The first issue of the Balkan Journal of Dental Medicine was published in 2014 The Journal continues the tradition of the Balkan Journal of Stomatology which was published between 1997 and 2013 Publisher: DE GRUYTER OPEN
Editor-in-Chief Editorial Board Prof. Dejan Marković, DDS, PhD Assoc. Prof. Dorjan Hysi, DDS, PhD School of Dental Medicine Faculty of Dentistry, University of Medicine-Tirana, Albania University of Belgrade, Serbia Prof. Virgjini Mulo, DDS, PhD [email protected] Faculty of Dentistry, University of Medicine-Tirana, Albania Associate Editors Assoc. Prof. Naida Hadžiabdić, DDS, PhD Ruzhdie Qafmolla, DDS, PhD Faculty of Dentistry Faculty of Dentistry University of Sarajevo, Bosnia and Herzegovina University of Medicine-Tirana, Albania Dr. Mihael Stanojević, DDS, MSc [email protected] Medical Faculty Foca, Bosnia and Herzegovina Maida Ganibegović, DDS, PhD Prof. Andon Filtchev, DDS, PhD Faculty of Dentistry, University of Sarajevo Faculty of Dental Medicine, Medical University, Bulgaria Bosnia and Herzegovina Prof. Georgi Todorov, DDS, PhD [email protected] Faculty of Dental Medicine, Medical University, Bulgaria Assoc. Prof. Nikolai Sharkov, DDS, PhD Dr. Huseyn Biçak, DDS Faculty of Dental Medicine General Hospital Nicosia, Cyprus Medical University, Sofia, Bulgaria [email protected] Dr. Aikaterine Kostea, DDS General Hospital Nicosia, Cyprus Assoc. Prof. George Pantelas, DDS, PhD The School of Medicine Assoc. Prof. Ilijana Muratovska, DDS, PhD European University Cyprus, Cyprus Department of Dentistry, Goce Delcev UN of Štip, FYROM [email protected] Assoc. Prof. Vera R. Nikolovska, DDS, PhD Prof. Ana Minovska, DDS, PhD Department of Dentistry, Goce Delcev UN of Štip, FYROM Department of Dentistry Prof. Lambros Zouloumis, DDS, PhD Goce Delcev University of Štip, FYROM School of Dentistry, Aristotle University, Greece [email protected] Prof. Athanasios Poulopoulos, DDS, PhD Prof. Anastasios Markopoulos, DDS, PhD School of Dentistry, Aristotle University, Greece School of Dentistry, Aristotle University, Greece Assoc. Prof. Zoran Vlahović, DDS, PhD [email protected] V Dental Centar, Montenegro Assoc. Prof. Mirjana Đuričković Prof. Andrei Iliescu, DDS, PhD Faculty of Medicine Faculty of Dentistry, Grigore T. Popa U. M. Ph. Iasi, Romania University of Montenegro, Montenegro [email protected] Assoc. Prof. Paula Perlea, DDS, PhD Faculty of Dentistry Prof. Forna Norina Consuela, DDS, PhD Carol Davila University of Medicine and Pharmacy, Romania Faculty of Dentistry Grigore T. Popa U. M. Ph. Iasi, Romania Assoc. Prof. Tamara Perić, DDS, PhD [email protected] School of Dental Medicine, University of Belgrade, Serbia Prof. Slavoljub Živković, DDS, PhD Dr. Slobodan Anđelković, DDS School of Dental Medicine, University of Belgrade, Serbia Private Dental Practice- Belgrade, Serbia [email protected] Prof. Gül Işik Özkol, DDS, PhD Prof. Ender Kazazoglu, DDS, PhD Istanbul University, Turkey Dental School, University of Yeditepe, Turkey Assoc. Prof. Zeynep Ozkurt Kayahan, DDS, PhD [email protected] Dental School, University of Yeditepe, Turkey Balk J Dent Med, Vol 21, 2017
International Editorial Board Publications Committee Prof. Nitzan Bichacho, DDS, PhD Chair The Hebrew University Prof. Ljubomir Todorović, DDS, PhD Hadassah School of Dental Medicine, Israel Academy of Medical Sciences Dr. Borko Čudović, DDS Serbian Medical Society, Serbia Angle Society of Europe, Germany [email protected] Prof. George Freedman, DDS, PhD BPP University School of Health, Faculty of Dentistry, Editorial Medical Staff United Kingdom Assoc. Prof. Elizabeta Gjorgievska, DDS, PhD Assoc. Prof. Alex Grumezescu, PhD Faculty of Dentistry Polytechnic University of Bucharest, Romania Ss. Cyril and Methodius UN, FYROM Prof. James Gutmann, DDS, PhD Prof. Bojan Petrović, DDS, PhD Texas A&M University Baylor College of Dentistry, USA Faculty of Medicine Prof. Christoph Hämmerle, DDS, PhD University of Novi Sad, Serbia Center of Dental Medicine, University of Zurich, Germany Dr. Marijan Denkovski, DDS, FYROM Dr. Chris Ivanoff College of Dentistry Dr. Georgios Tsiogas, DDS, Greece University of Tennessee Health Science Center, USA Dr. Ana Jotić, DDS Dr. Barrie Kenney, DDS Private Dental Practice Private practice- Los Angeles, USA Belgrade, Serbia Dr. Predrag Charles Lekic, DDS, PhD Translations supervisor University of Manitoba, Canada Gordana Todorović Prof. Joshua Moshonov, DDS, PhD The Hebrew University Technical Editing Hadassah School of Dental Medicine, Israel Dr. Milica Cindrić, DDS John Nicholson, PhD, DSc Bluefield Centre for Biomaterials, United Kingdom Publishing Managers Prof. Kyösti Oikarinen, DDS, PhD Jelena Jaćimović, PhD University of Oulu, Finland School of Dental Medicine Assoc. Prof. Sangwon Park, DDS, PhD University of Belgrade, Serbia Chonnam National University, South Korea [email protected] Prof. George Sandor, PhD Res. Asst. Bojana Ćetenović, DDS, PhD University of British Columbia, Canada Institute for Nuclear Sciences „Vinca“ Prof. Ario Santini, DDS, PhD [email protected] Faculty of General Dental Practice, United Kingdom Statistical Advisor Prof. Riitta Suuronen, DDS, PhD Institute for Regenerative Medicine Prof. Biljana Miličić, MD, PhD University of Tampere, Finland School of Dental Medicine Dr. Michael Weinlaender, DDS University of Belgrade, Serbia Private Practice- Vienna, Austria [email protected]
Editorial Office: School of Dental Medicine, Clinic for Paediatric and Preventive Dentistry, Dr. Subotića 11, 11000 Belgrade, Serbia e-mail: [email protected], Tel: +381641149773, Fax: +381112685361
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L BALKAN JOURNAL OF DENTAL MEDICINE A ISSN 2335-0245 IC G LO TO STOMA
VOLUME 21 NUMBER 1 MARCH 2017 PAGES 1-68
Contents
RP A. Harutyunyan Biomechanical Outcomes of Tooth-Implant-Supported 1 A. Pissiotis Fixed Partial Prostheses (FPPs) in Periodontally Healthy Patients using Root Shape Dental Implants
RP A. Dalopoulou Extrusion of Root Canal Sealer in Periapical Tissues - 12 N. Economides Report of Two Cases with Different Treatment Management and V. Evangelidis Literature Review
OP K. Veneti Demographic Characteristics, Referrals and Patients’ Accessibility to an 19 S. Stafylidis Oral and Maxillofacial Surgery Clinic T. Kafkia M. Kourakos K. Antoniades C. Zilides S. Dalampiras
OP A. Synarellis In Vitro Microleakage of class V Composite Restorations prepared by 24 P. Kouros Er,Cr:YSGG Laser and Carbide BUR E. Koulaouzidou D. Strakas E. Koliniotou-Koumpia
OP N. Majstorović Examination of Scanner Precision by Analysing Orthodontic Parameters 32 L. Čerče D. Kramar M. Soković B. Glišić V. Majstorović S. Živković
OP Sasho Jovanovski The Influence of Crown Ferrule on Fracture Resistance of 44 Julie Popovski Endodontically Treated Maxillary Central Incisors Alesh Dakskobler Ljubo Marion Peter Jevnikar
OP A. Cicmil Oral Symptoms and Mucosal Lesions in 50 O. Govedarica Patients with Diabetes Mellitus Type 2 J. Lečić S. Mališ S. Cicmil S. Čakić Balk J Dent Med, Vol 21, 2017
CR E. Anitua Treatment of Biphosphonate-Related Osteonecrosis of the Jaw (BRONJ) 55 Combining Surgical Resection and PRGF-Endoret® and Rehabilitation with Dental Implants: Case Report
CR F. Demiray Adams-Olıver Syndrome: a Case Report 60 E. Korkut O. Gezgin Y. Şener B. Bostancı
CR Z. Vlahović 3D Printing Guide Implant Placement: A Case Report 65 M. Mikić
10.1515/bjdm-2017-0001
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L BALKAN JOURNAL OF DENTAL MEDICINE A ISSN 2335-0245 IC G LO TO STOMA
Biomechanical Outcomes of Tooth-Implant-Supported Fixed Partial Prostheses (FPPs) in Periodontally Healthy Patients using Root Shape Dental Implants
SUMMARY Argine Harutyunyan1, Argirios Pissiotis2 Background: Connecting an osseointegrated implant and a natural 1Postgraduate student, Yerevan State Medical tooth is a treatment alternative for partially edentulous patients in some University after Mkhitar Heratsi (YSMU) clinical situations. The main issue of a connected tooth-implant system is Armenia derived from the dissimilar mobility patterns of the osseointegrated fixtures 2School of Dentistry and natural abutments causing potential biomechanical problems within the Aristotle University of Thessaloniki Thessaloniki, Greece entire system. Purpose: The aim of this review was to multilaterally analyze and discuss the main biomechanical factors that may question the reliability of splinted tooth-implant system and the long-term success of fixed partial prostheses (FPPs) supported by both teeth and implants with an emphasis on the disparity of mobility of these two different abutments. Material and methods: An electronic MEDLINE (PubMed) search supplemented by manual searching was performed to retrieve relevant articles. An assessment of the identified studies was performed, the most valuable articles were selected and biomechanical outcomes of tooth-implant splinting system were analyzed. Results: 3D FEM stress analyses and photoelastic studies show uneven load distribution between the tooth and the implant and stress concentration in the crestal bone around the implant neck when connected to a natural tooth by FPPs. However, clinical studies demonstrate good results for both the implants and FPPs supported by splinted implant-to- tooth abutments. Conclusion: Connecting implants to natural teeth is not a preferable treatment option because of possible inherent biomechanical complications. Whenever possible, this treatment option should be avoided. Keywords: Tooth-Implant Supported Prostheses, Natural Tooth, Osseointegrated Dental REVIEW PAPER (RP) Implant, Occlusal Force, Finite Element Analysis, Rigid Connector, Non-Rigid Connector Balk J Dent Med, 2017; 21:1-11
Introduction considerably, and some of them are even contradictory. Several studies demonstrate a good prognosis for implant- The introduction of osseointegrated implants by tooth-supported FPPs2-8, others reveal considerable bone Per-Ingvar Bränemark has had a revolutionary effect on loss, even loss of osseointegration and failure of FPPs all fields of dentistry1. Dental implants were originally supported by natural teeth and endosseous implants. developed for the treatment of complete edentulism. There are several biomechanical factors that may However they are now widely used to treat partial jeopardize the entire prosthetic treatment and affect edentulism, but the philosophy of this treatment concept, the long-term success of implant-tooth-supported particularly regarding the connection of dental implants FPPs such as: a) differences in the mobility pattern with natural teeth is still a big dilemma. The combined between natural teeth and osseointegrated implants, b) use of implants and teeth appeared in the mid 1980s2. occlusal force pattern (that is the magnitude, duration, Numerous studies and analyses have been performed since frequency, distribution and direction of the forces during then, but the conclusions derived from these studies differ the function), c) characteristics of prosthesis (rigidity, 2 Argine Harutyunyan, Argirios Pissiotis Balk J Dent Med, Vol 21, 2017 connector type (rigid, non-rigid), connector position( near the axial mobility of a connected tooth. They advocate the tooth, near the implant), length of span, the features that a tooth rigidly connected to a single Bränemark of materials of which the prosthesis is made etc.), d) implant will take an active part in supporting the axially characteristics of the implant system (implant shape, applied forces of the prosthesis due to the resiliency of length, diameter, surface macrostructure, implant-to- the implant screw joint and a momentary opening of the abutment connection), e) characteristic of the bone around abutment-implant interface without any additional flexible the teeth and the implants ( the quality and the quantity of element4. the bone), f) number of connected teeth and implants2,14,27, Chapman and Kirsch21 recommend the use of an 29. All these factors determine the stress which affects the intra-mobile element (IME) which would increase the bone around splinted implants and teeth. implant abutment compatibility with natural abutments. The main issue regarding splinting implants with This would therefore allow rigid interconnection through natural teeth is the difference of their mobility pattern the prosthesis21,22 . The question of whether additional which could be considered as a biomechanical challenge implant-integrated resilient elements are necessary is still for the entire splinted system11, 13, 14, 17, 20. controversial13. Natural teeth with a sound periodontal ligament The second issue is the difference of tactile have a mobility between 15-20µm (axial displacement) sensitivity threshold between implants and teeth which and 150-200µm (horizontal displacement)10, while is 8,75 times higher for implants23. This significant osseointegrated implants rigidly attached to the bone difference in mechanoperception may cause ineffective have a mobility of less than 10µm11, which is due to a bite force control and stress concentration on the implant combination of the bone elasticity and the flexibility of side of implant-tooth-supported FPPs. the implant system (implant-prosthesis, implant-abutment, Other studies affirm that the load condition is the prosthesis flexibility itself)12-14. Such a discrepancy main factor affecting stress distribution in different between the mobility patterns causes lever arm overload components of implant-tooth-supported FPPs (bone, forces on the stiffer abutment (implant) and may lead to prosthesis, fixture)14,15,24. Indeed, occlusal load duration, several physiological, mechanical and biomechanical magnitude, distribution, frequency and the direction of the problems (bone loss around the implants, abutment and forces during the function have a great influence on both prosthesis screw loosening and fracture, prosthesis and the FPPs and the abutments. Decreasing occlusal loading implant fracture, tooth intrusion) when implants are forces on the pontic area of the FPPs and directing these rigidly connected to teeth. forces through the long axis of abutments significantly To overcome the difference in mobility and the decrease the risk of unfavorable stresses within the above mentioned problems non-rigid connector types prosthesis and the bone around the teeth and the implants. have been proposed by different authors15-17. However, Data concerning the number of splinted teeth there is no clear consensus regarding the effectiveness of and implants are also controversial4-6, 20,40 . In their this type of connectors because of the potential clinical retrospective multicenter study, Lindh et al5 found out hazard of natural tooth intrusion5. Several studies reported that intrusion of natural teeth (which is one of the main no significant difference between rigid and non-rigid complications when connected with implants) was connector types12, 18. most common in the prosthesis design with one implant The position of the non-rigid connector in FPP is also connected to one tooth. Splinted natural teeth have less an issue of discussion. It has been shown that placement mobility compared with the mobility of a single tooth, of the non-rigid connector on the implant side rather thus making the whole unit mobility more comparable than the tooth side of FPPs has both biomechanical and to that of the implants12, 25-27. On the other hand, some technical advantages11, 19. It was also documented that authors insist that the addition of an extra tooth increases the use of the patrix part of the non-rigid connector on the load on the implants rather than supports them17. the implant site and the matrix part on the pontic site may Splinting more than one implant will increase their be biomechanically efficient by reducing the potential resistance against occlusal loading forces and reduce harmful cantilever forces and stress formation around the deflection of the prosthesis, thus reducing the risk of the implant11. Lawrence et al 17 advocated modifying mechanical complications4,6,20. Load transfer to implants the design of the conventional prosthesis (placing the and natural tooth changing the number of splinted attachment near one of the abutments (tooth or implant)) implants were estimated by Nishimura et al16. They and to extend the cantilevers from both sides of the performed quasi-3D testing, analyzed a photoelastic abutments and join them with an internal attachment at the model and changed the number of splinted implants by middle part of the prosthesis. They insist that using this removing of the abutment of the medial standing implant. design will create less torque and stress on the implants The results showed higher apical stress concentration without overloading the natural teeth. around the abutments when only one implant was splinted Rangert et al 4, 20 showed that a single Bränemark with a tooth regardless of the type of the connector. When implant has an inherent bending flexibility that matches forces were directed on the implant segment, the stress Balk J Dent Med, Vol 21, 2017 Tooth-Implant-Supported FPPs 3 concentration around the tooth and the implant were in peri-implant bone, the bone around natural teeth as similar to that of a two-implant condition. However, well as within the prosthesis. Articles based on 2D they concluded that a 13-mm implant as a posterior FEA and photoelastic stress analysis methods were abutment may adequately support the 3-unit prosthesis excluded because of their limitations and drawbacks rigidly connected to a tooth. Jemt et al9 performed a long- (lack of information and accuracy). One of the included term follow-up study using Bränemark implants. They articles contained both 2D and 3D FEA methods28. Only connected several implants to natural teeth and came to information from 3D FEA results was extracted. the conclusion that 2-3 implants (at least) are adequate Studies, included implant-tooth-supported FPPs to take the full load of the segment by themselves when in periodontally compromised patients were excluded. splinted with natural teeth (the continuous prosthesis Case reports, publications based on patient records only, stability rate was 98,7%). questionnaires or interviews were also excluded. The aim of this study was to summarize the results of the existent stress analysis studies (3D FEA and photoelastic methods) and clinical studies and to discuss the biomechanical outcomes of implant-tooth-supported Results FPPs with an emphasis on the differences between tooth and implant mobility patterns. It is known from literature that teeth have a certain physiologic mobility within their respective alveolar sockets. This physiological mobility is due to the presence of a periodontal ligament (PDL) between the tooth and Material and Methods the alveolar bone surrounding it. The PDL is composed of intercellular ground substance (matrix), fibers (collagen, An electronic MEDLINE (PubMed) search between oxytalan, elaunin), and cells with their neurovascular 1980 and 2015 was conducted to retrieve relevant supply. Tooth mobility is a direct function of the articles. A further manual search from the bibliographies mechanical properties of the periodontal protein matrix of the former articles was performed to include as many with its collagenous elements10. Tooth movement (TM) references as possible. The search included English- when a horizontal force is applied to the crown may be language articles published in the Dental Literature. divided into 3 phases: a) initial TM, b) intermediate TM, The search terms used were : “tooth-implant c) terminal TM10. connection”, “splinting”, “implant connected to a natural The initial (desmodontal) TM is explained by the tooth”, “tooth intrusion”, “rigid connector”, “biomechanics”, special syndesmotic anchorage of the tooth in the alveolar “load distribution”, “tooth-implant-supported fixed partial bone. Within this phase the resistance of the tooth against prosthesis” and combinations of these terms. the force is very small. This phase corresponds with a Manual searching was applied to the following first phase of readiness orientation and stretching of the journals: Clinical Oral Implants Research, International PDL fibers without strain. The collagen fibers of PDL Journal of Prosthodontics, Journal of Clinical have a wavy configuration in the relaxed state29 which Periodontology, Journal of Prosthetic Dentistry, enables the tooth enable to move easily without any Periodontology 2000, International Journal of Oral and resistance at the beginning of force application. This Maxillofacial Implants. initial displacement of a natural abutment would cause From a total of 1879 titles electronically identified stress concentration around a rigidly connected implant from the initial search, 95 studies were selected for abutment before the two become comparable in their potential inclusion (included by titles and abstracts). resiliencies. 63 studies were selected for full text evaluation (32 The degree of desmodontal TM depends on several studies were excluded: cross-sectional, case reports, old factors: the width of the PDL, the shape of the root, the implant technology), from which only 51 studies met the structure, disposition and interlacing of the collagen inclusion criteria and final data extraction. Prospective fibers10. and retrospective clinical studies, as well as randomized If the force is increased, the resistance of the tooth controlled clinical trials (RCT) were included in this against that force will suddenly increase-in this state, the paper. Inclusion criteria for clinical studies involved TM is at the limit between its initial and intermediate patients with periodontally healthy teeth, root shape phase. In order to push the crown over a distance similar endosseous osseointegrated dental implants and fixed to the phase of initial TM, greater forces are needed (100- partial prostheses supported by both teeth and implants. 1500Gm). In this phase tooth movement occurs due to an Studies based on 3D finite element analysis and elastic deformation of alveolar bone10. photoelastic stress analysis were also included as these With an increase in force over 1500Gm pain is methods are extremely useful and have become the main registered. During this phase the crown hardly moves tools for numerically assessing stresses and deformations anymore in spite of a strong increase in applied force 4 Argine Harutyunyan, Argirios Pissiotis Balk J Dent Med, Vol 21, 2017
(1500-1750Gm). Teeth with a healthy periodontium will In a free-standing implant-supported prosthesis, show a narrow and sharply delimited zone of terminal force application to one portion is distributed to the TM. For several seconds the tooth will not yield any nearest osseointegrated fixture-bone interface. The movement. Lasting stress produces further movement force is concentrated at that interface and the amount of the crown. A tooth with a sound PDL has horizontal of its distribution to the remaining implant(s) depends and vertical mobility and the upper limit of physiologic on the flexibility of the surrounding bone, implant, horizontal tooth mobility is greater than that of vertical abutment, retaining screws and prosthesis. The amount mobility (150-200µm vs 15-20µm) 3,4,10. of deformation of the retaining screws (most flexible part PDL damps the forces acting on a tooth. This of the system) are in the range of 100µm. Therefore, the damping effect is not only due to collagen fibers, but also amount of force distribution to the remaining fixtures due to the vascular system (blood and lymph vessels) and is much less than that found in natural teeth-supported the interstitial fluid of PDL. Saul et al.30 performed an in FPPs (PDL can permit 500µm of movement)17. However, vivo study on living and dead rats to find out the roles of the maximum load on each implant will be less than the different component parts of PDL in the reduction of the applied complete occlusal force27. oscillation amplitude of a tooth in its socket, when the In the case of the prosthesis supported by an implant tooth has been subjected to intrusive force. They showed and a tooth, the latter does not carry a fair share of that the extracellular and the intracellular fluid systems loading as the resilience of the tooth is higher than that have a hydraulic damping effect and dissipate the force of the implant. When the force is applied at the tooth acting on a tooth during an intrusion. side and/or in the middle part (pontic) of the FPPs, the It can be concluded that due to the presence of the tooth dips into its alveolar socket causing bending of the PDL the occlusal forces applied on the tooth are equally prosthesis. This creates a bending moment on the implant distributed on the bone around the root. The natural tooth neck-bone interface, which means that only one part of receives the impact energy and transfers it in to the end of the force is carried by the tooth while the other (main) the root in the form of a stress wave31. Most of the energy part is transmitted through the implant into the bone. is dissipated by the highly absorptive PDL. The magnitude of this bending moment is dependent on An osseointegrated endosseus implant has a the tooth mobility and the flexibility of the prosthesis, very close apposition to the bone. Besides, at the the implant and the bone4.On the other hand, forces microscopic level there is a bone ingrowth to the macro- directly applied on the implant do not load the tooth and and micropores of the implant surface. Such a close consequently, only the implant carries the complete load13. contact allows for a direct transfer of stress from the Landgren & Laurell14 reported theoretical implant to the surrounding bone without any relative calculations and showed that an implant-tooth-supported movement between them and without any changes bridge functions as a cantilever only for a very short time. in magnitude or duration as the PDL and related At the beginning of load application the FPPs is supported mechanoreception is absent around an osseointegrated by the implant only. After the moment is increased to implant27. An osseointegrated implant has only about a certain level (240Nm), the implant-abutment-crown 10µm displacement which is due to surrounding bone unit rapidly angles in the lateral direction with a certain elasticity13. Because of the lack of micromovement most amplitude. They assumed that this deflection is sufficient of the force distribution is concentrated at the crest of the for a tooth with a normal apical mobility to reach the ridge32. Lateral forces are concentrated at the crestal area bottom of the socket, and when intruded further, the of the alveolar ridge, vertical forces are concentrated at apical yield of the root is close to zero (as of an implant), the crestal and apical parts of the bone17. even if large forces are applied. If plus the bending of Because of the differences in the mobility pattern the beam, only 5-6N are needed to convert the bridge between teeth and implants, occlusal forces applied on the from an implant-supported cantilever construction to a FPPs supported by both implants and natural teeth will be bilateral construction (as the tooth touches the bottom of distributed on the bone differently compared with solely the socket, it doesn’t move apically anymore and starts teeth-supported and solely implant-supported FPPs. sharing the forces with an implant). In solely teeth-supported FPPs situations the load The presence of the PDL provides not only is equally distributed between both abutment teeth when physiologic tooth mobility, but also tactile sensitivity force is applied at the middle of the bridge. If the force which plays an important role in the coordination of is placed at the mesial or distal end of the FPPs the total masticator muscle activity and control of applied occlusal load is carried by the mesial or distal abutment tooth, forces. No periodontal ligament receptors are available for respectively13. However, Lawrence et al.17 note that tactile function if the tooth is replaced by an endosseous if occlusal force is applied only on one abutment it will implant23. When the threshold of perception of teeth and evoke a micro-movement of the other abutment and the implants are compared, higher values have been reported periodontal fibers will distribute generated compression, for implants. Hämmerle et al.23 conducted an in vivo tension and rotational forces on all teeth. study to determine the threshold of tactile perception of Balk J Dent Med, Vol 21, 2017 Tooth-Implant-Supported FPPs 5 endosseous dental implants and to compare it with that of results showed that lateral forces significantly increased natural teeth. Twenty-two healthy subjects with implants the stress values of implants, prostheses and the alveolar of the ITI Dental Implant System were included in the bone compared with axial occlusal forces, regardless study. A total of 34 implants were placed and served as of the bone quality. Maximum von Mises stress values abutments for single tooth crowns (in function for a in the implant system (σI,max) and prosthesis (σP,max) minimum of 1 year). An electronic measuring device demonstrated no significant differences between the was used to determine the threshold values. The range bone qualities under the same loading condition, but the of forces applied for calibration reached from 0,01N to maximal stress values for the alveolar bone (σAB,max) 10N (1-1000g, 1g represents 0,01N force). The obtained increased when the bone quality was reduced. The authors values ranged from 13,2 to 189,4g (mean value of 100,6g) of the aforementioned study also showed that decreasing for the implants and from 1,2 to 26,2g for the control the occlusal forces on the pontic area significantly teeth (mean value of 11,3g).The mean threshold value decreased the values of σI,max, σP,max and σAB,max for implants was 8,75 times higher than that for teeth. . Under axial forces the maximum stress concentrated Thus, when a tooth with exquisite mechanoreception locations in the implant system were found at the contact is connected to an implant with less mechanoreceptive butt-joint interface between the abutment and the implant, sensitivity by FPPs, the magnitude of bite forces may the bottom of the internal hexagon joint of the abutment increase when a patient bites on the implant side of the and threads of the abutment screws. Under the same prosthesis. However, several studies have proved that the forces the maximum stress concentrated locations of magnitude of bite forces in patients with osseointegrated σAB,max and σP,max were found at distal cervical areas implants is comparable to that of patients with natural in the cortical bone and bottom of the mesial connector, 33 34 teeth . Gunne et al in vivo measured vertical forces respectively. For the lateral loading condition the and bending moments on 10 three-unit prostheses in corresponding locations of σI,max, σP,max and σAB,max the posterior mandible of 5 patients (intra-individual were found at the contact butt-joint of the implant , measurement). All patients had a prosthesis supported lingual cervical areas in the cortical bone and the lingual by one implant and one tooth in the molar region on one bonded region between the prosthesis and the abutments, side (rigid connection) and a freestanding, two-implants- respectively. supported prosthesis on the other. The prostheses had been In another study Lin et al tried to investigate the worn for 5-6 years. The results showed no significant biomechanical interactions in TISP by varying the differences in functional load magnitudes related to number of splinted teeth and connector types15. They the abutment type. Akca et al35 performed a similar constructed a 3D FEA FPPs model which contained one study (in vivo) to evaluate maximal occlusal bite forces Frialit-2 implant in the mandibular second molar region (MOFs) and marginal bone level changes in patients splinted to the first and second premolars. They came to with tooth-implant-supported FPPs. They came to the conclusion that even MOFs under functional loading the conclusion that load condition was the main factor were higher for implants (mean: 353,61N) than for teeth affecting the stress developed in the implant, bone and (mean: 275,48N). These increased functional loads are prostheses when comparing it with the connector type far below an overloading of implants. In the same study, and the number of splinted teeth. The 3D FEA showed radiographic measurements revealed a stable marginal reduced stress values in centric and lateral contact bone level around the implants and a total marginal bone situations when the occlusal forces were decreased on level improvement from the baseline to 24 months at the the pontic (26-69%). Under uniform multiple oblique mesial site (mean:0,28±0,519mm) and at the distal site forces the σI,max were at the base of the internal hexagon (mean:0,097±0,518mm), which shows that this splinted joint of the abutment and mesial butt-joint interface system has a promising marginal bone level stability for between the abutment and the implant. The σAB,max the implants. were concentrated on the lingual cervical areas in the Several 3D finite element analyses have been cortical bone around the teeth and the implant side when implemented to assess load distribution and stress the occlusal forces acted only on the premolar and on concentration in TISP. Lin et al.24 analyzed the the prosthesis, respectively. Regarding the connector biomechanics in a tooth-implant splinted system using type they came to the conclusion that using non-rigid 3D FEA with different occlusal forces for various bone connector increased the prosthesis stress more than 3,4- qualities. They constructed a model which contained fold compared with the rigid connector. Depending on the one Frialit-2 implant splinted to the mandibular second specific connector used, the σP,max were on the concave premolar that was embedded in a simplified bony surface of the male component and bottom area for non- segment. Four bone quality categories were established, rigid and rigid connectors, respectively. Regarding the with the elastic parameters assigned to the bone values number of splinted teeth they found that this factor did varying. The stress distribution in the splinting system not affect stress values either for the implant or for the was observed under four different loading conditions. The alveolar bone or for the prosthesis. 6 Argine Harutyunyan, Argirios Pissiotis Balk J Dent Med, Vol 21, 2017
