of a maxillary ﬁrst molar with the unusual morphology role of CBCT as a diagnostic tool for managing these complex of three separate buccal roots. An accurate assessment of this cases successfully. morphology was made with the help of cone-beam computed Received: July 13, 2011 tomography (CBCT). This report also describes the varied root Accepted: September 20, 2011

rom both a technical and a been reported; however, this anom- clinical and radiographic findings, microbial point of view, the aly has not been documented in the a diagnosis of pulpal necrosis with Fmajor challenge of root canal maxillary first molar to date.10-12 symptomatic chronic apical peri- treatment is the complexity of the This article describes the rare case odontitis was made, and endodontic root canal system.1 It is important of a maxillary first molar with an treatment was initiated. to be familiar with variations in additional mesiobuccal root that The tooth was anesthetized using root and canal anatomy and the was confirmed using cone beam 1.8 mL (30 mg) of 2% lidocaine characteristic features of various computed tomography (CBCT) containing 1:200,000 epinephrine. racial groups, as untreated root and its successful non-surgical Following caries excavation (to allow canals can lead to endodontic fail- endodontic management. for optimal isolation), the mesial ure.2 Many teeth display anatomi- and distal surfaces of the tooth were cal variation; some teeth possess as Case report restored with composite resin. A many as eight separate root canals A 23-year-old man was referred with rubber dam was placed and a conven- to clean and shape.3 the chief complaint of tooth decay tional endodontic access opening was The largest tooth in terms of in his left posterior maxilla for the made. Using an endodontic explorer volume and the most complex in previous two months. The patient’s (DG16, Hu-Friedy Mfg. Co.), a terms of root and canal anatomy, medical history revealed intermit- clinical evaluation of the pulpal floor the six-year molar is perhaps the tent pain localized to the same tooth revealed three root canal entrances: most frequently treated and least during mastication and was deemed mesiobuccal (MB), distobuccal (DB), understood posterior tooth.4 It is non-contributory. Clinical exami- and palatal (P). Careful inspection of generally accepted that the maxil- nation revealed a grossly decayed the pulpal floor using a dental operat- lary first molar has three roots and asymptomatic left maxillary first ing microscope (Seiler Instruments) three canals. The most common molar (tooth No. 14). There was no disclosed the presence of a second variation is an extra mesiobuccal pain or tenderness to palpation and orifice, located 3 mm mesio-palatal canal, seen in 18–96.1% of cases.5,6 no tooth mobility. The tooth was from the MB canal, or the palato- Cases involving morphologic tender to percussion, and electric mesiobuccal canal (P-MB).13 variations, an abnormal number and thermal pulp tests showed a At first, it was believed that the of roots, or the existence of a negative response. Radiographic second mesiobuccal canal was C-shaped canal in the maxillary examination revealed a slight widen- located within the mesiobuccal root. first molar have all been reported ing of periodontal ligament space A radiograph with the K-file in previously in the literature.7-9 Case in relation to the palatal root apex place revealed that this was an extra reports of maxillary second molars and the distinct probability of an canal located in a separate mesio- with three buccal roots have also extra root (Fig. 1). Based on the buccal root, henceforth referred to

e404 November/December 2012 General Dentistry www.agd.org DB d

c a P MB b P-MBR

Fig. 1. A preoperative radiograph of tooth No. 14. Arrows indicate the location of four roots: a. mesiobuccal, b. second mesiobuccal, Fig. 2. An access opening shows four root canal oriﬁces named according c. distobuccal, d. palatal. to the nomenclature proposed by Kottoor et al.13

Fig. 3. A working length radiograph of tooth No. 14. Fig. 4. A post-obturation radiograph of tooth No. 14.

as the palato-mesiobuccal root canal informed consent from the patient. All root canals were cleaned and (P-MBR) (Fig. 2).13 Coronal flaring A CBCT scan (Simulix Evolution, shaped using ProTaper Ni-Ti rotary was performed using a rotary file Nucletron Corp.) obtained mor- instruments (Dentsply Maillefer) (ProTaper SX, Dentsply Maillefer) phology of the first molar in trans- with a crown-down technique. Irri- to improve the straight line access. verse, axial, and sagittal sections gation was performed using normal Working length was determined (each section 1 mm thick). CBCT saline, 2.5% sodium hypochlorite with the help of an apex locator axial images revealed that the right solution and 17% EDTA. After (Root ZX, J. Morita USA, Inc.) maxillary first molar had four roots completing the biomechanical and confirmed radiographically and four canals. Interestingly, the preparation, calcium hydroxide was (Fig. 3, 4). contralateral first molar also had a placed as an intracanal medicament Multiple working length radio- similar configuration. Four canal with a Lentulo spiral and the access graphs were taken at different orifices were located: a mesiobuccal cavity was sealed with Cavit G (3M angles; however, the radiographs did canal in the first mesiobuccal root, ESPE). At the next appointment, not clearly reveal the morphology a mesiopalatal canal in the second the patient was asymptomatic. or number of root canal systems. mesiobuccal root, a canal in the Final rinsing of the canals utilized The authors performed multi-slice distobuccal root, and a canal in the 2% chlorhexidine digluconate scans of the mandible after receiving palatal root (Fig. 5–7). coupled with ultrasonic agitation.

www.agd.org General Dentistry November/December 2012 e405 Non-surgical Endodontics Maxillary ﬁrst molar with three buccal roots evaluated with CBCT

A A A

RLRL RL

Fig. 5. A CBCT image of tooth No. 14, showing Fig. 6. A CBCT image of tooth No. 14, showing Fig. 7. A CBCT image of tooth No. 14, showing axial sections at the cervical level. axial sections at the middle level. four roots and four canals at the apical levels.

