International Dentistry Australasian Edition - Vol. 10, No. 1

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VOL. 1 0 NO. 1 IN THIS ISSUE Jonathan L. Ferencz and Marisa Notturno Simply more choice: Monolithic anterior crowns Douglas Terry and John Powers Using injectable resin composite: part one and part two Johan Hartshorne Do surgical prophylactic antibiotics reduce postoperative infection and early dental implant failure?

Gyula Marada Minimally invasive treatment on a stable basis Linda Greenwall Therapeutic aesthetics Andreas Krokidis and Riccardo Tonini CBCT in endodontic treatment of fused second and third mandibular molars Fadi Titinchi, Jean A Morkel and Sanjay Ranchod Treatment of postoperative sore throat after endotracheal intubation in third molar surgery

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Contents Volume 10 No. 1

4

10 Clinical Simply more choice: Monolithic anterior crowns Jonathan L. Ferencz and Marisa Notturno

10 Clinical

Using injectable resin composite: part one and two Douglas Terry and John Powers

28 Clinical

Do surgical prophylactic antibiotics reduce postoperative infection and early dental implant failure?

Johan Hartshorne

40

34 Case Report

Minimally invasive treatment on a stable basis Gyula Marada

40 Clinical

Therapeutic aesthetics Linda Greenwall

48 Clinical

CBCT in endodontic treatment of fused second and third mandibular molars Andreas Krokidis and Riccardo Tonini

48

54 Scientific

Treatment of postoperative sore throat after endotracheal intubation in third molar surgery Fadi Titinchi, Jean A Morkel and Sanjay Ranchod

62 Products

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OzHarvest Celebrating 10 years!

Henry Schein Halas together with our partners are committed to social responsibility programs both in the dental sector and the general wellbeing of those less fortunate. The Henry Schein Cares Program runs throughout the world providing support to volunteers and charities around the globe.

In November 2014 we were lucky to be with OzHarvest celebrating their 10 year anniversary and their new and improved premises in Alexandria.

OzHarvest is a food rescue service, who pick up excess food from all sorts of food providers and deliver it free of charge to almost 500 charities. This service provides much needed assistance to vulnerable men, woman and children across Australia. It means that small government budgets that charities may have can be stretched to other non-perishable necessities.

OzHarvest originated in Sydney, however over the last 10 years they have expanded and now operate across Sydney, Adelaide, Brisbane, Canberra, Gold Coast, Melbourne, Newcastle and Perth. OzHarvest is the only food rescue organisation in Australia collecting surplus food from all types of food providers, including fruit and vegetable markets, supermarkets, hotels, wholesalers, farmers, stadiums, corporate events, catering companies, shopping centres, delis, cafes, restaurants, film and TV shoots and boardrooms.

OzHarvest was founded in November 2004 by Ronni Kahn, who was named Australia’s Local Hero of the Year in 2010. In 2005, with the aid of pro-bono lawyers she lobbied the state governments to amend legislation to allow potential food donors to donate surplus food to charitable organisations.

The Civil Liabilities Amendment Act was passed in NSW in 2005 with ACT, SA and QLD following soon after. This ensured surplus food could be donated to charitable causes without fear of liability.

OzHarvest is proud of their achievements in delivering more than 30 million meals to people in need, and at the same time saving more than 10,000 tonnes of good quality surplus food from landfill.

Their new multipurpose built warehouse and office space was donated by Goodman to OzHarvest in celebration of their 10th Birthday. The new facility will be the hub of their food rescue service. It will not only house all the office staff and volunteers but will also be a place which brings together the community.

Their 10th birthday celebration showcased many of their supporters catering abilities. The food and drinks were simply delicious. There was also live entertainment by Australian band Air Land Sea who released their new song If You’ve Got Love, as a tribute to OzHarvest’s work in the community. The energy in the room was electric and when the Sydney Street Choir sang you could feel the pride and joy levels rise.

OzHarvest is a truly remarkable organisation and Henry Schein Halas through the Henry Schein Cares Foundation are proud to have supported them over the last 10 years.

To volunteer of donate please contact OzHarvest in your local community www.ozharvest.org

Vol. 10 No. 1 ISSN 2071-7962 PUBLISHING EDITOR Ursula Jenkins

EDITOR-IN-CHIEF Prof Dr Marco Ferrari

ASSOCIATE EDITORS Prof Cecilia Goracci Prof Simone Grandini Prof Andre van Zyl

EDITORIAL REVIEW BOARD Prof Paul V Abbott Prof Antonio Apicella Prof Piero Balleri Dr Marius Bredell Prof Kurt-W Bütow Prof Ji-hua Chen Prof Ricardo Marins de Carvalho Prof Carel L Davidson Prof Massimo De Sanctis Dr Carlo Ercoli Prof Livio Gallottini Prof Roberto Giorgetti Dr Patrick J Henry Prof Dr Reinhard Hickel Dr Sascha A Jovanovic Prof Ivo Krejci Dr Gerard Kugel Dr William H Liebenberg Prof Edward Lynch Prof Ian Meyers Prof Maria Fidela de Lima Navarro Prof Hien Ngo Prof Antonella Polimeni Prof Eric Reynolds Prof Jean-Francois Roulet Prof N Dorin Ruse Prof Andre P Saadoun Prof Errol Stein Prof Lawrence Stephen Prof Zrinka Tarle Prof Franklin R Tay Prof Manuel Toledano Dr Bernard Touati Prof Laurence Walsh Prof Fernando Zarone Dr Daniel Ziskind PRINTED BY KHL PRINTING, Singapore International Dentistry - Australasian Edition is published by Modern Dentistry Media CC, PO BOX 76021 WENDYWOOD 2144 SOUTH AFRICA Tel: +27 11 702-3195 Fax: +27 (0)86-568-1116 E-mail: dentsa@iafrica.com www.moderndentistrymedia.com

© COPYRIGHT All rights reserved.

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

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CLINICAL

Simply more choice: Monolithic anterior crowns Jonathan L. Ferencz1 and Marisa Notturno

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Introduction Given their translucency and shade characteristics, modern ceramic materials such as lithium disilicate can be efficiently applied to achieve convincing prosthetic results.

There is no denying the success of all-ceramic materials (e.g. IPS e.max® CAD). As awareness of CAD/CAM and digital dental technology increases, many dentists and dental laboratories are realizing new benefits for themselves and their patients, such as superior strength, accuracy, durability and cost-effectiveness. In-office manufacturing systems combined with modern all-ceramic materials afford dentists new opportunities to meet the needs of their patients. This case presentation describes the digital treatment planning, restoration design, milling and characterization steps to produce all-ceramic anterior crowns. The challenging demands of this case were met with a streamlined approach that delivered highly accurate and esthetically pleasing results.

Clinical case description

1

Jonathan L. Ferencz, DDS, FACP NYC Prosthodontics 275 Madison Avenue, New York, NY 10016, USA.

2

Marisa Notturno Dental technician NYC Prosthodontics 275 Madison Avenue, New York, NY 10016, USA.

A 42-year-old man presented with extensive demineralization and caries on his maxillary anterior teeth (Fig. 1). After the patient had been carefully diagnosed and given detailed advice, a treatment plan was established: Teeth 13 to 23 were to be restored with all-ceramic crowns. The teeth were prepared and temporarily restored with provisional crowns (Fig. 2). Ten days later, the patient was seen for a follow-up, at which time he felt generally comfortable and pleased with the esthetics of the temporary restorations. He only requested a few modifications that involved some minor recontouring and reshaping of the incisal edges and incisal embrasures.

Once these adjustments were made, the patient was completely satisfied with the appearance of his temporaries and it was therefore decided to use them for the digital “mock-up” of the final crowns (Fig. 3). A digital record of the oral situation was obtained with an intraoral scanning device (3Shape Trios® Color, 3Shape Denmark) (Fig. 4).

The opposing teeth were included in the scan to enable a digital bite registration.

Additionally, this was also the ideal time to determine the tooth shade with all its individual characteristics.

The temporaries were then removed, the patient was anaesthetized with local anaesthetic, and the gingival tissues were gently retracted using a retraction cord (Siltrax® Plus, Pascal International, USA), after which the preparations were refined.

Since the plan was to mill lithium disilicate crowns (IPS e.max CAD), it was essential to eliminate any sharp edges or line angles from the preparations. Sharp edges could make the milling process very challenging and cause major fitting problems. The intraoral scanner was again used to digitally scan the prepared teeth. An interocclusal scan was obtained to enable the articulation with the opposing dentition (Fig. 5). The data files were then transferred to the 3Shape design system and opened using the DentalDesigner™ program.

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CLINICAL

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1

Figure 1: First left mandibular molar before endodontic retreatment.

Figure 2: First left mandibular molar radiographic image after retreatment, in the moment of consultation due to pain.

Figure 3: Mandibular incisors radiographic image. A radiolucent periapical area can be observed in the central left mandibular incisor.

3

Digitally designing and milling the restorations When fabricating a CAD/CAM reconstruction that involves more than two teeth, it is helpful to use a physical model on which proximal and occlusal contacts can be verified. The Model Builder™ module of the 3Shape Design Center was used to design and order the model. The model design data were sent to Custom Milling Center (CMC, Arvada, USA) and printed out in high definition using 3D printer technology

(ULTRA2 HD, envisionTEC, Germany). The maxillary and mandibular models were extraordinarily accurate and had a very smooth, gypsum-like surface finish.

The digital design of the six full-coverage crowns began while awaiting arrival of the models. First, the manufacturing parameters were set in the software to control individual preferences (thickness of the restoration, cement spacer, occlusal con- tacts, proximal contacts, drill radius). These

Figure 4: Digital scans of the temporaries (3Shape Trios Color) served as a “mock-up” of the final restoration.

Figure 5: Scan of the prepared teeth and opposing dentition.

Figure 6: Colours in the design software indicate differences between the final crown design and the temporaries (proposed crown design: yellow; pre-preparation scan: grey).

Figure 7: Final restoration design.

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Figure 8: Milled crowns in the “blue stage” (IPS e.max CAD restorations on their spindles).

Figure 9: Printed 3D model.

Figure 10: The fit of the crowns was checked on the dies. Minor changes may be necessary if the preparations contain sharp angles or edges

parameters may vary by individual milling machines and/or milling centres.

The scan of the temporary restorations served as a prepreparation scan. The design software automatically morphed the proposed crown restoration into the scan of the temporaries. Generally, the crown design can be modified at this stage; however, in this case there was no need for changes. The design software uses different colours to help spot differences between the final crown design and the mock-up scan (temporary restorations) (Figs 6 and 7).

Next, attention was given to selecting the shade and translucency of the IPS e.max CAD block

Figure 11: Here the surface texture is already established. Glazing was accomplished using IPS e.max CAD Crystall./Glaze Pastes.