Meniccuci et al.28 implemented 2D and 3D FEAs to removed, a 3-unit fixed restoration was simulated with a assess the stress in the bone around an implant and a tooth pontic. In this type of model, when force was applied at which are rigidly connected when a load is applied on the the load point T, stresses concentrated at the apical part of tooth. Two different loading conditions were compared in the implant were twice as high as the 2-implant condition. this study: an axially directed static load (10 seconds) and The highest stresses were observed at the second implant a transitional load (5 miliseconds). The results of the 3D with the load applied at points 4 and 5. Low level stresses FEA showed the stress concentration at the neck of both were produced within the distal part of the tooth because the tooth and the implant when static load was applied. of its distal bending ability. Under short term transitional forces the stress around both In the rigid connection scenario the results showed abutments was much less (-50%) than that seen under the the following: for the 2-implant model, when the load static loading. Thereby, they concluded that load duration was applied on the tooth abutment, similar apical stresses has a greater influence on the amount of generated were generated around the tooth and the medial implant. stresses in the bone around the implant rigidly connected Some low level responses were noted at the distal surface to the tooth than load intensity, and that the static loads are of the medial implant and at the medial surface of the more detrimental for the bone than the transitional loads. distal standing implant. As the forces were directed to the They suggested that the main reason for these results were implant segment, stresses also transferred to the distal part the visco-elastic properties of the PDL and the very short of the splinted system. The highest stresses were observed load time which is removed before the loaded tooth starts around the distal implant along its distal surface and to sink in its alveoli (before visco-elastic creep occurs). As at the apex when the load was applied at point 5 (which a result the tooth reacts like a rigidly anchored abutment indicates the intrusion and distal bending of the implant). sharing the load with the implant. Several in vivo studies have been performed by Nishimura et al.16 conducted photoelastic stress different authors to investigate the biomechanics of analysis to evaluate stress distribution in an implant- TISP10,20,23,30,34-37. Richter et al.36 presented data from tooth splinted system using different types of connectors. their in vivo study in which 10 tooth-implant-supported They fabricated a life-size photoelastic model of an adult FPPs in the mandible of 9 different patients were human left mandible for quasi-3 dimensional testing. The examined while the intra-mobile elements (IME) of 3 edentulous area was extended distally from the second IMZ implants were replaced by a measuring device with premolar. Two screw-type implants (3,75mm diameter, strain gauges. After the abutment screws were fixed, the 13mm length) were included into the model at the first measuring device was calibrated. The results showed and second molars. Multiple restorations incorporating higher buccal than lingual directed stresses (only in 6 of 3 types of connections between the medial implant and 34 registrations). Measured lateral bending moments were the natural tooth were fabricated: a) non-connection up to 25N×cm during occlusion and chewing. (proximal contact only), b) rigid solder joint, c) non-rigid Another in vivo study was performed by Gunne and connection. Vertical point loads were applied at 6 fixed Rangert20. They measured in vivo bite forces, implant identified locations on the occlusal surface of the tooth- axial forces and bending moments on 5 patients with implant restoration: T, over natural tooth, 1- medial to FPPs supported by a natural tooth and a single Bränemark implants, 2-over medial implant, 3-inter-implant, 4- over implant rigidly connected to each other by a MacCollum distal implant, 5- distal to implants. The results of the attachment and a locking screw. The patients were divided non-connected model were as follows: loading directed into two groups according to the magnitude of the applied on the tooth (point T) transferred low stress to the apices forces, a light-biting group and a hard-biting group. The of both implants (the distal implant received a smaller results demonstrated mean forces of 12N and 95N for amount of forces compared with the medial implant), light-biting and hard-biting groups, respectively. They the highest stress intensity was seen apical to the natural also showed that in the light-biting group the tooth did not tooth. Loadings directed on the implant areas (loading fully engage and the implant carried the major portion of points 1-5) produced little or no discernible stress in the the applied bite force. For the hard-biting group, the tooth apical areas of the tooth; the later was concentrated to the shared the load on an equal basis with the implant. They distal parts close to the implants. Thus, when the load was reported bending moments of 3-5N×cm and 10-16N×cm applied over each abutment, the highest stress intensity for the light- and hard-biting groups, respectively. was seen apical to that abutment. The highest stress within As mentioned earlier the type of connector used the structure was produced under loading on point 5. The is also an important biomechanical factor affecting distal implant underwent intrusion and distal bending. stress distribution in the tooth-implant system. Several Stress was concentrated at the distal crest and at the apex authors advocate the use of a rigid connection25, 28, 35, 38, of that implant. 39, which assumes a stiff junction between component Results of the non-rigid connection between the parts of the structure with no relative motion of one abutments were similar to those of the non-connected part against another. The use of this type of connector situation. When the abutment of the medial implant was reduces tooth intrusion incidence and transfers the load Balk J Dent Med, Vol 21, 2017 Tooth-Implant-Supported FPPs 7 more evenly through the prosthesis, but as the tooth and bone quality. The maximum stress concentrations were the implant have a different degree of mobility, more found in type IV bone (Lekholm and Zarb classification, stress is concentrated around the implant which has been 1985) followed by type III, II and I. In a type I bone, shown by the aforementioned as well as other FEA and the stress distribution is more uniform as the entire bone photoelastic studies41,42. To overcome the disparity in block is compact and homogeneous. The results from mobility of the different abutments, non-rigid connectors studies24 confirm that implants connected to teeth should have been introduced. Indeed, a flexible prosthesis will be used with caution in softer (type IV) bone regions. tend to redistribute the load between the abutments with 3D FEA is generally accepted as a very useful tool unequal stiffness. With a flexible bridge the tendency to assess stress generation and mechanical responses of for any applied load is to be primarily transmitted to simulated clinical situations. However, the constructed FE the nearest abutment whether it is a natural tooth or an models are mathematical models of the real object and/ implant27. In this situation the exact point of applied or phenomenon. Hence, it is not possible to reproduce occlusal force becomes a priority. The use of a non-rigid all the details of the real loading conditions, material connector may be more efficient in terms of compensation properties and the geometries of the component parts for the dissimilar mobility under axial loading forces only. (especially the geometry of the alveolar bone), and some However, under lateral occlusal forces this compensation important parameters that influence the clinical outcomes becomes insignificant. It should be mentioned that most of implant-tooth-supported FPPs may be overlooked. of tooth intrusion cases in splinted systems were detected Such a parameter is the limitation of calculation of the when non-rigid connectors were used 4,6,38. Hence, a host reaction to the stresses applied. Therefore the results potential priority of one type of connector over another is derived from FEA only provide a general understanding still unclear. of the biomechanical aspects of the splinting system and To increase the compatibility of implants with need to be completed and validated by clinical studies. teeth IMZ implants (Interpore-IMZ, Irvine, Calif.) were Several clinical studies3,7,9,25,51 and systematic introduced with an intra-mobile element between the reviews25,38,44,45 have been implemented to find out the implant and the prosthesis. Richter et al.36 used IMZ survival rates of implants and FPPs supported by implants implants in in vivo and in vitro study to measure the and natural teeth. bending moments on the implant caused by axial and Mau et al.51 have compared two different coatings lateral forces. They fastened four different types of of intra-mobile cylinder implants (IMZ, Koch 1976) - connecting devices: 1. IME, 2. an intra-mobile connector hydroxyapatite (HA) and titanium plasma-flame (TPF) – (IMC), 3. a titanium metal IME and 4. a mobile test between patients with Kennedy Class I or II mandibular device. The results were as following: the max bending partially edentulous arches in a randomized controlled moment was 40% of the highest stress using a metal IME trial and estimated the cumulative success rates of the (640Nmm), 25% with the IME (400Nmm), 15% with the implants after 5 years of follow-up period. All FPPs IMC (240Nmm) and 14% for the test device (224Nmm). were supported by one natural tooth (first or second Van Rossen et al.43 estimated the effectiveness premolar) and one implant placed in the molar region. of stress-absorbing elements and their role in stress- The connection between the implants and the teeth was absorption and stress-distribution in the cortical and rigid (screw-retained attachments). From all 313 admitted trabecular bone around a tooth and an implant when patients 155 (49.5%) were randomized to HA-coated IMZ connected to each other. In their FEA they proved that implants as test group and 158 (50.5%) patients were using a stress-absorbing element with a low E-modulus randomized to TPF-coated IMZ implants as control group. both damps and distributes the loading forces more The main criteria of comparison were the duration of no uniformly in the bone surrounding the implant and integration deficiency (ID) and of no functional deficiency the tooth. We can summarize that resilient elements (FD) of the implants after the placement of FPPs (the improve the load distribution between two different authors defined ‘integration deficiency’ as implant loss, abutments by decreasing implant stiffness, thus, making bone loss since the operation of at least 4 mm at the the interconnection more compatible. Moreover, these medial or distal aspect, periotest value of at least 10, shock-absorbing elements allow a rigid, yet retrievable manual mobility grade >0). The 5-year cumulative success connection between teeth and implants22. It should be rates for no ID were 69.5% (95% CI, 58.3-80.7%) with mentioned, however, that this design of implant-prosthesis HA and 82.2% (95% CI, 74.2-90.6%) with TPF. connection has drawbacks, such as wear, fatigue and/ Naert et al.25 conducted a retrospective study to or fracture, which requires a frequent replacement of the evaluate the success of the freestanding and tooth-implant resilient component. connected FPPs up to 15 years of follow-up period. A total Bone characteristics (quality and quantity) are one of of 668 Bränemark implants were placed in 246 patients. In the most important issues to consider when planning an 123 patients, 339 implants were connected to 313 teeth by implant-tooth treatment. It has been proved that stress in means of FPPs (test group). In another randomly selected the bone surrounding the implant increases with reduced group of 123 patients, 329 implants were connected to 8 Argine Harutyunyan, Argirios Pissiotis Balk J Dent Med, Vol 21, 2017 each other (control group). The mean follow-up period survival rates for FPPs were 90.4% (95% CI: 79.8-95.6%) was 6.5 years (1.5-15y) for the test group and 6.2 years and 77.8% (95% CI: 66.4-85.7%), respectively. As it (1.3-14.5y) for the control group. The cumulative implant may be seen from the results, the survival rates for both success (based on the implant immobility and/or lack of implants and FPPs were lower for splinted implant-tooth- the implant fractures after loading) in the test and control supported cases compared with solely implant-supported groups were 94.9% and 98,4%, respectively. situations. Annual failure rates of implants in combined Hosny et al.3 performed an intra-individual implant-tooth-supported FPPs (1.33%) were significantly comparison in 18 partially edentulous patients up higher than those of implants in free-standing implant- to 14-year (mean 6.5) follow-up time to assess the supported FPPs (0.51%). outcome of FPPs supported by teeth and implants and by freestanding implants only. The combined FPPs were supported by 30 implants and 30 teeth (both rigid and non-rigid connection), and the freestanding FPPs were Discussion supported by 48 implants (Bränemark system). After 14 years of follow-up time the results were ‘excellent’: There are some clinical situations in which an no implant failed and no mechanical failures of implant implant-tooth connection is unavoidable and the only components (fracture, loosening) or superstructure was choice of treatment such as: a) an insufficient number of detected. Therefore, they concluded that splinting teeth natural teeth or implants (when insertion of additional with implants does not affect the long-term outcomes of implants is not possible because of systematic, local or the implants and the marginal bone stability. However, financial limitations) to serve as sole abutments for FPP, this study is limited by a small number of patients. b) additional support for periodontally compromised Gunne et al.7 compared the outcomes of the FPPs teeth from stable implants, c) unfavorable location and supported by implants only with FPPs supported by distribution of abutments (both teeth and implants), splinted implants and teeth. 23 patients with Kennedy d) prosthetic versatility and retrievability46. Splinting Class I dentitions in the mandible were included in the implants with natural teeth also has several advantages: study. All patients were provided with implants ad modum proprioception from natural teeth, broadened treatment Bränemark on each side posterior to the mandibular possibilities, better esthetic outcomes (retaining the residual teeth. On one side the FPPs were supported natural tooth preserves the adjacent papillae), reduced by two implants, and on the other side the FPPs were treatment cost, additional support for total load on supported by one tooth and one implant. A total of 69 dentition etc. However, decision-making criteria for implants were inserted and 46 FPPs were fabricated and rehabilitation of partially edentulous arches by splinting followed-up up to 3 years. The authors showed interesting implants with natural teeth are still a dilemma. Clinical results about fixture survival, FPPs survival and marginal studies (both prospective and retrospective) show good bone loss when comparing solely implant-supported prognosis for combined implant-tooth-supported FPPs. and implant-tooth-supported combination bridges. The Lindh et al.5 conducted a retrospective multicenter survival rate of the implants was 88.4% and for both study which comprised 185 implants in 111 patients types of FPPs it was the same. The survival rate of the from 6 different clinics in Sweden. The results showed FPPs was higher in implant-tooth combinations than in a cumulative implant survival rate of 95.4% for up to 3 solely implant-supported FPPs (91.3% vs 82.6%). They years of follow-up. The frequent complications were loss also observed lower mean marginal bone loss adjacent to of osseointegration (6/185), followed by peri-implant the implants connected to the natural teeth than those that infections (4/185) and natural tooth intrusion (15% of the were adjacent to the non-splinted implants. cases). Another retrospective study conducted by Hans Pjetursson and Lang performed a 2-part meta- et al.6 evaluated clinical treatment outcomes of FPPs analysis to find out the survival rates of implants and using different sizes and numbers of teeth and implants FPPs after an observation period of 5 and 10 years for as abutments (follow-up up to 8 years). They presented a free-standing implant-supported and implant-tooth- cumulative implant survival rate of 89.8% after 5 years of supported FPPs. After 5 years of observation, the survival service. Jemt et al.9 performed another retrospective study rates for implants were 95.4% (95% CI: 93.9-96.5%) and on 876 consecutively placed implants (Bränemark system) 90.1% (95%CI: 82.4-94.5%) in free-standing and implant- in a total of 244 patients treated and annually followed tooth-supported situations, respectively. After 10 years at the Bränemark clinic (Gothenburg, Sweden) for up to of observation the survival rates were 92.8% (95% CI: 20 years. The authors aimed to find out the results of the 90-94.8%) and 82.1% (95% CI: 55.8-93.6%), respectively. treatment of partially edentulousness by means of FPPs After 5 years of function the survival rates for FPPs in supported by osseointegrated implants. From 876 implants free-standing and implant-tooth-supported cases were 43 were connected to the adjacent teeth to support 12 96.6% (95% CI: 95.9-97.3%) and 94.1% (95%CI: 90.2- FPPs in total of 9 patients. The authors did not observe 96.5%), respectively. After 10 years of function the any significant problems associated with the connection Balk J Dent Med, Vol 21, 2017 Tooth-Implant-Supported FPPs 9 of implants with teeth. However, they mentioned that problems that may jeopardize the longevity and treatment involving a mechanical connection between successfulness of the complete treatment. Natural teeth teeth and implants should be approached with caution. have a physiologic mobility due to the PDL, which Although these and many other studies show is absent in osseointegrated dental implants. Hence, successful treatment outcomes, two main complications connecting these two different abutments causes uneven associated with splinting an implant with a natural tooth, load distribution between them, and as a result possible which are bone loss around the implant and natural implant abutment overloading. tooth intrusion, still question this treatment option. A decision should be based on well-considered Tooth intrusion is one of the main problems when treatment planning, i.e. choosing periodontally healthy connected to implants which can occur in up to 7.3% of teeth, planning the positions and number of inserted the cases29. Several studies tried to explain the causes implants, directing occlusal forces through the long axis 31,47 of this phenomenon , but till now there is no clear of abutments and performing a meticulous management of answer. Some authors insist that the cause of intrusion the occlusion. 31,48,49 is multifactorial . Some of the possible factors are: As we can see from the available studies there is disuse atrophy, differential energy dissipation, impaired no definite opinion neither about the number of splinted rebound memory, rachet effect, debris impaction, fixed implants and teeth, nor about the connector type, position prosthesis flexure, mandibular flexure (only in mandible). and rigidity. Only one thing is clear: when connecting It has been shown to occur mainly in teeth non-rigidly implants with teeth, the implants will always carry the 4,6,38 connected to implants . However, this problem can greater part of the loading. 37,48 also occur with any other attachment type . Several To give a definite answer to: “Is splinting an 31,50 authors showed a reversibility of tooth intrusion by osseointegrated implant with a natural tooth a reliable disconnecting solder joints or other methods (occlusal treatment option?” further research and long-term studies adjustment, changing the contours of coping sidewalls etc.). are needed. Studies involving 3D FEA and photoelastic analyses, in vivo and in vitro, prospective and retrospective studies were included in this study. Differences in mobility and tactile sensitivity of natural teeth and osseointegrated References implants were discussed, the main biomechanical factors affecting the longevity and success rate of combined FPPs 1. 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Extrusion of Root Canal Sealer in Periapical Tissues - Report of Two Cases with Different Treatment Management and Literature Review
SUMMARY Athina Dalopoulou1, Nikolaos Economides2, Background: Extrusion of root canal sealers may cause damage to the Vasilis Evangelidis3 surrounding anatomic structures. Clinical symptoms like pain, swelling and Aristotle University, Dental School paresthesia or anesthesia may be present. The purpose of this presentation 1Undergraduate student is to describe two cases of root canal sealer penetration into periapical 2Associate Professor tissues. A different treatment management was followed in each case. Case 3Graduate student, Dental School reports: A 55 year-old man underwent root canal retreatment of the right Thessaloniki, Greece mandibular first molar tooth due to a periapical lesion. Postoperative periapical radiographs revealed the presence of root canal sealer (AH26) beyond the apex in the distal root in proximity to the mandibular canal. The patient reported pain for the next 7 days. Radiographic examination after 1 year showed complete healing of the periapical area and a small absorption of the root canal sealer. A 42 year-old woman was referred complained of swelling and pain in the area of the right maxillary first incisor. Radiographic examination showed extrusion of root canal sealer in the periapical area associated with a periapical lesion. Surgical intervention was decided upon, which included removal of the sealer, apicoectomy of the tooth and retrograde filling with MTA. After 1 year, complete healing of the area was observed. Conclusion: In conclusion, cases of root canal sealer extrusion, surgical treatment should be decided on only in association with clinical symptoms or with radiographic evidence of increasing periapical lesion. REVIEW PAPER (RP) Key words: Extrusion, Root Canal Sealer, Symptoms, Treatment Management Balk J Dent Med, 2017; 21:12-18
Introduction hypoesthesia and anesthesia may appear, especially when the extruded filling materials are either close to, or Endodontic therapy is performed to clean the root in intimate contact with nerve structures2,3,4. There are canal system, alleviate pain and eliminate infection from generally considered to be four possible types of factors that the tooth. Ideally, the filling material should reach to the can cause tissue damage and lead to the above symptoms: apex of the root, without extending into periapical tissues ●● chemical factors because of the neurotoxic effects of or other neighboring structures. However, sometimes, the products used to clean or fill root canals, over-instrumentation of a root canal with manual or rotary ●● mechanical trauma from over-instrumentation (ex. instruments, allows the extrusion of sealers, dressing agents, perforation of mandibular canal), irrigation solutions and microorganisms out of the tooth, ●● a pressure phenomenon from the presence of core into the surrounding anatomical structures and periapical filling material or sealer within the inferior alveolar tissues1. Although small material extrusions are generally canal, and well tolerated by the periradicular tissues, clinical symptoms ●● overheating of tissues because of incorrect warm such as pain, swelling of the lip, dysesthesia, paraesthesia, condensation techniques2,5,6. Balk J Dent Med, Vol 21, 2017 Extrusion Of Root Canal Sealer 13
All these can initiate an inflammatory process which may lead to treatment failure. Generally, the normal therapeutic sequence for the complications mentioned above, is firstly to control pain and inflammation, and then, whenever possible, the surgical elimination of the cause6. However, total resolution of pain and reduction or disappearance of paraesthesia after a non-surgical management have been reported3,4. The aim of this paper is to describe two cases of endodontic sealer (AH26) penetration into periapical tissues and the treatment management followed in each Figure 2 Figure 2a Figure 2b case.
Materials and Method Discussion
Case report 1 Many factors can increase the risk of sealer extrusion, for example, over-instrumentation, the A 55 year-old man was referred for root canal complexity of the anatomy of the root canal system, retreatment of the right mandibular first molar due to a excessive amount of sealer, excessive compaction force, periapical lesion (Figure 1). Root canal preparation was hydrostatic pressure, the use of lentulo spirals, immature carried out by removing the old filling material, cleaning canal apices or root tip resorption7,8,9,10. Most of the and shaping of the root canals. The canals were dried case reports suggest that sealer extrusion, especially due and filled with AH26 and gutta-percha. Postoperative to over-instrumentation, is more likely to happen in periapical radiographs revealed the presence of root premolars and molars11. canal sealer (AH 26) beyond the apex in the distal root In the maxilla, root canal sealer can be extruded in proximity with the mandibular canal (Figure 1a). into the sinus and cause maxillary sinusitis, including Although there were no complications during treatment, aspergillosis infection, paraesthesia and similar neural the patient reported pain for the next 7 days. Radiographic complications as symptoms12. Many authors believe that examination after 1 year showed complete healing of the the extruded root canal filling material does not remain periapical area and a small absorption of the root canal in one specific area of the antrum and acts as a foreign sealer (Figure 1b). body. The ciliated mucosal cells tend to move it towards the natural orifice, which may then become occluded13. Stasis of secretion leads to an anaerobic condition which favors the growth of Aspergillus spores. In most cases, Aspergillus infection is caused by root canal filling materials which contain zinc oxide-eugenol (ZOE) and paraformaldehyde that are accidentally introduced into the sinus. The results are reactions of inflammation and the blocking of ciliary movement14,15. Khongkhunthian Figure 1 Figure 1a Figure 1b and Reichart12 reported a case of a 25-year-old woman who was sensitive to chewing and percussion on tooth #16 after root canal treatment several years previously. After radiographs had been taken, it was found that Case report 2 the root canal sealer of the tooth was extruded into the maxillary sinus, as well as the presence of a radiopaque A 42 year-old woman complained of swelling mass near the opening to the nasal cavity. The diagnosis and pain in the area of the right maxillary first incisor. was aspergillosis of the maxillary sinus with apical Radiographic examination showed extrusion of root periodontitis of #16 due to extrusion of the sealer. canal sealer in the periapical area in association with Treatment involved periapical surgery with retrograde a periapical lesion (Figure 2). Surgical intervention filling of the buccal roots of tooth #16, antroscopy, and was decided upon, including the removal of the sealer, removal of the foreign body from the maxillary sinus. apicoectomy of the tooth and retrograde filling with MTA In regard to the mandible, the main presenting (Figure 2a). After 1 year, complete healing of the area was symptoms are pain, swelling and paraesthesia. Post observed (Figure 2b). operative pain is thought to be associated with a 14 Athina Dalopoulou et al. Balk J Dent Med, Vol 21, 2017 periapical inflammatory response and may persist from extruded from the root canal on the lower right second a few hours to many days after endodontic therapy16. premolar. Surgical removal of the extruded material Severe endodontic pain after sealer extrusion requires was decided. Three weeks after the surgery, the patient early diagnosis and immediate management to reduce reported recovery of sensation and 2 months later all the risk of permanent nerve damage17. The pain can symptoms had disappeared. be spontaneous, intermittent, or permanent. Eating, Regarding the sealers that contain eugenol, a case speaking, cold, or heat may trigger its onset. The patient report with extrusion of ZOE-based sealer is referred may also complain of a burning sensation, a feeling of to by Gambarini et al.29. A 59-year-old woman, after ‘pins and needles’, or pressure on the teeth18. Pain can endodontic treatment on the mandibular left first be accompanied by local inflammatory signs with the premolar and second molar, presented paresthesia on the tooth painful on percussion, painful upon palpation of left posterior mandible, numbness on the left side of the the buccal alveolar process or a combination of signs of lower lip and a tingling sensation in the buccal gingival. mechanical trauma and inferior dental nerve inflammation Both teeth had been treated with ZOE –based sealer and with pain or numbness of the lower lip19. Paraesthesia a panoramic radiograph showed radiopaque material might be caused by over-instrumentation, by the pressure beyond the apex of the mesial root of the mandibular left of endodontic materials in the mandibular canal after its second molar and also beyond the apex of the mandibular perforation 20,21, by neurotoxic effects, reversible and left first premolar. The treatment was anti-inflammatory irreversible blockage of nerve conduction, or by alteration regimen for 4 weeks and periodic follow-up visits. of the nerve membrane potential1,22. Symptoms disappeared after 6 months. A similar case An acute inflammatory response develops in the report was referred to by Froes et al.3, where a 42-years- periradicular tissue as a result of additional insults from old woman complained of acute and intense pain during the root canal system, which can be of mechanical, the endodontic therapy. The root canal therapy (RCT) was chemical, or microbial origin. Mechanical and chemical halted and the patient was given potassium diclofenac, but injuries are usually associated with over-instrumentation, the symptoms persisted. Computed tomograph revealed apical extrusion of irrigants or sealers etc16. Root canal that the eugenol-based sealer had entered the mandibular sealers with varying formulas have been developed over canal. Treatment started with another anti-inflammatory time. Studies have shown that all root canal sealers are regimen including naproxen and RCT continued. One neurotoxic to some degree, and chemical neurotoxicity week later, pain had disappeared, but the paresthesia results from the constituents of the extruded materials23,1. persisted. At the end of the following 2 months, the Experimental studies have shown that sealers which paresthesia had completely disappeared. In contrast, contain both eugenol and paraformaldehyde, such as Scolozzi et al.30, describe a case of pain and persistent Endomethasone and N2, were the most toxic and could anesthesia after RCT with PCS (pulpal canal sealer ZOE) inhibit conduction of the action potential of the nerves due to the extrusion of this sealer, where symptoms had to to varying degrees24,25,26. Paraformaldehyde is a potent be resolved with surgical treatment. neurotoxin and may cause chemical destruction of the The sealer used in our cases was AH26. It is an nerve axon because of its gaseous nature27. Brodin et epoxy resin - based root canal sealer which has recently al.24 reported that Endomethasone can irreversibly inhibit become very popular due to its good physical properties. the conduction of the action potential in the rat phrenic In the literature Scolozzi et al.30, report a case where nerve. Serper et al.26 found that the inhibitory effect of AH26 along the mandibular canal caused pain and Endomethasone on isolated rat sciatic nerves is reversible paresthesia after RCT. The use of antibiotics, NSAIDs but is more pronounced than the effect of Sealapex or and carbamazepine, didn’t improved the symptoms, so Calciobiotic root canal sealers. sagittal osteotomy was decided on to remove the sealer Koseoglu et al.1 reported the case of a 32-year- and provide nerve decompression. After 6 months, the old woman with prolonged anesthesia in her right patient was symptoms free30. However, in the literature mandibular region following root canal treatment, there are case reports of AH26 with non-surgical treatment performed 3 weeks earlier by her local dentist. too, such as that of Gonzalez-Martin et al.4. A 32-year-old Panoramic radiographs revealed the presence of root woman underwent RCT in #37. A periapical radiograph canal sealer (Endomethasone) in the mandibular canal. revealed the presence of AH26 in the mandibular canal, Decompression of the nerve by removing the sealer with the patient reporting numbness, a tingling sensation surgically was therefore decided upon. Another case and anesthesia. The treatment followed was periodic report with Endomethasone extrusion is referred by Brkic follow- up visits and 7 months later decreased paresthesia et al.28. A 30-year-old woman had a sense of numbness in and anesthesia were observed. Nevertheless, AH26 has the region of right lower lip and chin, which had started mild-to-moderate irritating effects when freshly prepared 4 months earlier, one day after endodontic treatment and this toxicity is due to the release of a small amount of the mandibular right second premolar. A panoramic of formaldehyde or amines during the chemical setting radiograph revealed the presence of radiopaque material, process. These additives could be responsible for a Balk J Dent Med, Vol 21, 2017 Extrusion Of Root Canal Sealer 15 strong initial tissue response close to the sealer and for a few hours or days following the root canal treatment43. postoperative pain after extrusion of the sealer31,32. The It has been suggested that the presence of certain bacterial toxic epoxide bisphenol resin contained in the sealer may species is associated more with some clinical features of also cause toxicity33. Taken together, these explain the periradicular diseases, such as Porphyromonas species, propensity of AH26 to initiate periapical inflammatory Prevotella species, and Finegoldia44,45. Furthermore, reactions, if extruded into the periapical tissues. The Hashioka et al.46 observed that in cases with pain on chemical mediators of inflammation can cause pain by percussion, Peptostreptococcus species, Eubacterium direct effects on sensory nerve fibers. The particles of the species, Porphyromonas endodontalis, P. gingivalis and sealer are phagocytosed by macrophages and carried to Prevotella species were found to be present. The second the periphery of the inflammatory reaction. The result, in factor responsible for endodontic failure is foreign body the course of time, is that macrophages may completely reaction. Filling material extruded into the periapical area clear the sealer from the periapical area, which may causes a foreign body type reaction in the connective then eventually heal34, when the irritation or pain will tissue47. To be precise, the presence of microbial infection be subsided. Therefore, the conclusion supported by is the primary cause of endodontic failure but foreign many investigations, is that, the extrusion of sealer is body reaction can aggravate and sustain the disease and not a complicating factor in periapical healing and that its symptoms48. The mechanism of this reaction seems resorption of extruded material is not a prerequisite similar to the pathway of phagocytosis. The fine particles for periapical healing, so resorption and healing must and exudates evoke a local tissue response, characterized be considered separately35,36. Lin et al.37 state that by the presence of macrophages and multinucleated the extrusion of sealer is unlikely to be a factor in the giant cells and the large pieces of the sealer are well failure of endodontic treatment and that canal filler is encapsulated23. likely to cause less irritation to periradicular tissue than Regarding the treatment of symptoms that sealer microbial factors. Huang et al.38 concluded that the extrusion can cause, the first choice, in case of pain, is a biocompatibility of the filling material is very important wait-and-see approach, including anti-inflammatory drugs because biocompatibility stimulates the reorganization of and periodic follow up49,3,4,50. According to some authors, damaged apical tissue remaining in direct contact with the use of biocompatible materials did not suggest an the material. Tanomaru et al.39 have asserted that in teeth immediate surgical approach, but rather a wait-and-see with chronic periradicular periodontitis, root canal sealers approach, since these materials usually undergo resorption with antibacterial properties that do not irritate the apical overtime29. Surgical removal of the filling material or periradicular tissue may stimulate the deposition of from anatomic structures, combined with apicoectomy, mineralized tissue in the apical foramen, thereby assisting is mostly recommended in cases of prolonged pain in healing. Leonardo et al.40 have shown that periapical and swelling or pain and paraesthesia, when the sealer tissue reaction to AH Plus is excellent. Furthermore, the contains toxic additives, such as paraformaldehyde and study found the apposition of mineralized tissue on the when radiographic evidence shows increasing periapical root canal walls in the apical area, and, in many instances, lesion (Table 1). Russell et al.51 and Kothari and apical soft tissue that appeared to be in the process of Cannell52 report that, when a sealer containing eugenol becoming fully mineralized. In addition, it has been (Endomethasone) and paraformaldehyde is extruded found histologically that AH26 material initially induced into the mandibular canal, it should be removed from chronic periapical inflammatory reactions when extruded the mandibular canal as soon as possible because even a into the periapical tissues but after 6 months the material 4-day delay in the surgical removal of a nonresorbable was phagocytosed by macrophages and carried to the phenol-based sealer could result in persistent paresthesia. periphery of the inflammatory reaction34. In general, the In cases of paraesthesia, the medication used includes resorption period may be dependent upon the amount mostly corticosteroids, anti-inflammatory and vitamins of extruded material and/or individual variations in complex. Two new combinations of medicines, also immunodefense reactions at the periapex35. approved for peripheral neuropathy by the FDA and Therefore, it could be easily understood that the leading to a very rapid improvement in pain and main factor responsible for endodontic failures is not paraesthesia, are duloxetine and pregabalin17 and the probable extrusion of a sealer, but the flare-up that prednisone and pragabalin50. Alonso-Ezpeleta et al.17 can occur as a result of acute periradicular inflammation corroborate the above claim with a case report. A and apical extrusion of infected debris into the periapical 36-year-old woman, one day post endodontic treatment, tissues during chemo-mechanical preparation. The experienced severe pain in the treated tooth and numbness frequency of flare-ups ranges from 1.4% to 16% and their on the right side of the lower lip, due to AH Plus Jet intensity depends on the number and virulence of extruded extrusion. Non-surgical treatment was decided on which microorganisms41,42. Forcing microorganisms and their included prednisone, pregabalin and periodic follow-up products into the periradicular tissues can generate pain visits. After six weeks, all symptoms had disappeared. A and swelling, as well as an inflammatory response within similar treatment, with the combination of prednisone and 16 Athina Dalopoulou et al. Balk J Dent Med, Vol 21, 2017 pregabalin this time, has been also reported by Lopez- the reported non-surgically treated cases was higher Lopez et al.50. (63%) than the recovery rate of the reported surgically Finally, a systematic review53 reported that, in treated cases (46%). Regarding the obturation material, the majority of the treated cases of altered sensation the majority of reported cases occurred in teeth obturated after extrusion of root canal sealer, surgical treatment with paraformaldehyde-based sealers (39%), or resin- or a combination of nonsurgical and surgical had to be based sealers (29%). The full recovery of reported cases performed. Non-surgical treatment alone was performed with resin sealers was significantly better (62%) than the in only 24% of the cases, but the full recovery rate of paraformaldehyde cases, where it was only 27% .