roots while 3.2% have two roots. Table. Case reports of maxillary ﬁrst molar with unusual The authors concluded that the root morphology.8,9,16-22 incidence of either one root or four roots is very rare.14 An extensive ex vivo study by Root No. of Root canal anatomy Method of conﬁguration canals MB DBP diagnosis Reference Rwenyonyi et al examined 221 maxillary first molars and found 1 root 1 Single Single Single Spiral CT Gopikrishna 15 canal canal canal et al 8 none with four roots. How- ever, case reports of four-rooted 2 roots 2 1 C-shaped C-shaped Radiograph Newton & fi McDonald9 maxillary rst molars have been documented in the past, with 2 roots 4 C-shaped C-shaped 1 Radiograph Yilmaz et al 16 canal canal each reporting the presence of an additional palatal root; an overview 2 roots (1 palatal and 3 2 2 1 Radiograph Malagnino fused buccal root) et al 17 of these reports can be found in the table.8,9,16-22 A 1994 report by Sabala 3 roots (2 palatal roots 4 2 2 2 Spiral CT Gopikrishna and fused buccal root) et al 18 et al discovered that aberrations occurred in less than 1% of the Presumably fusion of 5 3 buccal 3 buccal 2 Radiograph Stabholz & teeth No. 3 and 4 Friedman19 cases and 90% of these aberrations were bilateral.23 In the present case, 4 roots (MB, DB, MP, DP) 4 1 1 2 Radiograph Thews et al 20 CBCT images revealed a similar 21 4 roots (MB, DB, MP, DP) 4 1 1 C-shaped CBCT Kottoor et al configuration in the patient’s con- 4 roots (MB, MP, P, DB) 6 MB, MP, M, P, DP, DB Radiograph Adanir22 tralateral maxillary first molar; in DB=Distobuccal, DP=Distopalatal, M=mesial, MB=Mesiobuccal, MP=Mesiopalatal, P=Palatal addition, the second mesiobuccal root was shorter than the other three principle roots of maxillary first molars (Fig. 6 and 7). The canals were dried with absor- verbal consultation did not reveal Although the incidence of root bent points (Dentsply Maillefer); any postoperative pathology. variations is rare, their importance at that point, obturation was per- should not be underestimated. formed using cold lateral compac- Discussion Therefore, giving adequate impor- tion of gutta-percha and resin sealer A 2006 article by Cleghorn et al tance to both the roots and their (AH Plus, Dentsply International) reviewed the root and root canal canal systems is imperative for (Fig. 7). The tooth was restored morphology of the maxillary long-term success of endodontic with a posterior composite resin first molar from four anatomical treatment. Accordingly, Kottoor core. The patient could not come studies and found that 96.2% of et al and Valerian Albuquerque et in person to the clinic; however, a first maxillary molars have three al proposed a new anatomically

e406 November/December 2012 General Dentistry www.agd.org based nomenclature for root canals Author information roots and root canals-Part 1: Maxillary molars. that provides a clear picture of any Dr. Kottoor is a senior lecturer, Int J Dent 2012;2012:120565. 14. Cleghorn BM, Christie WH, Dong CC. Root and existing root and canal aberran- Department of Conservative Den- root canal morphology of the human permanent cies in maxillary and mandibular tistry and Endodontics, Mar Base- maxillary first molar: A literature review. J Endod molars. In the present case, root lios Dental College, Kerala, India. 2006;32(9):813-821. fi 15. Rwenyonyi CM, Kutesa AM, Muwazi LM, Bu- canal ori ces were named accord- Dr. Nandini is a reader, Department wembo W. Root and canal morphology of maxil- ing to this nomenclature.13,24 of Conservative Dentistry and lary first and second permanent molar teeth in a At present, radiologic examina- Endondotics, Meenakshi Ammal Ugandan population. Int Endod J 2007;40(9): 679-683. tion usually is limited to two- Dental College and Hospital, Tamil 16. Yilmaz Z, Tuncel B, Serper A, Calt S. C-shaped dimensional periapical images Nadu, India, where Dr. Velmurugan root canal in a maxillary first molar: A case re- where overlying structures are is a professor and department head. port. Int Endod J 2006;39(2):162-166. 17. Malagnino V, Gallottini L, Passariello P. Some un- superimposed. Even with the usual clinical cases on root anatomy of permanent best intentions and paralleling References maxillary molars. J Endod 1997;23(2):127-128. techniques, essential information 1. Peters OA. Current challenges and concepts in 18. Gopikrishna V, Reuben J, Kandaswamy D. End- the preparation of root canal systems: A review. odontic management of a maxillary first molar related to the three-dimensional J Endod 2004;30(8):559-567. with two palatal roots and a single fused buccal anatomy of the tooth/teeth and 2. Sert S, Bayirli GS. Evaluation of the root canal root diagnosed with spiral computed tomogra- adjacent anatomy is not visible. configurations of the mandibular and maxillary phy—A case report. Oral Surg Oral Med Oral permanent teeth by gender in the Turkish popu- Pathol Oral Radiol Endod 2008;105(4):e74-e78. Recent innovations in high-end lation. J Endod 2004;30(6):391-398. 19. Stabholz A, Friedman S. Endodontic therapy of diagnostic technologies—such 3. Kottoor J, Velmurugan N, Surendran S. Endodon- an unusual maxillary permanent first molar. as CBCT and spiral computer- tic management of a maxillary first molar with J Endod 1983;9(7):293-295. eight root canal systems evaluated using cone- 20. Thews ME, Kemp WB, Jones CR. Aberrations in ized tomography (SCT)—could beam computed tomography scanning: A case palatal root and root canal morphology of two improve access to the internal report. J Endod 2011;37(5):715-719. maxillary first molars. J Endod 1979;5(3):94-96. root canal morphology and affect 4. Burns RC, Herbranson EJ. Tooth morphology and 21. Kottoor J, Velmurugan N, Ballal S, Roy A. Four- access cavity preparation. In: Cohen S, Burns rooted maxillary first molar having C-shaped the management of potentially RC, eds. Pathways of the pulp, ed. 8. St Louis: palatal root canal morphology evaluated using complex endodontic problems. Elsevier Mosby;2002:173-229. cone-beam computerized tomography: A case However, when exposing patients 5. Kulild JC, Peters DD. Incidence and configuration report. Oral Surg Oral Med Oral Pathol Oral Ra- of canal systems in the mesiobuccal root of diol Endod 2011;111(5):e41-e45. to ionizing radiation, it is essential maxillary first and second molars. J Endod 1990; 22. Adanir N. An unusual maxillary first molar with that the radiation dose is kept 16(7):311-317. four roots and six canals: A case report. Aust as low as reasonably achievable 6. Buhrley LJ, Barrows MJ, BeGole EA, Wenckus Dent J 2007;52(4):333-335. 25 CS. Effect of magnification on locating the MB2 23. Sabala CL, Benenati FW, Neas BR. Bilateral root (ALARA). Exposure to radiation canal in maxillary molars. J Endod 2002;28(4): or root canal aberrations in a dental school pa- must be justified and therefore the 324-327. tient population. J Endod 1994;20(1):38-42. patient’s radiation dose must be 7. Kottoor J, Velmurugan N, Sudha R, Hemamalathi 24. Valerian Albuquerque D, Kottoor J, Velmurugan S. Maxillary first molar with seven root canals N. A new anatomically based nomenclature for optimized. In our case, CBCT was diagnosed with cone-beam computed tomogra- the roots and root canals-Part 2: Mandibular used over SCT because of its low phy scanning: A case report. J Endod 2010; molars. Int J Dent. 2012;2012:814789. effective radiation dose. 36(5):915-921. 25. Farman AG. ALARA still applies. Oral Surg Oral 8. Gopikrishna V, Bhargavi N, Kandaswamy D. End- Med Oral Pathol Oral Radiol Endod 2005;100(4): odontic management of a maxillary first molar 395-397. Summary with a single root and a single canal diagnosed The present case report discusses with the aid of spiral CT: A case report. J Endod Manufacturers 2006;32(7):687-691. the endodontic management of Dentsply International, Des Plaines, IL 9. Newton CW, McDonald S. A C-shaped canal 847.640.4800, www.dentsply.com an unusual case of a maxillary first configuration in a maxillary first molar. J Endod 1984;10(8):397-399. Dentsply Maillefer, Tulsa, OK molar with four roots and four 800.924.7393, www.maillefer.com Th 10. Fahid A, Taintor JF. Maxillary second molar with canals. e presence of an extra three buccal roots. J Endod 1988;14(4):181-183. Hu-Friedy Mfg. Co., Chicago, IL mesiobuccal root was confirmed 11. Zmener O, Peirano A. Endodontic therapy in a 800.483.7433, www.hu-friedy.com with CBCT. Evaluating CBCT maxillary second molar with three buccal roots. J. Morita USA, Inc., Irvine, CA J Endod 1998;24(5):376-377. images can lead to a better under- 949.581.9600, www.morita.com 12. Jafarzadeh H, Javidi M, Zarei M. Endodontic re- Nucletron Corp, Columbia, MD standing of root canal anatomy, treatment of a maxillary second molar with 410.312.4100, www.elekta.us which in turn can help the clinician three separate buccal roots. Aust Endod J 2006; 32(3):129-132. Seiler Instruments, St. Louis, MO investigate the root canal anatomy 13. Kottoor J, Albuquerque DV, Velmurugan N. A 800.489.2282, www.seilerinst.com and to clean, shape, and obturate it new anatomically based nomenclature for the 3M ESPE, St. Paul, MN more efficiently. 888.364.3577, solutions.3M.com