In this case, the patient wanted a fairly light shade for his crowns. As his preparations were not badly discoloured, a translucent block (IPS e.max CAD HT, shade B1) was selected. IPS e.max CAD blocks for in-office milling are available in two degrees of translucency: HT = High Translucency and LT = Low Translucency. When selecting a block for monolithic crowns, using a light-coloured block with a high translucency and adding characterizations with stains and shades to achieve the final shade is preferable. This technique was described in great detail by Lee Culp.1 The six crowns were milled using an in-office CAD/CAM unit (E4D®, E4D Technologies, USA) (Fig. 8).

Figure 12: Finishing after crystallization firing. Polishing points were used for prepolishing.

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Figure 13: The finished crowns were further polished with a diamond polishing paste and a soft bristle brush.

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Figure 14: Retracted view of the seated anterior maxillary monolithic crowns (IPS e.max CAD).

Refining shape and esthetics Upon receipt of the 3D printed model, the restorations were tried for fit (Fig. 9). Milled IPS e.max CAD restorations usually fit accurately on the dies and internal adjustments are required only occasionally, especially if the teeth are prepared with sharp angles or edges. If this is the case, it is advisable to mill the crowns using the “detailed mode” (rather than the “standard mode”). The detailed mode utilizes thinner diamond drilling tools that are designed to reach narrow areas of the crown but take somewhat longer to mill. Milling in detail mode is preferable for all anterior restorations even if the milling process takes longer. The blue (pre-crystallized) crowns were seated on their respective dies and checked on the articulated printed models (Fig. 10).

Coloured markings applied on the labial surface of the crown to indicate the desired surface texture (perikymata, marginal ridges, etc.) provided valuable help when finishing the crowns. A series of diamond burs was then used to achieve the desired surface characteristics. After verifying the proximal contacts and occlusion one more time, the crowns were prepared for crystallization firing. This process was combined with staining and glazing using glaze and shade pastes (IPS e.max CAD Crystall./Glaze and Shade Pastes) in the gingival and incisal area (Fig. 11). Intensive colour characterizations were achieved using IPS e.max CAD Stain Pastes, a process that frequently requires multiple firings.

The crowns were polished using fine polishing points

(Dialite® LD Polishing Points, Brasseler, USA) (Fig. 12) followed by a soft bristle brush and diamond paste (Pasta Grigia, anaxdent GmbH, Germany) (Fig. 13). The monolithic crowns were now ready for try-in on the patient

Seating Proximal contacts, marginal fit and occlusion – all aspects were meticulously assessed and found to be excellent. The young man was delighted with the esthetic result. Final cementation was performed using a resin-reinforced glass ionomer cement (Fuji Plus, GC America, USA) (Fig. 14).

Conclusion Digital dental technologies make it possible to deliver esthetically pleasing monolithic restorations even in the anterior region. In the case presented here, the shape, fit and esthetics completely met the patient’s expectation By digitally “cloning” the temporary restorations, carefully selecting the ideal shade of the CAD lithium disilicate blocks and then staining and glazing the milled restoration, the dental team was able to undertake a streamlined fabri- cation process and deliver optimum results.

Literature: 1. Culp L. Personal communication, 2013.

Published with permission by Reflect 1/14

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CLINICAL

Using injectable resin composite: part one Douglas Terry1 and John Powers2

The injectable resin composite technique is a novel indirect/direct process of predictably translating a diagnostic wax-up into composite restorations.

There are a myriad of applications for this technique using a highly filled flowable resin composite. The clinical applications include emergency repair of fractured teeth and restorations, fabricating provisional restorations (Terry, 2012), transitional composite restorations (class III, IV, veneers) and paediatric composite crowns, resurfacing occlusal wear on posterior composite restorations, establishing incisal edge length prior to aesthetic crown lengthening, and developing composite prototypes for copy milling.

In addition, this technique can be used to establish vertical dimension and for altering occlusal schemes (anterior guidance and posterior disclusion) prior to restoring with final restorations. Furthermore, this non- invasive technique is an integral tool for enhancing communication between the patient and restorative team during treatment planning.

This article presents a case report involving the use of the injectable resin composite technique to develop transitional resin composite restorations.

Prototypes Developing transitional resin composite restorations using the injectable technique is an excellent method to increase the patient’s understanding of the planned clinical procedure and anticipated final result (Terry, Leinfelder, Geller, 2009).

1

Douglas Terry, DDS. Assistant Professor, Department of Restorative Dentistry and Biomaterials, University of Texas School of Dentistry, Houston, Texas, USA. Private Practice, Houston, Texas, USA

2

John Powers, PhD. Clinical Professor of Oral Biomaterials, University of Texas School of Dentistry, Houston, Texas, USA

Figure 1: Preoperative view of the maxillary anterior segment in a 63-year-old. Patient with incisal wear and fracture requested a conservative aesthetic enhancement without orthodontic treatment.

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CLINICAL

Transitional composite prototypes allow the patient and restorative team to establish parameters for: • Occlusal function (Heymann, 1987) • Tooth position and alignment (Gürel, 2003) • Restoration shape and physiologic contour (Baratieri, 1998) • Restorative material colour and texture • Lip profile • Phonetics • Incisal edge position • Gingival orientation.

In addition, this process helps to eliminate confusion and misunderstanding between the patient and the team during the treatment planning stage. This technique can also be used in the development and management of soft tissue profiles and in the design of the definitive restoration (Donovan, Cho, 1999; Preston, 1976; Yuodelis, Faucher 1980; Saba, 1997).

The clinician and technician can use this reversible and preparation-less technique as a guide for developing a pre-approved functional and aesthetic final restoration. This process aids them during the design and fabrication of the definitive restoration, by providing a visualisation for the patient and the team as well as communicating extensive details concerning the treatment plan and the fabrication of final restorations (Terry, Geller, 2013). In some cases, these transitional restorations can be worn for months or even years by patients during long-term interdisciplinary rehabilitation (Terry, 2012).

This technique can be performed without anaesthesia. A clear vinyl polysiloxane impression material is used to replicate the diagnostic wax-up. The clear matrix can be placed over the unprepared teeth and used as a transfer vehicle for the flowable composite resin to be injected and cured.

Once adjustment and polishing have been completed, the transitional composite restorations can be further modified to satisfy the functional and aesthetic needs of the patient.

This procedure can reduce the potential for patient

a

b

c Figures 2a, b and c: Clinical evaluation revealed multiple diastemas and cervical corrosion on the central incisors.

dissatisfaction and litigation since the process is reversible, can be performed without preparation and allows the patient to accept the visual and functional result before the definitive restorations are fabricated.

In addition, this simple procedure helps to regulate the dimensions of the preparation design, ensures uniform spatial parameters for the restorative material, and increases the potential for a more conservative preparation design (Terry, 2012).

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Figure 3a: Development of a diagnostic wax-up for the final restorations.

Case report A 63-year-old male patient presented with concerns regarding incisal wear and fracture of his maxillary anterior teeth (Figure 1).

Figure 3b: A clear vinyl polysiloxane matrix replicates the diagnostic wax-up.

Clinical evaluation revealed multiple diastemas and cervical corrosion on the central incisors from lemon sucking (Figures 2a and 2b). Additional occlusal findings indicated insufficient canine guidance and posterior disclusion. After occlusal evaluation, a new occlusal scheme was developed

Figure 4: A hybrid resin composite placed in the clear matrix and positioned on the maxillary right central and light-cured.

Figure 5a: Before the adhesive surface Figure 5b: A 37.5% phosphoric acid preparation, each tooth is separated by semi-gel was applied to the enamel surface applying Teflon tape on the adjacent teeth. for 30 seconds, rinsed and air-dried.

Figure 5c: A single component adhesive was applied to the enamel surface and allowed to dwell for 10 seconds.

Figure 5d: The adhesive is air-dried for five Figure 5e: The adhesive is then light-cured for 10 seconds. seconds.

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Figure 6a: A clear silicone matrix placed over the arch and an opacious A2-shaded flowable resin composite injected above each tooth.

with a diagnostic wax-up (Figure 3a). A clear vinyl polysiloxane matrix was used to replicate the diagnostic wax-up. The impression was taken in a non-perforated plastic tray (Figure 3b).

Each tooth was pumiced and cleaned with 2% chlorhexidine. Prior to the restorative procedure, a hybrid resin composite was placed in the clear matrix, positioned on the maxillary right central, and light-cured. This technique allowed the spatial dimension of a large diastema to be controlled during the composite injection

Figure 7a: The excess polymerised composite resin is removed.

Figure 6b: Resin composite cured through the clear resin matrix.

procedure (Figure 4).

Each tooth was then separated by applying Teflon or a small amount of glycerin to the adjacent teeth (Figure 5a).

This proximal adaptation technique allowed for optimal integration of flowable resin composite in the interproximal region while preventing adhesion of the material to adjacent tooth surfaces (Terry, Leinfelder, 2004; Terry, 2004; Terry, 2005).

Depending on the duration of treatment, the method for bonding requires selective spot etching or complete etching

Figure 7b: The incisal composite sprue was removed with a 30-fluted tapered finishing bur.

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Figure 7c: Using a tapered finishing diamond, the tooth composite resin interface was finished.

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a Figure 8: The initial hybrid composite mock-up was removed with a scalpel.

b

Figures 9a and 9b: The proximal surfaces and contours were smoothed with tapered finishing diamond and finishing strips.

of the tooth surfaces to be restored. A 37.5% phosphoric acid semi-gel was applied to the enamel surface for 30 seconds, rinsed for five seconds, and gently air-dried (Figure 5b). A single-component adhesive was applied to the enamel surface, allowed to dwell for 10 seconds (Figure 5c), air-dried for five seconds (Figure 5d), and light-cured for 10 seconds (Figure 5e).

The clear silicone matrix was placed over the arch and

an opacious A2-shaded flowable resin composite was initially injected through a small opening above each tooth, followed by a translucent B1 flowable resin composite (Figure 6a). The resin composite was cured through the

Figure 10a: Adhesive surface preparation completed using total-etch technique.

Figure 10b: Flowable composite material is injected through an opening in the matrix.

Figure 11a: The incisal composite sprue was removed, and excess composite resin removed with a scalpel.

Figure 11b: The gingival tissue was retracted and the tooth composite resin interface finished using a tapered finishing diamond.

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Figure 12: The lingual tooth composite resin interface was finished using a 30-fluted pyramidal-shaped finishing bur.

Figure 13: Proximal surfaces and contours were smoothed with finishing strips.

Figure 14: Incisal and proximal contouring and smoothing accomplished with finishing and polishing discs.

Figure 15: Facial surfaces polished with silicone points.

Figure 16: Gingival region polished with silicone hollow cups.