Table 1. Case reports of sealer’s extrusion
Article details Type of sealer Clinical manifestations Treatment
Spielman et al18,1981 AH26 Anesthesia, swelling Surgical
Tamse et al19, 1982 1)AH26 Paresthesia Non-surgical 2)AH26 Numbness Non-surgical
Orstavik et al54, 1983 Endomethasone Paresthesia, hypoesthesia Non-surgical
Khongkhuthian& Reichart12, 2001 Not specified Sensitive to chewing- Surgical percussion, aspergillosis
Yaltirik et al55, 2002 Endomethasone Paresthesia, swelling Tooth extraction-surgical
Yatsuhashi et al56, 2003 Paraformaldehyde Numbness Non-surgical
Scolozzi et al30, 2004 1)AH26 Pain, paresthesia Surgical 2)PCS(ZOE) Pain,paresthesia, Surgical hypoesthesia 3)Home made paste Pain, numbness, Surgical paresthesia 4) Not specified Pain Surgical
Lambrianides& Economides57, 2005 Not specified Pain, hypoesthesia Non-surgical
Koseoglu et al1, 2006 Endomethasone Numbness, anesthesia Tooth extraction-surgical
Poveda et al49, 2006 Endomethasone Numbness, tingling sensation Non-surgical
Pogrel6, 2007 Not specified Pain, paresthesia Surgical, non-surgical
Scarano et al58,2007 ZOE Pain, numbness, anesthesia Non-surgical
Escoda-Francoli et al59, 2007 Not specified Pain, paresthesia Tooth extraction, surgical, non-surgical
Batur & Ersev60, 2008 Endomethasone No symptoms Non-surgical
Froes et al3, 2009 Eugenol-based Paresthesia, pain Non-surgical
Brkic et al28, 2009 Endomethasone Numbness Surgical
Gonzalez-Martin et al4 2010 AH26 Numbness, tingling sensation, anesthesia Non-surgical
Gambarini et al29, 2011 ZOE Paresthesia, numbness, Non-surgical tingling sensation
Lopez-Lopez et al50, 2012 AH Plus Pain, numbness,tingling sensation, Non-surgical anesthesia
Alonso-Ezpeleta et al17, 2014 AH Plus Jet Pain, numbness, paresthesia Tooth extraction, non-surgical
Coskunses et al61, 2016 Forfenan Anesthesia, numbness, Surgical (paraformaldehyde) swelling Balk J Dent Med, Vol 21, 2017 Extrusion Of Root Canal Sealer 17
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Balk J and periapical repair of dog’s teeth with periapical lesions Dent Med, 2005; 9:152-154. after endodontic treatment with different root canal sealers. Pesqui Odontol Bras, 2003; 17:69-74. 58. Scarano A, Di Carlo F, Quaranta A, Piattelli A. Injury of the 41. Imura N, Zuolo ML. Factors associated with endodontic inferior alveolar nerve after overfilling f of the root canal flare-ups: a prospective study. Int Endod J, 1995; 28:261- with endodontic cement: a case report. Oral Surg Oral Med 265. Oral Pathol Oral Radiol Endod, 2007; 104:56-59. 42. Siqueira JF Jr. Tratamento das infeccoes endodonticas. Rio 59. Escoda-Francoli J, Canalda-Sahli C, Soler A, Figueiredo de Janeiro, Brazil: Medsi, 1997. R, Gay-Escoda C. Inferior alveolar nerve damage because 43. Siqueira J.F. Microbial causes of endodontic flare–ups. Int Endod J , 2003; 36:453-463. of overextended endodontic material: A problem of sealer 44. Siqueira JF Jr, Rocas IN, Oliveira JCM, Santos KRN. cement biocompatibility? 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Response of periapical tissues in the rat molar to root fillings with Diaket and AH-26. Oral Received on November 29, 2016. Surg Med Pathol, 1966; 21:786-804. Revised on December 1, 2016. 48. Nair PN. Non-microbial etiology: foreign body reaction Accepted on December 4, 2016. maintaining post-treatment apical periodontitis. Endod Topics, 2003; 6:114-134. Correspondence: 49. Poveda R, Bagan JV, Fernandez JMD, Sanchis JM. Mental nerve paresthesia associated with endodontic paste within Athina Dalopoulou the mandibular canal: report of a case. Oral Surg Oral Med Address: 28 Oktovriou 66, Thessaloniki, Greece Oral Pathol Oral Radiol Endod, 2006; 102:46-49. E-mail: [email protected]
10.1515/bjdm-2017-0003
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Demographic Characteristics, Referrals and Patients’ Accessibility to an Oral and Maxillofacial Surgery Clinic
SUMMARY Katerina Veneti1, Stavros Stafylidis2, 3 4 Background: Throughout the financial crisis in Greece, health Theodora Kafkia , Mixalis Kourakos , Konstantinos Antoniades5, Christos Zilides6, expenditures have been significantly reduced. As a result, patients’ Stilianos Dalampiras5 accessibility to various health care providers has been significantly reduced. 1 The aim of the present study was to determine the profile of patients visiting Theagenio Oncology Hospital Thessaloniki, Greece a maxillofacial clinic in Northern Greece and the patients’ accessibility 2Department of Medicine to the specific healthcare. Material and Methods: Data were collected Aristotle University of Thessaloniki from 481, out of the 600, patients visiting for the first time the University Thessaloniki, Greece 3 Maxillofacial Clinic of a hospital in Northern Greece during 2013 and Alexander Technological Institute of Thessaloniki Thessaloniki, Greece 2014. The sample was called to answer to an anonymous self-reference 4General Hospital “Asklepeion” Voulas questionnaire with questions regarding their demographic and clinical Athens, Greece characteristics, the pattern of their referral to the specific clinic, their city 5School of Dentistry of residence, as well as information regarding their hospitalization. Results: Aristotle University of Thessaloniki Thessaloniki, Greece The majority of patients (53.4%) were referred by a physician, while 6Technological Educational Institute of Thessaly 38.4% by a dentist. More than half (51.4%) were admitted to the specific Larisa, Greece clinic with admission diagnoses such as Benign Lesions-Cysts (25.2%), Masticatory Myalgia-Temporomandibular Joint Dysfunction (21.6%), Infections (19.5%) and Fractures (18%). The median time to seek to hospital evaluation/treatment, from the initial diagnosis, was 30 days. Nine out of ten patients stated that there was no Maxillofacial Surgery Clinic in their area of residence, while 80.3% reported using a private means of transport to access the clinic. Conclusions: The results indicated a delay with respect to the final diagnosis, as well as difficulty in patients’ accessibility, something that could contribute to an increase in morbidity and subsequently in the cost for managing patients’ maxillofacial problems. ORIGINAL PAPER (OP) Key Words: Oral and Maxillofacial Clinic, Referral, Patient, Accessibility Balk J Dent Med, 2017; 21:19-23
Introduction public healthcare system there are a lot of private clinics/ hospitals that provide services to Greeks. The Greek National Health System (GNHS) has Dental services are provided within the GNHS in some big district health centers, in secondary and tertiary been re-structured in the beginning of 1980s based on hospitals. More specifically they are provided in ten the British model. There are a lot of district health hospitals out of twenty-six in the Northern Greece, an centers with the basic medical specialties (medical, area that is inhabited by 2.806.000 million people and has surgical, paediatrics, obstetrics, general practitioners) provided shelter for more than 30.000 refugees. In the working 24 hours (primary healthcare), district general funding law of GNHS maxillofacial services were planned hospitals in the capital of every prefecture (secondary to be provided in tertiary, and some secondary, hospitals healthcare), big district general hospitals (>400 beds) and and more specifically in one university hospital and one university hospitals (tertiary healthcare). Alongside the unit in the Northeast part of Greece (Alexandroupoli 20 Katerina Veneti et al. Balk J Dent Med, Vol 21, 2017 and Komotini, respectively), in one general hospital in More than two thirds accepted to participate (n=481). the center of north Greece (Kilkis) and in one university The population was asked, while waiting in the reception and one oncology hospital in the center of north Greece area of the clinic, to answer to an anonymous printed self- (Thessaloniki). completed questionnaire, with questions regarding their Over the last years, the Greek health system has demographic and clinical characteristics, the pattern of suffered a major setback due to the financial adjustment their referral, their city/town of residence, as well as data program and the austerity policies. To be more specific, regarding their hospitalisations with the same problem based on the research conducted by the Organization for (where, when, why, procedures performed). Economic Co-operation and Development (O.E.C.D), Prior to the research, there was a pilot study reducing expenditures from 2009 to 2012 was estimated conducted on a sample of 50 individuals at the same to be 25%1. Inevitably, this reduction led to some clinic of the particular hospital. For the study gender and public regional hospital clinics’ permanent closure place of residence, were set as the independant variables, or to suspension of operations mainly due to doctors’ whereas hospital admissions, diagnosis, days from the retirements and luck of hiring new. Cutdowns in health first diagnosis and final diagnosis were the dependant services resulted in maxillofacial clinics (Alexandroupi variables. The reliability of the pilot study, using the same University Hospital) and outpatients’ clinics (Komotini questionnaire, based on the Cronbach’s a (Alpha) was District and Kozani District General Hospital and 0.91 (high reliability)8. Theagenio Oncology Hospital of Thessaloniki) on the Northern prefectures of Greece to be forced to close Statistical analysis permanently. As a result specialised care previously Statistical analysis of the results was conducted with delivered by maxillofacial healthcare professionals, was, the statistical package IBM SPSS v22. In descriptive at that moment, delivered by general surgical wards statistics, the continuous variables with normal and surgeons or ear nose throat (ENT) surgeons with no distribution were expressed by the mean value and the further specialisation. standard deviation (S.D.), whereas those not following a Several studies conducted internationally, have normal deviation were expressed by the median and range studied the tendency of patients with dental and values. The dichotomous and the categorical variables maxillofacial problems to seek immediate care in were expressed by frequencies. accidents and emergency departments and not in The nonparametric tests Mann-Whitney U and specialised clinics2. However, only few studies have Kruskal-Wallis were carried out to compare the mean researched the characteristics of those patients as well independent samples, while for the degree of correlation as their accessibility to public specialized maxillofacial between continuous variables that did not follow a normal healthcare structures3,4. distribution Spearman’s rho correlation coefficient was The financial crisis had major impact on the used. To test the dichotomous and categorical variables of provision of services in Public Health Centers and independent samples Chi-square test (x2) and the Fisher’s university hospital units5. Concerning is the fact that exact test were both used. Finally, the significance level closures of several healthcare units occurred when for the hypotheses testing was set at 5% (p<0.05). increased number of Greeks have reported that they do not seek health or dental care examination or treatment even though they believe it is necessary for them6,7. The aim of the present study was to determine the Results profile of patients seeking care for maxilofacial problems, emergencies or not, in a maxillofacial clinic in Northern Females were the 52.8% (254/481) of the sample Greece and the patients’ accessibility to the specific and the 49.3% (237/481) of the sample were married. The healthcare facility. The research question set was that 37% (170/481) of the respondents were employed, while whether the current maxillofacial clinic in Northern Greece 27% (124/481) were unemployed and the rest almost met the needs of the population of the specific area. equally divided between pensioners (84/481) and students (81/481). Most of the patients were residents of Central Macedonia prefecture (81.7%) and almost all had social insurance (97.3%). The mean age of the sample was 43.9 Material and Methods (±21.1) years old (42.1 to 45.9) with a median age of 41.3 years old (Table 1). All patients visiting the Out-Patient Clinic of From the patients visiting the OMFS Clinic, the the University Oral and Maxillofacial Surgery Clinic 86.5% (n=416) were, finally, hospitalized with the most (OMFS) at the General Hospital of Thessaloniki “G. common admission diagnoses of Benign Lesions-Cysts Papanikolaou”, during 2013 and 2014, were approached (25.2%), Masticatory Myalgia-Temporomandibular and were invited to participate in the study (n=600). Joint (TMJ) Dysfunction (21.6%), Infections (19.5%) Balk J Dent Med, Vol 21, 2017 Accessibility to an Oral and Maxillofacial Surgery 21 and Fractures (18%). The initial diagnosis was set by Most of the patients came to the OMFS clinic, after the referring physician, which was usually a surgeon, an being referred by a physician (53.2%) and by the dentist internal pathologist or an orthopedic surgeon. From the (38.3%). The majority of the physicians providing initial diagnosis until the visit in the outpatients’ clinic, referrals were surgeons (79.7%). The absence of included in the study, a median time of 30 days was found Maxillofacial Surgery Clinic in their area of residence was (1 day - 120 days) (Table 2). reported from the 94.8% of the patients. As for how the patients accessed the clinic, the 80.2% of them stated that Table 1. Demographic characteristics of the sample they used a private means of transportation (Table 3). n/N % Marital status Table 3. Referrals’ data Married 237/481 49.3 Person making the referral n/N % Single 178/481 37.0 Physician 256/481 53.2 Divorced 31/481 6.5 Maxillofacial Surgeon 37/481 7.7 Widowed 19/481 4.0 Dentist 184/481 38.3 Profession Other Health Professional 4/481 0.8 Employed 170/481 37.0 Specialty of the referring Physician Pensioner 84/481 17.5 Surgeon 204/256 79.7 Student 81/481 16.8 Pathologist 52/256 20.3 Unemployed-Homemaker 124/481 27.0 Means of transport Area of Residence Private Car 386/481 80.2 Central Macedonia 393/481 81.7 Bus 62/481 12.9 West Macedonia 30/481 6.2 Ambulance 20/481 4.2 East Macedonia 31/481 6.4 Other means of transport 13/481 3.1 Other 16/481 3.3 Is there an OMFS Clinic Social Insurance Yes 25/481 5.2 Yes 468/481 97.3 No 456/481 94.8 No 13/481 2.7
Table2. Clinical characteristics of the population Correlations OPD Diagnosis n/N % After correlating the patients’ place of residence with Fracture 75/416 18.0 admissions to the OMFS clinic, a statistical significancy Benign Lesions-Cysts 105/416 25.2 was found (p=0.025). To be more specific, patients from Masticatory Myalgia-Temporomandibular 90/416 21.6 West and East Macedonia prefecture were more frequently Joint (TMJ) Dysfunction admitted than those residing in Central Macedonia Infections 81/416 19.5 prefecture (Table 4). Cancer 18/416 4.3 Osteonecrosis 18/416 4.3 Comparing the actual time of visit to an OMFS Salivary Diseases 13/416 3.1 outpatients clinic from the initial diagnosis, in relation to Oro-Antral Communication 4/416 1.0 the area of residence, it was found that patients residing Orthognathic Clefts 12/416 3.0 in Central Macedonia prefecture had the lowest visit time Admission to clinic (30 days) compared to patients residing in West and East Yes 416/481 86.5 Macedonia prefecture (60 days respectively), however there No 65/481 13.5 no statistical significant difference (p=0.995) (Table 5).
Table 4. Comparison between area of residence and admission to the clinic
Place of Central West Macedonia East Macedonia Other P value residence Macedonia
Admission to 48.3% 68.6% 68.6% 68.4% YES 0.025 clinic (158/327) (24/35) (24/35) (13/19)
51.7% 31.4% 31.4% 31.6% NO (169/327) (11/35) (11/35) (6/19) 22 Katerina Veneti et al. Balk J Dent Med, Vol 21, 2017
Table 5. Comparison of actual time of visit to the OMFS clinic Discussion (from initial diagnosis) to the area of residence
Time of visit to OMFS clinic from initial The present paper provides information regarding diagnosis the demographic data as well as the patients’ accessibility median Value range to an OMFS Clinic in Northern Greece. The fact that p value Area of residence (in days) (in days) women seek for medical oral healthcare more than men9- Central Macedonia 30 1-2555 11, is confirmed in this paper as well. The most common West Macedonia 60 15-60 0.995 diagnoses observed were benign lesions-cysts, masticatory East Macedonia 60 10-90 myalgia- TMJ dysfunction, fractures and oral cavity infections. The majority of patients visiting the OMFS Afterwards, it was diceded to investigate any possible Clinic were referred by other medical professionals. In correlation between gender and actual admission to the particular, the majority of patients (53.2%) were referred OMFS clinic. It was found that males were more frequently by a physician, while 38.3% by a dentist. In a relevant admitted in the the clinic (56.4%) than females (46.6%), with study conducted by Haberland et al. in 1999, the opposite a statistically significance (p=0.045) (Table 6). was found; patients were referred mainly by dentists (55%) and physicians (45%)4. This could be attributed to the different structure of the healthcare systems. Table 6. Comparison between gender and admission to the clinic As regards to the patients’ accessibility to medical Gender maxillofacial services, it was found that a high percentage Admission to clinic of patients stated that there was no maxillofacial male female p value clinic close to their area of residence, and a significant 56.4% 46.6% YES percentage of patients used a private means of transport (110/195) (103/221) 0.045 to access the clinic, probably due to the fact that their 43.6% 53.4% NO (85/195) (118/221) health condition was good. With the particular data, it is undeniable that accessibility in terms of health services 12 Finally, as regards to gender and the clinical becomes more and more difficult not only in Greece , but 13 characteristics of the patients (admission diagnosis), it in other countries of the Balkan Peninsula as well, and 14 was found, with a statistically significance (p<0.001), this is more evident in rural and semi-urban areas . This is also confirmed by the highest percentage of admissions that males were more frequently diagnosed with fractures of patients coming from areas where there is no proximity (33.3% -64/192) and benign lesions and cysts (26% to the OMFS clinic in relation to the lowest percentage of - 50/192), while females were mostly diagnosed with patients residing in shorter distance to the clinic. masticatory myalgias – TMJ dysfunctions (31.2% - Finally, while comparing gender to admission to 69/221) (Table 7). the OMFS clinic, a statistically significant relationship was found, with men being more frequently admitted to Table 7. Comparison between gender and admission diagnosis the clinic than women. To some extent, this phenomenon could be explained by the fact that men mostly suffer Gender p value from fractures, while women are usually diagnosed with Diagnosis on admission Male Female masticatory myalgia-TMJ dysfunction15. 33.3% 5% Fracture (65/195) (11/221) 26.1% 24.4% Benign Lesions-Cysts (51/195) (54/221) Conclusions Masticatory Myalgia – 10.3% 31.2% Toothache TMJ Dysfunction (20/195) (69/221) In this paper, we studied the demographic and 16.5% 22.2% Infections (32/195) (49/221) clinical characteristics, the referral patterns, as well as 4.6% 4.1% patients’ accessibility to an OMFS Clinic in Northern Cancer (9/195) (9/221) Greece. The results of the study indicated a delay 1% 7.2% <0.001 regarding the final diagnosis of the disease, as well as Osteonecrosis (2/195) (16/221) difficulty in the patients’ accessibility in relation to their 5.2% 1.4% area of residence, something that could contribute to an Salivary diseases (10/195) (3/221) increase in morbidity and in costs for managing patients. 1% 0.9% As the study was conducted only in one geographical Oro-Antral Communication (2/195) (2/221) part of the country (Northern Greece), generalisation of 2% 3.6% Orthognathic & Clefts the results to the whole Greek population could be risky. (4/195) (8/221) Furthermore an update in the data is due, as two years have Balk J Dent Med, Vol 21, 2017 Accessibility to an Oral and Maxillofacial Surgery 23 passed since the collection of the present data. Further 8. Galanis P. Validity and reliability of questionnaires in study of the phenomenon in other maxillofacial clinics epidemiological studies. Arch Hell Med / Arheia Ellenikes could help the public authorities to update the health map Iatrikes, 2013; 30:97-110. according to population needs. It could be usefull to have 9. Antunes JLF, Junqueira SR, Frazão P, Bispo CM, Pegoretti T, Narvai PC. City-level gender differentials in the frequent, every five years, updates of the health policies in prevalence of dental caries and restorative dental treatment. order to improve healthcare services and have a, possible, Heal Place, 2003; 9:231-239. decrease in costs for the public health system. 10. Honorato J, Rebelo MS, Dias FL, Camisasca DR, Faria PA, E Silva GA, et al. Gender differences in prognostic factors for oral cancer. Int J Oral Maxillofac Surg, 2015; 44:1205- 1211. References 11. CDC/NCHS, National Health Interview Survey. Dental visits in the past year, by selected characteristics: United 1. Bonovas S, Nikolopoulos G. High-burden epidemics in States, selected years 1997–2014. Available at: http://www. Greece in the era of economic crisis. Early signs of a public cdc.gov/nchs/hus/contents2014.htm#084 health tragedy. J Prev Med Hyg, 2012; 53:169-171. 12. Kondilis E, Giannakopoulos S, Gavana M, Ierodiakonou I, 2. Laverick S, Siddappa P, Jones DC. Patterns of emergency Waitzkin H, Benos A. Economic crisis, restrictive policies, maxillofacial referrals and provision of services. Br J Oral and the population’s health and health care: the Greek case. Maxillofac Surg, 2009; 47:99-101. Am J Public Health, 2013; 103:973-979. 3. Allen CM. Managed care and its relationship to οral and 13. Ursulica TE. The Relationship between Health Care Needs μaxillofacial pathology. Oral Surg Oral Med Oral Pathol and Accessibility to Health Care Services in Botosani Oral Radiol Endod, 1996; 81:1996-1996. County- Romania. Procedia Environ Sci, 2016; 32:300-310. 4. Haberland CM, Allen CM, Beck FM. Referral patterns, 14. Kontodimopoulos N, Nanos P, Niakas D. Balancing lesion prevalence, and patient care parameters in a clinical efficiency of health services and equity of access in remote oral pathology practice. Oral Surg Oral Med Oral Pathol areas in Greece. Health Policy, 2006; 76:49-57. Oral Radiol Endod, 1999; 87:583-588. 15. Niessen LC, Gibson G, Kinnunen TH. Women’s oral 5. Falagas ME, Vouloumanou EK, Mavros MN, health. Why sex and gender matter. Dental Clinics of North Karageorgopoulos DE. Economic crises and mortality: America, 2013; 57:181-94. a review of the literature. Int J Clin Pract, 2009; 63:1128- 1135. Received on October 5, 2016. 6. Kentikelenis A, Karanikolos M, Papanicolas I, Basu S, Revised on January 18, 2017. McKee M, Stuckler D. Health effects of financial crisis: Accepted on January 20, 2017. omens of a Greek tragedy. The Lancet, 2011; 378:1457- 1458. Correspondence: 7. Kentikelenis A, Papanicolas I. Economic crisis, austerity Veneti Aikaterini and the Greek public health system. Eur J Public Health, Al. Symeonidi 2, Postcode: 54007, Thessaloniki, Greece 2012;22:4-5. Ε-mail: [email protected]
10.1515/bjdm-2017-0004
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In Vitro Microleakage of class V Composite Restorations prepared by Er,Cr:YSGG Laser and Carbide BUR
SUMMARY Athanasios Synarellis, Pantelis Kouros, Background: The aim of this in vitro study was to compare the Elisabeth Koulaouzidou, Dimitrios Strakas, degree of microleakage on enamel and dentin margins of class V cavities Eugenia Koliniotou-Koumpia prepared with either a high-speed drill or an Er,Cr:YSGG laser (2780 nm) Aristotle University of Thessaloniki and to associate their use with a beveling method for the margin. Method School of Dentistry and Materials: Sixty bovine incisors were randomly distributed into three Department of Operative Dentistry Thessaloniki, Greece groups. Group 1 (G1) cavities were laser prepared and bur beveled, group 2 (G2) cavities were bur prepared and beveled, while cavities of group 3 (G3) were laser prepared and beveled. Cavities were restored with selective enamel etching, using the same bonding agent and nano-hybrid resin composite for all groups. After thermocycling, microleakage was assessed using a methylene blue dye penetration method. Results: Statistical analysis (Mann-Whitney, Kruskal-Wallis and post-hoc Dunn’s multiple comparison tests) demonstrated significantly higher microleakage for dentin compared to enamel margins in G1. Enamel margin microleakage was found to be significantly higher at G3 compared to G1 (p=0.032) and G2 (p=0.001), while no significant differences were found between G1 and G2 (p=0.850). Regarding dentin margins, G2 group performed significantly better than G1 and G3 (p<<0.001), while there was no significant difference among G1 and G3 scores (p=1.000). Conclusions: The conventional cavity preparation method seems to perform better in terms of microleakage than the Er,Cr;YSGG laser. Laser-prepared cavities could perform better in terms of microleakage if an additional step of enamel bur-beveling is performed prior to restoration. ORIGINAL PAPER (OP) Keywords: Bovine Teeth, Enamel Etching, Er,Cr:YSGG Laser, Microleakage Balk J Dent Med, 2017; 21:24-31
Introduction improvement3,4. Achieving good marginal sealing remains a considerable challenge in composite restorations5. The Current dentistry supports a minimal invasive nature of dentin and its complex structure compromise approach focusing on sound dental tissue preservation the stability of the dentin-resin bond. The highly organic and caries removal1. Minimal invasive dentistry is content of dentinal tubules makes adhesion to dentin more directly associated with the wide use of composite resins difficult than adhesion to enamel6,7. and adhesive systems2. However, despite continuous The durability and integrity of the marginal seal development of resins and adhesive systems, there are still plays a crucial role in the longevity of composite resin some problems concerning adhesion. restorations8. Although the mechanical, physical and esthetic Microleakage is defined as the penetration of properties of contemporary composites have improved in minute amounts of fluids, debris and microorganisms comparison to their predecessors, polymerization shrinkage through the interface space between a dental restoration and its related stress remain a major concern which requires and the adjacent cavity walls. Microleakage leads to Balk J Dent Med, Vol 21, 2017 Microleakage of class V Composite Restorations 25 hypersensitivity, secondary caries, possible pulpal teeth19. Several studies show no statistically significant pathology and marginal staining9,10. differences between bovine and human substrates Factors that contribute to the formation of regarding microleakage20,21. interproximate gaps and cause microleakage include: Several techniques have been described in the polymerization shrinkage, different thermal expansion literature for microleakage evaluation22. One of the coefficients of composite resin and tooth structures, no most widely accepted techniques is the dye penetration incremental technique during restoration, roughness of technique8,23. The dyes usually used are methylene blue, composite margins caused by inadequate finishing and basic fuchsin, silver nitrate, rhodamine and erythrocin24. polishing that leads to microgaps/ microfractures on the In the present study, we choose to use the methylene blue interface2. 2% solution, because of its low molecular weight and its The removal of decayed tooth structure is routinely high penetrability25. performed by high-speed handpieces and burs or even the The aim of this study was to compare the degree of use of instruments by hand. This conventional method microleakage on both incisal/enamel and cervical/dentin of cavity preparation has disadvantages, such as pain margins of class V cavities prepared with either a high- and discomfort for the patient, noise, overheating of the speed drill or an Er,Cr:YSGG laser and to associate them 1 dental structure and vibration . Recently, the use of laser with the beveling method applied to the margin. The null irradiation, as an alternative method of cavity preparation, hypothesis was that there is no difference at microleakage 11,12 has been suggested and is increasingly investigated . on the enamel and dentin margins for each cavity In 1997, the Food and Drug Administration (FDA) preparation and beveling method. approved the clinical use of Er:YAG lasers in cavity preparation. Later, another laser of the erbium family, the Er,Cr:YSGG was also approved for the same application1. Despite the initial concerns about the safety of the laser Material and Methods irradiation, several studies showed that a laser is as safe as the conventional high-speed drills13,14. The erbium Sixty bovine incisors were cleaned by removing family of lasers can be used on dental hard tissues. The their organic remnants with periodontal curettes and then Er:YAG laser emits a wavelength of 2780 nm, which is polished with flour of pumice and a rubber cup in a slow- highly absorbed in water and hydroxyapatite. In contrast, speed handpiece before being stored in chloramine 0.5% the Er,Cr:YSGG laser’s wavelength of 2780 nm has a solution at 4°C for 30 days. higher absorbance in hydroxyapatite than in water. Both Class V cavities were prepared on the buccal surfaces wavelengths can remove dental hard tissues through a of the bovine incisors. Τhe incisal margins were placed thermomechanical ablation process10,15. on enamel, while the gingival margins were placed on Cavities prepared with an erbium laser are shown by dentin. Thus, the cementoenamel junction was located SEM evaluation to lack a smear layer, with open dentinal 26 tubules, ablation focused mainly on intertubular than on at the center of the preparation . The cavity dimensions peritubular dentin, exposed enamel rods, extensive surface were standardized with the use of a template to trace an fissuring, and less homogeneous and regular surface outline at a mesio-distal and inciso-gingival width of 2 patterns4,10,16. This surface’s micromorphology is likely mm. The cavity depth was defined as 2 mm with the use to promote adhesion17. However, there are controversial of a periodontal probe. results regarding microleakage in laser-prepared cavities. The teeth were divided randomly into 3 groups The collagen fibrils’ fusion caused by dentin laser ablation (n=20) and prepared as follows: could be related to the higher microleakage at dentin Group 1 (G1): The cavity was prepared with an walls. Collagen fibrils’ fusion and the consequent lack Er,Cr:YSGG laser (2780 nm; Waterlase MD, Biolase, of inter-fibrillar space produce conditions in which resin Irvine, CA, USA). The parameters used for cavity is obstructed from diffusing into the subsurface of the preparation with the laser handpiece ‘Gold’ and tip MZ8 intertubular dentin16,18. are: power of 4 W, repetition rate of 20 Hz, air cooling The ideal substrate for in vitro research is human 50%, water spray 90%, pulse width 150 μsec (H mode) teeth. However, collecting an adequate amount of sound and spot size 800 μm. The enamel margin was beveled and healthy teeth without defects, such as caries or with a diamond bur (6847KR, 018, Komet, Besigheim, other conditions that lead to extraction is often difficult. Germany). Additionally, there are some parameters, such as age Group 2 (G2): The cavity was prepared with a and source that are difficult to control. These could carbide bur No 330 in a high-speed handpiece cooled with affect tissue quality and, consequently, the results of air-water spray. The bur was replaced with a new one after the experiment. Concerns also arise about transmitting every five preparations. The enamel margin was beveled diseases and about ethical issues. Bovine teeth are with a diamond bur (6847KR, 018, Komet, Besigheim, the most widely used substrate substituted for human Germany). 26 Athanasios Synarellis et al. Balk J Dent Med, Vol 21, 2017