www.agd.org General Dentistry November/December 2012 e407 Operative (Restorative) Dentistry

Effect of curing unit and adhesive system on marginal adaptation of composite restorations

Denise Sa Maia Casselli, PhD, MD, DDS n Andre Luis Faria-e-Silva, PhD, MD, DDS n Henrique Casselli, PhD, MD, DDS Luis Roberto Marcondes Martins, PhD, MD, DDS

This study sought to evaluate how a curing unit and adhesive 500X). The widest gaps in each margin were recorded, and data system affected the marginal adaptation of resin composite were submitted to Kruskal-Wallis, Mann-Whitney, and Wilcoxon restorations. Class V cavities were prepared in bovine teeth with tests (α = 0.05). Differences between the adhesives were a gingival margin in dentin and an incisal margin in enamel. The observed only when the dentin margins were evaluated: Clearfil cavities were restored with a micro-hybrid resin composite using SE Bond demonstrated better marginal adaptation than Prime & one of four adhesives: Single Bond 2, Prime & Bond NT, Clearfil Bond NT or Single Bond 2 (which demonstrated the widest gaps SE Bond, Xeno IV. The light-activations were performed using in the dentin margin). The type of curing unit only affected the a quartz-tungsten-halogen (QTH) lamp or a second-generation results for Xeno IV when the enamel margin was analyzed; the light-emitting diode (LED). Restorations were finished and pol- LED lamp promoted smaller gaps than the QTH lamp. ished and epoxy replicas were prepared. Marginal adaptation was Received: August 15, 2011 analyzed by using scanning electronic microscopy (magnification Accepted: November 7, 2011

espite the improvements shrinkage and, consequently, Differences in the emissions of restorative material in increased stress generated by spectrum can affect polymerization. Drecent decades, the marginal shrinkage.6,7 If stress exceeds the Adhesives usually have different integrity of restoration remains bond strength between the dental comonomers than resin compos- a challenge for dentistry. Poor substrate and the adhesive system, ites; in addition, they may have marginal adaptation may lead to a gap will form, jeopardizing the organic solvents that can affect marginal discoloration, postop- longevity of the restoration.8,9 polymerization.14 A high degree of erative sensitivity, and secondary For many years, quartz-tungsten- adhesive conversion is important to caries, the most frequent reasons halogen (QTH) lights have been improve their cohesive strength and, to replace or repair an adhesive used as the primary curing unit consequently, the bond strength restoration.1-3 Marginal failure of for photopolymerization of dental to dental substrate.15 Despite these composite resin restorations is due composites. This unit generates a differences, the effect of curing primarily to the stress generated broad wavelength (usually between units on the marginal integrity of by polymerization shrinkage of 370 and 520 nm).10 Some factors restorations treated with adhesive composites and to the quality of may compromise the performance systems has seldom been evaluated. bonding to the dental structure; a of QTH units, such as line voltage The substrate to which the adhesive stress higher than bond strength fluctuation, long-term degradation is applied also can influence the results in gap formation.4,5 of the bulb and filter, light guide marginal integrity of the restoration. Resin composites contain (di)meth- contamination, damage to the fiber- Traditionally, the dental substrate acrylates that polymerize under optic bundle, and bulb overheating is etched with phosphoric acid and irradiation with visible light. These within the unit.11,12 rinsed prior to application of the composites shrink because of Light emitting diodes (LEDs) adhesive agent.16 Subsequently, sim- the reduction in intermolecular are becoming increasingly popular pler adhesives were introduced with distance that takes place between among clinicians, as they consume the development of self-etching monomer units during the poly- little power and do not require fil- primers/adhesives, eliminating the merization process.6 In other words, ters to produce blue light.11,13 LEDs need for conditioning, rinsing, and a high degree of conversion is have a narrower wavelength spec- drying; however, this simplification related to increased polymerization trum (usually centered at 470 nm).13 did not improve bonding.17,18

e408 November/December 2012 General Dentistry www.agd.org This study sought to evaluate how the marginal integrity of composite Table 1. Median gap measurements (µm) based on the adhesive and restorations was affected by curing curing unit used. lights and adhesive systems. Three null hypotheses were proposed: Margin Curing Adhesive First, the type of curing light (that location unit Single Bond 2 Prime & Bond NT Clearﬁl SE Bond Xeno IV is, LED or QTH) has no effect on Enamel LED 0.0 1.2 0.0 0.3 the marginal adaptation of composite restorations; second, that the QTH 0.0 1.3 0.0 2.3 location of the restoration margin P 0.168 0.562 0.670 0.034* (that is, enamel or dentin) has no Dentin LED 5.6 5.8 0.0 2.2 effect on marginal adaptation; and QTH 5.8 7.8 0.0 1.7 third, that the adhesive system has P 0.648 0.273 0.078 1.000 ff no e ect on the marginal adaptation *Indicates statistical difference between curing unit for each adhesive/margin location according to the of composite restorations. Mann-Whitney test (α = 0.05).