Figure 17: A goat hair wheel and diamond polishing paste are used to further refine the surface lustre of the composite resin.

clear resin matrix for 40 seconds (Figure 6b) and the excess polymerised resin composite was removed with a scalpel (Figure 7a). The incisal composite sprue was removed with a 30-fluted tapered finishing bur (Figure 7b).

The gingival tissue was retracted with a gingival protector, and the tooth-resin composite interface was finished using a tapered finishing diamond (Figure 7c). The initial mock-up on the maxillary right central was removed with

a scalpel blade (Figure 8). The proximal surfaces and contours were smoothed with a tapered finishing diamond and finishing strips.

This restorative procedure was completed for each tooth before restoration of the next tooth (Figures 9a and 9b).

After isolation of the adjacent central, the adhesive surface preparation was completed using total-etch technique (Figure 10a). The same shade combination of flowable composite

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Figure 18: High surface gloss was achieved with a dry cotton buff applied with an intermittent staccato motion.

material was injected through a small opening in the matrix above the tooth, allowing the material to completely cover the conditioned enamel surface (Figure 10b). The resin composite was cured through the clear resin matrix for 40 seconds. After the incisal composite sprue was removed, the excess polymerised composite resin was removed (Figure 11a). After each composite injection, the same restorative procedure was completed for each tooth in the

a

anterior segment.

An optimally finished transitional restoration should provide a smooth surface that will prevent plaque accumulation (Terry, 2004; Stewart, Bachman, Hatton, 1991; Berastegui et al, 1992; Yap, Sau, Lye, 1998), and resist staining (Goldstein, 1989). It should also possess proper marginal adaptation and integrity (Yap, Ang, Chong, 1998) with the ideal contours and emergence profile for improved tissue compatibility.

For this patient, the gingival tissue was retracted with a gingival protector to prevent tissue laceration, and the tooth resin composite interface was finished using a tapered finishing diamond (Figure 11b).

The lingual tooth resin composite interface was finished using a 30-fluted pyramidal shaped finishing bur. This bur has an ideal shape that conforms to the appropriate curvature of the tooth surface and restoration (Figure 12).

The interproximal surfaces were smoothed with aluminium oxide finishing strips, which were used sequentially from fine to extra-fine (Figure 13). The incisal edges of the resin composite were contoured with finishing and polishing discs (Figure 14). Pre-polish and high-shine silicone points were used to smooth and polish

b

c

Figures 19a, b and c: The completed transitional resin composite restorations with optimal anatomical form. The composite injection technique allows the establishment of harmonious proportions of the transitional restorations and the surrounding biologic framework.

a

b

c

Figures 20a, b and c: The transitional resin composite restorations are inspected in centric relation, protrusive and lateral excursions.

Notice the improved posterior disclusion and anterior guidance.

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Figure 21: The composite transitional restorations establish the optimal aesthetic parameters for a natural smile.

the resin composite surface (Figure 15).

The gingival region was smoothed and polished with pre-polish and high-shine silicone hollow cups, which provide additional flexibility at the cervical curvature of the tooth (Figure 16). The facial surface was polished to a high lustre with synthetic diamond paste using a goat hair wheel, and the final surface gloss was accomplished with a dry cotton buff using an intermittent staccato motion applied at conventional speed (Figures 17 and 18).

The transitional resin composite restorations were completed and inspected in centric relation, protrusive and lateral excursions (Figures 19a-c).

The composite prototype achieved using this non-invasive injectable technique established the optimal aesthetic parameters for a natural smile (Figures 20a-c and Figure 21).

Conclusion The injectable resin composite technique is a valuable communication tool for increasing the patient’s

understanding of the clinical procedure and anticipated final result. This process allows the functional and aesthetic concerns to be resolved by the entire restorative team before final restorative treatment is initiated.

The future clinical applications of this novel technique may provide clinicians and technicians with alternative approaches to various clinical situations while allowing them to deliver improved and predictable dental treatment to their patients.

Although the long-term benefits of this technique remain to be determined, the clinical results achieved in the past seven years by the authors are extremely promising.

Further information The second part of this series, will describe and illustrate another application of the injectable resin composite technique for use with the primary dentition.

The list of references that accompany this series is available on request.

Published with permission by Private Dentistry November 2014

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CLINICAL

Using injectable resin composite: part two Douglas Terry1 and John Powers2

Douglas Terry and John Powers illustrate another application of the injectable resin composite technique for use with the primary dentition.

The first part of this series provided an overview of the clinical applications of an injectable resin composite technique and described the procedure and its predictability for developing transitional resin composite restorations in the adult dentition.

Composite prototyping can be used to establish aesthetic and occlusal parameters such as restoration shape, physiologic contour, phonetics and occlusion. This article will describe and illustrate another application of the injectable resin composite technique for use with the primary dentition, described as the Terry Injectable Primary Composite Crown (TIPCC).

Extensive caries and trauma represent the major reasons for the restoration of primary teeth with full coronal coverage (Motisuki, Santo-Pinto, Giro, 2005; Mehta et al, 2012). Clinical indications for the use of full coverage crown include: • Primary teeth with multiple carious surfaces • Fractured primary teeth with a significant loss of tooth structure • Primary teeth with developmental defects and discolouration • Class II lesions in which the caries has extended beyond the anatomic line angles • Pulpectomised primary teeth with a significant loss of tooth structure • Hypoplastic deciduous teeth (Mahoney, Kilpatrick, Johnston, 2013) • Patients with special needs (Troutman, 1976; Salama, Myers, 1992; Waggoner, 2002; Waggoner, 2012; Kindelan et al, 2008; American Association of Pediatric Dentistry, 2013; Gilchrist et al, 2013; Christensen, 2012; Schwartz, 2014).

There is a myriad of methods and materials for restoring primary teeth with full coronal coverage (crowns) (Webber et al, 1979). These include polycarbonate crowns, traditional stainless steel crowns, open faced stainless steel crowns, stainless steel crowns veneered with tooth-coloured materials (ie, composite, ceramic), the acid-etched resin strip crown and zirconium crowns. The treatment challenges associated with these various types of crowns in the past include improper anatomical contours, gingival inflammation, fractured facings, microleakage, poor retention and an unnatural appearance (Figure 1).

In paediatric dentistry, manufacturers, researchers and clinicians continue to search 1

Douglas Terry, DDS. Assistant Professor, Department of Restorative Dentistry and Biomaterials, University of Texas School of Dentistry, Houston, Texas, USA. Private Practice, Houston, Texas, USA

2

John Powers, PhD. Clinical Professor of Oral Biomaterials, University of Texas School of Dentistry, Houston, Texas, USA

Figure 1: The resin strip crowns on the maxillary primary central incisors reveal improper anatomical contours with gingival inflammation. Note the unnatural appearance.

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a

b

Figures 2a and 2b: Preoperative facial view of the maxillary anterior primary incisors. Patient presented at the age of six with extensive interproximal caries on the maxillary primary incisors from excessive sugar intake and inadequate plaque control.

Figure 3a: A diagnostic wax-up was created to develop the original contours of the incisors.

Figure 3b: A clear vinyl polysiloxane matrix was fabricated to replicate the diagnostic wax-up, intraorally.

Figure 4a: Initial caries was removed.

Figure 4b: Shade determination was completed before final preparation.

for an ideal material and technique that will allow duplication similar to natural tooth structure and morphology.

This biomaterial should be resistant to masticatory forces and possess an appearance akin to natural dentine and enamel.

In addition, it should have similar physical and mechanical properties to that of the natural tooth, because as the mechanical properties of a restorative material approximate

the enamel and dentine, the restoration’s longevity increases (Summitt, 2001).

Also, in paediatric dentistry, the material should have the ability to be easily and efficiently placed and repaired. In addition, the technique should require minimal chair time (Mehta et al, 2012; Croll, 1998).

While no restorative material and technique currently fulfil all these prerequisites, one treatment modality and material

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a Figure 5a: Before initiating the adhesive protocol, the preparation design was completed and each tooth separated by applying tape on the adjacent teeth.

c

b Figure 5b: A 37.5% phosphoric acid semi-gel was applied to the enamel and dentine surfaces, rinsed, and air dried.

d

Figure 5c: A single component adhesive was applied with an applicator to the tooth surfaces, allowed to dwell and air dried.

Figure 5d: Light cured for 10 seconds using a halogen LED curing light.

may provide some of these attributes.

A minimal invasive approach, known as the TIPCC, has been described for primary crown placement. This injectable resin composite technique is a novel indirect/ direct process of predictably translating a diagnostic wax-up into composite restorations using a highly filled flowable resin composite.

As a transitional technique, its application would be favourable for a transitional dentition such as the primary teeth. When selecting this procedure for children, several factors should be considered prior to selecting the injectable composite material, including: • Caries risk assessment • Age • Behaviour • Periodontal health • Adequate remaining tooth structure • Moisture-controlled field

• The longevity of the tooth • Treatment conditions for the patient (Roberts, Lee, Wright, 2001; Guelmann et al, 2011).

The criteria for tooth replacement, defects, trauma, and caries, as well as the basic definition of cavity preparation, has remained unchanged over the last 100 years.

However, the physical preparation design for the replacement of natural tooth structure and/or existing restorations has been continuously altered as advances in materials occur.

The newer formulations of syringeable universal composites have improved physical, mechanical, and optical characteristics (Dixon, Moon, 2011; Illie, Renez, Hickel, 2013). Thus, the adhesive application of these highly filled flowable resin composite systems permits a more conservative tooth preparation Furthermore, restoring the natural dentition with bonded resin composite reinforces the

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a

b

c

Figure 6a: The clear silicone matrix was placed over the anterior segment of the maxillary arch and an opacious A1 shaded flowable resin composite was initially injected through a small opening above each tooth, followed by a B1 shaded flowable resin composite.

Figures 6b and 6c: The resin composite was cured through the clear matrix on the incisal, facial and lingual aspect for 40 seconds

Figure 7: The primary composite crown after composite sprue removal and prior to the finishing and polishing procedure.

tooth and restoration, which results in an increased structural integrity while reducing and dissipating functional forces along the entire restorative interface (Terry, Geller, 2013).

Although many of the basic preparation principles are similar for all adhesive preparations, there is consideration in the preparation design that is different for vital and pulpectomised primary teeth.

Vital teeth require only removal of pre-existing defective restorative material and/or caries while pulpectomised teeth should have a resin-modified glass ionomer placed

a

intracoronally to improve marginal seal of the pulpotomy (Guelmann et al, 2011; Berg, Donly, 1988).

The general design guidelines for the adhesive preparation for vital and pulpectomised anterior and posterior primary teeth include the following: • Any pre-existing defective restoration (composite or alloy) and/or caries should be removed • To allow for a better resin adaptation, all internal or external line angles should be rounded and cavity walls smooth. Unsupported enamel walls should be removed to improve the path of flow of material • A circumferential chamfer is placed 0.3mm in depth to increase the enamel adhesive surface and to allow for a sufficient bulk of material at the margins (Terry, Leinfelder, 2004) • Occlusal reduction 1.5-2mm should be achieved.