Group 3 (G3): The cavity was prepared with an Oberkochen, Germany). Microleakage scores were based Er,Cr:YSGG laser (2780 nm; Waterlase MD, Biolase, on a 4-grade scale presented in Table 128. Irvine, CA, USA). The parameters used for cavity Two blinded examiners evaluated both sections of preparation with the laser handpiece ‘Gold’ and tip MZ8 each tooth and scored the highest microleakage for each are: power of 4 W, repetition rate of 20 Hz, air cooling tooth’s section. Incisal (enamel) and gingival (dentin) 50%, water spray 90%, pulse width 150 μsec (H mode) and margins were separately scored for each tooth. spot size 800 μm. The enamel margin was ablated with the laser using altered parameters compared with those for the cavity preparation, namely a power of 1.25 W, repetition Table 1. Qualitative scale for dye penetration rate of 50 Hz, air cooling 50%, water spray 90%, pulse width 150 μsec (H mode) and spot size 800 μm. Score Content All cavities were restored with the same nano-hybrid 0 No dye penetration resin composite (Filtek Z550, 3M ESPE, St. Paul, MN, 1 Dye penetration reaching enamel/cementum USA, shade A2). Initially, the enamel margins were acid etched (selective etching technique) with orthophosphoric 2 Dye penetration reaching dentin acid 37% (Etching Gel DMP Ltd, Markopoulo, Greece) 3 Dye penetration reaching cavity floor for 30 sec, then rinsed thoroughly and air-dried. The bonding agent (Single Bond Universal, 3M ESPE, St. Paul, MN, USA) was then applied with the use of a small Samples that demonstrated evidence of dye brush for 20 sec, thoroughly dried to evaporate the solvent penetration through the sealed area of the root apex, were and light cured for 10 sec with LED photopolymerization not scored and were excluded from statistical analysis. light (Silverlight, Mectron, Carasco, Italy – 3.6 V Thus, from the initial number of 20 samples for each and light radiation 440-480 nm). The light intensity group, we analyzed 16, 18 and 15 samples for G1, G2 and was checked with the light-intensity sensor on the G3, respectively. The statistical analysis was performed polymerization unit during the experimental procedure. using the SPSS 17 and SPSS 22 (for the post hoc tests) for The cavities were filled with the resin composite in two Windows. oblique increments. The first increment was placed at the inciso-axial part of the cavity and the second increment was placed at the cervico-axial part of the cavity. Each increment was light-cured for 20 sec using the same light Results source. All specimens were stored in distilled water for 24 hours at 37°C. Afterwards, they were polished with The Mann-Whitney non-parametric test (level of abrasive discs (Super-Snap, Shofu Dental, San Marcos, significance was set at 5%) was conducted for each group CA, USA). Four abrasive discs with progressively separately. The test revealed statistically significant higher reduced roughness were used for each tooth. To simulate microleakage at the dentin margins as compared to the clinical stress, the specimens were thermocycled for 3000 enamel margins in only the G1 (p<0.05). In G2 and G3 ° ° ° ° cycles (5 C, 37 C, 55 C and 37 C, respectively) with 15 despite slightly higher microleakage scores at the dentin sec dwell time and 10 sec transfer time. margins, there were no statistically significant differences Following thermocycling, the apices were cut with (p=0.251 and p=0.326, respectively). G3 samples had a diamond bur (5881, 016, Komet, Besigheim, Germany) the highest microleakage score at both margins. The dye in a high-speed handpiece cooled with air-water spray penetration scores at the enamel and dentin margins for and sealed with sticky wax (Yeti dental Thowax, each group separately are presented in Figure 1. Keystone Industries, Gibbstown, NJ, USA) to prevent A non-parametric Kruskal-Wallis one-way analysis dye penetration. The specimens were air-dried and fully test of the three groups was performed on enamel and covered with two coats of colored nail varnish (Beauty Line Cosmetics, red shade, Cream Team Ltd, Greece, dentin margins separately. This test revealed statistically www.creamteam.gr), excluding the restoration and a 1 significant differences among the groups (p<0.05). A mm rim zone of tooth structure around it. The samples post-hoc Dunn’s multiple comparison test showed that were then immersed in a 2% methylene blue solution for G3 microleakage for enamel margins was statistically 24 hours27. After storage, the teeth were rinsed thoroughly significantly higher than G1 (p=0.032) and G2 (p=0.001). under running tap water and then sectioned longitudinally No significant differences were found between G1 and through the center of the restoration from the buccal G2 regarding enamel margins (p=0.850). For the dentin to the lingual surface, using a water-cooled low-speed margins, the G2 had lower microleakage scores than did diamond disc (Isomet low-speed saw, Buehler, Germany). the G1 and G3 (p<<0.001), while there was no significant Evaluation was performed at 25X magnification under difference among G1 and G3 scores (p=1.000). These a light stereomicroscope (Carl Zeiss Stemi/DV4, results are presented in Figure 2 & 3. Balk J Dent Med, Vol 21, 2017 Microleakage of class V Composite Restorations 27
Figure 1. Microleakage scores at enamel and dentin margins for each Figure 3. Representative photos of each group (magnification x25) group separately G1 sample with microleakage score 1 on enamel and 3 on dentin margin (a). G2 sample with microleakage score 1 on enamel and 2 on dentin margin (b). G3 sample with microleakage score 3 on enamel and dentin margin (c).
According to these results, this study showed that for enamel margins there is significantly higher microleakage for the cavities prepared and modified exclusively by laser, while for dentin margins bur prepared cavities demonstrated the lowest microleakage. Therefore, the null hypothesis that there is no difference in microleakage via enamel and dentin margins for each cavity preparation and beveling method has to be rejected.
Discussion
The results of the present study showed that conventional preparation with the use of a high-speed bur led to significantly less microleakage at enamel margins, compared to Er,Cr:YSGG laser preparation. These results are in agreement with those of other studies that have used an Erbium group laser device (Er:YAG laser)3,12,29-31. Bahrololoomi et al. reported results that are similar to our study when an etch-and-rinse adhesive system is applied, but for cavities treated with a self-etch adhesive system, Figure 2. Microleakage scores of the three groups for enamel margins they reported no significant difference independently of (a) and dentin margins (b) the preparation method31. This could be attributed to self- 28 Athanasios Synarellis et al. Balk J Dent Med, Vol 21, 2017 etch systems being not sufficient to decalcify enamel. An than for those prepared with a carbide bur (G2). A single- additional selective enamel etching step is required when step self-etch adhesive system was applied without an self-etch systems are applied to such margins. According additional acid etching step, which would interfere with to several studies, this additional step is important to the morphological characteristics of the residual dentin reduce enamel margin microleakage23,27,32-35. surface. Conventional bur preparations leave a smear Acid etching or laser etching of enamel margins prior layer, which blocks the dentinal tubules, while laser to adhesive application has been studied by Fattah et al. ablation produces a smear layer free surface with irregular who tested microleakage at cavity margins treated either characteristics, which probably favors mechanical resin with laser, or acid etching, or with the combination of interlocking and microretention7,10,41. Bertrand et al. the two procedures23. They reported that the combined showed that dentinal margin microleakage is minimized method demonstrated the lowest microleakage, followed when an etch-and-rinse adhesive system is used34. Given by the group that had acid etching alone23. In addition, this, and the fact that we applied an adhesive system with Ceballos et al. concluded that cavities prepared with a a pH=2.7 (ScotchBond Universal), which is classified bur and treated by acid etching before bonding yielded as one of the “mild” self-etch adhesives7 and does not less microleakage at the enamel margins when compared totally remove the smear layer or penetrate it towards with cavities prepared with a bur and treated by Er:YAG sound dentin, one would expect the results to be the laser irradiation with or without acid etching32. They reverse. The possible justification of these results is that also compared enamel laser etching to acid etching the cavosurface margins produced by laser irradiation are and reported that laser etching alone does not provide quite rough, and the adhesive did not completely penetrate adequate marginal sealing and cannot be deemed as the texture of the residual dentin surface, creating a reliable alternative32. Muhammed et al. found that microspacing and increasing microleakage. conventional preparation led to higher microleakage Our results are in accordance with those of similar scores on enamel margins when using a self-etch adhesive studies by Korkmaz et al. who used an adhesive with (Swiss TEC SL Bond). Acid etching of enamel margins pH=2.3 (Clearfil S3 Bond)12 and Trelles et al. who used a was performed prior to adhesive application, but no self-etch system with pH=2 (Clearfil SE Bond)8. The same beveling was performed36. results have been acquired by Baghalian et al. for Clearfil Beveling appears to play an important role in S3 Bond; however they reported less microleakage when a microleakage restriction. Independently of the cavity two-step self-etch adhesive was used (Clearfil SE Bond)1. preparation method, microleakage was reduced when The more acidic nature (pH=2) and the dual hydrophobic the enamel margins were beveled with a diamond bur. primer-hydrophilic resin nature of the two-step adhesive Significantly less microleakage was found for the groups improve marginal sealing and restrict micropenetration. G1 and G2, when beveling was performed with a high- Despite acidic modification of dentin improves marginal speed diamond bur compared to the G3, in which the sealing, microleakage remains higher for laser ablation margins were modified with an Er,Cr:YSGG laser. compared to diamond bur preparation even when a separate Beveling exposes a larger number of enamel rods, which acid-etching step is added29. are susceptible to acid decalcification and bonding A contemporary alternative to acid-etching method resin infiltration. According to Armengol et al., the is laser conditioning (BLc) for marginal modification so combination of acid etching and diamond bur beveling that hard tissues can become susceptible to adhesives. was better in terms of microleakage than acid etching There are numerous studies with controversial results and laser margin modification33. Several studies that did regarding marginal sealing that can be achieved with not include beveling and/or acid etching modification this method and its comparison to the conventional of marginal enamel in their methodology found no preparation. Three studies reported that acid-etching significant differences in microleakage between the is superior in terms of microleakage compared to laser two cavity preparation methods4,10,26,27,35-38. Trelles conditioning23,33,37. Ceballos et al., attribute superiority to et al. found higher microleakage of conventional acid etching, which makes the orifices of dentinal tubules preparations than those prepared with a low and a high wider and exposes collagen fibers of dentin, promoting energy Er,Cr:YSGG laser. Trelles et al. used a single- penetration of the adhesive and hybrid zone formation32. step self-etch adhesive (Clearfil S3 Bond) and did not However, laser ablation does not expose collagen fibers perform beveling or/and acid etching8. The results of and does not widen tubules, leaving a calcified surface Trelles et al. can be accepted because self-etch adhesives that is not susceptible to adhesive penetration32. The are intermediate in acidity, and despite their adequate micromorphology pattern of the dentin surface is also adhesion to dentin, they are unable to sufficiently modify different according to the method used. Laser irradiation and seal enamel margins39,40. is mostly absorbed by intertubular dentin due to its Regarding cervical margins, which are not protected conciseness in water and organic components, while acid- by enamel, our microleakage scores were significantly etching influences the most calcified part of dentin, which higher for cavities prepared with laser ablation (G1, G3) is peritubular dentin42. According to Esteves-Oliveira et Balk J Dent Med, Vol 21, 2017 Microleakage of class V Composite Restorations 29 al., even an additional laser modification step following ●● Microleakage at gingival/dentin margins is higher the acid-etching does not improve sealing37. Arami et than at incisal/enamel margins. al. did not find any statistically significant differences ●● Laser cavity preparation in conjunction with laser between the two methods27, while Shahabi et al. reported ablation on enamel margins seems to produce the larger amounts of microleakage for acid-etched dentin25. highest microleakage scores at both incisal and The last group used a two-step etch-and-rinse adhesive gingival margins. system (Adper Single Bond 2), which is based on water and ethanol. Such systems perform optimally on dry Acknowledgements The authors are expressing their surfaces. The laser ablation function is based on explosive compliments to Papapreponis Panayiotis* for his precious 32 evaporation of dentin water. This leads to a dry surface help to the statistical analysis of our results. on which a water-ethanol based adhesive should penetrate better. The hypothesis is that etch-and-rinse adhesive *PhD Epidemiology, Laboratory of Immunology, “Theageneio” systems perform better at the laser-ablated marginal Cancer Hospital of Thessaloniki, Greece. E-mail: pdpapas@ gmail.com dentin than do self-etch systems. This is verified also by the study by Moldes et al10. According to this study, an equal amount of microleakage occurs when an etch- and-rinse adhesive is used on dentinal margins either on conventional cavity preparation or on a laser-prepared References cavity. For the self-etch systems, the same authors are reporting less microleakage for laser preparations10 1. Baghalian A, Nakhjavani YB, Hooshmand T, Motahhary P, Bahramian H. Microleakage of Er:YAG laser and dental and this is in compliance with the findings of two other bur prepared cavities in primary teeth restored with different studies37,43. A possible explanation of less microleakage adhesive restorative materials. Lasers Med Sci, 2013; could be that laser alterations on dentin surfaces leave 28:1453-1460. micro-irregularities and no smear layer. Such alterations 2. Lima AF, Soares GP, Vasconcellos PH, Ambrosano GM, result in both macro and micro-roughness. Laser induced Marchi GM, Lovadino JR, Aguiar FH. Effect of surface changes in the surface texture of the dentin could sealants on microleakage of Class II restorations after potentially affect the microleakage of adhesive restorative thermocycling and long-term water storage. J Adhes Dent, materials4. 2011; 13:249-254. When comparing microleakage between enamel 3. Yaman BC, Guray BE, Dorter C, Gomeç Y, Yazıcıoglu O, and dentin margins for all groups and each one of the Erdilek D. Effect of the erbium:yttrium-aluminum-garnet samples individually, dentinal margins demonstrate laser or diamond bur cavity preparation on the marginal vastly larger amounts of dye penetration. In agreement microleakage of class V cavities restored with different with this observation is a summation of the published adhesives and composite systems. Lasers Med Sci, 2012; literature1,3,8,10,12,23,27-30,32,37,38,44,45. This agreement can 27:785-794. 4. Korkmaz FM, Baygin O, Tuzuner T, Bagis B, Arslan I. be attributed to the more difficult and technically sensitive The effect of an erbium, chromium: yttrium-scandium- procedure involving adhesion to dentin8, as well as to gallium-garnet laser on the microleakage and bond strength the more complex and reduced inorganic content of the of silorane and micro-hybrid composite restorations. Eur J 1 dentin compared to enamel . An additional factor that Dent, 2013; 7:33-40. could promote microgap formation on the dentinal margin 5. Costa Pfeifer CS, Braga RR, Cardoso PE. Influence of is polymerization contraction that occurs at the strongest cavity dimensions, insertion technique and adhesive system bonded surface of the cavity, which is the enamel margin8. on microleakage of Class V restorations. J Am Dent Assoc, 2006; 137:197-202. 6. Pashley DH, Carvalho RM. Dentine permeability and dentine adhesion. J Dent, 1997; 25:355-372. Conclusions 7. Van Meerbeek B, De Munck J, Yoshida Y, Inoue S, Vargas M, Vijay P, Van Landuyt K, Lambrechts P, Vanherle G. Based on the findings of our study and within the Buonocore memorial lecture. Adhesion to enamel and limitations of an in-vitro study, we can conclude the dentin: current status and future challenges. Oper Dent, 2003; 28:215-235. following: 8. Trelles K, Arnabat J, España-Tost T. Microleakage in ●● The conventional cavity preparation method with Class V cavities with self-etching adhesive system and a bur performs significantly better in terms of conventional rotatory or laser Er,Cr:YSGG. Laser Ther, microleakage than preparation with a laser. 2012; 21:255-268. ●● The method of enamel margin beveling seems to 9. Aranha AC, Turbino ML, Powell GL, Eduardo Cde P. influence the sealing ability of a resin composite Assessing microleakage of class V resin composite restoration. Beveling with a diamond bur leads to restorations after Er:YAG laser and bur preparation. Lasers less microleakage. Surg Med, 2005; 37:172-177. 30 Athanasios Synarellis et al. Balk J Dent Med, Vol 21, 2017
10. Moldes VL, Capp CI, Navarro RS, Matos AB, Youssef MN, 26. Yazici AR, Yıldırım Z, Antonson SA, Kilinc E, Koch D, Cassoni A. In vitro microleakage of composite restorations Antonson DE, Dayangaç B, Ozgünaltay G. Comparison of prepared by Er:YAG/Er,Cr:YSGG lasers and conventional the Er,Cr:YSGG laser with a chemical vapour deposition drills associated with two adhesive systems. J Adhes Dent, bur and conventional techniques for cavity preparation: a 2009; 11:221-229. microleakage study. Lasers Med Sci, 2012; 27:23-29. 11. Gokcelik A, Ozel Y, Ozel E, Arhun N, Attar N, Firatli S, 27. Arami S, Shahabi S, Tabatabaie M, Chiniforush N, Firatli E. The influence of Er:YAG laser conditioning versus Morshedi E, Torabi S. Assessing microleakage of composite self-etching adhesives with acid etching on the shear bond restorations in class V cavities prepared by Er:YAG strength of orthodontic brackets. Photomed Laser Surg, laserirradiation or diamond bur. J Conserv Dent, 2014; 2007; 25:508-512. 17:216-219. 12. Korkmaz Y, Ozel E, Attar N, Bicer CO, Firatli E. 28. Baygin O, Korkmaz FM, Arslan I. Effects of different types Microleakage and scanning electron microscopy evaluation of adhesive systems on the microleakage of compomer of all-in-one self-etch adhesives and their respective restorations in Class V cavities prepared by Er,Cr:YSGG nanocomposites prepared by erbium:yttrium-aluminum- laser in primary teeth. Dent Mater J, 2012; 31:206-214. garnet laser and bur. Lasers Med Sci, 2010; 25:493-502. 29. Corona SA, Borsatto MC, Pecora JD, De SA Rocha RA, 13. Navarro RS, Gouw-Soares S, Cassoni A, Haypek P, Zezell Ramos TS, Palma-Dibb RG. Assessing microleakage of DM, de Paula Eduardo C. The influence of erbium:yttrium- different class V restorations after Er:YAG laser and bur aluminum-garnet laser ablation with variable pulse width on morphology and microleakage of composite restorations. preparation. J Oral Rehabil, 2003; 30:1008-1014. Lasers Med Sci, 2010; 25:881-889. 30. Ozel E, Korkmaz Y, Attar N, Bicer CO, Firatli E. Leakage 14. Corona SA, Souza-Gabriel AE, Chinelatti MA, Pécora JD, pathway of different nano-restorative materials in class Borsatto MC, Palma-Dibb RG. Influence of energy and V cavities prepared by Er:YAG laser and bur preparation. pulse repetition rate of Er:YAG laser on enamel ablation Photomed Laser Surg, 2009; 27:783-789. ability and morphological analysis of the laser-irradiated 31. Bahrololoomi Z, Heydari E. Assessment of Tooth surface. J Biomed Mater Res A, 2008; 84:569-575. Preparation via Er:YAG Laser and Bur on Microleakage of 15. Celik EU, Ergücü Z, Türkün LS, Türkün M. Shear bond Dentin Adhesives. J Dent (Tehran), 2014; 11:172-178. strength of different adhesives to Er:YAG laser-prepared 32. Ceballos L, Osorio R, Toledano M, Marshall GW. dentin. J Adhes Dent, 2006; 8:319-325. Microleakage of composite restorations after acid or Er-YAG 16. Ceballos L, Toledano M, Osorio R, Tay FR, Marshall GW. laser cavity treatments. Dent Mater, 2001; 17:340-346. Bonding to Er:YAG laser-treated dentin. J Dent Res, 2002; 33. Armengol V, Jean A, Enkel B, Assoumou M, Hamel H. 8:119-122. Microleakage of class V composite restorations following 17. Esteves-Oliveira M, Zezell DM, Apel C, Turbino ML, Aranha Er:YAG and Nd:YAP laser irradiation compared to acid- AC, Eduardo Cde P, Gutknecht N. Bond strength of self- etch: an in vitro study. Lasers Med Sci, 2002; 17:93-100. etching primer to bur cut, Er,Cr:YSGG, and Er:YAG lased 34. Bertrand MF, Semez G, Leforestier E, Muller-Bolla M, dental surfaces. Photomed Laser Surg, 2007; 25:373-380. Nammour S, Rocca JP. Er:YAG laser cavity preparation and 18. Sennou HE, Lebugle AA, Grégoire GL. X-ray photoelectron composite resin bonding with a single-component adhesive spectroscopy study of the dentin-glass ionomer cement system: relationship between shear bond strength and interface. Dent Mater, 1999; 15:229-237. microleakage. Lasers Surg Med, 2006; 38:615-623. 19. Yassen GH, Platt JA, Hara AT. Bovine teeth as substitute for 35. Marotti J, Geraldo-Martins VR, Bello-Silva MS, de Paula human teeth in dental research: a review of literature. J Oral Eduardo C, Apel C, Gutknecht N. Influence of etching with Sci, 2011; 53:273-282. erbium, chromium:yttrium-scandium-gallium-garnet laser 20. Reeves GW, Fitchie JG, Hembree JH Jr, Puckett AD. on microleakage of class V restoration. Lasers Med Sci, Microleakage of new dentin bonding systems using human 2010; 25:325-329. and bovine teeth. Oper Dent, 1995; 20:230-235. 36. Muhammed G, Dayem R. Evaluation of the microleakage of 21. Almeida KG, Scheibe KG, Oliveira AE, Alves CM, different class V cavities prepared by using Er:YAG laser, Costa JF. Influence of human and bovine substrate on the ultrasonic device, and conventional rotary instruments with microleakage of two adhesive systems. J Appl Oral Sci, two dentin bonding systems (an in vitro study). Lasers Med 2009; 17:92-96. Sci, 2015; 30:969-975. 22. Owens BM, Halter TK, Brown DM. Microleakage of tooth-colored restorations with a beveled gingival margin. 37. Esteves-Oliveira M, Carvalho WL, Eduardo Cde P, Zezell Quintessence Int, 1998; 29:356-361. DM. Influence of the additional Er:YAG laser conditioning 23. Fattah T, Kazemi H, Fekrazad R, Assadian H, Kalhori step on the microleakage of class V restorations. J Biomed KA. Er,Cr:YSGG laser influence on microleakage of class Mater Res B Appl Biomater, 2008; 87:538-543. V composite resin restorations. Lasers Med Sci, 2013; 38. Quo BC, Drummond JL, Koerber A, Fadavi S, Punwani I. 28:1257-1262. Glass ionomer microleakage from preparations by an Er/YAG 24. Van Meerbeek B, Peumans M, Poitevin A, Mine A, Van laser or a high-speed handpiece. J Dent, 2002; 30:141-146. Ende A, Neves A, De Munck J. Relationship between bond 39. Pashley DH, Tay FR. Aggressiveness of contemporary strength tests and clinical outcomes. Dent Mater, 2010; self-etching adhesives. Part II: etching effects on unground 26:e100-121. enamel. Dent Mater, 2001; 17:430-444. 25. Shahabi S, Ebrahimpour L, Walsh LJ. Microleakage of 40. Ibarra G, Vargas MA, Armstrong SR, Cobbb DS. composite resin restorations in cervical cavities prepared by Microtensile bond strength of self-etching adhesives to Er,Cr:YSGG laser radiation. Aust Dent J, 2008; 53:172-175. ground and unground enamel. J Adhes Dent, 2002; 4:115-124. Balk J Dent Med, Vol 21, 2017 Microleakage of class V Composite Restorations 31
41. Hossain M, Nakamura Y, Yamada Y, Murakami Y, 45. Delmé KI, Deman PJ, De Bruyne MA, Nammour S, De Matsumoto K. Microleakage of composite resin restoration Moor RJ. Microleakage of glass ionomer formulations after in cavities prepared by Er,Cr:YSGG laser irradiation and erbium:yttrium-aluminium-garnet laser preparation. Lasers etched bur cavities in primary teeth. J Clin Pediatr Dent, Med Sci, 2010; 25:171-180. 2002; 26:263–268. 42. Ekworapoj P, Sidhu SK, McCabe JF. Effect of different power parameters of Er,Cr:YSGG laser on human dentine. Received on October 5, 2016. Lasers Med Sci, 2007; 22:175-182. Revised on December 4, 2016. 43. Phanombualert J, Chimtim P, Heebthamai T, Weera-Archakul Accepted on January 28, 2016. W. Microleakage of Self-Etch Adhesive System in Class V Cavities Prepared by Using Er:YAG Laser with Different Correspondence: Pulse Modes. Photomed Laser Surg, 2015; 33:467-472. 44. Delme KI, Deman PJ, De Moor RJ. Microleakage of class V Eugenia Koliniotou-Koumpia resin composite restorations after conventional and Er:YAG Department of Operative Dentistry, Aristotle University of Thessaloniki laser preparation. J Oral Rehabil, 2005; 32:676-685. E-mail: [email protected]
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L BALKAN JOURNAL OF DENTAL MEDICINE A ISSN 2335-0245 IC G LO TO STOMA
Examination of Scanner Precision by Analysing Orthodontic Parameters
SUMMARY Nemanja Majstorović1, Luka Čerče2, Davorin 2 2 Background: 3D modelling in orthodontics is becoming an Kramar , Mirko Soković , 1 3 increasingly widespread technique in practice. One of the significant Branislav Glišić ,Vidosav Majstorović , Srđan Živković4 questions already being asked is related to determining the precision of the scanner used for generating surfaces on a 3D model of the jaw. Materials 1University of Belgrade, Faculty of Dentistry and methods: This research was conducted by generating a set of identical Belgrade, Serbia 2University of Ljubljana 3D models on Atos optical 3D scanner and Lazak Scan laboratory scanner, Faculty of Mechanical Engineering which precision was established by measuring a set of orthodontic Ljubljana, Slovenia parameters (54 overall) in all three orthodontic planes. In this manner we 3University of Belgrade explored their precision in space, since they are used for generating spatial Faculty of Mechanical Engineering models – 3D jaws. Results: There were significant differences between Belgrade, Serbia 4Military Technical Institute, Belgrade, Serbia parameters scanned with Atos and Lazak Scan. The smallest difference was 0.017 mm, and the biggest 1.109 mm. Conclusion: This research reveals that both scanners (Atos and Lazak Scan), which belong to general purpose scanners, based on precision parameters can be used in orthodontics. Early analyses indicate that the reference scanner in terms of precision is Atos. ORIGINAL PAPER (OP) Key words: Scanning, 3D modelling, Orthodontics, Precision Balk J Dent Med, 2017; 21:32-43
Introduction Materials and Methods
Examination of scanner precision represents a This research was conducted by generating a set significant aspect of its utilisation. Nowadays, it is of identical 3D models on Atos optical 3D scanner and performed via the following approaches: (i) calibration and Lazak Scan laboratory scanner, measuring and analysing precision analysis using the relevant international standard 54 orthodontic parameters10,13. Impressions from a group (laser measurement systems)1-6, (ii) comparison of the of 25 patients were randomly collected at the Clinic for precision of two scanners, with different levels of nominal Orthodontics within the Faculty of Dentistry, Belgrade. precision, using measurements of real parameters7, and Jaw models were cast in the light reflecting plaster (iii) indirect examination by comparison of orthodontic and therefore were ideal for the scanning even without parameter precision by using manual and 3D models8-9. the use of anti-reflection protection, as it was important This paper uses the second approach, the comparison of to obtain accurately scanned plaster models (from a two scanners on the examples of the measurement of the “cloud” of points gathered by scanning), primarily of same parameters and the analysis of obtained results10. The teeth and gingival margin. Correctly positioned referential advantage of this model lies in the fact that a scanner is geometrical entities (RGEs) were used for measuring analysed on real examples for which it will be later used. orthodontic parameters of the global coordinate system of The aim of this paper was to examine and the jaw (GCSJ)13. determine the precision of two general scanners (Atos At the beginning of model scanning, the area of optical 3D scanner11 and Lazak Scan laboratory scanner12) scanner measurement was first defined, accompanied by which could be used for the analysis and synthesis of the calibration of Lazak Scan by the following procedures: orthodontic parameters on 3D models. setting the camera in the desired position and adjusting the Balk J Dent Med, Vol 21, 2017 Examination of Scanner Precision 33 camera focus for the projection. After that, the calibration was done using the “Main Alignment by Coordinate plate was rotated, whereby the scanner independently Systems” function (Figure 5). The model was positioned in generated images every few seconds. The calibration such a way that GCSJ was aligned to the coordinate system plate was moved over the entire measured area and then of the scanner (their axes were parallel). rotated so that the scanner would be at different angles. That is how an adequate algorithm was clearly defined, with the aim of adjusting the scanner to the space where scanning would be performed. In order to achieve model precision on occlusal surface, Lazak Scan was placed in such a way that beams aimed downwards in the direction of the plaster model with an angle of 55o, attaining a significantly smaller reflection of inner, outer and occlusal tooth surfaces. Each plaster model was scanned from 20 angles. Furthermore, 16 projections were positioned- rotated clockwise at approximately 22.5o. After scanning and completing the 3D jaw model on the Lazak Scan, whilst operating Flex Scan 3D software from different angles/positions, the alignment of obtained models using the “Align” function was performed (Figure 1). This was achieved by using means of photogrammetric points on the impression, the entire jaw geometry and part of the 3D model (tooth) geometry. This procedure Figure 2. Connecting sets of scans using the “Combine” function for the allowed removal of the redundant and unclear elements upper jaw as well as various points in space, as a consequence of the alignment. In the subsequent step, by dint of the “Combine” function, a cleared individual scan was added to the set of scans (Figure 2). In this step we also chosed the surface roughness parameter and the texture. Finally, using the “Finalise” function, we obtained the final 3D model from a set of scans. This final model could later be improved and adjusted if necessary (Figure 3).