Materials and methods One week after extraction, 40 sound bovine incisors were cleaned, Caulk). Two different adhesives divided into three regions each for polished, and examined under a were used for this last category to SEM analysis. The margins were light microscope (Eclipse E 600, evaluate both ethanol- and acetone- analyzed (magnification 500X) and Nikon, Inc.); incisors with cracks based adhesives. All adhesive sys- the maximum length of the marginal were excluded. Teeth were stored in tems were applied according to the gap of each region was recorded. distilled water (at 5°C) for less than manufacturers’ recommendations. A nonparametric statistical one month before the restorative The cavities were restored with a analysis was performed because the procedure. Standard-shaped Class V microhybrid resin composite (Filtek Kolmorogov-Sminorv test showed cavities (3 mm height x 3 mm width Z250, 3M ESPE), filled in one P < 0.05, indicating absence of x 2 mm depth) were prepared using (bulk) increment of 2 mm and cured normal (or Gaussian) distribution a 169L carbide bur (KG Sorensen) for 20 seconds. The curing proce- of data. A Kruskal-Wallis test on the buccal surface. Each prepara- dures were performed with either was used to compare the adhesive tion was designed so that the incisal a QTH light (Optilux 501, Kerr systems in each level of substrate/ margin was located in enamel and Dental) or an LED light (Radii-Cal, curing light. The effect of the the gingival margin located in SDI North America). For the same curing light was analyzed using a dentin. Within these dimensions, cavity, only one light curing unit was Mann-Whitney test. A Wilcoxon the cavity had a C-factor of 3.7. The used. All restored cavities were stored test was used to compare the sub- cavities were made with a water- in distilled water (at 37°C ) for 24 strates in each experimental condi- cooled, high-speed turbine using a hours and polished using a water tion. The level of significance of all standard cavity preparation device spray and flexible aluminum oxide analyses was established at 5%. that permits the control of bur disks (Sof-Lex Pop-On, 3M ESPE). penetration. A new bur was used for Impressions were taken by using Results each of the five preparations. a polyvinyl siloxane impression The results based on adhesive The cavities were restored using material (Express, 3M ESPE) and system and curing unit are dis- one of three types of adhesive replicas were made with epoxy played in Table 1. There was no systems: a two-step, self-etching resin (Epoxide, Buehler). Replicas significant difference between adhesive (Clearfil SE Bond, Kura- were mounted on aluminum stubs, the adhesives in terms of enamel ray America, Inc.); a single-step, sputter-coated with gold (Bal-Tec margins. In terms of gaps in self-etching adhesive (Xeno IV, Sputter Coater SCD 050, Leica dentin margins, Clearfil SE Bond Dentsply Maillefer); and two differ- Microsystems) and examined with a demonstrated the lowest mean gap ent two-step, etch-and-rinse adhe- scanning electron microscope (SEM) measurements. These values dif- sives: Single Bond 2 (3M ESPE) (JSM-5600LV, JEOL USA). The fered significantly from either of the and Prime & Bond NT (Dentsply enamel and gingival margins were two-step, etch-and-rinse adhesives,

www.agd.org General Dentistry November/December 2012 e409 Operative (Restorative) Dentistry Effect of curing unit and adhesive system on marginal adaptation

The curing light only had a Table 2. Median gap measurements (µm) based on margin location. significant effect for Xeno IV, and only when enamel margins were Adhesive evaluated. In this experimental Curing Margin condition, the LED improved the unit location Single Bond 2 Prime & Bond NT Clearﬁl SE Bond Xeno IV restoration’s marginal adaptation. LED Enamel 0.0 1.2 0.0 0.3 According to the manufacturers, Dentin 5.6 5.8 0.0 2.2 camphorquinone is the photoini- P 0.016* 0.044* 0.250 0.074 tiator for all materials evaluated QTH Enamel 0.0 1.3 0.0 2.3 in this study. Camphor-quinone Dentin 5.8 7.8 0.0 1.7 absorbs a wide spectrum of wave- lengths (360 to 510 nm), with an P 0.025* 0.004* 1.000 0.492 absorbance peak of 468 nm. For *Indicates statistical difference between the margin location for each adhesive/curing unit ff according to the Wilcoxon test (α = 0.05). e ective photopolymerization, the curing light’s spectral irradiance has to overlap with the absorption spectrum of the photoinitiator as regardless of the curing light used. The effect of the adhesive system much as possible.14 Both curing The type of curing light used only on gap formation was observed lights used in this study were able demonstrated a significant effect only for restoration margins to activate the camphorquinone on gap measures for Xeno IV, when located in dentin. The two-step efficiently, so the results of this enamel margins were evaluated; self-etching adhesive Clearfil SE study are not due to differences in samples treated with the Optilux Bond demonstrated lower gap the activation of the adhesives. 501 QTH light demonstrated a measures than the two-step etch- Self-etching adhesives require larger gap than those treated with and-rinse adhesives, regardless of water to ionize the acid monomers the Radii-Cal LED. the curing light used. A positive that are essential to their etching Table 2 presents the results based correlation has been demonstrated ability.23 In addition to the water on the margin location, which only between gap formation and bond content in the composition of had a significant effect for samples strength.18 Despite the differences Xeno IV, the presence of water in treated with Single Bond 2 or Prime in terms of gap measures, these dentin increases the potential of acid & Bond NT, regardless of the curing adhesive systems have shown monomers’ ionization. Thus, a more light used. For both adhesives, gap similar bond strength to dentin.18 effective etching is expected for this measure values were lowest when the The results of the present study are substrate, resulting in higher bond- margin was located in enamel. due to differences in terms of the ing to dentin than enamel. The LED layer produced by each adhesive used in this study includes an activa- Discussion and its ability to absorb and tion mode called soft-start: Activa- Microleakage in composite restora- distribute the stress generated by tion is initiated at a low intensity, tions often is related to polymeriza- polymerization shrinkage. Unlike while final polymerization is accom- tion shrinkage, which causes stress Single Bond 2 and Prime & Bond plished at high intensity.24 This in the interface between the cavity NT, the bonding agent used in activation mode is able to reduce the wall and the restoration.1 This stress Clearfil SE Bond does not include shrinkage stress.25,26 However, the can disrupt the bond and cause gap a solvent; as a result, the Clearfil difference between the light-curing formation.7 A proper bond between produced a thicker layer, which units was observed only with Xeno an adhesive and dental tissue helps produced a greater elastic effect, IV on enamel. This occurred prob- prevent marginal microleakage.19,20 since the shrinkage stress results in ably due to the low bond strength In the present study, the curing a deformed adhesive layer.21,22 As a between Xeno IV and enamel. light, adhesive system, and margin result, the adhesive system that cre- Regardless of which curing light location all had a significant effect ates a thicker adhesive layer reduces was used, Prime & Bond NT and on the marginal adaptation of resin the stress concentration on the Single Bond 2 presented the largest composite restorations. As a result, adhesive interface and favors the gap measures in dentin compared all null hypotheses were rejected. maintenance of gap-free margins. to enamel. These outcomes were