Vertical proximal, facial/buccal and lingual walls with slight convergence toward the occlusal will break proximal contacts. The preparation can be completed with a finishing disc but with no silicone points or cups because these contaminate the bond.

A premix slurry of pumice and an aqueous 2% chlorhexidine solution can be used to remove potential

b

c

Figure 8a: The composite crown was completed on the maxillary right primary central using the same restorative procedure.

Figure 8b: The excess polymerised composite resin was removed.

Figure 8c: The incisal composite sprue was removed with a 30-fluted tapered finishing bur.

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a

b

Figure 9a: Before the adhesive procedure, tape is applied to the teeth adjacent to the maxillary left primary lateral to ensure an optimal integration of the flowable composite in the interproximal region. This also prevents adhesion of the material to the adjacent tooth surfaces. The tape can be adapted to the tooth surfaces and tucked into the gingival sulcus, using an interproximal instrument.

c

Figure 9b: The etchant was applied to the enamel and dentine surfaces for 15 seconds, rinsed and gently air dried.

d

Figure 9c: Adhesive was applied to the enamel and dentine surfaces with a #2 sable brush, allowed to dwell, air dried and light cured.

Figure 9d: After the same shade combination of flowable composite material was injected into the clear matrix and allowed to cover the entire tooth surface, the material was cured through the matrix from all aspects for 40 seconds.

contaminants.

The following case study illustrates the use of the Terry Injectable Primary Composite Crown (TIPCC) technique to restore the primary maxillary anterior dentition.

performed, a treatment plan was established. Upon explaining the restorative technique to the patient and his parents, they accepted the suggested treatment and signed an informed consent form before the treatment started.

A full-mouth alginate impression was taken of the patient’s maxillary arch and poured with type IV stone. The stone model was removed from the impression one hour later and shaped on the model trimmer.

This process can be expedited by using a fast-set dental die stone. The maxillary incisors were waxed to an ideal contour and a clear vinyl polysiloxane matrix was fabricated to replicate the diagnostic wax-up (Figures 3a and 3b). The impression was taken in a non-perforated plastic tray. Other

Case report A six-year-old male was referred to the VS Dental College and Hospital in Bangalore, India. The child was healthy and had no history of systemic disease.

On examination, a complete primary dentition was present with extensive caries on the maxillary primary (Figures 2a and 2b).

After clinical and radiographic evaluations were

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a

b

Figures 10a and 10b: After the incisal composite sprue was removed, the excess polymerised composite resin was removed with a scalpel.

a

b

c

Figure 11a: Gingival tissue was retracted with a protector while the tooth composite resin interface was finished using a tapered finishing bur. After finishing each primary composite crown with interproximal finishing strips and discs, silicone polishing points and cups.

Figure 11b: A goat hair wheel and diamond polishing paste are used to further enhance the surface luster of the composite resin.

Figure 11c: The final surface gloss was achieved with a dry cotton buff using an intermittent staccato motion applied at conventional speed.

methods for restoring ideal contour include the use of block-out resin, resin composite or utility wax.

During the next visit, local anaesthesia was administered and the initial caries was removed (Figure 4a). Shade selection was performed prior to the restorative procedure and confirmed during the procedure (Figure 4b). It is important to perform a shade analysis before the restorative treatment to prevent an improper colour matching that may result from dehydration and elevated values (Terry, 2005; Fahl, Denehy, Jackson, 1995).

The adhesive preparation was completed according to the aforementioned design guidelines for the vital primary anterior incisor. It is important that the unsupported enamel walls of the class III be removed to allow the material an unrestricted path of flow.

After the preparations were completed, each tooth was

separated by applying Teflon tape (Figure 5a) or a small amount of glycerin to the adjacent teeth. This proximal adaptation technique allows for optimal integration of flowable resin composite in the interproximal region while preventing adhesion of the material to the adjacent tooth surfaces.

A 37.5% phosphoric acid semi-gel was applied to the enamel and dentine surfaces for 15 seconds (Figure 5b), rinsed for five seconds, and gently air dried. A single- component adhesive was applied with an applicator to the enamel surface, allowed to dwell for 10 seconds (Figure 5c), air dried for five seconds, and light cured for10 seconds using an LED curing light (Figure 5d).

The clear silicone matrix was placed over the maxillary arch, and a highly filled flowable resin composite (G-aenial Universal Flo, GC) was injected through a small opening above each tooth. An opacious A1 shaded flowable resin

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Conclusion

Figure 12: The completed maxillary primary incisors.

composite (G-aenial Universal Flo, GC America) was initially injected followed by a B1 shaded flowable resin composite (Figure 6a). The resin composite was cured through the clear silicone matrix on the incisal, facial and lingual aspect for 40 seconds (Figures 6b and 6c).

After the incisal composite sprue was removed, the excess polymerised resin composite was removed with a scalpel for each restoration (Figures 7-8c). This restorative procedure was completed for each tooth prior to initiation of the next tooth (Figures 9a-10b).

As described in part one of this series, an optimally finished restoration should provide a smooth surface that will prevent plaque accumulation and resist staining. In addition, the presence of microfine particles, composed of mineral filler and strongly bound to the organic matrix, has been proven to produce the appearance of an aesthetically polished and smooth surface (Joniot et al, 2000).

Furthermore, finishing and polishing directly affect the aesthetic qualities of colour and gloss of the composite restoration. Thus, finishing and polishing techniques for composite primary crowns require a simplified, methodical and efficient protocol to achieve a pleasing outcome and may provide the benefit of increased longevity of the restoration while promoting improved gingival health.

The same simplified finishing and polishing protocol as described in part one of this series was utilised (Figures 11a-11c).

Aesthetic restoration of primary teeth in children has been an ongoing challenge for the paediatric and general dentist, and the most effective aesthetic materials and techniques for restoring deciduous teeth are still in question.

With the advancement of dental materials and techniques in conservative dentistry, a multitude of aesthetic treatment modalities have been introduced for the management of dental caries and trauma in the primary dentition.

The TIPCC is a technique that can be used to restore caries and fractured anterior and posterior primary teeth to an ideal anatomical form. The described technique is simple and can be used to predictably replicate anatomical morphology, re-establish function and restore natural aesthetics in children (Figure 12).

Although not a panacea to all paediatric restorative challenges, this technique offers an alternative restorative solution for various clinical situations and is provided to complement (not replace) our existing clinical repertoire.

However, there is need for long-term clinical studies to further assess the success and potential clinical benefits of this technique with these alternative biomaterials.

Although the philosophy for the modern restorative dentist has remained the same, the mindset of the clinician must be transformed to continue to explore and develop ideas, techniques and protocol.

The materials that clinicians are able to utilise in restorations limit the knowledge and desire to create.

Continuing technological breakthroughs allow the clinician to not only comprehend the ‘building blocks’ of the ideal restoration, but also to implement and maximise new materials in attaining more predictable and aesthetic results. This knowledge must be integrated with the proper technique for each clinical situation and requires the clinical experience and judgment of the operator.

While the past may have given us great minds with great discoveries, continuing to strive for excellence will produce an even greater number of advances for future generations to write about.

References The list of references that accompany this available on request.

article are

Published with permission by Private Dentistry December 2014

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Do surgical prophylactic antibiotics reduce postoperative infection and early dental implant failure?

Johan Hartshorne1 A critical appraisal of meta-analysis: Chrcanovic BR, Albrektsson T, Wennerberg A. (2014) Prophylactic antibiotic regimen and dental implant failure: a meta-analysis. Journal of Oral Rehabilitation. Published online 8 July 2014, doi: 10.10.1111/joor.12211

Summary Systematic review conclusion: Prophylactic use of antibiotics significantly decreases the risk of implant failure by 45%. The number needed to treat to prevent one patient having an implant failure was 50 (95% CI 33-100), based on an implant failure rate of 6.32% in patients not receiving antibiotics. Prophylactic antibiotics had no apparent significant effect on the occurrence of postoperative infections in healthy patients receiving implants.

Critical appraisal conclusion: Overall the quality of the evidence was weak and contributed no new knowledge. The results of the review however, supports current scientific evidence that in general, prophylactic antibiotics are beneficial for reducing failure of dental implants placed in ordinary conditions.

Implications for clinical practice: 2 g of Amoxicillin given orally in a single dose, one hour pre-operatively before implant placement, in general, is beneficial for reducing failure of dental implants placed in ordinary conditions. The purpose of this regimen is to attain elevated levels of antibiotic in serum during, and for some hours after the surgical procedure. Good surgical technique performed together with good asepsis and sterile surgical procedures remain the cornerstone for minimizing infection and successful outcome of implant surgery.

Clinical question Do prophylactic antibiotic regimens have any positive effect on implant failure rates and post-operative infection when performing dental implant treatment in healthy individuals compared to those not receiving prophylactic antibiotic treatment?

Review methods 1

Johan Hartshorne B.Sc., B.Ch.D., M.Ch.D, M.P.A. Ph.D. (Stell), FFPH.RCP (UK), Visiting Professor, Department of Periodontics and Oral Medicine, University of Pretoria, Pretoria, South Africa.

E-mail: jhartshorne@kanonberg.co.za

Search strategy and study selection Three independent investigators searched the following electronic databases: [MEDLINE-Pubmed, Web of Science, and the Cochrane Oral Health Group Trials Register in March 2014 to identify articles on the topic in the clinical question. They also conducted a manual search of most dental implant-related journals. Reference lists of identified studies and reviews were also screened for studies. Online clinical trial databases were also checked for information about clinical trials in progress. They used no time or language restrictions. Disagreements on inclusion of a study were resolved by discussion between the authors. The investigators recorded all studies that were rejected as well as the reason for exclusion. This systematic review methodology and subsequent meta-analysis followed the guidelines of PRISMA statement.1

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Eligibility and exclusion criteria The reviewers searched for randomised or non-randomised clinical trials in any group of patients receiving versus not receiving antibiotic prophylaxis regimen for the placement of implants in human subjects and comparing implant failure/survival rates. Subjects receiving grafts were also eligible for inclusion in the study. Case reports, technical reports, animal studies and review papers were excluded.

Outcome measures and data extraction All patients receiving antibiotics were considered for quantitative analysis in the group ‘use of antibiotics’.

Variation of antibiotic regiment by type of antibiotic, dosage, and time of administration was not taken into consideration in the data analysis. Implant failure and post-operative infection were the outcomes that were measured. They contacted the authors of the primary studies to gain information on missing data.