Figure 3. Independent filling of holes using the “Hole Filling” function - blue spots are ready to be filled, whilst green ones are not – an example of an upper jaw
Figure 1. Merging scans into a set of scans – an example of an upper jaw
Once orthodontic planes were defined, the “Manual“ function was selected for coordinate system orientation, whereby the directions of X, Y and Z axes were established (Figure 4). When determining the coordinate system on upper jaw models it is necessary to define the direction of X axis on the left (the model is observed from the side of the tooth) and Z axis in accordance with the model because its direction depends on the patient’s head and not jaw; and Figure 4. An example of a dialogue for defining the coordinate system on Y axis is directed to the incisors. The alignment/connecting a lower jaw model 34 Nemanja Majstorović et al. Balk J Dent Med, Vol 21, 2017
Figure 5. Alignment of coordinate systems (scanner – jaw) – lower jaw
Figure 8. Defined orthodontic parameters from D9 to D16 on a 3D After all coordinate systems and orthodontic planes lower jaw model were defined, using different intersections and projections, we could determine RGE and the points on tooth surface (most often anatomical points) for establishing orthodontic parameters in all three planes. We specified sets of linear orthodontic parameters using RGE10 to define orthodontic planes in space. If the bumps on the gingival margin were developed as a result of the presence of air bubbles in the negative on the plaster model (Figure 6), the lowest points on the gingival margin, not covered in bumps, should be used. RGM 7 was a mark used only for points on lower jaw models, representing the best mesial point on the edge between teeth and gums (Figure 7-9).
Figure 9. Defined orthodontic parameters from D17 to D26 on a 3D lower jaw model
In order to define/determine orthodontic parameters on the whole model (jaw) by the Atos system, we first performed the alignment by using means of the entire geometry of the model (jaw). This was realised in a way that we “import” the digital model and then define the global coordinate system on it with the help of RGEs. In the next step we defined orthodontic planes using at the same Figure 6. The position of the point for setting the median plane on a time the defined global coordinate system. This procedure lower jaw model utilises the “Change Actual Mesh to CAD Data” function. The same procedure was applied to the CAD model obtained by Lazak Scan. The alignment was conducted by means of the overall geometry of the jaw model, using the “Prealignment” function (Figure 10). On the surface of the model obtained by Lazak Scan we choosed the points which were located on the teeth, paying special attention not to select the filled spaces between the teeth and on their outer surfaces (Figure 11). In the next step we used the “Main Alignment by Local Best Fit” function, whereby we perform the exact alignment bearing in mind the chosen surfaces of the jaw model. In the end we provided a comparison of the surfaces using the “Surface Comparison on CAD” function, whereby we defined the interval/ Figure 7. Defined orthodontic parameters from D1 to D8 on a 3D lower tolerance for the desired value of error (on the scanned jaw model surface), defined in the interval of ±0,15 mm. Balk J Dent Med, Vol 21, 2017 Examination of Scanner Precision 35
Figure 10. Using the “prealignment” function – an example of an upper jaw Figure 11. The representation of the selected surface for alignment using CAD model. The chosen surfaces are coloured red – upper jaw
Results parameters obtained by 3D models scanned with Lazak Scan for the same jaw. Table 5. and Table 6. include the differences The results of measurements in Table 1. and Table 2. are difference between orthodontic parameters D1 – D26, related to lower jaw orthodontic parameters from D1 to D26 obtained by Atos and LazakScan, for the lower jow, while the acquired using GOM Inspect on 3D models, scanned with differences in orthodontic parameters for upper jaw G1 - G28 Atos. Table 3. and Table 4. contain data regarding the same in model 4 Atos and LazakScan are shown in Table 7.
Table 1. Mean values (mm) of orthodontic parameters D1 - D26, measured on 3D models, scanned using Atos scanner for the lower jaw (the first seven models)
Par / Model Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Model 7 D1 26.241 25.977 26.570 26.521 27.271 27.181 25.492 D2 35.612 35.711 36.543 36.621 37.141 38.091 38.894 D3 44.032 45.374 45.851 46.181 46.196 46.693 47.170 D4 29.781 28.892 30.166 29.448 30.235 30.978 31.261 D5 40.792 40.421 40.083 39.350 39.571 39.992 40.211 D6 53.521 53.842 53.151 53.398 53.097 53.723 53.565 D7 55.453 55.910 55.212 55.391 55.111 55.597 55.521 D8 47.958 48.380 48.211 48.071 47.561 48.301 48.040 D9 10.961 11.811 11.538 12.483 12.134 12.291 12.582 D10 21.323 21.672 20.851 22.473 21.975 22.363 22.081 D11 29.379 29.544 28.720 29.556 29.577 29.891 29.898 D12 33.681 34.061 32.933 33.522 33.726 34.215 33.189 D13 4.734 5.961 5.272 7.718 7.697 8.612 8.267 D14 14.976 16.011 13.991 15.763 15.732 16.315 16.128 D15 23.546 23.792 21.451 23.423 22.867 24.239 24.132 D16 28.528 27.960 26.550 27.920 27.790 28.330 27.750 D17 5.227 5.363 5.232 5.316 5.179 5.544 5.346 D18 5.156 5.062 4.771 5.712 5.326 5.548 5.291 D19 9.325 10.042 10.138 10.045 9.942 10.114 9.949 D20 10.123 10.422 10.341 8.710 10.130 10.211 10.252 D21 8.861 9.097 9.112 8.931 8.936 8.965 8.997 D22 4.868 4.960 4.632 4.621 4.521 4.781 4.869 D23 4.723 4.788 4.841 4.546 4.885 4.874 4.890 D24 9.951 10.361 9.88 10.050 9.940 10.040 10.02 D25 8.362 10.262 10.081 9.867 9.863 9.922 9.938 D26 8.923 9.314 9.048 8.961 8.887 9.152 8.981 36 Nemanja Majstorović et al. Balk J Dent Med, Vol 21, 2017
Table 2. Mean values (mm) of orthodontic parameters D1 - D26, measured on 3D models, scanned using Atos scanner for the lower jaw (the remaining six models)
Par/ Model Model 8 Model 9 Model 10 Model 11 Model 12 Model 13 D1 24.691 26.030 26.082 26.741 26.935 26.666 D2 38.522 38.430 38.942 39.011 39.030 38.790 D3 46.991 46.894 47.675 46.536 47.432 47.161 D4 30.922 31.340 31.532 32.050 31.480 31.382 D5 40.061 40.563 40.812 40.471 40.467 40.463 D6 53.021 52.960 53.490 53.753 53.361 53.282 D7 55.292 55.101 55.483 55.562 55.401 55.335 D8 47.793 47.561 48.040 48.123 48.056 47.872 D9 12.437 12.136 12.723 13.188 12.921 12.772 D10 22.356 21.742 21.591 21.460 22.123 22.167 D11 30.415 29.310 29.547 29.285 29.739 30.012 D12 33.921 33.402 33.460 33.590 33.751 33.956 D13 8.813 8.441 8.120 7.863 8.458 8.581 D14 16.821 17.041 17.093 16.476 17.148 16.925 D15 25.358 25.155 25.250 24.562 25.145 25.187 D16 28.561 28.393 28.901 28.310 29.113 28.856 D17 5.332 5.501 5.612 5.676 5.495 5.551 D18 5.235 5.402 5.690 5.491 5.426 5.460 D19 9.731 9.690 9.992 9.770 9.867 10.058 D20 9.843 9.991 10.361 10.150 10.012 10.060 D21 9.227 8.712 9.120 9.034 9.057 9.011 D22 4.496 4.801 4.993 4.921 5.110 5.338 D23 4.741 5.312 4.377 4.969 4.962 5.290 D24 9.982 10.187 10.320 10.194 10.228 10.313 D25 9.657 9.751 9.960 10.042 9.873 9.901 D26 8.643 8.821 9.186 9.283 9.082 9.133
Table 3. Mean values (mm) of orthodontic parameters D1 - D26, measured on 3D models, scanned using LazakScan scanner for the lower jaw (the first seven models) Par / Model Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Model 7 D1 25.963 25.702 26.553 26.498 27.191 27.305 25.552 D2 35.751 35.702 36.530 36.497 37.021 37.970 38.710 D3 43.661 45.202 45.450 45.840 45.830 46.455 46.721 D4 29.763 30.001 29.461 29.496 30.301 30.771 31.260 D5 40.567 40.191 39.503 39.661 39.470 39.910 40.333 D6 53.918 53.260 53.390 53.691 53.005 53.367 53.377 D7 55.491 55.191 55.262 55.558 55.002 55.383 55.335 D8 47.814 47.714 48.190 47.841 47.481 48.050 47.740 D9 10.878 12.002 11.771 11.540 12.501 12.350 12.361 D10 21.132 21.011 21.001 21.961 21.810 21.936 21.670 D11 29.337 29.560 29.254 29.288 29.450 29.546 29.661 D12 33.526 33.810 33.461 33.230 33.925 34.110 33.387 D13 4.869 5.730 5.421 7.290 7.670 8.538 8.560 Balk J Dent Med, Vol 21, 2017 Examination of Scanner Precision 37
Par / Model Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Model 7 D14 14.831 14.911 14.010 15.430 15.732 16.254 16.226 D15 23.492 23.312 21.280 22.951 22.787 23.850 23.950 D16 28.351 28.292 26.560 27.662 27.801 28.336 27.467 D17 4.828 5.322 5.051 4.850 5.041 5.080 5.066 D18 4.922 5.110 4.892 5.310 4.760 5.041 4.992 D19 9.128 9.830 9.981 9.760 9.582 9.810 9.618 D20 9.927 10.061 10.071 8.462 9.430 9.852 9.635 D21 8.563 8.964 9.051 8.657 8.601 8.702 8.692 D22 4.921 4.690 4.222 4.541 4.171 4.650 4.968 D23 4.134 4.230 4.380 4.450 4.441 4.492 4.542 D24 9.838 10.091 9.690 9.842 9.754 9.792 9.770 D25 8.144 9.930 9.781 9.520 9.354 9.342 9.661 D26 8.959 8.949 8.945 8.787 8.728 8.742 8.711
Table 4. Mean values (mm) of Orthodontic parameters D1 - D26, measured on 3D models, scanned using LazakScan scanner for the lower jaw (the remaining six models)
Par / Model Model 8 Model 9 Model 10 Model 11 Model 12 Model 13 D1 24.817 25.801 26.085 26.530 26.920 26.781 D2 38.212 38.312 38.910 39.043 38.861 38.670 D3 46.521 46.731 47.320 46.644 47.287 46.994 D4 30.933 31.172 31.731 32.255 31.743 31.410 D5 39.851 40.221 40.694 40.620 40.570 40.381 D6 53.158 53.040 53.623 53.642 53.741 53.735 D7 55.428 55.170 55.791 55.542 55.861 55.744 D8 47.951 47.822 48.210 47.910 48.313 48.231 D9 12.864 12.273 12.561 13.075 12.970 12.862 D10 22.168 21.510 21.323 21.212 22.150 21.865 D11 30.195 29.190 29.322 29.474 29.725 29.566 D12 33.828 33.160 33.652 33.391 33.923 33.761 D13 8.761 8.510 8.272 8.151 8.362 8.492 D14 16.663 16.940 16.801 16.704 16.866 16.553 D15 24.94 25.172 25.061 24.640 24.792 24.770 D16 28.421 28.760 29.034 28.741 28.913 28.990 D17 5.011 5.401 5.492 5.127 5.350 5.050 D18 4.891 5.370 5.612 5.443 5.191 5.051 D19 9.425 9.682 9.851 9.582 9.640 9.701 D20 9.668 9.770 10.130 9.740 9.990 9.831 D21 8.932 8.492 9.153 8.820 8.720 8.840 D22 4.489 4.671 5.101 4.950 4.802 5.230 D23 4.571 4.781 4.401 4.960 4.973 4.890 D24 9.625 9.872 9.971 9.950 9.891 9.987 D25 9.222 9.470 9.752 9.856 9.810 9.557 D26 8.327 8.627 9.011 9.542 8.991 8.966 38 Nemanja Majstorović et al. Balk J Dent Med, Vol 21, 2017
Table 5. The difference between orthodontic parameters D1 – D26, obtained by Atos and LazakScan, for the lower jaw, for the first seven 3D models
Par / Model Model 1 Model 2 Model 3 Model 4 Model 5 Model 6 Model 7 D1 0.278 0.275 0.017 0.023 0.080 -0.124 -0.060 D2 -0.139 0.009 0.004 0.214 0.120 0.121 0.184 D3 0.371 0.172 0.401 0.34 0.356 0.238 0.419 D4 0.018 -1.109 0.705 -0.048 -0.066 0.207 0.001 D5 0.225 0.230 0.580 -0.311 0.101 0.082 -0.122 D6 -0.397 0.582 -0.239 -0.293 0.092 0.356 0.188 D7 -0.038 0.719 -0.050 -0.167 0.109 0.214 0.186 D8 0.144 0.666 0.021 0.230 0.080 0.251 0.300 D9 0.083 -0.191 -0.233 0.943 -0.367 -0.059 0.221 D10 0.191 0.661 -0.150 0.512 0.165 0.427 0.411 D11 0.042 -0.016 -0.534 0.268 0.127 0.345 0.237 D12 0.155 0.251 -0.528 0.292 -0.199 0.105 -0.198 D13 -0.135 0.231 -0.149 0.428 0.027 0.074 -0.293 D14 0.145 1.101 -0.019 0.333 0 0.061 -0.098 D15 0.054 0.480 0.171 0.472 0.080 0.389 0.182 D16 0.177 -0.392 -0.010 0.258 -0.011 -0.006 0.283 D17 0.399 0.041 0.181 0.466 0.138 0.464 0.280 D18 0.234 -0.048 -0.121 0.402 0.566 0.507 0.299 D19 0.197 0.212 0.157 0.285 0.360 0.304 0.331 D20 0.196 0.361 0.270 0.248 0.700 0.359 0.617 D21 0.298 0.133 0.061 0.274 0.335 0.263 0.305 D22 -0.053 0.270 0.410 0.080 0.350 0.131 -0.099 D23 0.589 0.558 0.461 0.096 0.444 0.382 0.348 D24 0.113 0.270 0.190 0.208 0.186 0.248 0.250 D25 0.218 0.332 0.300 0.347 0.509 0.580 0.277 D26 -0.036 0.365 0.108 0.174 0.159 0.410 0.270
Table 6. The difference between orthodontic parameters D1 – D26, obtained by Atos and LazakScan, for the lower jaw, for the remaining six 3D models
Par / Model Model 8 Model 9 Model 10 Model 11 Model 12 Model 13 D1 -0.126 0.229 -0.003 0.211 0.015 -0.115 D2 0.910 0.118 0.032 -0.032 0.169 0.120 D3 0.470 0.163 0.355 -0.108 0.145 0.167 D4 0.059 0.168 -0.199 -0.205 -0.263 -0.028 D5 0.210 0.342 0.118 -0.149 -0.103 0.082 D6 -0.137 -0.080 -0.133 0.111 -0.380 -0.453 D7 -0.136 -0.069 -0.308 0.020 -0.460 -0.409 D8 -0.158 -0.261 -0.170 0.213 -0.257 -0.359 D9 -0.427 -0.137 0.162 0.113 -0.049 -0.090 D10 0.188 -0.038 0.268 0.248 -0.027 0.302 D11 0.220 0.120 0.225 -0.189 0.014 0.446 D12 0.093 0.242 -0.192 0.199 -0.172 0.195 D13 0.052 -0.069 -0.152 -0.288 0.096 0.089 D14 0.152 0.101 0.292 -0.228 0.282 0.372 Balk J Dent Med, Vol 21, 2017 Examination of Scanner Precision 39
Par / Model Model 8 Model 9 Model 10 Model 11 Model 12 Model 13 D15 0.418 -0.017 0.189 -0.079 0.353 0.417 D16 0.140 -0.367 -0.133 -0.431 0.200 -0.134 D17 0.321 0.100 0.120 0.549 0.145 0.501 D18 0.344 0.032 0.078 0.048 0.235 0.409 D19 0.306 0.008 0.141 0.030 0.227 0.357 D20 0.175 0.221 0.231 0.410 0.022 0.229 D21 0.295 0.220 -0.033 0.214 0.337 0.171 D22 0.007 0.130 -0.108 -0.029 0.308 0.108 D23 0.170 0.531 -0.024 0.009 -0.011 0.400 D24 0.357 0.315 0.349 0.244 0.337 0.326 D25 0.435 0.218 0.208 0.186 0.063 0.344 D26 0.316 0.184 0.175 -0.259 0.091 0.167
Table 7. The differences in orthodontic parameters for upper jaw G1 - G28 in model 4 Atos and LazakScan
Parameter Atos Upper model 4 LS Upper model 4 Difference Abs. Value Raz. G1 32.771 32.733 0.038 0.038 G2 40.175 40.101 0.074 0.074 G3 45.798 45.777 0.021 0.021 G4 29.64 29.885 -0.245 0.245 G5 35.721 35.793 -0.072 0.072 G6 50.310 50.458 -0.148 0.148 G7 53.48 53.361 0.119 0.119 G8 41.712 41.798 -0.086 0.086 G9 10.910 10.840 0.070 0.070 G10 18.696 18.763 -0.067 0.067 G11 26.987 26.842 0.145 0.145 G12 34.961 34.850 0.111 0.111 G13 41.620 41.613 0.007 0.007 G14 11.128 11.081 0.047 0.047 G15 19.313 19.092 0.221 0.221 G16 27.311 27.244 0.067 0.067 G17 35.520 35.271 0.249 0.249 G18 41.601 41.798 -0.197 0.197 G19 6.918 6.810 0.108 0.108 G20 6.329 6.091 0.298 0.298 G21 8.990 8.754 0.236 0.236 G22 9.194 8.938 0.256 0.256 G23 9.721 9.550 0.171 0.171 G24 6.934 6.842 0.092 0.092 G25 6.617 6.655 -0.038 0.038 G26 9.260 9.110 0.150 0.150 G27 9.921 9.741 0.180 0.180 G28 9.846 9.670 0.176 0.176 40 Nemanja Majstorović et al. Balk J Dent Med, Vol 21, 2017
There were significant differences between parameters scanned with Atos and Lazak Scan. The smallest difference was 0.017 mm, and the biggest 1.109 mm. The results shown in Figure 12 and Figure 13, exhibiting predominantly yellow, green and light blue, practically signify that the precision of both scanners is satisfactory, with the comparison being performed in relation to the 3D model from the Atos scanner which possesses a greater nominal precision.
Figure 13. Comparison of surface differences – another angle of view / upper jaw
The difference between α, β i γ angles of the “master” model and 2-13 models of the upper and lower jaw scanned with Atos are presented in Table 8 and Table 9. The differences (mm) in median points position Figure 12. Comparison of surface differences using the “Surface between the “master” model and 2-13 models of the upper Comparison on CAD” function– upper jaw jaw are shown in Table 10.