e410 November/December 2012 General Dentistry www.agd.org expected, since it has been demon- on the results of the present study, 4. Van Ende A, De Munck J, Mine A, Lambrechts P, strated that etch-and-rinse adhe- the curing unit, adhesive system, Van Meerbeek B. Does a low-shrinking composite induce less stress at the adhesive interface? sives produce greater bond strength and margin location have an impor- Dent Mater 2010;26(3):215-222. with enamel compared with dentin, tant effect on marginal adaptation 5. Banomyong D, Palamara JE, Messer HH, Burrow due to enamel’s high mineral con- of composite restorations. MF. Sealing ability of occlusal resin composite 17 restoration using four restorative procedures. tent. By contrast, dentin is a more Eur J Oral Sci 2008;116(6):571-578. heterogeneous substrate, consisting Summary 6. Spinell T, Schedle A, Watts DC. Polymerization of hydroxyapatite, collagen fibrils, The occurrence of marginal gaps shrinkage kinetics of dimethacrylate resin-cements. Dent Mater 2009;25(8):1058-1066. and water. During polymerization in restorations of composite resin 7. Braga RR, Ballester RY, Ferracane JL. Factors in- of resin composite, it is expected seems to be dependent on the inter- volved in the development of polymerization that shrinkage stress leads to de- action between such factors as the shrinkage stress in resin-composites: A systematic review. Dent Mater 2005;21(20):962-970. bonding on the weaker interface, adhesive system, light-curing unit, 8. Papadogiannis D, Kakaboura A, Palaghias G, resulting in wider gaps. and location of the margin (dentin Eliades G. Setting characteristics and cavity ad- Self-etching adhesives do not or enamel). aptation of low-shrinking resin composites. Dent Mater 2009;25(12):1509-1516. demonstrate higher bonding ability 9. Takahashi H, Finger WJ, Wegner K, Utterodt A, to enamel than to dentin, primar- Disclaimer Komatsu A, Wöstman B, Balkenhol M. Factors ily because these adhesives have a The authors have no financial, influencing marginal cavity adaptation of nano- 17 filler containing resin composite restorations. relatively high pH. As a result, economic, commercial, and/or Dent Mater 2010;26(12):1166-1175. they are unable to produce an acidic professional interests related to 10. Nomoto R, McCabe JF, Hirano S. Comparison of environment that will allow for the topics or products presented in halogen, plasma and LED curing units. Oper Dent 2004;29(3):287-294. ffi 27 Th e cient etching of enamel. e this manuscript. 11. Jimenez-Planas A, Martin J, Abalos C, Llamas R. ineffectiveness on enamel etching Developments in polymerization lamps. Quintes- of self-etching adhesives results Author information sence Int 2008;39(2):e74-84. 12. Strydom C. Dental curing lights—Maintenance in similar bond strength for both Dr. D. Casselli is a professor, of visible light curing units. SADJ 2002;57(6): enamel and dentin. Single-step Department of Dentistry, Campus 227-233. adhesives like Xeno IV produce low of Sobral, Federal University of 13. Leonard DL, Charlton DG, Roberts HW, Cohen ME. Polymerization efficiency of LED curing bond strength for both dentin and Ceara, Sobral, Ceara, Brazil. Dr. lights. J Esthet Rest Dent 2002;14(5):286-295. enamel; as a result, debonding at Faria-e-Silva is a professor, Depart- 14. Faria-e-Silva AL, Lima AF, Moraes RR, Piva E, both margins would be expected.17 ment of Dentistry, Federal Univer- Martins LR. Degree of conversion of etch-and- fi rinse and self-etch adhesives light-cured using By contrast, Clear l SE Bond sity of Sergipe, Aracaju, Sergipe, QTH or LED. Oper Dent 2010;35(6):649-654. produces a more effective bond Brazil. Dr. H. Casselli is a professor, 15. Reis A, Ferreira SQ, Costa TR, Klein-Júnior CA, strength that, combined with the Sao Leopoldo Mandic School of Meier MM, Loguercio AD. Effects of increased exposure times of simplified etch-and-rinse ad- elasticity from its adhesive layer, Dentistry, Campus of Fortaleza, For- hesives on the degradation of resin-dentin makes it possible to maintain a taleza, Ceara, Brazil. Dr. Martins is a bonds and quality of the polymer network. Eur marginal seal in both the dentin professor, Department of Restorative J Oral Sci 2010;118(5):502-509. doi: 10.1111/j. 1600-0722.2010.00759.x. and enamel margins. Dentistry, Piracicaba Dental School, 16. Marshall SJ, Bayne SC, Baier R, Tomsia AP, Mar- A proper margin seal is essential State University of Campinas, Piraci- shall GW. A review of adhesion science. Dent to improve the longevity of resin caba, Sao Paolo, Brazil. Mater 2010;26(2):e11-e16. 17. Peumans M, Kanumilli P, De Munck J, Van Lan- composite restorations. A sealed duyt K, Lambrechts P, Van Meerbeek B. Clinical margin avoids marginal discolor- References effectiveness of contemporary adhesives: A sys- ation and secondary caries, while 1. Heintze SD. Systematic reviews: I. The correla- tematic review of current clinical trials. Dent tion between laboratory tests on marginal qual- Mater 2005;21(9):864-881. this last occurrence is the main ity and bond strength. II. The correlation 18. De Munck J, Van Landuyt K, Peumans M, reason for replacing restorations. between marginal quality and clinical outcome. Poitevin A, Lambrechts P, Braem M, Van Meer- Class V cavities were chosen for this J Adhes Dent 2007;9 Suppl 1:77-106. beek B. A critical review of the durability of ad- fi 2. Bernardo M, Luis H, Martin MD, Leroux BG, Rue hesion to tooth tissue: Methods and results. study due to their cavity con gura- T, Leitao J, DeRouen TA. Survival and reasons for J Dent Res 2005;84(2):118-132. tion, which impairs resin composite failure of amalgam versus composite posterior 19. Khosravi K, Ataei E, Mousavi M, Khodaeian N. flow during polymerization shrink- restorations placed in a randomized clinical trial. Effect of phosphoric acid etching of enamel J Am Dent Assoc 2007;138(6):775-783. margins on the microleakage of a simplified age. Moreover, these cavities often 3. Sarrett DC. Prediction of clinical outcomes of a all-in-one and a self-etch adhesive system. Oper have gingival margins in dentin, restoration based on in vivo marginal quality Dent 2009;34(5):531-536. which produces an additional bar- evaluation. J Adhes Dent 2007;9 Suppl 1:117- 20. Moldes VL, Capp CI, Navarro RS, Matos AB, 120. Youssef MN, Cassoni A. In vitro microleakage of rier to a proper margin seal.28 Based