Data analysis Meta-analysis was done on studies that presented with similar comparisons reporting the same outcomes. Data from the selected studies were combined to estimate the treatment effect size. The estimate of relative effect was expressed by risk ratio (RR) with 95% confidence intervals. Heterogeneity of effect across the studies was formally assessed with the Cochran Q test and characterized with the I2 statistic to describe the proportion of total variation in the estimated effect sizes due to heterogeneity among studies. Random effects models were utilized throughout to estimate the effect size of implant failure rate and the fixed-effects model was used to assess post-operative infection outcomes of the pooled data. Risk of bias of the included RCT’s was assessed according the Cochrane Collaboration risk of bias assessment tool.2 Potential publication bias for the studies was assessed using the funnel plot approach. A sensitivity analysis was also conducted by excluding the studies with high risk of bias.

Main results The search process yielded 14 studies eligible for qualitative analysis, (8 RCTs, four controlled clinical trials (CCT’s), and two retrospective studies. Seven studies were judged a high risk of bias, one study at moderate risk, and six studies were considered low risk of bias. A statistically significant heterogeneity was found when assessing implant failure (p= 0.004; I2 = 58%) but not when assessing post-operative infection (p= 0.690; I2 = 0%).

A total of 8603 implants were placed in patients receiving antibiotics with 304 failures (failure rate of 3.53%) and 6269 implants were placed in patients not receiving antibiotics with 396 failures (failure rate of 6.32%). Only 8 articles provided information on post-operative infection. Twenty-five (25) occurrences of post-operative infection were observed in 1000 patients receiving antibiotics (2.5%) and 29 episodes of postoperative infection in 770 patients not receiving antibiotics (3.8%).

The pooled data showed that use of antibiotics significantly affected the implant failure rates. A RR of 0.55 (95% CI 0.41 – 0.75) (p = 0.0002) for prophylactic use of antibiotics implies that implant failures in patients receiving prophylactic antibiotic treatment were 0.55 times likely to happen than implant failures in patients not receiving prophylactic antibiotic treatment.

Excluding the studies with high risk of bias presented similar estimate of the overall treatment effect.

The meta-analysis showed that there were no apparent significant effects of prophylactic antibiotics on the occurrence of post-operative infections in health patients receiving implants (RR of 0.84, 95% CI 0.49 – 1.44; p = 0.52)

Conclusion The authors concluded that the evidence suggests that a prophylactic antibiotic regimen significantly reduces failures of dental implants placed in ordinary conditions. They also concluded that there were no apparent significant effects of prophylactic antibiotics on the occurrence of post-operative infections in health patients receiving implants.

The authors received financial support and declared no potential conflict of interest with respect to the authorship and/or publication of this review.

Commentary Background and importance Fear of surgical site infection and the financial and legal repercussions of failure is generally the key motivation for the use of prophylactic antibiotics.3 Preventing post-operative infection in implant related surgical sites are of great importance to both patient and clinician. The routine use of prophylactic antibiotics to prevent infection in implant dentistry is a controversial issue with conflicting evidence in the literature. Some studies have shown that antibiotic prophylaxis used prior to surgical placement of an implant can reduce the occurrence of post-operative infection, and increases the success rates of osseointegration.4, 5 In comparison, other studies found no such effect.6,7 Making an incision and placing a dental implant causes

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a break in the tissue barrier, allowing invasion and contamination by microorganisms that can potentially lead to infection of the wound and risk of implant failure. Opening of the mucosa and hard tissues in the oral cavity is classified as a clean-contaminated wound and has a confirmed infection rate of 5-15%.8 Factors that might be of great importance towards contributing to the risk of post-operative infection and early implant failures include the patients medical status, impaired healing ability, smoking, inadequate asepsis and sterile technique, poor surgical technique, degree of surgical trauma, and bacterial contamination during implant insertion.9,10 Surgical trauma together with anatomical conditions are believed to be the most important etiological factor for early implant losses.9 The question of using prophylactic antibiotics to prevent postoperative infection is an important issue and a need exists to answer this question in order to improve the successful outcome of dental implants, whilst minimising biological complications, harms and adverse effects.

Are the results valid?

The studies included in this review had several basic limitations and weaknesses that affected the quality of the evidence presented. Firstly, the reviewers did not provide a precise statement of what range of patients and exposures they decided to include in the study. The review pooled results from a wide range of antibiotic regimens, for all types of patients (biologic and individual variation) and a variety of procedure and skill subsets to generate a single estimate of the effect of antibiotics on implant failure. From a biological perspective one would not expect the same treatment effect across the range of patients due to the wide range of target population risk variation (i.e. younger vs. older; smoking vs. non-smoking; healthy vs. sick) and variation in target bacteria present in individuals. Pooling of results across a wide range of type of antibiotics, dosages, timing and duration is also a concern.

Therefore, it is reasonable to conclude that treatment effect is not likely to be similar across the range patients and exposures.

Based on this construct, the clinical question (or hypothesis in this case) may be too broad, to provide a valid estimate because there are many factors likely to lead to variation in treatment effect such as biologic and individual variation, differences in the intervention and different surgical and procedural skills.

Secondly, the investigators did not state whether their search included recently published abstracts presented at scientific meetings and databases held by pharmaceutical companies in their search strategy. Systematic reviews based on a number of small studies with limited total sample sizes are particularly

susceptible to publication bias. The asymmetry observed by the funnel plots is indicative of potential publication bias.

Thirdly, eligibility of studies was not restricted to RCT’s. Of the 14 trials included 8 were RCT’s, 4 CCT’s and 2 were retrospective studies. The less rigorous CCT and retrospective studies included in this review may tend to overestimate the effect of therapeutic and preventive interventions.11 Fourthly, two of the review authors decided whether potentially eligible trials met eligibility criteria, with disagreement resolved by consensus by third party adjudication. The reviewers reported no measures of agreement for either eligibility or quality rating decisions.

Overall, the methods of the systematic review and the methodological quality of the trials included in the systematic review were weak, thus resulting in poor quality of evidence.

What were the key findings?

Generally there was marked variability and inconsistencies between the studies included in the meta-analysis for all outcomes measured. This is likely due to differences in the sample population characteristics, interventions used, and outcome measurement.

For the outcome implant failure risk ratio (RR) point estimates were similar and confidence intervals overlapping supporting the reviewers decision to pool the results in a single estimate of effect (RR) = 0.55 95% CI [0.41, 0.75] p= 0.0002.

However, the test for heterogeneity across studies was statistically significant (p= 0.004) and I2 = 58%, thus representing substantial heterogeneity that raises serious concern about a single pooled estimate of effect. When studies judged as having a high risk of bias were excluded from the meta-analysis the trend still favoured use of antibiotics (P=0.003 statistically significant) RR = 0.37 95% CI [0.19, 0.72]; p =0.003. The test for heterogeneity in this subgroup of results was statistically non-significant (p = 0.38) and I2 = 6%, thus representing minimal variability and therefore increasing our confidence in the overall estimate of the effect of favouring antibiotic use. However, using post hoc subgroup analysis also raises concerns in using these results.

For the outcome post-operative infection the point estimates for RR across studies showed no trend for either favouring use or non-use of antibiotics. Test for heterogeneity showed minimal variability (p= 0.66; I2 = 0%), and therefore increasing our confidence in the overall estimate of the effect of antibiotic use on post-operative infection. The estimate of the overall effect of antibiotic use or non-use on the outcome post-operative infection was statistically non-significant and clinically inconclusive RR = 0.84 95% CI [0.49, 1.44]; p= 0.52.

Irrespective of the limitations and weaknesses of review

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we can reasonably assume that in 95% of cases when an antibiotic is used the true effect of the RR = 0.55 95% CI [0.41, 0.75] for the outcome implant failure, will lie between the lower and upper level of the confidence interval as indicated.

The results of this review are in accordance with that reported in other meta-analysis on this question.12, 13 How are the results of this review applicability in clinical practice?

Post-operative complications and early implant failures are important patient outcomes because of health, inconvenience and cost implications thereof. As a general rule, antibiotic prophylaxis is always indicated when there is an important risk of infection, either because of the characteristics of the surgical procedure (i.e. type and duration of surgery), because of the patient’s local or systemic infection risk (i.e. diabetes, immunodeficiency’s, inflammatory arthropathies), or for patients with post-bacteraemia focal infection risk factors (i.e. infectious endocarditis, infection of joint prostheses).

Do the benefits outweigh the potential harm and costs?

Scientific evidence suggests, specifically that 2g of Amoxicillin given orally in a single dose, one hour preoperatively before implant placement, in general, is beneficial for reducing failure of dental implants placed in ordinary conditions.12 The Cochrane Oral Health Group authors also reported that no significant adverse events were found with this prophylaxis regimen.

The benefit of antibiotic prophylaxis is the prevention of infectious and biological complications subsequent to implant surgical procedures; however, their indiscriminate use may result in emergence of resistant pathogens, increased cost, adverse reactions, and a false sense of security.

The most common adverse effects of antibiotics are direct toxicity, hypersensitivity, allergic- or anaphylactic reactions.

The ill-advised use of antibiotics has proven to be expensive as well as directly responsible for development of resistant microorganisms. This risk of adverse effects is minimal if prophylactic antibiotics are initiated just prior to start of surgery and if use is restricted to less than 24 hours postoperatively.14 this finding is endorsed by the study of the Cochrane Oral Health Group.12 The clinician’s criterion for using antibiotic prophylaxis or not, must be based on the benefit and the cost of risk. The economic cost of short-term surgical antibiotic prophylaxis is acceptable when compared with the total cost of managing biological complications and implant re-treatment due to infection.

The aim of antibiotic prophylaxis in dental implant surgery

is to prevent possible peri-operative or post-operative infection in the surgical wound as this could compromise the osseointegration process thus resulting in biological complication and early implant failure. This is primarily achieved by attaining elevated levels of antibiotic in the serum during the surgical process, and for some hours after the implant is placed and surgical wound is closed.

Risk of contamination of the surgical site increases with exposure time (duration) and complexity of the procedure (i.e. grafts), and is minimized with proper sterile surgical technique and when the patient is in a healthy condition. 9, 10 It is widely accepted that the benefits of providing surgical antibiotic prophylaxis is worth the potential risks thereof. Meticulous surgery and careful preoperative and post-operative care is still the mainstay in minimizing wound infection and risk of post-operative complications.

Clinical Resolution The clinical question addressed in this review is of great importance to the patient and the clinician. Overall the quality of the evidence was weak and contributed no new knowledge. The results however supports the scientific evidence that, “in general antibiotics are beneficial for reducing failure of dental implants placed in ordinary conditions”. Implant related surgery will always have a risk of infection, and as a general rule, prophylaxis is always indicated when there is an important risk of infection, either because of the characteristics of the operation or because of the patient’s local or systemic health situation. It is still unknown whether post-operative antibiotics are beneficial, and which antibiotic works best.12 Double blind randomized control trials remain elusive in this regard due to the ethical implications of such studies. Regardless of use or non-use of antibiotic prophylaxis, asepsis and good surgical technique still remain cornerstones in the prevention of wound infection and early implant failure.