Table 8. The difference between α, β i γ angles (°) of “master” model and 2-13 models of upper jaw scanned with Atos
M2 – M3 – M4 – M5 – M6 – M7 – M8 – M9 – M11 M12 M13 Rot. rav. M10 M1 M1 M1 M1 M1 M1 M1 M1 –M1 –M1 –M1 Θx 1.77 0.40 -0.71 -0.93 -2.17 -2.95 -4.41 -5.49 -5.00 -5.91 -4.97 -5.07 Θy 0.09 0.08 0.03 0.13 0.17 0.28 0.20 0.22 0.19 0.13 0.13 0.05 Θz -0.26 0.14 -0.07 0.18 -0.02 0.00 -0.39 -0.40 0.12 0.34 0.26 0.19
Table 9. The difference between α, β i γ angles (°) of “master” model and 2-13 models of lower jaw scanned with Atos
Rot. M2 – M3 – M4 – M5 – M6 – M7 – M8 – M9 – M10 M11 M12 M13 rav. M1 M1 M1 M1 M1 M1 M1 M1 –M1 –M1 –M1 –M1 Θx -1.25 1.30 -1.11 -0.80 -0.89 0.07 1.14 0.48 0.73 0.45 1.28 1.04 Θy -0.31 1.16 -0.41 -0.52 -0.38 -0.72 -0.88 -1.07 -0.88 -1.07 -1.02 -0.96 Θz -0.15 0.13 0.11 0.41 0.04 0.27 -0.04 -1.28 -1.25 -1.08 -1.21 -1.34
Table 10. The differences (mm) in median points position compared to the origin of the coordinate system, and between the “master” model and 2-13 models of the upper jaw
M2 – M3 – M4 – M5 – M6 – M7 – M8 – M9 – M10 – M11 – M12 – M13 – S.K. M1 M1 M1 M1 M1 M1 M1 M1 M1 M1 M1 M1 Δx 0.55 0.65 0.70 0.73 0.46 0.75 1.44 1.43 1.16 0.77 0.60 0.33 Δy 0.18 0.15 0.23 0.37 0.07 0.20 0.42 0.73 0.59 0.63 0.40 0.36 Δz 0.11 0.06 0.12 0.20 0.16 0.12 0.05 -0.07 -0.01 -0.08 -0.11 -0.11
Yθx -0.11 -0.02 0.04 0.06 0.13 0.18 0.27 0.34 0.31 0.36 0.30 0.31
Yost 0.28 0.18 0.19 0.31 -0.06 0.02 0.15 0.39 0.28 0.26 0.10 0.05 Balk J Dent Med, Vol 21, 2017 Examination of Scanner Precision 41
Discussion Due to tooth damages, we could not position the points for marking a great number of orthodontic In the system of 3D models there are three coordinate parameters on two teeth in the lower jaw, so for that systems– the coordinate system of the scanner (CSS), global reason we placed them elsewhere, but these changes had coordinate system of the jaw (GCSJ) and local coordinate no impact on the accuracy of the obtained results, since system of the jaw (LCSJ). Prior to any measurement on 3D we examined scanner precision and not orthodontic models, these systems have to be determined, i.e. defined characteristics of a patient’s teeth and jaw. Hence the and interconnected. The coordinate system of the scanner position of orthodontic parameters on upper jaw models is defined as per rules regarding the scanner, and it can be remained as defined in theory, and lower jaw models had absolute (the origin is always in the same point), and relative two orthodontic parameters fewer than anticipated, also (the origin can be in any point of the scanner work space). due to teeth damages, without the possibility of replacing More accurate measurement results are obtained by relative them with other points. coordinate system, which was used in this research. As GCSJ It is more demanding to determine the exact position is defined, the orthodontic planes can be determined. The of L 2 D and R 2 D points, not because of the tip of the GCSJ is defined and set in accordance with the American tooth, but due to the occlusal edge and distal surfaces of Board of Orthodontics (ABO) regulations13, with RGE lateral incisors. That should be emphasised because we used for its definition, by using the “Construct Coordinate did not take the highest point but the one on the edge of System” function. the tooth, which always had to be defined in the same This research utilised examples of 3D models obtained manner. Points on broken teeth were set by using means by Atos professional scanner11 and 3D models created by of intersections and projections, whereby a high level of the Lazak Scan scanner12. If we know that the Atos scanner precision was achieved. We encountered certain problems precision equals +/-0.01 mm, and the Lazak Scan scanner in the set-up, as it was difficult to define points LG x, RG equals +/-0.05 mm, we can see the differences in the x and RGM 7 on Lazak Scan, since the line between the position of points of up to +/-0.12 mm. In order to clarify gums and teeth was not clear enough. First we concluded the differences in accuracy, we carried out measurements that it was hard to precisely mark the RGM 7 point, so we of orthodontic parameters on 3D models of the same jaws chosed the optimal mesial point which was best positioned by GOM Inspect comprehensive software, for both types of in Y-direction. Points L 4 L, L 5 L, R 4 L and R 5 L were 3D models obtained from both scanners. marked as the highest point had it been possible, and that Measurement results revealed the most significant was performed on the basis of evaluation. Due to the fact difference regarding the second model parameters D4 and that lower models do not contain points R 6 LM, R 6 BM D14. L 4 L point was probably inaccurately positioned and R 6 BD, R 7 LM should be used for calculation and due to the damage to the lingual side of a tooth. It can be rotation of orthodontic planes. When it comes to lower ignored since it is a consequence of plaster model damage. models, points RG 4, RG 5, LG 4, LG 5, L 6 BD, L 6 BM, The tip of R 4 L was damaged on that model, and it was L 6 LM and R 7 LM were used for all the analyses. related to D4, D10 and D18 parameters. The RGM 7 For example, when it comes to Atos, the upper point was also approximately positioned, which caused a jaw model had the L 3 point at 0.049 mm more to the discrepancy in values of D6-D8 parameters. Parameters left, whilst on Labod Scan the same point was 0.051 G13 and G18 were defined using L 2 D and R 2 D points, more to the right, which constituted the discrepancy which were also positioned according to calculations in the point position of 0.100 mm. Similarly, in the R 3 (easy to set the exemplary model), since the lateral incisor point, the discrepancy between G1 parameters on both on the model was broken, as in the example of G13 scans was approximately 0.200 mm. In our example parameter on model 4. something similar occurred in the G4 parameter, where Because there was some significant damage and the discrepancy in the value of orthodontic parameter was uneven surfaces on plaster models, we got different values 0.245 mm. The greatest discrepancy was 0.256 mm at the for parameters both on different plaster models and on G22 parameter, since it depends on the R 2 D point, which 3D models of the same plaster models obtained on both is more difficult to position on a particular tooth. scanners. The discrepancy in values resulted from incorrect Apart from the errors regarding linear distances, positioning of the points RG x, LG x and RGM 7. The directly related to defined orthodontic parameters, there analysis of this inaccuracy clearly indicates that, when the were also errors in tooth/jaw rotation compared to the same point is on models from both scanners, the position global coordinate system, and they are the following: α of points is improved by placing the same point on the angle – rotation in relation to the X axis, β angle – rotation same models on both scanners. The results show that the in relation to the Y axis, γ angle – rotation in relation to most significant deviation in value of parameters was 0.256 the Z axis. The analysis of data led to the conclusion that mm, with the average deviation of 0.129 mm. This can be there was a significant shift of the occlusal plane in the explained by means of measurement inaccuracy of both first model of the upper jaw, which was noticeable due scanners, which was analysed earlier. to the change of α angle between the first and the second 42 Nemanja Majstorović et al. Balk J Dent Med, Vol 21, 2017 model. The change of angle occured as a consequence of alignment of both models. Each model has to be defined numerous bumps on the gingival margin. We also deduced as a CAD file after scanning, and the alignment can be that the difference between the angles is 0.5 degrees, easily achieved by defining/determining orthodontic which was not far from anticipated values and could even planes and the GCSJ for both models, and then carry out be negligible due to its low value. The γ angle exhibited a the alignment via the GCSJ. Alignment could be also difference of 0.74 degrees (greater than the one for the β achieved taking into account the overall model geometry, angle, and the expected one) which was a consequence of as the option is suitable for application on models an inaccurate positioning of points on the distal surfaces obtained from the same plaster model, or part of the of first permanent molars. model s geometry, as it provides numerous possibilities by Differences between angles β and γ were larger using comprehensive software equipment. on lower jaw models compared to the upper jaw ones. That is a result of uneven surfaces on tooth tips and the occurrence of bumps on the gingival margin on the plaster model, thereby generating additional rotation, Conclusions best observed on model 3 of the lower jaw because of the Y-axis rotation. Another irregularity was observed This research reveals that both scanners (Atos here, arising from the incorrect positioning of the R 7 LM and Lazak Scan), which belong to general purpose point due to the tooth damage. There were also substantial scanners, based on precision parameters can be used in deviations from the anticipated values of rotation around orthodontics. Early analyses indicate that the reference the Y and Z axes. Whilst analysing the model and the scanner in terms of precision is Atos. The procedure of position of points it was evident that the lack of a tooth generating 3D models, whilst taking into account the in the jaw had an impact on the position and orientation scanner precision, would include the following steps: of orthodontic planes. Rotations were therefore strikingly Efforts should be made to create a plaster mould with realistic and constitute a lifelike representation of the no irregularities on tooth tips or gingival margin, position of orthodontic planes. If necessary, the final 3D model should to be formed The differences in the X axis direction were related to using cleaning and smoothing. Each irregularity due to the points for positioning the median plane, influencing the excessive material on tooth tips can significantly influence dental arch shape. The differences in the Z axis direction measurement results, were largely within the anticipated values (±0,100 mm), The final 3D model should be compose out of a small whilst the differences in the Y axis direction were exactly number of recorded projections, because the errors on tips/ as expected. We predicted a difference in the Y direction edges of a tooth turn into radial a transition view, which of Yθx ± 0,1 mm. Analysing the results, we inferred that impedes the positioning of anatomical points on tooth, the θx angle changed in almost linear fashion, which should It is important to precisely define and position imply the linearity of changes in differences in Y direction orthodontic planes, because any rotation of the occlusal shifts. The Yost value represents a shift in the global plane leads to positioning of different points on tooth tips. coordinate system in the Y direction of Δy, from which The procedure of positioning orthodontic planes has to we subtracted the Yθx shift, originating from the rotation be repeated if the highest point on the tip of distal buccal around the X axis. The shift in Yost was a consequence cusp above the plane is too high (0.01 mm). The initial of incorrectly positioned origin of the coordinate system step, the adjustment of the coordinate system of the jaw, via distal surfaces on first molars due to not entirely greatly influences the determination of RGE, which form precise positioning of RG 4, RG 5, LG 4 and LG 5 points the base for establishing the orthodontic parameters. (hampered by the bumps on the gingival margin and plaster One of the courses for future research will include models). We expected the shift to be in the range of ±0,100 the enhancement of repeatability of the adjustment of mm, and the deviation to be greater. In order to understand the coordinate system of the jaw. Prospective research in these results, on model 9 we performed the alignment of the this field could be focused on examining the precision of second and the ninth models via the first molar on the left. these scanners based on the example of the orthodontic It was clearly observed that the rotation between the left parameters of the class of the curve and the surface. and the right molars occurred, as a shift in the position of distal points on the molars, used for setting the position of the tuber plane and, in accordance with that, the origin of the global coordinate system. References We can conclude that the differences between surfaces of the same models scanned with Atos and Lazak 1. EN ISO 10360-10; Geometrical product specifications Scan are expected to be in the region of ±0.060 mm. In (GPS)-Acceptance and reverification tests for coordinate order to determine/calculate all orthodontic parameters, measuring systems (CMS)- Part 10: Laser trackers for for the entire 3D model, it is necessary to do a mutual measuring point-to-point distances, ISO Geneva, April 2016. Balk J Dent Med, Vol 21, 2017 Examination of Scanner Precision 43
2. Juds S. Photoelectric Sensors and Controls, Selection and 9. Siebert P, Bell A, Ayoub A. Assessment of the accuracy of a Application, First Edition. Opcon, Everett, Washington, three-dimensional imaging system for archiving dental study 1998. models. J Orthod, 2003, 30, 219-223. 3. Bräuer-Burchardt C, Kühmstedt P, Notni G.. Calibration of 10. ATOS Triple Scan- Revolutionary scanning technique, 2016, Stereo 3D Scanners with Minimal Number of Views Using http://www.gom.com/metrology-systems/atos/atos-triple- Plane Targets and Vanishing Points. 16th International scan.html Conference CAIP, 2015; 61-73. 11. Mujanović E. Uporaba optičnih 3D skenerjev za določanje 4. Barone S, Paoli A, Razionale V. Automatic alignment položaja zob pri uporabi stalnega zobnega aparata, Fakulteta of multi-view range maps by optical stereo-tracking. za strojništvo Ljubljana, 2016. International Conference IMProVe, 2011; 368-376. 12. Majstorović N, Mačužić J, Glišić B. Referent geometric 5. De Angelis D, Sala R, Cantatore A, Grandi M, Cattaneo entities in orthodontics on 3D models. Serb Dent J, 2014; C. A new computer-assisted technique to aid personal 61:102-112. identification. Int J Legal Med, 2009; 123:351-356. 13. The American Board of Orthodontics (ABO). Digital Model 6. El-etriby S. 3D Range Data Acquisition Using Structured Requirements, https://www.american boardortho.com Lighting and Accuracy Phase-Based Stereo Algorithm. Int J Comput Syst, 2015; 2: 337-348. 7. Bathow C, Breuckmann B, Scopigno R. Verification and Received on October 29, 2016. Revised on December 1, 2016. acceptance tests for high definition 3D surface scanners. Accepted on January 28, 2017. VAST 2010, The 11th International Symposium on Virtual Reality, Archeology and Cultural Heritage, Paris, 2010, 9-16. Correspondence: 8. Keating A, Knox J, Bibb R, Zhurov A. A comparison of Nemanja Majstorović plaster, digital and reconstructed study model accuracy, J University of Belgrade, Faculty of Dentistry, Belgrade, Serbia Orthod, 2008; 35:191-201. E-mail: [email protected]
10.1515/bjdm-2017-0006
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The Influence of Crown Ferrule on Fracture Resistance of Endodontically Treated Maxillary Central Incisors
SUMMARY Sasho Jovanovski1,3, Julie Popovski1, Alesh Background: Prefabricated zirconia posts can contribute to increasing Dakskobler2, Ljubo Marion3, Peter Jevnikar3 the fracture resistance of the endodontically treated teeth. Purpose. This 1Department of Prosthodontics in vitro study compared the fracture resistance of endodontically treated Faculty of Dental Medicine, University of Ss. central maxillary incisors prepared with 2mm ferrule length to the ones Cyril and Methodius, Skopje, Macedonia 2 without ferrule. Material and methods: Twenty-four caries-free maxillary Ceramics Engineering Department Institute Joseph Stefan (IJS) Ljubljana, Slovenia central incisors were divided into 2 groups of 12. In group A circumferential 3Department of Prosthodontics external dentin shoulders were prepared for 2mm external dentin ferrule Faculty of Medicine (MF) length. There was no ferrule preparation in Group B. Zirconia VALLPOST University of Ljubljana, Slovenia BO-S (Ø 1,6mm), Ljubljana, Slovenia were used with retention forms in the coronary part. Core build-up was made of pressed ceramics (IPS e.max Press, Ivoclar, Liechtenstein). Crowns were manufactured from the same ceramic material (IPS e.max Press, Ivoclar). After root canal treatment and post space preparation, all posts were cemented with an adhesive resin cement (Multilink Automix, Ivoclar). The specimens were embedded in acrylic resin blocks (ProBase Polymer/Monomer, Ivoclar) and loaded at an angle of 45o to the long axis in an Instron Testing Machine 4301 (Instron Corp., USA) at a crosshead speed of 1mm/min until fracture. Fracture patterns and loads were recorded. A significance level of p<0.05 was used for all comparisons. Two-way analysis of variance was used for statistical analysis. Failure patterns were analyzed with the optical microscope Stereo Discovery V.8 (Carl Zeiss, Germany) and compared using the chi- square nonparametric test. Results: The mean values (±SD) of fracture loads (N) for the Groups A and B were 664.63N (±49.14) and 519.36N (±71.65) recpectively. Significantly lower failure loads were recorded for the specimens in the group B. Failure patterns within the groups revealed non-catastrophic failure in 70% of the specimens for group A and 85% for group B. Conclusions: Within the limitations of this in vitro study, it can be concluded that zirconia VALLPOST BO-S (Ø 1,6mm) with press-ceramic cores and crowns, can be used for restoration of endodontically treated teeth. The teeth prepared with 2mm external dentin ferrule length were found to be more fracture resistant than teeth without ferrule. ORIGINAL PAPER (OP) Key words: Endodontically Treated Teeth, Zirconia Post, Press Core, Press Crown, Ferrule Balk J Dent Med, 2017; 21:44-49
Introduction metal, fiber reinforced composite or ceramic posts, which are used for the restoration in the frontal region3. There is Numerous post and core systems are used to no agreement in the literature regarding the most suitable strengthen weakened endodontically treated teeth choice of material and post placement method, that will (ETT)1,2. There are various individualized or prefabricated result in the highest probability of successful treatment. Balk J Dent Med, Vol 21, 2017 The Influence of Crown Ferrule 45
Metal post systems might compromise the aesthetics and biocompatibility of the restorations due to corrosion and gingival discoloration. Regarding the strength, zirconia ceramics is superior compared to other ceramic and composite post materials. Therefore, the application of the high-strength all-ceramic zirconia posts are preferred for esthetic restoration of the ETT with zirconia crown and bridges4,5. It has been demonstrated, however, that placement of endodontic post can create stresses that lead to root fracture6,7. Moreover, the strength of ETT was directly related to the remaining tooth structure2,3. In order to protect the root from vertical fractures it is necessary to adequately prepare dentin shoulder in the remaining coronal dentin for most favorable stress-distribution8,9. The shoulder preparation of the external part of the coronal dentin was a step to obtaining a ferrule effect from dentin and crown10,11. Several authors5,12,13 have suggested that the tooth should have a minimum amount of 2mm external coronal structure above the cement- enamel junction (CEJ) to ensure proper strength. Figure 1. Y-TZP VALLPOST BO-S (Ø 1,6mm) with 3 retentive rings However, studies concerning the effects of ferrule length on the fracture resistance of ETT, remain controversial2,14. Therefore, the purpose of this study was to investigate the influence of the ferrule length on the fracture resistance of the endodontically treated maxillary central incisors.
Material and methods
A total of 24 extracted caries free maxillary central incisors were stored in 0.1% thymol solution immediately after extraction. The root canals were endodontically treated and prepared for the post placement. The anatomic crowns of the teeth were sectioned horizontal to the long axis, 2mm above the CEJ. The sectioned teeth were divided into 2 groups of 12. Group A was prepared with 2mm external dentin shoulder, and the control group B was without external dentin shoulder. The restoration was made using the Y-TZP VALLPOST BO-S (Ø 1,6mm), Ljubljana, Slovenia with length 15/8.5mm15. The coronary Figure 2. IPS e.max Press crown cemented over Y-TZP VALLPOST BO-S design of the posts included retention forms16 (Figure 1). (Ø 1,6mm) with press core The first retention element was a full ring, and the remaining two were half-rings, which provided sufficient space for core build-up material. The posts were built-up The specimens were stabilized in a paralleling with the press ceramic cores (IPS e.max Press, Ivoclar). device (Bego, Germany) and embedded in acrylic The crowns were made of the same press material with two different dimensions (2mm longer in group A). The resin blocks (ProBase Cold, Ivoclar, Liechtenstein). zirconia posts and crowns were cemented using resin Standardized silicone 0.1-0.2mm thin layers simulated cement (Multilink Automix, Ivoclar, Vivadent) following periodontal ligament. The specimens were stored for the manufacturers guidelines (Figure 2). 24h in a thermostatically controlled destilled water bath 46 Sasho Jovanovski et al. Balk J Dent Med, Vol 21, 2017
(TWB 14, Julabo, Seelbach, Germany) at 37°C. The test Table 1. Average values and standard deviation of fracture specimens were then placed into a special jig and loaded forces on ETT with and without 2mm ferrule at an angle of 45° to the long axis in Instron Testing ETT/Y-TZP VALLPOST BO-S (Ø 1,6mm) / Press Core-Crown Machine 4301 (Instron Corp., USA) with a crosshead speed of 1mm/min until fracture. Load was applied in Ferrule (mm) 0 mm 2 mm the middle of the lingual surface, 2mm below the incisal F (N) 519.36 664.63 margin. Test specimens were considered to have failed ±SD ± 71.65 ± 49.14 when the crowns or cores separated from the posts, posts failures occurred or tooth fractured (Figure 3).
Figure 4. Average values of fracture forces on ETT/Y-TZP VALLPOST BO-S (Ø 1,6mm) / Press Core-Crown with and without 2mm ferrule
Two-way ANOVA revealed a significant difference (p<0.05) in fracture resistance between the groups A and B. With respect to the cervical third of the root, fracture patterns were classified according to the root fracture site. Failure patterns within the groups (Table 2) revealed non- catastrophic failure in 70.7% (0mm B group) and 85.3% (2mm A group).
Table 2. Modes of Fractures (number and %) Figure 3. IPS e.max Press fractured crown over Y-TZP VALLPOST BO-S (Ø 1,6mm) with press core ETT/Y-TZP VALLPOST BO-S (Ø 1,6mm) / Press Core-Crown FERRULE Fracture loads (N) and the type of fractures Fractures Ø (mm) were recorded. Fractures that could be restored were 0 mm 2 mm denominated as reparable and catastrophic fractures Reparable 1.6 8 (70.7%) 10 (85.3%) as non-reparable5,6,7,8,17-19. Two-way analysis of variance (ANOVA) was used for statistical analysis Nonreparable 1.6 4 (29.3%) 2 (15.7%) (p<0.05). Failure patterns were analyzed with the optical microscope Stereo Discovery V.8 (Carl Zeiss, Germany) and compared using the chi-square nonparametric test. Discussion
This in vitro study compared the fracture resistance Results of endodontically treated anterior central maxillary incisors prepared with two different ferrule length. Human The mean values of failure loads (N) and standard teeth were used for the preparation of the specimens. All deviations are shown in Table 1. Average values and roots received endodontic treatment and were restored standard deviation of fracture force on ETT with and with zirconia WALLPOST with 3 retentive rings, press without 2mm ferrule are presented in Figure 4. core build-ups and press crowns. Balk J Dent Med, Vol 21, 2017 The Influence of Crown Ferrule 47
The prepared dentin shoulder is primary factor that the teeth prepared with and without EF showed similar affects the durability of the restored ETT4,16,20-24. In this fracture modes, all in favor of the reparable fractures. study the contribution of the remaining coronal dentin to However, we should not forget the fact that the same the achievement of »ferrule effect« (FE) was examined. zirconia posts with retentive coronal elements were used The external surface of the circular shoulder preparation for restoration of the teeth in all the groups. Therefore, it on the peripheral, cervical part of the tooth, forms a dentin is evident that the retentive coronal form of the zirconia ring, which allows a better fit for the internal surface posts contributes to the more favorable outcome of of the cervical part of the crown. Only the interaction fractures. In addition, it should be noted that the fractures between these two different structures (dentin and crown), in the different groups occurred under different loads. creates a protective ferrule effect13,15. The difference in fracture loads among the groups shows In this study, the compressive load was applied that the ferrule effect combined with the retentive coronal directly to the inclined surfaces of the crowns, which is form of the posts lead to more favorable fracture modes similar as reported in previous studies8,14,23. The results under increased loading. showed that, the teeth prepared with 2mm ferrule length A study conducted by Akkayan and Guelmez8 showed significantly increased fracture resistance. This stated catastrophic fractures of zirconia posts. However, corresponds with the results from the other studies18,22. this study was performed with zirconia posts without According to the results of this study, it can be retentive coronal forms. Similar to this study, Ozkurt and concluded that it is important to use the external surface of Kazazoglu36 stated that the high rigidity of the zirconia prepared dentin in order to improve the fracture resistance posts is a predisposing factor for vertical root fractures. of the tooth and restoration. It is generally accepted that Dilmener at al.9 assumed that the use of a zirconia post for a restoration extending at least 2mm apical to the with an elastic modulus closer to that of dentin would be junction of the core and the remaining tooth structure, mechanically more advantageous for the preservation of encirclement of the root with external ferrule length will recipient roots. Other studies38-45 have shown maximum protect the ETT against fracture by counteracting and beneficial effects from a ferrule length with 1.5 to 2mm. distributing the stresses better which are generated by the The fracture patterns were more favorable when a ferrule post8,25,26. Sorensen and Engelman27 stated that ferrule length was present. The results from the mentioned studies, with 1mm of vertical height has been shown to double the compared with ours, confirm that preparation dentin fracture resistance versus teeth restored without ferrule. length and posts design with retentive coronal elements On the other hand, Nothdurft and Pospiech20 stated additionally increase the fracture resistance and contribute noticeably lower values for the fracture resistance which to more favorable modes of fracture. The present study were not significantly different for 1mm and for 2mm shows that in order to achieve better survival rates of the ferrule. Meng at al.28 concluded that the provision of a post and core restorations, it is of great importance to pay long, heavy ferrule decreased the volume of sound root more attention to the preparation design of the tooth using dentin and increased the clinical crown length relative to dentin and crown ferrule. the embedded root length. It should be emphasized that zirconia posts with retention rings were used in this study. In contrast, there are many reports on the fracture resistance using posts Conclusion with no retention elements1,2,26,30-32. In their studies, Ottl at al.33 reported lower fracture strengths of zirconia The dentin and crown ferrule influences the fracture posts in artificial root canals compared to the results resistance of root treated maxillary central incisors. from this study. Similarly, Asmussen at al.34 found lower Within the limitations of this in vitro study, the following fracture strengths for BioPost and CeraPost. In both of conclusions were drawn: these studies, zirconia posts without retention forms were 1. Teeth without (dentin and crown) ferrule effect used, because of the use of artificial roots, lower fracture were fractured at a significantly lower load than teeth strength values were obtained. They reduced the effect restored with an apical extended 2 mm long ferrule, of structural differences between natural teeth and the 2. The fracture patterns of the post-core restored posts14,26,35,36. In our study, the results primarily depend teeth were restorable in 70% to 85% of the cases in both on the prepared remaining dentin. groups. Similar to our study, Hazaimeh and Gutteridge37 Therefore, the presented hypothesis that the (dentin concluded that the fracture patterns were more favorable and crown) ferrule increases the fracture resistance of when a ferrule length was present. On the other hand, the maxillary central incisors was confirmed. The higher same authors found that the majority of the fractures in the percentage of restorable fractures, confirm the second teeth without ferrule were non-restorable29,30. In our study, hypothesis that the zirconia posts with retentive forms the results showed increased percentage of reparable in the coronal part result in reparable fractures when fractures in all groups. Namely, in the present study, subjected to fracture loads. 48 Sasho Jovanovski et al. Balk J Dent Med, Vol 21, 2017
References 19. Strub JR, Pontius O, Koutayas S. Survival rate and fracture strength of incisors restored with different post and core 1. Schwartz SR, Robbins WJ. Post placement and restoration systems after axposure in the artificial mouth. J Oral of endodontically treated teeth: a literature review. J Endod, Rehabil, 2001; 28:120-124. 2004; 30:289-301. 20. Nothdurft PF, Pospiech RP. Clinical evaluation of pulpless 2. Tang W, Wu Y, Smales JR. Identifying and reducing risks teeth restored with conventionally cemented zirconia posts: for potencial fractures in endodontically treated teeth. A pilot study. J Prosthet Dent, 2006; 95:311-314. review article. J Endod, 2010; 36:609-617. 21. Paul SJ, Werder. Clinical success of zirconium oxide 3. Fraga RC, Chaves BT, Melo GS, Siquera JFJ. Fracture posts with resin composite or glass-ceramic cores in resistance of endodontically treated roots after restoration. J endodontically treated teeth: a 4-year retrospective study. Int Oral Rehabil, 1998; 25:809-813. J Prosthodont, 2004; 17:524-528. 4. Meyeberg KH, Luthy H, Scharer P. Zirconium post. A new 22. Oblak C, Jevnikar P, Kosmac T, Funduk N, Marion Lj. all-ceramic concept for nonvital abutment teeth. J Esthet Fracture resistance and reliability of new zirconia posts. J Dent, 1995; 7:73-80. Prosthet Dent, 2004; 91:342-348. 5. Friedel W, Kern M. Fracture strength of teeth restored with all- 23. Kosmac T, Dakskobler A, Oblak C, Jevnikar P. The strength ceramic posts and cores. Quintessence Int, 2006; 37:289-295. and hydrothermal stability of Y-TZP ceramics for dental 6. Zhi-Yue L, Yu-Xing Z. Effects of post core design and ferrule applications. Int J Appl Ceram Technol, 2007; 4:164-174. on fracture resistance of endodontically treated maxillary central incisors. J Prosthet Dent, 2003; 83:368-373. 24. Gegauf AG. Effect of crown lengthening and ferrule 7. Heydecke G, Butz F, Strub JR. Fracture strength and survival placement on static load failure of cemented cast post-cores rate of endodontically treated maxillary incisors with and crowns. J Prosthet Dent, 2000; 84:169-179. approximal cavities after restoration with different post and 25. Butz F, Lennon A, Haydecke G, Strub J. Survival rate and core systems: an in-vitro study. J Dent, 2001; 29:427-433. fracture strength of endodontically treated maxillary incisors 8. Akkayan B, Guelmez T. Resistance to fracture of with moderate defect restored with different post and core endodontically treated teeth restored with different post systems: an in vitro study. Int J Prosthodont, 2001; 14:58-64. systems. J Prosthet Dent 2002; 87:431-437. 26. Assif D, Bitenski A, Pilo R, Oren E. Effect of post design 9. Dilmener FT, Sipahi C, Dalkiz M. Resistance of three new on resistance to fracture of endodontically treated teeth with esthetic post-and-core systems to compressive loading. J complete crowns. J Prosthet Dent, 1993; 69:36-40. Prosthet Dent, 2006; 95:130-136. 27. Sorensen JA, Engelman MJ. Ferrule design and fracture 10. Libman WJ, Nicholls JI. Load fatigue of teeth restored with resistance of endodontically treated teeth. J Prosthet Dent, cast posts and cores and complete crowns. Int J Prosthodont, 1990; 63:429-436. 1995; 8:155-161. 28. Meng QF, Chen YM, Guang HB, Yip KHK, Smales RJ. 11. Rosen H. Operative procedures on mutilated endodontically Effect of a ferrule and increased clinical crown length on the treated teesth. J Prosthet Dent, 1961; 11:973-986. in vitro fracture resistance of premolars restored using two 12. Whitworth JM, Walls AWG, Wassell RW. Crowns and dowel-and-core systems. Oper Dent, 2007: 32:595-601. extra-coronal restorations: Endodontic considerations: the pulp, the root-treated tooth and the crown. Br Dent J, 2002; 29. Stankiewicz NR, Wilson PR. The ferrule effect: a literature 192:315-327. review. IntEndod J, 2002; 35:575-581. 13. Pereira JR, Valle AL, Shiratori FK, Ghizoni JS, Melo MP. 30. Stankiewicz N, Wilson P. The ferrule effect. Dent Update, Influence of intraradicular post and crown ferrule on the 2008; 35:222-224. fracture strength of endodontically treated teeth. Braz Dent 31. Juloski J, Radovic I, Goracci C, Vulevic RZ, Ferrari M. J, 2009; 20:297-302. Ferrule effect: A Literature Review. J Endod, 2012; 38:11-19. 14. Akkayan B. An in vitro study evaluating the effect of ferrule 32. Cohen IB, Pagnillo KM, Newman I, Musikant LB, Deutsch length on fracture resistance of endodontically treated teeth SA. Retention of a core material supported by three post restored with fiber-reinforced and zirconia dowel systems. J head designs. J Prosthet Dent, 2000;,83:624-628. Prosthet Dent, 2004; 92:155-162. 33. Ottl P, Hahn L, Lauer HCH, Fay M. Fracture characteristics 15. Jovanovski TS. Assesment of the effects of treatement of the of carbon fibre, ceramic and non-palladium endodontic post ceramic posts and their effect on fracture resistance on the systems at monotonously increasing loads. J Oral Rehabil, endodontic treated teeth. (Doctoral dissertation), Faculty of 2002; 29:175-183. Dental Medicine - Skopje, 2012. 34. Asmussen E, Peutzfeldt A, Heitmann T. Stiffness, elastic 16. Dakskobler A, Jevnikar P, Oblak C, Kosmac T. The limit, and strength of newewr types of endodontic posts. J processing-related fracture resistance and reliability of root Dent, 1999; 27:275-278. dental posts made from Y-TZP. J Eur Ceram Soc, 2007; 35. Ozkurt Z, Iseri U, Kazazoglu E. Zirconia ceramic post 27:1565-1570. 17. Pereira JR, de Ornelas F, Conti PC, do Valle AL. Effect of systems: a literature review and a case report. Dent Mater J, a crown ferrule on the resistance of endodontically-treated 2010; 29:233-245. teeth restored with prefabricated posts. J Prosthet Dent, 36. Ozkurt Z, Kazazoglu E. Clinical success of zirconia in 2006; 95:50-54. dental applications. J Prosthodont, 2010; 19:64-68. 18. Butz F, Lennon A, Haydecke G, Strub J. Survival rate and 37. Hezaimeh N, Gutteridge DL. An in vitro study into the fracture strength of endodontically treated maxillary incisors effect of ferrule preparation on the fracture resistance with moderate defect restored with different post and core of crowned teeth incorporating prefabricated post and systems: an in vitro study. Int J Prosthodont, 2001; 14:58-64. composite core restorations. Int Endod J, 2001; 34:40-46. Balk J Dent Med, Vol 21, 2017 The Influence of Crown Ferrule 49