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composite restorations prepared by Er:YAG/ bonding effectiveness of self-etch adhesive to Er,Cr:YSGG lasers and conventional drills associ- ground enamel. Eur J Dent 2010;4(4):418-428. ated with two adhesive systems. J Adhes Dent 28. Santiago SL, Passos VF, Vieira AH, Navarro MF, 2009;11(3):221-229. Lauris JR, Franco EB. Two-year clinical evalua- 21. de Silva AL, Lima DA, de Souza GM, dos Santos tion of resinous restorative systems in non- CT, Paulillo LA. Influence of additional adhesive carious cervical lesions. Braz Dent J 2010;21(3): application on the microtensile bond strength of 229-234. adhesive systems. Oper Dent 2006;31(5):562- 568. 22. Ausiello P, Apicella A, Davidson CL. Effect of ad- Manufacturers hesive layer properties on stress distribution in Buehler, Lake Bluff, IL composite restorations—A 3D finite element 800.283.4537, www.mybuehler.com analysis. Dent Mater 2002;18(4):295-303. 23. Van Landuyt KL, Snauwaert J, De Munck J, Dentsply Caulk, Milford, DE Peumans M, Yoshida Y, Poitevin A, Coutinho 800.532.2855, www.caulk.com E, Suzuki K, Lambrechts P, Van Meerbeek B. Dentsply Maillefer, Tulsa, OK Systematic review of the chemical composition 800.924.7393, www.maillefer.com of contemporary dental adhesives. Biomater JEOL USA, Inc., Peabody, MA 2007;28(26):3757-3785. 978.535.5900, www.jeolusa.com 24. F e Silva AL, Pereira GD, Dias CT, Sartini Paulillo Leica Microsystems, Buffalo Grove, IL LA. Effect of the composite photoactivation 800.248.0123, www.leica-microsystems.com mode on microtensile bond strength and Knoop microhardness. Dent Mater 2006;22(3):203-210. Kerr Dental, Orange, CA 25. Froes-Salgado NR, Pfeifer CS, Francci CE, Kawa- 800.537.7123, www.kerrdental.com no Y. Influence of photoactivation protocol and KG Sorensen, Sao Paulo, Brazil light guide distance on conversion and micro- 55.11.4195.3275, www.kgsorensen.com.br leakage of composite restorations. Oper Dent Kuraray America Inc., New York, NY 2009;34(4):408-414. 800.879.1676, www.kuraraydental.com 26. Rodrigues Junior SA, Pin LF, Machado G, Della Nikon Inc., Melville, NY Bona A, Demarco FF. Influence of different re- 631.547.4200, www.nikonusa.com storative techniques on marginal seal of class II composite restorations. J Appl Oral Sci SDI North America, Bensenville, IL 2010;18(1):37-43. 800.228.5166, www.sdi.com.au 27. Ibrahim IM, Elkassas DW, Yousry MM. Effect of 3M ESPE, St. Paul, MN EDTA and phosphoric acid pretreatment on the 888.364.3577, solutions.3m.com

e412 November/December 2012 General Dentistry www.agd.org Dental Materials

Bond strength of resin-modiﬁed glass ionomer restorative materials using a no-rinse conditioner

Rian W. Suihkonen, DDS, ABGD n Kraig S. Vandewalle, DDS, MS, MAGD, ABGD n Jon M. Dossett, DMD, MAGD, ABGD

A paste-paste resin-modified glass ionomer (RMGI) restorative inserted into a mold and photocured. The specimens were loaded material has been introduced recently with a new conditioner that until failure in a universal testing machine after 24 hours storage requires no rinsing. The purpose of this study was to compare the in distilled water. Fuji II LC had significantly greater bond strength shear bond strength of an encapsulated RMGI (Fuji II LC) and a to dentin than Fuji Filling LC. The use of Cavity Conditioner or Self new paste-paste RMGI (Fuji Filling LC) to dentin conditioned with Conditioner resulted in bond strengths that were not significantly 20% polyacrylic acid (Cavity Conditioner), a new no-rinse condi- different from each other; however, both produced greater bond tioner (Self Conditioner), or no conditioner. Mounted human third strengths than those in the non-conditioned groups. molars were flattened and the dentin surface was conditioned. Received: August 3, 2011 The RMGI restorative materials were mixed and incrementally Accepted: October 3, 2011

esin-modified glass ionomer Controlled clinical studies have composite resin to tooth structure. A (RMGI) materials were intro- shown a superior or comparable study by Besnault et al showed that Rduced to the dental market retention rate of glass ionomer- various self-etch adhesives increased to overcome the disadvantages of based materials compared to the bond strength of RMGI restor- conventional glass ionomer and to adhesive-retained resin-based com- ative materials to dentin compared expand clinical applications. RMGI posite restorative materials in Class to the conventional etch-and-rinse materials are similar to conventional 5 restorations.4,5 Chemical bonding approach with polyacrylic acid.9 One glass ionomers with an ion-leachable of the glass ionomer to the hydroxy- major advantage of a self-etch adhe- fluoroaluminosilicate glass, but apatite in dentin and enamel could sive is the elimination of the need to they are modified by the inclusion be responsible for the enhanced rinse the tooth after conditioning. of resin monomers, particularly stability of the bonded interface.1 Not only does it save time, it reduces 2-hydroxyethylmethacrylate Conditioning agents for bonding the potential contamination of the (HEMA), and initiators. The mate- of RMGI to tooth structure have freshly conditioned dentin surface. rial sets via an acid-base reaction historically consisted of a 10% or Cavity Conditioner (GC America) and free-radical polymerization.1 20% polyacrylic acid. The purpose is a 20% polyacrylic acid solution, RMGI materials are easier to use of the conditioner is to remove the and Self Conditioner (GC America) and more esthetic than conventional smear layer from the dentin without is a new no-rinse conditioning solu- glass ionomers because of their chemically etching it, allowing an tion that contains primer compo- resin content. These materials are ionic bond of the restorative material nents similar to resin-based adhesive marketed as restorative materials for to the tooth substrate.3 The signifi- bonding agents. Both Cavity and small Class 1, Class 3, and Class 5 cance of surface conditioning on the Self Conditioner are used to condi- restorations, and for use as a liner, performance of RMGI materials tion the bonding surface of the tooth core buildup material, or luting has been demonstrated in multiple prior to using glass ionomer materi- agent. RMGI materials are available studies, proving that it is essential als, but Cavity Conditioner must in a liquid-powder, paste-paste, or for the success of an RMGI restora- be rinsed off the tooth surface. The encapsulated delivery system.2 tion.3,6-8 With the advent of newer new Self Conditioner is specifically RMGI bonds to tooth structure generations in bonding materials, recommended for use with Fuji Fill- through both an ion exchange self-etch bonding agents have been ing LC (GC America), while Cavity and micromechanical interlock.3 introduced to adhesively bond Conditioner is recommended for use

www.agd.org General Dentistry November/December 2012 e413 Dental Materials Bond strength of resin-modiﬁed glass ionomer restorative materials using a no-rinse conditioner