Disclosure Dr Johan Hartshorne is trained in clinical epidemiology, biostatistics, research methodology and critical appraisal of research evidence. This critical appraisal is not intended to, and do not, express, imply or summarize standards of care, but rather provide a concise reference point for dentists to aid in understanding and applying research evidence from referenced early view or pre-published articles in top ranking scientific publications and to facilitate clinically sound decisions as guided by their clinical judgement and by patient needs.

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2. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. B Med J 2011; 343: d5928.

3. Kreutzer K, Storck K, Weiutz J. Current evidence regarding prophylactic antibiotics in head and neck and maxillofacial surgery.

BioMed Res Int 2014; Article ID 879437. Accessed online: http://dx.org/10.1155/2014/879437 4. Dent CD, Olson JW, Farish SE, Bellome J, Casino AJ, Morris HF, et al. The influence of pre-operative antibiotics on success of endosseous implants up to and including stage II surgery: a study of 2641 implants. J Oral Maxillofac Surg 1997; 55: 19-24.

5. Laskin DM, Dent CD, Morris HF, Ochi S, Olson JW. The influence of pre-operative antibiotics on success of endosseous implants at 36 months. Ann Periodontol 2000; 5: 166-174.

6. Gynther GW, Kondell PA, Moberg LE, Heimdahl A. Dental implant installation without antibiotic prophylaxis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998; 85: 509-511.

7. Mazzocchi A, Passi L, Moretti R. Retrospective analysis of 736 implants inserted without antibiotic therapy. J Oral Maxillofac Surg 2007, 65(11): 2321-2323.

8. Altemeier WA, Burke JP, Pruitt BA, Sandusky WR. Manual of control of infection in surgical patients. JB Lippincott Co., Philadelphia 1976.

9. Esposito M, Hirsch J-M, Lekholm U, Thomsen P. Biological factors contributing to failure of osseointegrated oral implants. (I) Success criteria and epidemiology. Eur J Oral Sci 1998; 106: 527-551.

10. Esposito M, Hirsch J-M, Lekholm U, Thomsen P. Biological factors contributing to failure of osseointegrated oral implants. (II) Etiopathogenesis. Eur J Oral Sci 1998; 106: 721-764 11. Kunz R, Oxman AD. The unpredictability paradox: review of empirical comparisons of randomised and non-randomised clinical trials. BMJ. 1998; 317(7167): 1185-1190.

12. Esposito, M, Grusovin MG, Worthington HV Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Database of Syst Rev 2013, Issue7.

Art.No.: CD004152. DOI 10.1002/ 14651858.CD004152. pub4 13. Ata-Ali J, Ata-Ali F, Ata-Ali F. Do antibiotics decrease implant failure and postoperative infections.? A systematic review and metaanalysis. Int J Oral Maxillofac Surg 2014; 43: 68-74.

14. Schrag SJ, Peña C, Fernández J, Sánchez J, Gómez V, Pérez E et al. Effect of short-course, high-dose amoxicillin therapy on resistant pneumococcal carriage: a randomized trial. J Amer Med Assoc 2001; 286: 49-56.

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Minimally invasive treatment on a stable basis Gyula Marada1

In the case of restorations in the sensitive anterior region, in addition to direct and indirect ceramic solutions, minimally invasive options for realising direct and highly durable restorations using composites have also been long established. However, one particular challenge which remains is the treatment of dental traumas and tooth gaps.

In such cases a stable and reliable basis for the artificial tooth is required. This article describes the use of the material GrandTEC (VOCO) as an ideal medium for creating direct and natural-looking restorations using composites. GrandTEC is a glass fibre strand consisting of multiple, densely packed, parallel running glass fibres that are impregnated with a light-curing resin. This results in the glass fibres binding closely with the flowable composite during polymerisation, whereby the latter is used to embed and fix the strand on the natural dental hard tissue. The glass fibre strand embedded in the flowable composite forms the basis for the restoration with packable composites using the modelling and layering techniques. Thanks to this high-strength glass fibre/composite combination, the masticatory forces which occur are distributed evenly

1

Dr. med. dent. Gyula Marada, University of PĂŠcs (Hungary)

Figure 1: Fracture on tooth 11 in the cervical region from mesial to distal.

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Figure 2: A wax wire in the maxilla impression is used to produce a template made from bite registration silicone in order to position the glass fibre strand between tooth 12 and tooth 21.

Figure 3: The working field following removal of the fracture fragment and completion of endodontic treatment.

Figure 4: Customisation of the template made from bite registration silicone.

Figure 5: Teeth 12 and 21 are etched palatally using 35% phosphoric acid.

over the restoration and the abutment teeth. This, in turn, increases the flexural strength and fracture resistance of the restoration which, in terms of both its appearance and functionality, cannot be distinguished from a natural tooth.

conditions for a subsequent surgical and prosthetic restoration with an implant. Following the root filling, the next step involved temporary treatment of the gap with a composite build-up using a minimally invasive approach. For this, a stable basis was first created using GrandTEC. Only minimal preparation was required for this. A wax wire inserted in the plaster cast helped to determine the length and design of a template made from bite registration silicone (Registrado Clear, VOCO) for the arch-shaped positioning of the glass fibre strand in the gap between tooth 12 and tooth 21. Following isolation of the working field using a rubber dam, as well as cleaning and drying of the tooth surfaces, teeth 12 and 21 were etched palatally using 35%

Clinical case An 11-year-old female patient presented at our clinic with an anterior tooth trauma. Tooth 11 had a complex crown fracture (Figure 1). Following a physical and radiographical examination, we decided to remove the broken clinical crown. As the root canal was not infected, we were able to immediately place a permanent root-canal filling. Another argument for preserving the root was to ensure favourable

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Figure 6: After conditioning the tooth surfaces, adhesive (Futurabond M, VOCO) is rubbed in and light cured.

Figure 7: The glass fibre strand located on the silicone template (GrandTEC, VOCO) is positioned between tooth 12 and tooth 21 and placed on the palatal surfaces coated with flowable composite.

Figure 8: The tooth build-up modelled on the basis of a glass fibre strand and flowable composite (GrandioSO Heavy Flow, VOCO) using the highly aesthetic composite (Amaris, VOCO) closes the gap between tooth 12 and 21.

Figure 9: The vestibular view shows the harmonious proportions vis-Ă -vis tooth 21 and the natural-looking design of the incisal edge.

a

b

Figure 10a and 10b: The finished restoration has a natural-looking appearance and cannot be distinguished from the original tooth.

This is due in part to the modelled mamelon structures and white spots.

phosphoric acid (Vococid, VOCO) with an exposure time of 20 seconds. The teeth were rinsed thoroughly with water, all excess material was suctioned away and then dried briefly.

A light-curing one-component adhesive (Futurabond M, VOCO) was then applied to and rubbed into the conditioned tooth surfaces. After drying briefly, the adhesive

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was light cured for 20 seconds. A thin layer of a flowable composite (GrandioSO Heavy Flow, VOCO), shade A2, was subsequently applied to the areas covered with adhesive in order to fix the glass fibre strand in place. This was cut to the required length using fine-tip scissors and then removed from the protective film. Resting facially on the silicone template, the glass fibre strand was then positioned from the palatal direction between tooth 12 and tooth 21 and placed on the areas coated with flowable composite.

After light curing the bond sites for 20 seconds, the glass fibre strand was completely embedded in shade A2 flowable composite and light cured uniformly for 20 seconds. The basis for incrementally building up the tooth with the composite was then ready.

We used the highly aesthetic restorative material Amaris (VOCO) to reconstruct the traumatically damaged anterior tooth. With the two-layer technique, the restoration can be created using just one opaque and one translucent shade.

For this, the core is built up using an opaque base shade to which a layer of a translucent enamel shade is applied. The final shade of the tooth is thus developed during layering, accents and especially fine structures can be achieved using the individual shades. In this case, after shade matching using the Amaris shade guide, the dentine core was first modelled with the help of the silicone index using opaque material in shade O2. When modelling the opaque

material in the incisal third, care had to be taken to gradually decrease its thickness towards the incisal edge in order to be able to subsequently apply a correspondingly thicker layer of translucent material. After light curing the opaque material for 40 seconds, thin layers of the flowable individual shade, Amaris Flow High Opaque (HO), were applied in a finger-shaped pattern in corono-apical direction to recreate the pronounced mamelon structures seen in the teeth of most young people. In addition, the restoration was accentuated with "white spots" to help recreate the original character of the tooth. 40 seconds of light curing again followed application of the individual shade. Finally, the overall restoration was lightened slightly with the layer of translucent material Light (TL) which was applied last. This layer had to be applied from incisial to cervical direction, decreasing in thickness from 1.0 mm to 0.5 mm, and was subsequently light cured for 10 seconds. A one-step diamond polisher (Dimanto, VOCO) was used for finishing and polishing, working with a small tip on the vestibular face and a small cup on the palatal face. The finished restoration is a natural-looking result which cannot be distinguished from the original tooth and blends in exceptionally well with the dental hard tissue of this young patient. In conclusion: Good stability, functionality and morphological features have all been combined in this restoration.

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Therapeutic aesthetics Linda Greenwall1

With the success of tooth whitening treatments, several health benefits have emerged that can improve patients’ oral health (Li and Greenwall, 2013).

Utilising these resulting health benefits and developing them further can help the clinician create a programme that improves patients’ dental health throughout the different periods of their lives. The purpose of this article is to discuss this further and elaborate on the benefits of introducing a programme of therapeutic aesthetics as part of an oral health maintenance programme and helping the patient to achieve sustainable health.

What is therapeutic aesthetics?

Therapeutic aesthetics is the process of sustaining a patient’s oral health while improving and maintaining the aesthetic health of their teeth. The bleaching tray can be transformed into a therapeutic tray to deliver chemicals that help the patient achieve a sustained health gain throughout their lives.

The trays are used for different purposes throughout a patient’s life. This may be related to a high caries susceptibility at a young age or an elderly patient who is experiencing dry mouth from multiple medications.

The trays are worn to undertake a therapeutic use, whether that is to reduce caries, reduce the high-risk classification of a caries exposure, reduce root caries, or assist with protecting the mouth during and post-radiation treatment.

Tooth whitening materials

1

Linda Greenwall BDS MGDS MSc MRD RCS FFGDP Private practice in Hampstead, London, UK

The two main materials used in tooth whitening are both derived from hydrogen peroxide. Hydrogen peroxide is used as a day product. When hydrogen peroxide is placed into a tray, it mixes with saliva and releases water and oxygen as effervescent bubbles.

The oxygen penetrates into the enamel and dentine, and reaches the pulp within five to 15 minutes. Hydrogen peroxide flows multi-directionally, expanding in three dimensions and also tracking into the gingival crevice and pockets.