38. Ng CC, Al-Bayat MI, Dumberigue HB, Griggs Ja, 44. Isidor F, Brondum K, Ravnholt G. The influence of post Wakefield CW. Effect of no ferrule on failure of teeth length and crown ferrule length on the resistance to cyclic restored with bonded posts and cores. Gen Dent, 2004; loading of bovine teeth with prefabricated titanium post. Int 52:143-146. J Prosthodont, 1999; 12:79-82. 39. Tjan AHL, Whang SB. Resistance to root fracture of post 45. Milot P, Stein RS. Rooth fracture in endodontically treated channels with various thicknesses of buccal dentin walls. J Prosthet Dent, 1985; 53:496-500. teeth related to post selection and crown design. J Prosthet 40. Bateman G, Ricketts D, Saunders W. Fiber-based post Dent, 1992; 68:428-435. systems: a review. Br Dent J, 2003: 195:43-48. 41. Guzy GE, Nicholls II. In vitro comparison of intact Received on September 28, 2016. endodontically treated teeth with and without endo-post Revised on December 27, 2016. reinforcement. J Prosthet Dent, 1979: 42:39-44. Accepted on January 5, 2017. 42. Cheung W. A review of the management of endodontically treated teeth: Post, core and the final restoration J Am Dent Assoc, 2005; 136:611-619. Correspondence: 43. Clarisse CHN, Dumbrigue HB, Al-Bajat IM, Griggs AJ, Wakefield WC. Influence of remaining coronal tooth Sasho Jovanovski structure location on the fracture resistance of restored Department of Prosthodontics, Faculty of Dental Medicine endodontically treated anterior teeth. J Prosthet Dent, 2006; University of Ss “Cyril and Methodius” Skopje, Macedonia 95:290-296. E-mail: [email protected]
10.1515/bjdm-2017-0007
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Oral Symptoms and Mucosal Lesions in Patients with Diabetes Mellitus Type 2
SUMMARY Ana Cicmil1, Olivera Govedarica1, Background: Good glycoregulation at patients with diabetes mellitus Jelena Lečić1, Snežana Mališ3, 1 2 is essential for prevention of many complications, including those in Smiljka Cicmil , Saša Čakić oral cavity. Results of numerous studies indicate that xerostomia and 1Faculty of Medicine, University of East Sarajevo neurosensory oral disorders are present in type 2 diabetics. A review of the Foca, Bosnia and Herzegovina literature shows contradictory results about prevalence of oral mucosal 2Faculty of Dental Medicine lesions in diabetics. The aim of this study was to evaluate the presence of University of Belgrade, Belgrade, Serbia 3University Hospital, Foca xerostomia, neurosensory disorders and mucosal lesions in oral cavity of Bosnia and Herzegovina type 2 diabetics. Material and Methods: This study involved 90 adults, 60 with type 2 diabetes and 30 healthy subjects, aged 45-65 years. With regard to value of HbA1c level diabetics were divided into two groups: 30 subjects with satisfactory glycoregulation (HbA1c<9%) and 30 subjects with poor glycoregulation (HbA1c≥9%). All patients recruited into the study completed a questionnaire that included their demographic, medical and oral health data. Clinical examination of the oral mucosa was performed by a single examiner. Results: In relation to the presence of xerostomia and dysgeusia between satisfactory controlled diabetics and healthy subjects a significant difference was observed (p<0.05). Compared with healthy subjects, poor controlled diabetics had significantly higher presence of xerostomia (p<0.001) and neurosensory disoders (p<0.05). A higher prevalence of oral mucosal lesions was found in poor controlled diabetics, but significant difference between groups was not observed (p>0.05). A significant positive correlation was revealed between smoking and glossodynia as well as smoking and glossopyrosis (p>0.05). Conclusion: Glycemic control level seems to influence the susceptibility of type 2 diabetics to xerostomia and neurosensory disorders. Less clear is whether diabetes are corellated to oral mucosal lesions. ORIGINAL PAPER (OP) Keywords: Diabetes Mellitus, Xerostomia, Glossodynia, Dysgeusia, Oral Mucosa Balk J Dent Med, 2017; 21:50-54
Introduction decrease in collagen synthesis3, diabetic microangiopathy and neuropathy4. Diabetes Mellitus (DM) is a metabolic disorder Dry mouth or xerostomia is often present in characterized by chronic hyperglycemia and disturbances patients with diabetes. It is believed that a decrease in of carbohydrate, fat and protein metabolism1. Chronic saliva secretion by 50% below the normal range leads hyperglycemia leads to many complications, including to xerostomia5. Shepard was the first one who described those in oral cavity, therefore metabolic control is very xerostomia in 1942 as a feature of uncontrolled diabetes6. important. Possible mechanisms that may be associated It seems that oral dryness in type 2 DM is particularly with some oral manifestations of diabetes are impaired influenced by xerogenic drugs and autonomic neuropathy. chemotaxis as well as adherence and phagocytosis of Moreover, neurosensory disorders such as burning mouth neutrophil2, increased collagenase activity together with a sensation and taste alteration are present in diabetics7. Balk J Dent Med, Vol 21, 2017 Oral Symptoms in Diabetes Mellitus Type 2 51
In patients with diabetes, a pain or burning is usually All recruited patients completed a questionnaire expressed on the tongue (glossodynia and glossopyrosis), that included their demographic and tobacco history but other parts of the mouth may be affected as well. The data as well as oral health data which included a list of underlying cause of these sensation in diabetics could be questions about their subjective oral symptoms. Some of diabetic neuropathy. the questions regarding dry mouth were patterned after Many factors might have been implicated in altered those of Zielinski et al.14: Does your mouth frequently taste sensation in the oral cavity. One study reports that feel dry? Does your mouth feel dry when you are eating 8 one-third of patients with diabetes have dysgeusia , but a meal? Do you have difficulties swallowing dry foods? not all studies describe these changes and their prevalence Does oral dryness wakes you from sleep at night? is unknown. Although the physiology of dysgeusia is not A response of “yes” to two or more questions was completely understood, relationship between dysgeusia considered positive for xerostomia. Also, the questions of and diabetic neuropathy has been described in earlier dry mouth-associated complaints were included15: Do you studies9. Taste alteration is reported to be more prevalent have a painful tongue sensation? Do you have a burning especially in poor controlled diabetics10. tongue sensation? Do you have a taste alteration? Painful A number of oral mucosal lesions, including lichen tongue sensation and burning tongue sensation are also planus, recurrent aphthous stomatitis11 and angular cheilitis12 have been reported in diabetic patients, but referred as glossodynia and glossopyrosis respectively. All there is no consensus whether oral mucosal lesions are symptoms was evaluated with binary response options. more prevalent in diabetics than in healthy subjects. The In relation to diabetes mellitus, data included a relationship between diabetes and oral mucosal lesions is level of metabolic control and duration of diabetes still unclear. according to their medical records. Clinical examination The aim of this study was to evaluate the presence of was performed by a single examiner on Dental Clinic, xerostomia, neurosensory disorders and mucosal lesions Faculty of Medicine Foca, University of East Sarajevo, in oral cavity of type 2 diabetics. Republic of Srpska, Bosnia and Herzegovina according to WHO criteria16 and included inspection of the soft tissues. Two mouth mirrors were used as well as digital palpation for the examination of particular lesions. The Material and Methods following oral mucosal changes were recorded: angular cheillitis (fissures or inflammation at lip corners), possible Study design and participants lichenoid lesion (white areas of the mucosa that do not The present study was approved by the institutional wipe off, lacey or patch-like white pattern over reddened committee of ethics (No. 01-8/140 issued on 24th of surface) and aphtae (ulcer(s) on oral mucosa except December 2009) and was conducted in accordance with gingiva and hard palate). the Helsinki Declaration of 1975, as revised 1983. This study was designed as a cross-sectional study. Statistical analyses A total of 90 adults, aged 45-65 years, participated in All statistical analyses were performed with SPSS the study. The study group included 30 satisfactory version 19.0 for Windows. Results were expressed as controlled diabetes mellitus type 2 patients (HbA1c<9%) mean values ± standard deviation (SD) for numerical and 30 poor controlled diabetes mellitus type 2 patients variables and as percentage for attributive variables. The (HbA1c≥9%), who were recruited from the Department differences between the groups were assessed by One of Endocrinology University hospital Foca, Republic Way ANOVA, T test and chi-square test. Spearman’s of Srpska, Bosnia and Herzegovina. The 9% cut-off correlation coefficient were obtained in order to assess the point has been suggested to represent an indicator for ineffective blood glucose management in type 2 relationship between smoking and oral complaints as well diabetes13. The mean duration of diabetes was 8.57±7.44 as smoking and mucosal lesions. The value of p<0.05 was years in patients with satisfactory glycoregulation considered statistically significant. and 9.18±6.97 in patients with poor glycoregulation. The control group consisted of 30 healthy individuals who visited Dental Clinic, Faculty of medicine Foca, University East Sarajevo, for regular check up. Results After the study was explained to the patients, written informed consent was obtained from all. Table 1. shows sociodemographic characteristics of The presence of other systemic disorder or severe all respondents. Statistically significant difference was mental illness, pregnancy, signs or symptoms of AIDS and observed for smoking habits and average of age between antibiotic administration during the last 6 months were the groups, while significant difference was not observed exclusion criteria in this study. for gender. 52 Ana Cicmil et al. Balk J Dent Med, Vol 21, 2017
Table 1. Sociodemographic characteristics of the sample
Variables All patients SCD PCD HS p Age 57.58±7.19 59.50±6.64 60.73±5.89 52.50±6.27 p*<0.05 ( ±SD)
Gender Male 57.8 53.3 43.3 30.0 p**>0.05 (%) Female 42.2 46.7 56.7 70.0
Smoking Yes 38.9 33.3 46.7 36.7 p**<0.05 (%) No 61.1 66.7 53.3 63.3 *ANOVA; * * χ2 test; SCD-satisfactory controlled diabetics; PCD-poor controlled diabetics; HS-healthy subjects;
Table 2. shows the presence of xerostomia and Spearman’s correlation revealed a statistically neurosensory disorders in all patients. A statistically significant correlation between smoking and glossodynia significant difference was observed between healthy as well as smoking and glossopyrosis. For all other subjects and diabetics with satisfactory glycoregulation, variables investigated (xerostomia, dysgeusia and mucosal except for glossodynia and glossopyrosis. Compared with lesions), we observed a positive but nonsignificant healthy subjects, poor controlled diabetics had significantly correlation between them and smoking (Table 4). higher presence of xerostomia and neurosensory disorders. Table 4. Correlation between smoking and oral complaints as Table 2. Presence of xerostomia and neurosensory disorders in well as smoking and mucosal lesions patients
Variables (%) SCD PCD HS p* yes 53.3 83.3 20.0 SCD:HS<0.05 lesions
Xerostomia Mucosal Dysgeusia
no 46.7 16.7 80.0 PCD:HS<0.001 Xerostomia Glossodynia yes 13.3 26.7 3.3 SCD:HS>0.05 Glossopyrosis Glossodynia no 86.7 73.3 96.7 PCD:HS<0.05 Smoking 0.079 0.256* 0.256* 0.090 0.042 yes 13.3 26.7 3.3 SCD:HS>0.05 Glossopyrosis * p< 0.05; Spearman’s correlation coefficient no 86.7 73.3 96.7 PCD:HS<0.05 yes 30.0 30.0 3.3 SCD:HS<0.05 Dysgeusia no 70.0 70.0 96.7 PCD:HS<0.05 *χ2 test; SCD- satisfactory controlled diabetics; PCD-poor Discussion controlled diabetics; HS-healthy subjects; Xerostomia is one of DM oral manifestations. The frequency of oral mucosal lesions in all Its presence can lead to numerous clinical and social respondents are presented in Table 3. Poor controlled problems and certainly may have a negative impact on diabetics had higher prevalence of oral mucosal lesions, patients’ quality of life. It is a result of reduction in saliva than satisfactory controlled diabetics and healthy subjects, secretion, although it may occur in presence of a normal but statistically significant difference between the groups saliva flow rate as well17. In fact, autonomic neuropathies was not observed. diminish the ability to respond to a salivary stimulus, but also microvascular changes may compromise the ability of salivary glands to respond to neural and hormonal Table 3. Presence of oral mucosal lesions in patients stimulation in poor controlled diabetics18. Xerostomia Oral mucosal lesions may also be caused by administration of drugs. Drug- LP RAS AH induced xerostomia occurs most often as a result of p* (%) (%) (%) reversible action of drugs on the neural mechanism SCD 6.7 10.0 3.3 responsible for salivation. Medications with anticholinergic PCD 10.0 10.0 6.7 p>0.05 activity, such as tricyclic antidepressants, anxiolytics and HS 6.7 6.7 0.0 antihypertensives exhibit the greatest xerogenic potential19. *χ2 test; LP-Lichen planus;RAS-recurrent aphtosus Presence of xerostomia can contribute to many clinical stomatitis;AH-angular cheilitis; problems such as difficulty in eating, swallowing and SCD- satisfactory controlled diabetics; PCD-poor controlled speaking. Some patients may have a halitosis, burning diabetics; HS-healthy subjects sensation and altered taste perception15. Balk J Dent Med, Vol 21, 2017 Oral Symptoms in Diabetes Mellitus Type 2 53
The results of our study showed a higher presence of Studies have reported decreased phagocytic activity xerostomia in diabetics. The highest percentage of patients of neutrophils in diabetics. Also, collagen synthesis is with xerostomia was observed in the group of diabetics under the influence of the glucose level which may lead with poor glycemic control (83.3%). Numerous studies to increased susceptibility to infections and impaired reported a significantly higher presence of xerostomia in wound healing. Previous studies reported contradictory 20-22 patients with diabetes compared to healthy subjects . results about oral mucosal lesions prevalence in patients Carda et al. observed presence of xerostomia in 76.4% with diabetes mellitus type 2. In our oral mucosal lesions diabetics, while the presence was significantly less frequency analysis, diabetics had a greater presence 23 (18.7%) in healthy subjects . These findings are similar of oral mucosal lesions, but there was no significant to those by Sandberg et al., which was conducted on 102 difference between the groups. Other studies have patients suffering from type 2 diabetes and 102 healthy also found that patents with type 2 DM did not have subjects24. Results of their study show that xerostomia an increased presence of oral lesions28. Some studies was present in 53% diabetics and in 28% healthy however, demonstrated significantly higher prevalence respondents. Oral dysesthesia or burning mouth sensation have of mucosal changes in diabetics. Bastos et al. observed been reported in patients with diabetes, but prevalence 146 patients suffering from type 2 diabetes and 111 29 data are not available. In fact, neuropathy may lead to healthy subjects . In their study, lichen planus was glossodynia and glossopyrosis caused by pathological diagnosed in 6.1% of diabetics, while in the group of changes involving the nerves in the oral region. In fact, healthy individuals there were no respondents with this neuropathy may lead to glossodynia and glossopyrosis oral lesion. More over, angular cheillitis was present in caused by pathological changes involving the nerves in 15.0% diabetics and 9.0% healthy subjects. However, the the oral region. Our study pointed out significantly higher review of literature show conflicting results regarding presence of glossodynia and glossopyrosis in diabetics, the presence of oral mucosal lesions in type 2 diabetics. especially in poor controlled ones. Similar results were Thus, for example, the prevalence of lichen planus varies obtained by Collin’s et al.7. In their study, conducted in from 1.6% to as much as 85%30. Some authors believe 45 patients with type II diabetes and 77 healthy subjects, that the higher prevalence of oral lesions is associated the authors observed a significantly greater presence of with poor metabolic control of the disease31,32. Others glossodynia in diabetics (17.8%) compared to healthy believe that the key is in the immune response such as subjects (5.6%). There is substantial evidence that lower chemotaxis and phagocytosis and the involvement smoking habit in diabetic patients significantly increases of microcirculation with the reduction of blood supply, 4 24 the risk of xerostomia and some mucosal disorders . which contributes to diabetics becoming more prone to But, results of our study indicate a significant positive infections and alterations in the oral cavity29,33. correlation only between smoking and glossodynia as well as between smoking and glossopyrosis. The main cause of taste disorders in patients with diabetes is unknown, but it is assumed that it is a Conclusions congenital or acquired disorders of taste or peripheral neuropathy. Also, decreased salivary flow results in The results of this study indicate that patients with altered taste sensation. Saliva has important role in the maintenance of the milieu of taste receptors. It is secreted diabetes mellitus type 2 are more susceptible to oral in response to food, assisting intake and initiating the changes, especially poor controlled ones. Glycemic digestion of starch and lipids and acts as a solvent of taste control level seems to influence the susceptibility of type substances and affects taste sensitivity25. In our research, 2 diabetics to xerostomia and neurosensory disorders. analyzing the presence of dysgeusia, we observed Less clear is whether diabetes is correlated to oral significantly less presence in the healthy subjects, while mucosal lesions. However, it was not possible to observe both groups of diabetics were equally affected, what is in a clear relationship between the frequency of oral mucosal accordance with the results reported by Gondivkar et al.10. lesions related to diabetes mellitus type 2, probably due to Authors included 120 patients aged 25-55 years in their small sample size. study and diagnosed dysgeusia in 62.5% of patients with diabetes and 12.5% healthy subjects, whereby statistically significant difference between groups was observed. Some studies indicate an association of taste alteration References with the level of HbA1c10,26, while different results were obtained by Perros et al. who revealed no association 1. American Diabetes Association. Diagnosis and classification between the HbA1c level and taste disorders27. of diabetes mellitus. Diabetes Care, 2014; 37:S81-90. 54 Ana Cicmil et al. Balk J Dent Med, Vol 21, 2017
2. Alba-Loureiro TC, Munhoz CD, Martins JO, Cerchiaro GA, 19. Narhi TO, Meurman JH, Ainamo A. Xerostomia and Scavone C, Curi R, Sannomiya P. Neutrophil function and Hyposalivation. Drugs & Aging, 1999; 15:103-116. metabolism in individuals with diabetes mellitus. Braz J 20. Navea Aguilera C, Guijarro de Armas MG, Monereo Megías Med Biol Res, 2007; 40:1037-1044. S, Merino Viveros M, Torán Ranero C. The relationship 3. Gurav A, Jadhav V. Periodontitis and risk of diabetes between xerostomia and diabetes mellitus: a little known mellitus. J Diabetes, 2011; 3:21-28. complication. Endocrinol Nutr, 2015; 62:45-46. 4. Moore PA, Guggenheimer J, Etzel KR, Weyant RJ, Orchard 21. Busato IMS, Ignácio SA, Brancher JA, Moysés ST, T. Type 1 diabetes mellitus, xerostomia and salivary flow Azevedo-Alanis LR. Impact of clinical status and salivary rates. Oral Surg Oral Med Oral Pathol Oral Radiol Endod, conditions on xerostomia and oral health-related quality of 2001; 92:281-291. life of adolescents with type 1 diabetes mellitus. Community 5. Sreebny LM, Vissink A (ed). Dry mouth, the malevolent Dent Oral Epidemiol, 2012; 40:62-69. symptom: a clinical guide. Singapore: Wiley-Blackwell, 22. Sandberg GE, Wikblad KF. Oral health and health-related 2010. quality of life in type 2 diabetic patients and non-diabetic 6. Shepard IM. Oral manifestation of diabetes mellitus: a study controls. Acta Odontol Scand, 2003; 61:141-148. of one hundred cases. J Am Dent Assoc, 1942; 29:1188- 23. Carda C, Mosquera-Lloreda N, Salom L, Gomez de Ferraris 1192. ME, Peydró A. Structural and functional salivary disorders 7. Collin HL, Niskanen L, Uusitupa M, Töyry J, Collin P, in type 2 diabetic patients. Med Oral Patol Oral Cir Bucal, Koivisto AM et al. Oral symptoms and signs in elderly 2006; 11:E309-314. patients with type 2 diabetes mellitus. A focus on diabetic 24. Sandberg GE, Sundberg HE, Fjellstrom CA, Wikblad KF. neuropathy. Oral Surg Oral Med Oral Pathol Oral Radiol Type 2 diabetes and oral health. A comparison between Endod, 2000; 90:299-305. diabetic and non-diabetic subjects. Diabetes Res Clin Pract 8. Stolbova K, Hahn A, Benes B, Andel M, Treslova L. 2000; 50:27-34. Gustometry of diabetes mellitus patients and obese patients. 25. Mese H, Matsuo R: Salivary secretion, taste and Int Tunnitus J, 1999; 5:135-140. hyposalivation. J Oral Rehabil, 2007; 34:711-723. 9. Fomina EI, Pozharitskaia MM, Davydov AL, Starosel’tseva 26. Klasser GD, Fischer DJ, Epstein JB. Burning mouth LK, Budylina SM, Simakova TG. Changes of gustatory syndrome: recognition understanding and management. Oral perception in elderly patients with type II sugar diabetes. Maxillofac Surg Clin North Am, 2008; 20:255-271. Surgical section. Stomatologiia (Mosk), 2007; 86:30-34. 27. Perros P, Counsell C, MacFarlane TW, Frier BM. Altered 10. Gondivkar SM, Indurkar A, Degwekar S, Bhowate R. taste sensation in newly-diagnosed NIDDM. Diabetes Care, Evaluation of gustatory function in patients with diabetes 1996; 19:768-770. mellitus type 2. Oral Surg Oral Med Oral Pathol Oral Radiol 28. De Lima DC, Nakata GC, Balducci I, Almeida JD. Oral Endod, 2009; 108:876-880. manifestations of diabetes mellitus in complete denture 11. Lamster IB, Lalla E, Borgnakke WS, Taylor GW. The wearers. J Prosthet Dent, 2008; 99:60-65. relationship between oral health and diabetes mellitus. 29. Bastos AS, Leite AR, Spin-Neto R, Nassar PO, Massucato JADA, 2008; 139:19S-24S. 12. Saini R, Al-Maweri SA, Saini D, Ismail NM, Ismail AR. EM, Orrico SR. Diabetes mellitus and oral mucosa Oral mucosal lesions in non oral habit diabetic patients alterations: Prevalence and risk factors. Diabetes Res Clin and association of diabetes mellitus with oral precancerous Pract, 2011; 92:100-105. lesions. Diabetes Res Clin Pract, 2010; 89:320-326. 30. Seyhan M, Özcan H, Sahin I, Bayram N, Karincaoglu Y. 13. Chávez EM, Borrell LN, Taylor GW, Ship JA. A High prevalence of glucose metabolism disturbance in longitudinal analysis of salivary flow in control subjects and patients with lichen planus. Diabetes Res Clin Pract, 2007; older adults with type 2 diabetes. Oral Surg Oral Med Oral 77:198-202. Pathol Oral Radiol Endod, 2001; 91:166-173. 31. Manfredi M, McCullough MJ, Vescovi P, Al-Kaarawi ZM, 14. Zielinski MB, Fedele D, Forman LJ, Pomerantz SC. Oral Porter SR. Update on diabetes mellitus and related oral health in the elderly with non-insulin-dependent diabetes diseases. Oral Dis, 2004; 10:187-200. mellitus. Spec Care Dentist, 2002; 22:94-98. 32. Al-Maweri SA, Ismail NM, Ismail AR, Al-Ghashm A. 15. Cho MA, Ko JY, Kim YK, Kho HS. Salivary flow rate and Prevalence of oral mucosal lesions in patients with type clinical characteristics of patients with xerostomia according 2 diabetes attending hospital Universiti Sains Malaysia. to its aetiology. J Oral Rehabil, 2010; 37:185-193. Malays J Med Sci, 2013; 20:39-46. 16. Kramer IR, Pindborg JJ, Bezroukov V, Infirri JS. Guide to 33. Delamaire M, Maugendre D, Moreno M, Le Goff M, epidemiology and diagnosis of oral mucosal diseases and Allannic H, Genetet B. Impaired leucocyte functions in conditins. World Health Organization. Community Dent diabetic patients. Diabet Med, 1997; 14:29-34. Oral Epidemiol, 1980; 8:1-26. 17. Yamamoto K, Kurihara M, Matsusue Y, Imanishi M, Received on November 24, 2016. Tsuyuki M, Kirita T. Whole saliva flow rate and body Revised on December 1, 2016. profile in healthy young adults. Arch Oral Biol, 2009; Accepted on January 27, 2017. 54:464-469. 18. Anderson LC. Hormonal regulation of salivary glands, with Correspondence: particular reference to experimental diabetes. In: Garrett JR, Ana Cicmil Ekström J, Anderson LC, (ed). Glandular mechanisms of Faculty of Medicine salivary secretion. Frontiers of oral biology. Basel: Karger, Studentska 5, 73300 Foča, Bosnia and Herzegovina 1998, pp 200-221. E-mail: [email protected]
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Treatment of Biphosphonate-Related Osteonecrosis of the Jaw (BRONJ) Combining Surgical Resection and PRGF-Endoret® and Rehabilitation with Dental Implants: Case Report
SUMMARY Eduardo Anitua Background: The first cases of bisphosphonate-related osteonecrosis Eduardo Anitua Foundation of the jaw (BRONJ) were reported in 2003. Since then number of possible Vitoria, Spain treatments have been proposed. Case report: We report a case of a 50-year- old patient with bisphosphonate-related osteonecrosis of the jaw (BRONJ). The treatment included resection of necrotic bone and the application of plasma rich in growth factors (PRGF®-Endoret®). We closed the ulcer in the soft tissue and the treated bone was regenerated one year later. Finally the regenerated area was rehabilitated with dental implants. Conclusion: Resection followed by PRGF® -Endoret® was successful in promoting closure of the wound and the recovery of nerve function. Key words: Bisphosponates-Related Osteonecrosis (BRONJ), Medicament-Related CASE REPORT (CR) Osteonecorosis (MRONJ), Nerve Injury, Platelet Rich Plasma, PRGF Balk J Dent Med, 2017; 21:55-59
Introduction and hard tissue of the fourth quadrant, associated with the extraction of lower right first molar with history of The first cases of bisphosphonate-related osteonecrosis treatment with intravenous bisphosphonates (zoledronate) of the jaw (BRONJ) were reported in 20031. A number of for the breast cancer and with the presumptive diagnosis possible mechanisms of treatments have been proposed2, of medicament-related osteonecrosis of the jaw (MRONJ) including immunomodulation, infection, excessive due to bisphosphonates. reduction in bone turnover, impaired angiogenesis, and In April 2008, the lesion was treated in a hospital direct toxicity to soft tissue and bone3,4. with a conservative treatment consisting of chlorhexidine We report the management of a patient with BRONJ. In mouthwashes, systemic antibiotics and hyperbaric oxygen addition to resection we used plasma rich in growth factors until December 2009, without obtaining positive results at (PRGF®-Endoret®) because of its potential to stimulate any time. During this time the patient developed constant healing of gingival ulceration and wound closure. The treated acute pain in the area and hemimandibular paraesthesia bone was regenerated one year later and dental implants were (due to the affection of the inferior alveolar nerve). The placed in the regenerated bone. No bone loss or negative patient also reported loss of sensation in the lower lip effects were reported regarding the dental implants. (Figure 1). In March 2010, the patient attended the clinic. After clinical and radiographical evaluation the lesion was in stage 2 according to the classification of the Case report American Association of Oral and Maxillofacial Surgeons (AAOMS). Once the case had been studied and the In 2010 a 50-year-old patient attended the Clinic poor response to conventional treatment, the lesion was with an ulceronecrotising lesion that affected the soft treated with Endoret (PRGF). To do so, the necrotic 56 Eduardo Anitua Balk J Dent Med, Vol 21, 2017 bone fragments were excised paying the attention not 1 coagulated and retracted). Finally, a primary closure to cause any trauma to the surrounding hard and soft of the edges was performed with 5/0 monofilament and tissues. For this reason, ultrasonic surgery was used for some PTFE 5/0 stitches in the area where the tissue was the excision of necrotic bone. In the same intervention the in poorer conditions, in order not to elongate the flap and tooth in position 45 was extracted due to high degree of mobility. Once excised, a recently formed clot of Endoret cause the dehiscence of the sutures. To finish, the edges of (PRGF) was placed, prepared from fraction 2 in the bone the surgical wound were infiltrated with recently activated socket and covered it with fibrin membranes (fraction PRGF fraction 2 (liquid) (Figure 2).
A B C Figure 1. (A) Pre-operative panoramic radiograph showing the presence of necrotic bone at the site of tooth extraction (lower right first molar), although it does not provide information on its extent. (B) Intraoral appearance of the lesion at the time of examination where we can see a large amountof necrotic bone exposed to the oral medium. (C) Cone-beam computerised tomography (CBCT) showing the lesion to extend apically up to the inferior dental nerve canal indicated with a pink dot in the image.
A B C
E F Figure 2. (A) Excision of necrotic bone with ultrasound surgery. (B) Primary closure of the surgical wound after the placement of Endoret (PRGF). (C) After this the incision margins were infiltrated with Endoret (PRGF) liquid (fraction 2 recently activated). (D) Soft tissue fragments that surrounded the bone sequestrum. (E) Bone fragments of necrotic tissue after the excision.
The bone fragments, once excised, were referred for bottom of the defect can also been observed as shown in the histopathological report and to confirm the presence of the Figure 4. In addition, the patient reported a complete bisphosphonate-related osteonecrosis of the jaw (BRONJ). absence of pain for the first time since the start of the The patient was then followed up once a week. necrotic process. Intake of painkillers was also stopped, Signs of epithelization at the surgical margins were that had become routine since 2008. observed. The suture that had lost tension was removed Four weeks after the first procedure, tissue at the and another recently formed clot of Endoret (PRGF) bottom of the defect that is almost fully epithelised fraction 2 was placed in the wound without any surgical can be observed. At that time cone-beam computerised manipulation of the site. Sutures were only used in the tomography (CBCT) was also performed to evaluate area of the wound with a larger opening to avoid losing the radiographic changes. Complete elimination of the the PRGF clot (Figure 3). Two weeks after the first necrotic tissue can be observed, and new bone tissue surgery the soft tissue was well respecting the process appears to be starting to colonise the empty bonesocket of regeneration and closure. New tissue formed at the from the lingual cortical wall (Figure 5). Balk J Dent Med, Vol 21, 2017 Treatment of Biphosphonate-Related Osteonecrosis 57
A A
B B Figure 3. (A) Appearance of the lesion a week later. (B) Appearance Figure 4. Appearance of the tissue after 2 weeks. We can see that there is once the suture has been removed and Endoret (PRGF) added again. tissue at the bottom of the defect.
B
A C Figure 5. Appearance of the tissue after 4 weeks. The newly formed tissue at the bottom of the defect has matured and we can consider the closure of the surgical wound a success, as there is no bone exposed to the oral cavity. (C) CBCT images showing the complete excision of necrotic bone and the start of bone regeneration from the lingual cortical wall to the centre of the defect.