tooth structure to ensure dentin Table. Application technique and composition of materials exposure. Each specimen was used in this study. examined with a stereomicroscope to ensure complete exposure of Material Application Composition the dentin surface with no residual Th fi Fuji II LC Triturate for 10 seconds, place Powder: alumino-silicate glass; enamel. e dentin was nished with applicator, photocure for Liquid: polyacrylic acid, HEMA, with 600 grit silicon-carbide paper 20 seconds initiators, water to create a uniform smear layer. Fuji Filling LC Dispense, mix for 10 seconds, Paste A: alumino-silicate glass, All surface conditioning steps place with instrument or HEMA, UDMA; Paste B: polyacrylic were performed according to manu- syringe tip, photocure acid, UDMA, silica dioxide, facturer’s instructions (See Table). initiators, water Six different group combinations Cavity Conditioner Apply, wait 10 seconds, rinse Polyacrylic acid, aluminum chloride, were created: with water, dry, do not desiccate water 1. Fuji II LC/Cavity Conditioner Self Conditioner Apply, wait 10 seconds, dry gently Ethanol, HEMA, 4-META, water 2. Fuji II LC/Self Conditioner for 5 seconds, do not rinse 3. Fuji II LC/No surface HEMA: 2-hydroxyethyl methacrylate; UDMA: urethane dimethacrylate; 4-META: 4-methacryloxyethyltri- mellitate anhydride conditioner 4. Fuji Filling LC/Cavity Conditioner 5. Fuji Filling LC/Self Conditioner with Fuji II LC (GC America).10,11 (control) using encapsulated or 6. Fuji Filling LC/No surface Fuji II LC is an encapsulated RMGI hand-mixed RMGI restorative conditioner restorative material, whereas Fuji materials. Two null hypotheses were Specimens were placed in an Filling LC is a new paste-paste, evaluated: There was no significant Ultradent jig (Ultradent Products, hand-mixed material. Both are difference in bond strength to dentin Inc.) and secured beneath a white marketed for Class 3 and 5 restora- based on surface treatment, and nonstick Delrin insert (DuPont de tions, Class 1 restorations in primary there was no significant difference Nemours & Co.). The bonding area teeth; and as a base or core buildup in bond strength to dentin based on was limited to a 2.4 mm diameter material. The new Fuji Filling LC RMGI restorative material. circle determined by the Delrin reportedly has increased adhesion insert. The RMGI was mixed and and superior esthetics with the Materials and methods applied in 2-mm incremental layers inclusion of dimethacrylate mono- One hundred twenty extracted to a height of 3–4 mm as recom- mers and silica filler particles.12,13 human third molars were stored mended by the manufacturer. Each One concern with RMGI materials in 0.5% chloramine-T and used layer was cured for 20 seconds using that require manual mixing is a within three months following the Bluephase 16i photocuring unit potential loss in cohesive strength extraction. Teeth were randomly (Ivoclar Vivadent, Inc.). Irradiance due to an increase in porosity. divided into two groups based of the curing light was monitored Very little research has been pub- on the restorative material to be with an LED Radiometer (Kerr lished that compares the traditional evaluated (Fuji II LC or Fuji Filling Corporation) to verify irradiance polyacrylic acid conditioner to a LC). For each restorative group levels of at least 1,200 mW/cm2. All new commercially available, no-rinse there were three surface treatments specimens were stored for 24 hours conditioner, nor has much been (Cavity Conditioner, Self Condi- in distilled water at 37°C. published comparing encapsulated tioner, or no surface conditioner), The specimens were loaded and hand-mixed RMGI restorative creating a total of six group combi- perpendicularly with a customized materials on the bond strength to nations with 20 teeth per group. probe (Ultradent Products, Inc.) in dentin. The purpose of the present Teeth were mounted in dental a universal testing machine (MTS study was to determine the shear stone supported with a PVC pipe Systems) using a crosshead speed of bond strength to dentin of a new no- matrix to keep the crown exposed 1.0 mm/min. Shear bond strength rinse self-conditioner as compared to and accessible. A diamond saw values were calculated from the that of the conventional polyacrylic (Isomet, Buehler) was used to peak load of failure divided by acid conditioner or no conditioner remove at least 2 mm of coronal the specimen surface area. Means

e414 November/December 2012 General Dentistry www.agd.org and standard deviations were Chart 1. Shear bond strength of RMGI restorative materials determined for each group. The to dentin. Error bars represent one standard deviation. data were analyzed using a two-way ANOVA and a Tukey multiple 15 comparison test to evaluate the No conditioner effects of restorative material (two Cavity conditioner levels) or surface treatment (three Self conditioner levels) on the shear bond strength 10 of RMGI to dentin (α = 0.05).

After testing, each specimen MPa was examined using a stereomicroscope at 10X magnification to 5 determine failure mode as either adhesive fracture at the RMGI-dentin interface, cohesive fracture in RMGI or dentin, or mixed 0 Fuji II LC Fuji Filling LC (combined adhesive and cohesive) in RMGI or dentin.

Results Chart 2. Failure modes of RMGI restorative materials to dentin. A significant difference was found based on surface treatment 100 (P < 0.001) and RMGI restorative material (P < 0.001), with no significant interactions (P = 0.847). 75 Chart 1 displays the bond strength to dentin of the different groups. No significant differences were found % 50 among the two restorative materials when comparing Cavity Condi- tioner to Self Conditioner, but both 25 conditioners produced significantly higher bond strengths than no conditioner. Fuji II LC showed higher bond strengths among the different 0 No Cavity Self No Cavity Self surface treatments than Fuji Filling conditioner conditioner conditioner conditioner conditioner conditioner LC. Chart 2 shows the failure modes Fuji II LC Fuji Filling LC of the various groups. Groups with Self Conditioner had the greatest Cohesive Mixed Adhesive incidence of cohesive failures, followed by Cavity Conditioner, then no conditioner. evaluate their performance, at least the adhesive bond, it still remains Discussion initially. The shear bond strength the most common technique to New restorative materials are test is one method of evaluating measure bond strength.14 continuously being introduced to the new no-rinse conditioners, The first null hypothesis was the dental profession, often without specifically their ability to retain the rejected. The shear bond strengths clinical research. Clinical trials RMGI restorative material in an to dentin using Self Conditioner require long observation times, so environment where it might be sub- and Cavity Conditioner were in vitro testing of newly developed jected to significant forces. Although significantly greater than with no materials is recommended to the shear test does not actually assess conditioner, but they were not

www.agd.org General Dentistry November/December 2012 e415 Dental Materials Bond strength of resin-modiﬁed glass ionomer restorative materials using a no-rinse conditioner