The liberation of oxygen into the gingival crevice changes the bacterial environment to remove the gram-negative bacteria, cleanse the pocket and stimulate healing to take place. All the oxygen is released within one hour, so there are no further benefits of using the material for longer than an hour.

Carbamide peroxide, however, is a slower-release material. It contains carbopol, which allows oxygen to be released slowly over a period of 8 to 10 hours.

Carbamide peroxide breaks down into urea and ammonia. Urea elevates the pH in the mouth, stimulating healing. It is also thought to reduce caries by elevating the pH of the mouth to a level above that at which the caries process can comfortably occur, in addition to debriding the teeth and improving gingival health. It heals the soft tissues and gingival areas.

Ammonia and carbon dioxide are also released from carbamide peroxide, though these are considered to be by-products.

Most of the at-home bleaching materials also contain fluoride or potassium nitrate to act as soothers. These help to reduce the likelihood of sensitivity and reduce areas

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Table 1: White spot lesions The first line of defence when treating white spot lesions due to decalcification is improvement in oral hygiene, reduction of sugary food and the use of the therapuetic tray with fluoride gel inside to reduce the appearanace of the white spots that are due to demineralisation. Some spots are easier to treat than others.

Aetiological classification

Appearance classification

Hereditary

Size (small/medium/large)

Trauma

Depth (deep/shallow/flecks)

Fluorosis

Appearance (bright/faint/opaque white spot)

Decay hypomineralisation Molar incisor hypoplasia (MIH) Congenital premature birth

susceptible to caries. Within five minutes of the application of the material in the tray, salivary pH is elevated for a period of two hours. The pH in the tray also remains raised for two hours (Haywood, 2007).

• Teeth whitening, brightening and lightening • Reduction in caries formation (Lee et al, 2005) • Reduction in root caries formation • Teeth feel cleaner as a result of the improved oral hygiene.

Benefits of tooth whitening

Patient effects • Improves patients’ self esteem and self-worth • Patients smile more

There are a number of benefits associated with tooth whitening: Teeth Whitens and lightens the teeth, reduces stain build-up on teeth, preserving tooth structure.

Gingivae • Reduces gingival inflammation and swelling • Reduces plaque formation • Reduces extrinsic stain build-up • Reduces plaque adherence onto teeth • Reduces gingival bleeding • Improvement in gingival index scores.

Other benefits • Tooth whitening materials have antibacterial properties which help to heal the mouth (Lazarchik and Haywood, 2010).

• A reduction in oral malodour (DeVizio, 2008) • Carbamide peroxide was originally used as an oral antiseptic • Patients are walking adverts for the practice.

History

Soft tissues • Improvement in soft tissue, healing of soft tissue lacerations • Improvement in wound healing in the mouth.

Oral health • Improvement in oral hygiene as the patient looks in the mirror to see the whiter teeth

Over the last century, hydrogen peroxide has been used as a treatment for reducing gingival inflammation. Initially, patients were instructed to use hydrogen peroxide mouthwash on a toothbrush to help reduce gingival swelling and irritation. In 1968, orthodontist Bill Klausmier advised his patients to use 3% hydrogen peroxide mouthwash in their retainers after completing orthodontic treatment. At the sixmonth evaluation, he noted that not only was the gingival inflammation reduced, but the teeth were also significantly

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whiter. He developed and used this technique over the next 40 years and wrote a retrospective report about it. Klausmier wrote that in the 40 years of using the orthodontic retainer to apply the mouthwash to reduce the inflammation and also to whiten the teeth, nobody lost a tooth, needed a root canal or damaged a tooth as a result of the technique. Since then, whitening gels have changed significantly and have become much thicker and more viscous, thus adhering to the trays more in order to deliver the materials more effectively.

Delivering materials Using the tray as a delivery vehicle, various chemicals can be placed in order to deliver sustained health benefits to the teeth over a chosen period of time, according to the effectiveness of the material as it is released.

The placement of the tray helps to keep the material in situ even if it comes into contact with saliva.

The tray can be made of a flexible material, such as Evacryl, or a rigid material, such as that used for orthodontic Essix retainers.

The various materials are applied into the trays. The concept is that the tray remains in place overnight while the materials are soaking into the teeth or gingivae.

Tray design for therapeutic use When it comes to therapeutic uses, tray design can be varied (and multipurpose), depending on the material being used. That said, a scalloped tray is often a useful design, as this avoids impinging on the gingivae. The tray margins are

cut just next to the gingival crevices. An orthodontic aligner can be used as a therapeutic tray as well as a retainer.

Suitable tray types There are a variety of tray designs that can be used and modified for therapeutic use: 1. Aligners 2. Retainers, such as an Essix retainer 3. Bleaching trays 4. Specially designed trays similar to a bleaching tray, using a thicker strength material for extended wear time.

Using the therapeutic trays throughout the patient’s life depends on health needs. There are times in a patient’s life when they may be subjected to additional health challenges.

This can put them at risk for tooth decay, root decay, gingival inflammation and dry mouth.

Who can benefit?

1.

2.

3.

4.

5.

6.

7.

Those with special needs Those at high risk of tooth decay Dry mouth suffers Elderly patients (Kelleher et al, 2011) Chemotherapy patients Patients having radiation therapy Patients suffering from gingival and periodontal conditions 8. Patients suffering from white spots for aesthetics 9. Patients who are immuno-compromised 10. Patients with eating disorders or acid reflux.

Figure 1: Concept of therapeutic aesthetics in aesthetic and restorative dentistry

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Figure 2: Carbamide peroxide bleaching gel is placed into the middle of the tray.

Figure 4: Cross-section of a tooth, demonstrating the therapeutic tray in place over the tooth.

Elderly patients Many elderly patients take multiple medications, which can reduce saliva flow and cause them to suffer from xerostomia (dry mouth). Some patients suck mints to relive this, which exacerbates the condition.

The lack of saliva can make patients more susceptible to root decay and increase decay around the margins or crowns. A study by Van Haywood (2007) has shown that using a nightly bleaching tray with carbamide peroxide can reduce that susceptibility to root caries.

The whitening material kills caries bacteria and reduces plaque adherence on the teeth. Furthermore, elderly patients who have difficulty holding a toothbrush may find it easier to apply the carbamide peroxide gel and place this in the mouth overnight.

Special needs patients In a study undertaken by Lazarchik and Haywood (2010), the authors found 10% carbamide peroxide delivered in a

Figure 3: Early root caries in a patient who also wants to whiten his teeth. See the early root decay on the lower left first and second premolars. The patient’s brushing techniques were revised and after completing the whitening treatment, the patient continued to use the tray twice a week placing amorphous calcium phosphate inside to reduce the demineralisation on the root surfaces.

custom-fitted tray to be an effective treatment for caries in patients with compromised oral hygiene. Plaque suppression and caries control resulted from a carbamide peroxideinduced increase in salivary and plaque pH caused by its urea component, and from possible antimicrobial action via physical debridement and the direct chemical effect of hydrogen peroxide.

Patients at high risk of decay There are many people in this category that can be helped by the use of therapeutic trays.

There may be patients who have poor oral hygiene and cannot maintain a clean mouth. Patients with a high sugar diet, patients that are immunologically compromised and have a poor diet and cannot maintain their oral hygiene.

Some patients who have eating disorders or who have reflux and acid regurgitation problems can also be helped by the use of a therapeutic tray.

These patients can use carbamide peroxide gel to help reduce the plaque and also may place amorphous calcium phosphate into the tray to help elevate the pH further while restoring the oral environment to a neutral pH. A concentration of 10% carbamide peroxide kills lactobacillus, one of the bacteria that causes tooth decay.

Chlorhexidine kills streptococcus mutans bacteria, which is also responsible for tooth decay.

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Figure 5: A patient with the upper bleaching tray in place. This treatment involved whitening followed by placement of chlorhexidine gel inside the tray after completing the crown lengthening surgery undertaken for the upper left first molar.

The bleaching tray was placed after surgery to help heal the palatal area.

Salivary changes inside the tray The research from Leonard et al (1994) has shown that when saliva comes into contact with carbamide peroxide, there is an elevation in pH, which raises to a value of about pH 8 due to the liberation of urea. The urea and ammonia are byproducts of the breakdown process of the carbamide peroxide. Hydrogen peroxide breaks down to water and oxygen.

The critical pH for demineralisation is 5.2-5.5 for enamel and 6.0-6.8 for dentine (Leonard et al, 1994b).

Summary The use of carbamide peroxide in a bleaching tray has additional benefits to help patients improve and maintain their oral health.

Dentists are advised to consider this therapeutic approach to improve aesthetics while improving health sustainability for many patients. Many patients can benefit from this approach.

References DeVizio W (2008) The efficacy of a new dentifrice with caries, plaque, gingivitis, calculus, tooth whitening, and oral malodor benefits. J Clin Dent 19(3): 79-80 Haywood VB (2007) Bleaching and Caries Control in Elderly Patients. Aesthetic Dentistry Today 1(4): 42-44 Kelleher MG, Djemal S, Al-Khayatt AS, Ray-Chaudhuri J, Briggs PF, Porter RW (2011) Bleaching and bonding for the

Figure 6: Close-up cross-section of the therapeutic tray for placement of various materials for different purposes.

older patient. Dent Update 38(5): 294-6, 298-300, 302-3 Lazarchik DA, Haywood VB (2010) Use of tray-applied 10 percent carbamide peroxide gels for improving oral health in patients with special-care needs. J Am Dent Assoc 141(6):639-46 Lee SS, Zhang W, Lee DH, Li Y (2005) Tooth whitening in children and adolescents: a literature review. Pediatr Dent 27(5): 362-8 Leonard RH, Austin SM, Haywood VB, Bentley CD (1994) Change in pH of plaque and 10% carbamide peroxide during nightguard vital bleaching. Quintessence Int 25: 819-823 Leonard RH, Bentley CD, Haywood VB (1994a) Salivary pH changes during 10% carbamide peroxide bleaching.

Quintessence Int 25: 547-550 Li Y, Greenwall LH (2013) Safety issues of tooth whitening using peroxide-based materials. Br Dent J 215(1): 29-34. doi:10.1038/sj.bdj.2013.629 Nathoo S, Mateo LR, Delgado E, Zhang YP, DeVizio W (2011) Extrinsic stain removal efficacy of a new dentifrice containing 0.3% triclosan, 2.0% PVM/MA copolymer, 0.243% NaF and specially-designed silica for sensitivity relief and whitening benefits as compared to a dentifrice containing 0.3% triclosan, 2% PVM/MA copolymer, 0.243% NaF and to a negative control dentifrice containing 0.243% NaF: a six week study. Am J Dent 24 Spec No A:28A-31A

Published with permission by Aesthetic Dentistry Today May 2014

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CBCT in endodontic treatment of fused second and third mandibular molars Andreas Krokidis1 and Riccardo Tonini2 Abstract The aim of this article is to report a rare anatomic case and the contribution of new technologies in best resolving it. Fusion is defined as the union of two separate tooth germs at any stage of tooth development.