A B C Figure 6. Clinical images of the regeneration of soft tissue a year after surgery. CBCT showing the complete regeneration of the tissue. 58 Eduardo Anitua Balk J Dent Med, Vol 21, 2017
In the revision, one year after the procedure, After 31 months, CBCT carried out to plan the the same image of regeneration in the soft tissue can prosthesis shows sufficient bone volume and suitable bone be observed, accompanied by an almost complete quality for the insertion of two implants, so the surgery bone regeneration of the defect, even observing the was performed and implants were placed and immediately regeneration of the mandibular canal. The bone density measured in Hounsfield units in the area regenerated is loadded after 24 hours. In the same procedure tooth 47 similar to that of the preserved basal bone and the patient was extracted as it presented a vertical fracture with is asymptomatic (Figure 6). infectious symptoms (Figure 7).
A B C Figure 7. (A) CBCT image for treatment planning showing the 100% regeneration of bone volume. (B) Planning the position of the dental implants (C) Image of the immediately-loaded dental implants. The extraction socket of the lower right second molar can be observed. The post-extraction alveolus was treated with Endoret (PRGF) without any secondary effects or complications.
A B C Figure 8. (A) CAD-CAM correcting the angle of screw chimneys, which were finally much more favourable. In addition, the cold micromilling seated on transepithelial abutments ensures a correct passive fit accompanied by excellent hermetism. (B) Image of the definitive prosthesis on the day it was placed. (C) Patient with the definitive prosthesis one year after loading.
After 4 weeks a CBCT was performed to evaluate Discussion and conclusions the condition of the area corresponding to the dental extraction, and any type of adverse effects were found in This case report entails the use of Endoret(PRGF) in the area treated with Endoret (PRGF) despite the patient’s the treatment of medicament-related osteonecrosis of the history. jaw in conjunction with surgical resection of the necrotic After 3 months of implant insertion, the bone. The described clinical treatment has been able to manufacturing of the definitive prosthesis began. This close the gingival ulcer and regenerate the alveolar bone was done on Multi-Im abutments placed slightly at defect. supragingival level (0,5 - 1mm) and using CAD-CAM Until now, treatments for MRONJ have been limited to correct the angle of emergence of the screws, so and results were inconclusive. Hyperbaric oxygen (HBO) they come out in the centre of the occlusal surfaces. has been proposed7 but it cannot be recommended as the The patients follow-up indicated an excellent healing, sole treatment8. Recently the use of platelet-rich plasma presenting satisfactory function and integration of has been reported to have potential for the prevention the implants a year after the placement of the definite and treatment of MRONJ, as shown by Mozzati et prosthesis. The area treated and regenerated after the al.9,10. The mechanism of action of PRGF®-Endoret® existence of BRONJ has responded satisfactorily to the in tissue regeneration has been widely studied. In the regeneration treatment and subsequent implant treatment case of BRONJ, bisphosphonates inhibit bone resorption (Figure 8). and angiogenesis by blocking the action of vascular Balk J Dent Med, Vol 21, 2017 Treatment of Biphosphonate-Related Osteonecrosis 59 endothelial growth factor (VEGF). The application of 5. Yu W, Wang J, Yin J. Platelet-rich plasma: a promising PRGF®-Endoret® provides proteins and growth factors product for treatment of peripheral nerve regeneration after to the local milieu like angiogenic factors (VEGF and nerve injury. Int J Neurosci, 2011; 121:176-180. angiopoietin), and factors that promote osteogenic 6. Anitua E, Prado R, Orive G. A lateral approach for sinus elevation using PRGF technology. Clin Implant Dent Relat differentiation, which can activate and accelerate the Res, 2009; 11:e23-e31. regeneration of the involved tissues. Moreover, it has 7. Freiberger JJ, Feldmeier JJ. Evidence supporting the use of been recently demonstrated the cytoprotective effects of hyperbaric oxygen in the treatment of osteoradionecrosis of the Endoret(PRGF) against the damage that zoledronic the jaw. J Oral Maxillofac Surg, 2010; 68:1903-1906. acid (intravenous bisphosphonate) could cause to the 8. Ruggiero SL, Dodson TB, Assael LA, Landesberg R, alveolar osteoblasts and the gingival fibroblasts11. In our Marx RE, Mehrotra B. American Association of Oral and case, conservative treatment was unsuccessful. Resection Maxillofacial Surgeons position paper on bisphosphonate- followed by PRGF® -Endoret® was successful in related osteonecrosis of the jaws—2009 update. J Oral promoting closure of the wound and the recovery of nerve Maxillofac Surg, 2009; 67:2-12. function. 9. Mozzati M, Gallesio G, Arata V, Pol R, Scoletta M. Platelet rich therapies in the treatment of intravenous bisphosphonate-related osteonecrosis of the jaw: a report of 32 cases. Oral Oncol, 2012; 48:469-474. 10. Mozzati M, Arata V, Gallesio G. Tooth extraction in patients Rereferences on zoledronicacid therapy. Oral Oncol, 2012; 48:817-821. 11. Anitua E, Zalduendo M, Troya M, Orive G. PRGF exerts a 1. Marx RE. Pamidronate (Aredia) and zoledronate (Zometa) cytoprotective role in zoledronic acid-treated oral cells. Clin induced avascular necrosis of the jaws: a growing epidemic. Oral Investig, 2016;20 :513-521. J Oral Maxillofac Surg, 2003; 61:1115-1117. 2. Novince CM, Ward BB, McCauley LK. Osteonecrosis of the Received on June 18, 2016. jaw: an update and review of recommendations. Cell Tiss Revised on December 1, 2016. Organ, 2009; 189:275-283. Accepted on January 19, 2017. 3. European Medicines Agency (EMEA). Committee for Medicinal Products for Human Use (CHMP). EMEA/ CHMP assessment report on bisphosphonates and Correspondence: osteonecrosis of the jaw. EMEA/CHMP/291125/ 2009. Dr. Eduardo Anitua 4. Otto S, Hafner S, Grotz KA. The role of inferior alveolar C/ Jose Maria Cagigal 19 nerve involvement in bisphosphonate-related osteonecrosis 10005 Vitoria, Spain of the jaw. J Oral Maxillofac Surg, 2009; 67:589-592. E-mail: [email protected]
10.1515/bjdm-2017-0009
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Adams-Olıver Syndrome: a Case Report
SUMMARY Fatma Demiray, Emre Korkut, Onur Gezgin, Background: Adams-Oliver Syndrome has been described by Adams Yağmur Şener, Büşra Bostancı and Oliver in 1945. Original definition, along with aplasia cutis congenital Necmettin Erbakan University syndrome and limb defects, has neurological and cardiological problems. Faculty Of Dentistry In the first description, genetic defect passes variable autosomal dominant Department of Pediatrıc Dentistry pattern. Afterwards the autosomal recessive and sporadic cases were published. Case Report: 11-year old male patient complained of mobile teeth admitted to our clinic. He was noted to have characteristic view with distal-phalanx and nail hypoplasia of his hand and feet with occipital scalp defect. We consulted to genetics because of these findings and learned that he has the Adams-Oliver Syndrome. The patient has some orofacial manifestations including high-narrow palate, fissured tongue, crowding, dysmorphic facial features, facial asymmetry, deep-philtrum, delayed eruption, class III malocclusion. The extraction of mobile deciduous teeth, restoration of caries and also oral hygiene motivation was made. Then, the patient was referred to orthodontics. Conclusions: Adams-Oliver syndrome represents are rare congenital alteration, insufficiently documented in scientific literature. This shows the need to document news cases. CASE REPORT (CR) Key words: Adams-Oliver Syndrome, Genetic Diseases, Dental Findings Balk J Dent Med, 2017; 21:60-64
Introduction includes limb defects (partial or complete absence of all toes or fingers, which looks like amputation), and they Adams-Oliver syndrome (AOS) was first defined may vary from mild (unilateral or bilateral short distal in 1945. The syndrome is characterised by aplasia cutis phalanx) to severe. Lower limbs are more affected than congenita (ACC) and terminal transverse limb defects. the upper limbs in almost all of the cases. Aplasia cutis While its original definition was based on ACC syndrome congenita and terminal transverse limb defects should and limb defects, neurologic and cardiac problems be researched in the differential diagnosis of the disease. accompany the disease1. ACC lesions are among the Terminal transverse limb defects (TTLD) can include most classical findings of the disease and frequently are short distal phalanx, brachysyndactyly or ectrodactyly. seen along the posterior sagittal suture as hairless spaces Early embryonic vascular impairment is considered the of different sizes on the skull. These lesions generally are underlying reason for the pathogenic mechanism. A wide seen on the parietal and occipital midline; however, they spectrum of defects indicates impairment of multiple also can appear on the abdomen and legs. ACC lesions development pathways. Congenital heart diseases also can appear at birth as an epithelised scar. ACC associated with the syndrome are seen in more than lesions are generally bigger than 5 cm, and they tend to 20% of AOS patients and present a serious mortality heal within the first month after birth. Major lesions risks2,3. The most frequent cardiac defect resulting from have a high probability of including the skin and cerebral anomalies in systemic vascular structures has been stated cortex. This brings the possibility of complications, as cutis marmorata telangiectasia congenita (CMTC)4. such as haemorrhage and thrombosis, which may cause A phenotypic variation seen in AOS is differentiated infection and death. Another symptom of the disease from an autosomal dominant feature. The low incidence Balk J Dent Med, Vol 21, 2017 Adams-Olıver Syndrome 61 of the disease in relatives is compatible with autosomal recessive gene transmission. In addition, sporadic cases which present with similar clinical features show that the genes which cause the disease occur as a result of de novo mutations. Cardiovascular malformation/dysfunctions (23%), brain anomalies and, less frequently, kidney, liver and eye anomalies can be given as examples of frequently seen characteristics. A review of the literature about the disease showed that there were a great number of studies about the genetic aspect of the disease. However, it was found that there were limited numbers of studies about the orofacial findings of the disease. The purpose of this study is to present the clinical radiological findings of a patient with
AOS. Figure 2. Characteristic appearance of fingers
Case Report
An 11-year-old male patient was admitted to Konya Necmettin Erbakan University’s Department of Pediatric Dentistry. The patient was found to have occipital scalp defects, characteristic appearance in distal phalanges of hands and feet and nail hypoplasia. As a result of these findings, the patient was consulted to Konya Necmettin Erbakan University, Meram Faculty of Medicine, Department of Genetics. The patient was diagnosed with AOS. Figure 3. Characteristic appearance of toes
The patient had some orofacial findings thought to be associated with the syndrome, including occipital skin defect, growth retardation when compared with peers, dysmorphic facial features, asymmetry of the face and deep philtrum, distal phalanx in hands and feet and nail hypoplasia (Figure 1-3). As a result of consultations with Konya Necmettin Erbakan University, Meram Faculty of Medicine, Department of Pediatrics, it was learned that the patient was under control due to his heart disease. In addition, the patient’s biological parents were non-kin, and the other siblings did not have the syndrome. The first notable finding of the intraoral examination was bad oral hygiene (Figure 4 & 5). Intraoral findings were high-arched palate, fissured tongue, malocclusion, delayed eruption and Class III malocclusion (Figure 6). In addition, maxillary deficiency was found in teeth, along with malocclusion. Dental plaque tartar accumulation was found, especially in the lower jaw anterior area, due to bad oral hygiene and oral respiration. Edema and hyperaemia were found in all of the gingiva in general. No hypominerilisation was found in the teeth. Extreme material loss was found, especially in the maxillary left Figure 1. Characteristic appearance of ADAMS OLIVER syndrome first molar. However, the patient did not have the other 62 Fatma Demiray et al. Balk J Dent Med, Vol 21, 2017 first molars. The panoramic film of the patient showed that the permanent teeth, which were still germ, were not missing (Figure 7). The treatments were conducted under general anaesthesia since the patient did not cooperate and had a strong nausea reflex.
Figure 8. Post operative anterior photography (healing of the gums after detertrage and oral hygiene mativation)
Figure 4. Preoperative intraoral photograph of lower jaw
Figure 9. Post operative intraoral photograph of upper jaw
Figure 5. Preoperative intraoral photograph of upper jaw
Figure 10. Post operative intraoral photograph of lower jaw
Figure 6. Preoperative photography showing malocclusion and gingivitis
Figure 7. Preoperative OPG Figure 11. Post operative OPG (Six months follow up) Balk J Dent Med, Vol 21, 2017 Adams-Olıver Syndrome 63
The patient and his family were informed about the The clinical symptoms in this case are quite varied, treatment, and oral and written consent were taken. Pre- just like other case reports; there is a consensus on treatment photos were taken in the first session. The patient symptoms, such as presence of distended veins, limb was given oral-hygiene training. In the second session, all deformities in the form of syndactyly (webbed fingers the treatments were conducted under general anaesthesia and toes) proximal and medial phalanx reduction, nail at Konya Necmettin Erbakan University, Meram Faculty hypoplasia, club foot, eye anomalies, growth hindrance, of Medicine. The maxillary left first molar, maxillary left hydrocephaly, psychomotor delay, facial cleft, bi-lateral second premolar, maxillary right second premolar and cleft lip and Grade III cleft palate. Facial cleft, bi-lateral mandibular right pre-canine teeth were extracted. The cleft lip and Grade III cleft palate are rare symptoms mandibular right second molar had a cavity, and it was which are seen in 0.3% of individuals10. restored with compomer, or composite resin (Figure 8-11). The treatment was oral and dental in this study. At Thus, the patient’s restorative and surgical operations were this stage, the objective was to increase the oral hygiene completed. The patient was directed to the Department and to make the hypocalcified areas in the teeth resistant of Orthodontia for Class III malocclusion treatment. to the consumption of carbohydrate-rich foods. Thus, the However, the treatment was delayed due to the patient’s risk factors which caused decay formation were decreased uncooperative behaviour. The patient’s regular controls are and oral health was improved11. still continuing in Konya Necmettin Erbakan University’s Department of Pediatric Dentistry.
Conclusions
Discussion AOS is a rare congenital disorder which has not been sufficiently studied. This shows the need for more case AOS is a rare congenital disorder consisting of reports. AOS requires a multidisciplinary approach for distal limb anomalies (absent or short phalanges) and successful treatment and control. Paedodontics is a part vascular anomalies (dilated veins, cutis marmorata and of the working team that provides the means to develop haemangiomas). Cardiac and ophthalmic anomalies, facial oral and dental conditions and controls the risk factors to asymmetry, cryptorchidism and spina bifida occulta are prevent decay development as well as harmful habits and among rare symptoms5. According to a literature review, malocclusion. AOS requires multidisciplinary assessment there are a great number of studies about the characteristics of protective measurements in oral and dental treatment. A of the disease. However, there are limited numbers of special approach is necessary for the treatment of children studies about the orofacial findings of the disease. with AOS, and thus, the responsibility of pedodontists In 1945, Dr. Adams and Dr. Olivers reported increases twofold. eight members of a family who had ACC and distal transverse limb reduction defects1. Since then, AOS has shown variations from the mildest form of aplasia cutis congenita to skull defects at birth and denude wide areas on the skin to limb reduction defects and cutis marmorata References telangiectatica congenita6. Mortality is low in patients 1. Adams FH, Oliver CP. Hereditary deformities in man due to with AOS, representing 20% of known patients. The most arrested development. J Hered, 1945; 36:3–7. common reason for mortality is haemorrhage in aplasia 2. Lin AE, Westgate MN, Van der Velde ME, Lacro RV, 7 areas, secondary infections and meningitis . Holmes LB. Adams-Oliver syndrome associated with Dentistry is one of the important departments which cardiovascular malformations. Clin Dysmorphol, 1998; require a multidisciplinary approach of AOS. The dentist 7:235–241. can prepare a program to prevent or eliminate the changes 3. Digilio MC, Marino B, Dallapiccola B. Autosomal according to the patient’s age, oral and dental health. dominant inheritance of aplasia cutis congenita and In order to succeed, it is important to know the varying congenital heart defect: a possible link to the Adams-Oliver clinical findings of AOS8. Hepatic neurological, vascular syndrome. Am J Med Genet A, 2008; 146A:2842–2844. and cardiac anomalies have been found in 13% of AOS 4. Snape KM, Ruddy D, Zenker M, Wuyts W, Whiteford M, patients. Thus, a program should be prepared for dental Johnson D et al. The spectra of clinical phenotypes in aplasia cutis congenita and terminal transverse limb defects. treatment after suitable medical assessment. Following Am J Med Genet, 2009; 149A:1860–1881. this, protective measures are very important in preventing 5. Keymolen K, De Smet L, Bracke P, Fryns JP. The endocarditis. These should include prophylactic antibiotic concurrence of ring constrictions in Adams-Oliver use in AOS patients who have congenital cardiopathy syndrome: additional evidence for vascular disrup- tion or bone defects which cause the exposure of parts of the as common pathogenetic mechanism. Genet Couns, 1999; brain. 10:295–300. 64 Fatma Demiray et al. Balk J Dent Med, Vol 21, 2017
6. Whitley CB, Gorlin RJ. Adams-Oliver syndrome revisited. 11. Barragán MG, Vidrio GP, Aguirre AH , Nagano AY. Adams- Am J Med Genet, 1991; 40:319–326. Oliver syndrome. Case report. Rev Odonto Mex, 2011; 7. Luján JI, Ibarra AG, Méndez FV. Síndrome de Adams- 15:175–182. Oliver. Reporte de un caso. Rev Hosp Jua Mex, 2004; 71:124–127. Received on August 23, 2016. 8. Girard M, Amiel J, Fabre M, Pariente D, Lyonnet S, Revised on October 22, 2016. Jacquemin E. Adams-Oliver syndrome and hepatoportal Accepted on December 2, 2016. sclerosis: occasional association or common mechanism? Am J Med Genet A, 2005; 135:186–189. 9. Zapata HH, Sletten LJ, Pierpont ME. Congenital cardiac Correspondence: malformations in Adams-Oliver syndrome. Clin Genet, Fatma Demıray 1995; 47:80–84. Necmettin Erbakan University Faculty of Dentistry 10. Roca OJL, Cendán MI, Alonso LF, Ferrero OME, Lantigua Department of Pediatrıc Dentistry Karaciğan Mah. Ankara Cad. № 74/A CA. Caracterización clínica del labio hendido con fisura PK: 42050 Karatay/Konya/Turkey palatina o sin ésta en Cuba. Rev Cubana Pediatr, 1998; 70: E-mail: [email protected] 43–47. Tel: +903322200026
10.1515/bjdm-2017-0010
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3D Printing Guide Implant Placement: A Case Report
SUMMARY Zoran Vlahović1, Mirko Mikić2 Background: Cone Beam Computer Tomography (CBCT) is 1Faculty of Medicine, Department for Dentistry representing a new concept of radiological diagnostics and its application University of Priština - Kosovska Mitrovica occupies a special place in implantology. Today, preoperative planning, and Serbia quantitative and qualitative jaw bone analysis cannot be done without the 2Faculty of Medicine, Department for Dentistry use of these techniques. The latest in a series of achievements in this field is University of Montenegro, Montenegro a method of making a guide for implant using a 3D printing technique. This way pre implantology planning reduces the chance of surgical complications to a minimum and allows installation of dental implants in the most optimal position for future prosthetic work. Aim: To show benefits of guide implantation in clinical practice. Case report: The patient M.D. 36 years old. After making CBCT there was a qualitative and quantitative analysis of bone tissue, after which we decided to install five implants in positions #36, #37, #45, #46 and #47. The software appliance made virtually implants in the most optimal positions; treatment plan was forwarded by the internet connection into the DICOM format to Simplant Company, along with a folder of scanned plaster models in order to develop a guide. A few days later, after approval sent, we received the guide. Preparation by the pilot bur we did through transmucosal plum of the guide, and then we continued the classic flap surgery technique. Control footage shows the optimal position of the implant from both surgical and prosthetic aspects. Conclusion: Application guide implantology represents a safe and modern method that provides ability of implant placement in optimal positions in terms of future prosthetic rehabilitation. CASE REPORT (CR) Keywords: 3D printing, Guide implantology, CBCT Balk J Dent Med, 2017; 21:65-68
Introduction concept, became important with the emergence of a Cone Beam Computer Tomography (CBCT). Historically, the implant procedure was performed CBCT has been promoted as a new concept of only on the basis of available jaw bone1. Several studies radiological diagnostics, but with improved technical have clearly showed that implants placed on this way, characteristics of the device and accompanying software often appear to be more buccally or lingualy position, support; today, it became a gold standard in diagnostics. which leads to aesthetic problems that cannot be corrected This technique occupies a special place in probably by prosthetics. Implants that are placed incorrectly in the most attractive dental branch, implantology, where relation to the vertical axis are exposed to damaging preoperative planning and quantitative and qualitative lateral forces, resulting in a number of biomechanical analysis of bone base cannot be imagined without the use problems. For these reasons, there was idea introduced of this technique. through “prosthesis-driven implant dentistry”, which The latest in a series of achievements in this field is in addition to the structure of the bones gives also a method of making a guide for implant using 3D printing importance and position of the planned implant2-4. This technique. Prepared guide reduces surgical complications 66 Zoran Vlahović, Mirko Mikić Balk J Dent Med, Vol 21, 2017 to a minimum and allows installation of dental implants implant placement in the most optimal positions. Virtual in the most optimal position for future prosthetic work5-7. positioning was guided with appearance of future prosthetic work, and software made correct implants’ positions (Figure 3). The treatment plan was forwarded by Internet connection in DICOM format to the company Case Report Simplant (Brussels, Belgium), along with a folder of scanned plaster model in order to develop a guide for the preparation with the pilot bur. After designing a guide in the Simplant Company (Figure 4), we received a request for approval of 3D printing guide that we sent by the mail. A few days later, after we sent approval, we got the finished guide (Figure 5).
Figure 1. Orthopantomogram
After clinical examination and analysis of panoramic roentgen image (Figure 1), the patient MD, 36 years of age, was submitted to implant-prosthetic Figure 3. The virtual positioning of the implants in the software rehabilitation of toothless parts of the mandible. The advantage of this option compared to the production of prosthetic bridges is given due to the range of potential between the abutments and the age of the patient. After making CBCT image in device Planmeca Pro 3D Max, a qualitative and quantitative analysis of the bone tissue was performed. The results showed a satisfied bone density type D2, D3 by Misch, as well as vertical and horizontal dimension of the bone that provides possibility of installing the implant with appropriate diameter and length (Figure 2). We decided to install five Bredent implants, diameter of 4 mm and a length of 12 mm, 2 implants on the left side at the positions #36 and #37 and 3 implants on the right side at the positions #45, #46 and #47. Romexis software executed a virtual
Figure 4. Design of the surgical guide
Figure 2. Sagittal section of the mandible with measurements Figure 5. Finished 3D printing guide Balk J Dent Med, Vol 21, 2017 3D Printing Guide Implant Placement 67
Before surgery, it was necessary to check stability of the guide in the mouth and make corrections if necessary. Sometimes, it happens that the guide is not completely stable in the mouth. In our case, there were bilateral edentulous areas with natural teeth both anterior and posterior to the areas; therefore, a SLA surgical guide was tooth-supported and stable. We conducted transmucosal preparation with pilot bur through basins guide (Figure 6), and then we continued surgery with classic flap technique. Control footage shows the optimal position of the implant from both surgical and prosthetic aspects (Figure 7). In the last phase, the implants were loaded with two zirconia prosthetic bridges.
Figure 8. Lack of work space in the distal region
Also some other shortcomings, such as surgical guide shape, length of metal sleeve and surgical drill, template supporting problem, can be found in the literature13,15-18.
Conclusions
With all of these advantages of using guides, a Figure 6. Preparation of pilot drill certain caution is needed in the selection of patients, taking into the consideration technical mistakes and deviations recorded in the precision of preparation that may arise.
Note: The results of this paper were presented as a part of an invited lecture at the 21st BaSS Congress.
Figure 7. Control orthopantomogram after the completion of implant placement References
1. Eggers G, Patellis E, Mü hling J. Accuracy of template-based dental implant placement. Int J Oral Maxillofac Implants, Discussion 2009; 24:447-454. 2. Kopp KC, Koslow AH, Abdo OS. Predictable implant There are few clinical studies in the literature placement with a diagnostic/surgical template and advanced regarding use of SLA surgical templates in dental radiographic imaging. J Prosthet Dent, 2003; 89:611-615. implantology. Tooth-supported SLA guide, which was 3. Marković A, Miš ić T. Implant Therapy in the Esthetic Zone - used in our case, according to many authors, is more Surgical Considerations. Balk J Dent Med, 2016; 20(2):83-88. 4. Ramasamy M, Giri R, Subramonian K, Narendrakumar stable and leads to better precision than other types of 8-12 R. Implant surgical guides: From the past to the present. SLA guides (bone supported, mucosa supported) . Journal of Pharmacy & Bioallied Sciences, 2013; 5:S98- As one of the drawbacks of guide implants, the lack of S102 space is referred in the literature, especially in the lower 5. Vlahović Z, Marković A, Todorović A, Šćepanović M. 13,14 posterior region . That problem we also had during Application of ‘SKY PLAN X’ system in the planning of prepration in positions of #37 and #47 (Figure 8), and we implant placement with the terminal mutual loss of teeth of overcame it using shorter borer in an early stage. the upper jaw. PONS, 2010; 7(4):157-160. 68 Zoran Vlahović, Mirko Mikić Balk J Dent Med, Vol 21, 2017
6. Gupta J, Parveez AS. Cone beam computed tomography in 14. Cushen SE, Turkyilmaz I. Impact of operator experience on oral implants. Natl J Maxillofac Surg, 2013; 4:2-6. the accuracy of implant placement with stereolithographic 7. Jaju PP, Jaju SP. Clinical utility of dental cone-beam surgical templates: an in vitro study. J Prosthet Dent, 2013; computed tomography: current perspectives. Clinical, 109:248-254. Cosmetic and Investigational Dentistry, 2014; 6:29-43. 15. Valente F, Schiroli G, Sbrenna A. Accuracy of Computer- 8. Cassetta M, Stefanelli LV, Giansanti M, Calasso S. Aided Oral Implant Surgery: A Clinical and Radiographic Accuracy of implant placement with a stereolithographic Study. International Journal of Oral & Maxillofacial surgical template. Int J Oral Maxillofac Implants, 2012; Implants, 2009; 24:234-242. 27:655-663. 16. Papaspyridakos P, Lal K. Flapless implant placement: a 9. Geng W, Liu C, Su Y, Li J, Zhou Y. Accuracy of different technique to eliminate the need for a removable interim types of computer-aided design/computer-aided manu prosthesis. J Prosthet Dent, 2008; 100:232-235. facturing surgical guides for dental implant placement. Int J 17. Beretta M, Poli PP, Maiorana C. Accuracy of computer- aided template-guided oral implant placement: a prospective Clin Exp Med, 2015; 8:8442-8449. clinical study. J Periodontal Implant Sci, 2014; 44:184-193. 10. Nokar S, Moslehifard E, Bahman T, Bayanzadeh M, 18. Koshy E, Surathu N, Raj FS. Computer guided implant Nasirpouri F, Nokar A. Accuracy of implant placement surgery: A clinical report. International Journal of Clinical using a CAD/CAM surgical guide: an in vitro study. Int J Implant Dentistry, 2009; 1:23-29. Oral Maxillofac Implants, 2011; 26:520-526. 11. Dandekeri SSL, Sowmya MK, Bhandary S. Received on September 28, 2016. Stereolithographic surgical template: a review. J Clin Diagn Revised on November 11, 2016. Res, 2013; 7:2093-2095. Accepted on November 29, 2016. 12. Moon SY, Lee KR, Kim SG, Son MK. Clinical problems of computer-guided implant surgery. Maxillofac Plast Reconstr Correspondence: Surg, 2016; 38:15. Zoran Vlahović 13. Lin YK, Yau HT, Wang IC, Zheng C, Chung KH. A novel Vlada Cetkovica 64/130 dental implant guided surgery based on integration of 81000 Podgorica surgical template and augmented reality. Clin Implant Dent Montenegro Relat Res, 2015; 17:543-553. E-mail: [email protected]
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Parts of the manuscript are: Title page (separate file), Discussion is to emphasize the new and significant aspects Summary with Key words, Text, Acknowledgements (to of the study and the conclusions that result from them. the authors’ desire), References. Relate the observations to other relevant studies. Link Balk J Dent Med, Vol 21, 2017 the conclusions with the goals of the study, but avoid Sternbach RA. Pain patients - traits and treatment. New unqualified statements and conclusions not completely York, London, Toronto, Sydney, San Francisko: Academic supported by your data. Press; 1974. Koulourides T, Feagin F, Pigman W. Experimental changes References in enamel mineral density. In: Harris RS, editor. Art and Science of Dental Caries Research. New York: Academic References should be numbered consecutively in the Press; 1968. p. 355-378. order in which they appear in the text. 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All illustrations, labelled as figures (such as photographs, line drawings, charts or tracings) should be submitted as Balkan Journal of Dental Medicine recommends that high-contrast prints, suitable for publications. Illustrations authors refer to NLM guidelines for formatting references should have a final resolution of 300 dpi, and line drawings at the Citing Medicine Web site of 800-1200 dpi. They must be numbered with Arabic (http://www.nlm.nih.gov/citingmedicine). numerals in the same order as they are cited in the text. Photomicrographs should have the magnifications and Several examples of references in NLM format are shown details of staining techniques shown. Short explanatory below. captions of all illustrations should be typed on a separate For more samples of formatted references visit the NLM site sheet. (http://www.nlm.nih.gov/bsd/uniform_requirements.html). Abbreviations and symbols Examples of references: Brown JS, Browne RM. Factors influencing the patterns of Use only standard abbreviations. Avoid abbreviations in the invasion of the mandible by squamous cell carcinoma. Int J title and abstracts. The full term for which an abbreviation Oral Maxillofac Surg. 1995; 24:417-426. stands should precede its first use in the text.