significantly different from each have created a more porous mate- Department of Defense or other other. The results of this study agree rial than capsule-mixed products. departments of the United States with those of a study by Coutinho These porosities could have contrib- Government. The authors do not et al, who found no significant dif- uted to the lower cohesive strength have any financial interest in the ference between a polyacrylic acid of Fuji Filling LC compared to companies whose materials are conditioner and an experimental Fuji II LC. A previous laboratory discussed in this article. no-rinse conditioner when bond- study found a significant increase ing RMGI materials to dentin.15 in porosities and decrease in bond Author information However, the quality of the bond to strength to dentin after the manual Maj Suihkonen is a general dentist, dentin should not be based solely on mixing of an RMGI adhesive com- Ramstein, Germany. Col. Vande- bond strength values. The type of pared to an encapsulated RMGI walle is director of dental research, bond failure can provide additional restorative material.15 Also, it can Lackland Air Force Base, Texas. information regarding the potential be speculated that the inclusion of Col. Dossett is director of dental performance of the materials sub- the cross-linking dimethacrylate materials evaluation, USAF Dental jected to forces experienced clini- monomers in the new Fuji Filling Evaluation and Consultation Ser- cally. Groups in the present study LC might have contributed to the vice, Fort Sam Houston, Texas. that used Self Conditioner had reduction in the chemical adhesion more cohesive failures, suggesting a to dentin of the glass ionomer com- References more stable interface.16 ponents of the material. 1. Summitt JB, Robbins WJ, Hilton TJ, Schwartz RS. Th Fundamentals of operative dentistry: A conser- Studies have shown that condi- e present study showed vative approach, ed. 3. Chicago: Quintessence tioning of the dentin is a crucial stronger bond strength to dentin Publishing;2006:245-247. step in the bonding process of utilizing Self Conditioner compared 2. Powers J, Sakaguchi R. Craig’s restorative dental materials, ed. 12. St. Louis: Mosby Publishing; RMGI, and that RMGI materials to Cavity Conditioner with either 2006:73-179. bond primarily through a dual-fold Fuji II LC or Fuji Filling LC, but 3. Tay FR, Smales RJ, Ngo H, Wei SH, Pashley DH. mechanism that includes micro- not to a statistically significant Effect of different conditioning protocols on adhesion of a GIC to dentin. J Adhes Dent mechanical retention and chemical level. However, in the interest of 2001;3(2):153-167. interactions of carboxyl groups from time management, a no-rinse self- 4. Heintze SD, Rufﬁeux C, Rousson V. Clinical per- the polyalkenoic acid and calcium conditioner might be appealing to formance of cervical restorations—A meta- analysis. Dent Mater 2010;26(1):993-1000. from the partially demineralized dental professionals. In addition, 5. Peumans M, Kanumilli P, De Munck J, Van Lan- dentin.15,17-20 Although a hybrid layer the encapsulated Fuji II LC might duyt K, Lambrechts P, Van Meerbeek B. Clinical forms and micromechanical bonding be easier to mix and apply, with the effectiveness of contemporary adhesives: A sys- fi tematic review of current clinical trials. Dent is possible, a recent study found additional bene t of greater strength Mater 2005;21(9):864-881. minimal evidence of micromechani- compared to Fuji Filling LC. 6. Tanumiharja M, Burrow MF, Tyas MJ. Microten- cal bonding through resin tags.21 Self sile bond strengths of glass ionomer (polyalke- noate) cements to dentin using four Conditioner has a similar composi- Conclusion conditioners. J Dent Res 2000;28(5):361-366. tion (HEMA, 4-META, ethanol) to Fuji II LC had significantly greater 7. Charlton DG, Haveman CW. Dentin surface primers and solvents in resin-based bond strength to dentin than Fuji treatment and bond strength of glass ionomers. Am J Dent 1994;7(1):47-49. composite adhesive bonding agents, Filling LC and was less technique- 8. Garcia-Godoy F. Dentin surface treatment and potentially producing a stronger sensitive. There was no significant shear bond strength of a light-cured glass iono- hybrid layer and increasing micro- difference in bond strength to dentin mer. Am J Dent 1992;5(5):283-285. Th 9. Besnault C, Attal JP, Ruse D, Degrange M. Self- mechanical bonding. e no-rinse among the RMGI materials with etching adhesives improve the shear bond conditioner might have increased the use of either Cavity Conditioner strength of a resin-modiﬁed glass-ionomer ce- the number of cohesive fractures or Self Conditioner; however, both ment to dentin. J Adhes Dent 2004;6(1):55-59. fi 10. Cavity Conditioner product brochure, Alsip, IL: compared to the use of polyacrylic conditioners showed signi cantly GC America. Available at www.gcamerica.com/ acid found in Cavity Conditioner. greater shear bond strength than products/operatory/Cavity_Conditioner/index. The second null hypothesis non-conditioned dentin surfaces. php. Accessed June 1, 2011. 11. GC Self Conditioner Material Safety Data was also rejected. Fuji II LC had Sheet. Alsip, IL: GC America. Available at significantly greater bond strength Disclaimer www.gcamerica.com/downloads/msds/GC% to dentin compared to Fuji Fill- The views expressed in this article 20Self%20Conditioner%20MSDS012209.pdf. Accessed June 1, 2011. ing LC. Mixing the paste-paste are those of the authors and do 12. GC Fuji II LC Capsules product brochure. Alsip, IL: material of Fuji Filling LC might not reflect the official policy of the GC America. Available at www.gcamerica.com/

e416 November/December 2012 General Dentistry www.agd.org products/operatory/GC_Fuji_II_LC_CAPSULES/ acids to hydroxyapatite, enamel and dentin. Bio- index.php. Accessed June 1, 2011. materials 2003;24(11):1861-1867. 13. GC Fuji Filling LC product brochure. Alsip, IL: GC 20. Yoshida Y, Van Meerbeek B, Nakayama Y, Snau- America. Available at www.gcamerica.com/ waert J, Hellemans L, Lambrechts P, Vanherle G, products/operatory/GC_Fuji_Filling_LC/index. Wakasa K. Evidence of chemical bonding at bio- php. Accessed June 1, 2011. material-hard tissue interfaces. J Dent Res 2000; 14. El-Askary FS, Nassif MS. The effect of the pre- 79(2):709-714. conditioning step on the shear bond strength of 21. El-Askary FS, Nassif MS, Fawzy AS. Shear bond nano-filled resin-modified glass-ionomer to strength of glass-ionomer adhesive to dentin: dentin. Eur J Dent 2011;5(2):150-156. Effect of smear layer thickness and different 15. Coutinho E, Van Landuyt K, De Munck J, Poitevin dentin conditioners. J Adhes Dent 2008;10(6): A, Yoshida Y, Inoue S, Peumans M, Suzuki K, 471-479. Lambrechts P, Van Meerbeek B. Development of a self-etch adhesive for resin-modified glass Manufacturers ionomers. J Dent Res 2006;85(4):349-353. Buehler, Lake Bluff, IL 16. Frankenberger R, Perdigao J, Rosa BT, Lopes M. 847.295.6500, www.buehler.com “No-bottle” vs “multibottle” dentin adhesives: A microtensile bond strength and morphological DuPont de Nemours & Co, Wilmington, DE study. Dent Mater 2001;17(5):373-380. 302.999.4592, www2.dupont.com 17. Tay FR, Smales RJ, Ngo H, Wei SH, Pashley DH. GC America, Alsip, IL Effect of different conditioning protocols on ad- 800.323.7063, www.gcamerica.com hesion of a GIC to dentin. J Adhes Dent 2001; Ivoclar Vivadent, Inc., Amherst, NY 3(2):153-167. 800.533.6825, www.ivoclarvivadent.us 18. Yip HK, Tay FR, Ngo HC, Smales RJ, Pashley DH. Kerr Corporation, Orange, CA Bonding of contemporary glass ionomer ce- 877.685.1484, www.kerrdental.com ments to dentin. Dent Mater 2001;17(5):456- 470. MTS Systems, Eden Prairie, MN 19. Fukuda R, Yoshida Y, Nakayama Y, Okazaki M, 800.328.2255, www.mts.com Inoue S, Sano H, Suzuki K, Shintani H, Van Ultradent Products, Inc., South Jordan, UT Meerbeek B. Bonding efficacy of polyalkenoic 888.230.1420, www.ultradent.com

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