Planning treatment for this condition can be difficult and requires all diagnostic means available. A 45-year-old female patient presenting with a fused second and third molar underwent endodontic treatment and direct restoration after CBCT imaging revealed a direct relationship between the two germs. The treatment was successful once the correct diagnosis had been made.

Introduction Fusion is defined as the union of two separate tooth germs at any stage of tooth development. Fused elements may be attached at the dentine or enamel. This process involves the epithelial and mesenchymal germ layers, and results in irregular tooth morphology.1 Depending on the stage of development in which the fusion occurs, pulp chambers and canals may be linked or separated.

The reason for this phenomenon is unknown, but genetic factors, physical forces, pressure, and trauma may be influencing factors.2 The prevalence of dental fusion is higher in primary dentition (0.5–2.5%) than in permanent dentition (0.1%); in both cases, the anterior region has the highest prevalence.3 The incidence is the same between males and females.

Cases of affected posterior teeth are rare in the literature. Most posterior teeth are fused with fourth molars (supernumerary). Fusion between premolars and molars or second and third molars has also been reported, but is less common. In some reported cases, teeth are bilaterally fused with supernumerary molars.4–9 In these cases, the number of teeth in the dental arch is also normal and differentiation from gemination is clinically difficult or impossible. A diagnostic consideration, but not a set rule, is that supernumerary teeth are often slightly aberrant and have a cone-shaped clinical appearance. Thus, fusion between a supernumerary and a normal tooth will generally involve differences in the two halves of the joined crown. However, in gemination cases, the two halves of the joined crown are commonly mirror images.9

1

Andreas Krokidis, DDS, MSc, Research Associate, National and Kapodistrian University, Athens, Greece.

2

Riccardo Tonini, DDS, MSc, Private Practice, Brescia, Italy.

Address for correspondence: Dr Andreas Krokidis andreaskrokidis@hotmail.com

Figure 1. Initial clinical situation. Observe the plaque in the lingual side in the fusion area and discoloration due to caries.

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Figure 2. Initial X-ray situation.

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This case report demonstrates the usefulness of a CBCT scan in addition to conventional intra-oral X-rays from different projections in diagnosing and designing appropriate treatment for this rare case.13,14

Case presentation

Figure 3. Reconstruction

Periodontic problems occur as a part of the pathology in these cases.5–8 A high prevalence of caries also occurs due to anatomically abnormal plaque retention. In the anterior region, an anti-aesthetic effect occurs owing to the abnormal anatomy. In contrast, crowding and occlusal dysfunction may occur in the posterior region, especially in cases with supernumerary teeth, which often leads to tooth extraction.5,10,11 Fused teeth are usually asymptomatic. The collaboration of practitioners with expertise in multiple areas of dentistry is important to create or achieve functional and aesthetic success in these cases. Several treatment methods have been described in the literature with respect to the different types and morphological variations of fused teeth, including endodontic, restorative, surgical, periodontal, and orthodontic treatment.3–6,10–12 In cases in which endodontic therapy is indicated, clinicians must be very careful during access because anatomy is not predetermined and canals may be displaced from their normal position, depending on the position of the two germs and whether the teeth involved are part of the normal dentition or supernumerary. For this reason, clinicians should examine the element meticulously, both clinically and radiographically.

Figure 4. Axial images where fusion is obvious.

A 45-year-old woman was referred by an oral surgeon who had proposed an extraction of the last mandibular molar because of pain and abnormal anatomy. The patient complained of pulsing pain in the right side of the oral cavity, which extended to the ear region and worsened at night.

After a comprehensive extra-oral and intra-oral examination, the pain was found to be localised to the region of teeth 47 and 48 (Fig. 1). Both cold and hot stimuli consistently caused pain in those teeth. An obvious anatomic abnormality noted during the clinical examination was confirmed with intra-oral X-rays using a parallel-cone technique and various projections. The X-ray (Fig. 2) also revealed a deep amalgam restoration extending into the pulp chamber, which had been infiltrated, and distal caries in the fused tooth. A deep carious lesion was also observed on tooth 46, but a simple filling was scheduled because the tooth responded normally to cold and hot stimuli.

In this case, the treatment plan was determined to be root-canal therapy for the pulpitis in the fused tooth and a direct restoration for the same tooth. In addition, dental hygiene sessions were scheduled for the patient because of generalised plaque and to avoid worsening of periodontal conditions in the area of the fused tooth. Direct restorations were also arranged with the general practitioner to avoid any other pulp implications in other teeth with marked infiltrated restorations.

Initially, the treatment plan was targeted at the root-canal therapy of the fused tooth, which was urgent. In order to clarify the anatomy of this element, a CBCT examination was also performed; it revealed two independent mesial roots

Figure 5. Access cavity. Non-conventional shape due to abnormal anatomy.

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Figure 6: Working length X-ray.

Figure 7: Finished case.

(lingual and buccal) and a single distal root. The fused root in the middle involved two independent canals ending in the same area (Figs. 3 & 4).

After anaesthetic with 1:100,000 lidocaine had been administered, the tooth was isolated with a rubber dam. Because of the abnormal anatomy, the use of a liquid photopolymerising dam was necessary to seal gaps completely and to avoid leakage of saliva into the treated tooth and sodium hypochlorite into the patient’s mouth. An extended access cavity using a 1.2mm cylindrical bur and a #2 Start-X ultrasonic tip was created to visualise all five orifices (Fig. 5).

Once the surface was clean and canals were visible, negotiation with hand files (K-files) and PathFiles was performed to ensure patency of the canals. First #10 and #08 K-files (if needed) were alternated along the canals with copious irrigation with sodium hypochlorite and using 17% EDTA gel until the #10 file was at the apex. Working length was measured with an apex locator. Afterwards #1–3 PathFiles were used until the #3 file reached working length in all five canals. Once patency had been confirmed, working length

was also confirmed radiographically (Fig. 6).

The next step was to shape the canals using reciprocating files with a single-file reciprocating technique.

Since the anatomy was slightly different, the shaping technique was changed. After the primary file (25.08, red code), apical gauging was performed with manual NiTi K-files to measure the apical restriction diameter. For the distal canal, the large file was also needed. Throughout the procedure, irrigation with preheated 5.25% sodium hypochlorite was performed with 30g irrigating needles and the irrigant was activated with IrriSafe files .15–17 Once the shaping had been completed, apical diameter was confirmed through apical gauging, and cones were fitted. Irrigation with preheated and activated 17% EDTA solution was used to remove inorganic debris from the canals.

Canals were then dried with paper cones and the roots were sealed with vertical condensation of hot gutta-percha with standardised gutta-percha cones and Pulp Canal Sealer. Backfilling was performed with warm liquid gutta-percha (Figs. 7 & 8). The treatment was completed with a direct composite restoration (Figs. 9 & 10). All treatment was performed under clinical microscope.

Figure 8: X-rays of the finished case.

Figure 9: After restoration.

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Figure 10: After restoration.

Figure 11: One-year recall X-ray.

The patient kept to her treatment plan and attended several recall appointments after the root-canal therapy. She also attended six-monthly oral hygiene appointments with the dental hygienist (Figs. 11–13).

chosen for this case was adapted to the need of the tooth. Since the anatomy was complex, the direct use of a large file in the distal root might have failed. Had different diameters been established during apical gauging, the shaping technique would have been changed and more files would have been introduced. For this reason the shaping technique was modified using more files for this particular root.

Discussion Treatment planning for rare conditions such as fused teeth is fundamental to the success of each case. For this reason, clinicians must consider every parameter before starting treatment. In this case, a tooth extraction would have been the likely outcome without a CBCT examination. Because the fused teeth complex did not involve any occlusal or periodontal problems, the extraction would have caused significant biological damage and held significant financial implications.

Once a treatment plan was in place, a CBCT scan was very helpful in determining the exact position of the canals and in designing the access cavity according to the exact anatomy, which was different from that of a normal single tooth. The single-file reciprocating technique

Figure 12: One-year recall.

Conclusion In conclusion, this case demonstrates the importance of treatment planning. In designing a treatment plan, all diagnostic methods should be considered. In this case, a CBCT examination resulted in a successful and predictable treatment.

Editorial note: A complete list of references is available from the publisher.

Reprinted from Roots - International Magazine of Endodontology 4/2013

Figure 13: Four-year recall.

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Treatment of postoperative sore throat after endotracheal intubation in third molar surgery Fadi Titinchi1, Jean A Morkel2 and Sanjay Ranchod3 Abstract Objectives: The aim of this study was to evaluate the efficacy of honey and lemon juice in tea versus Strepsils® versus no pain remedy in relieving postoperative sore throat (POST). Methods and materials: Sixty American Society of Anesthesiologists (ASA) physical status I, non-smoking patients scheduled to undergo removal of third molars under general anesthesia were enrolled after obtaining signed informed consent. Participants were randomly divided into three groups to receive no medication, honey and lemon in tea, or Strepsils® lozenges at the following intervals: at 30 minutes after surgery; before going to sleep on the first night; and the following morning. The incidence and severity of POST were evaluated using a four-point scale at three different intervals i.e. prior to administering medication and 30 minutes and 24 hours after surgery. Results: POST scores for the groups given honey and lemon in tea (P < 0.01) and Strepsils® (P < 0.001) were significantly lower after administration of the first dose. The severity of POST significantly decreased for 24 hours after surgery for all three groups (P < 0.05). Overall, Strepsils® were the most effective in relieving POST. Discussion: POST was reduced significantly with the administration of honey and lemon in tea and Strepsils® immediately after surgery. Likewise, a 24-hour follow-up of patients confirmed the effectiveness of honey and lemon in tea and Strepsils® lozenges in relieving POST. Conclusions: Postoperative use of honey and lemon in tea and Strepsils® lozenges reduces sore throat after third molar surgery, especially if administered within 30 minutes postoperatively. Clinical significance: Early postoperative administration of honey and lemon in tea or Strepsils® lozenges reduces postoperative sore throat after endotracheal intubation for third molar surgery.

Short title: Treatment of postoperative sore throat Keywords: Postoperative sore throat; Strepsils®; Honey; Third molar surgery.

Fadi Titinchi, BChD, Department of Maxillo-Facial and Oral Surgery, Faculty of Dentistry, University of the Western Cape, South Africa

1

2

Jean A Morkel, BChD, MBChB, MChD, FCMFOS(SA), Prof and Academic Head, Department of Maxillo-Facial and Oral Surgery, Faculty of Dentistry, University of the Western Cape, South Africa

Sanjay Ranchod, BChD, PDD, Department of Maxillo-Facial and Oral Surgery, Faculty of Dentistry, University of the Western Cape, South Africa 3

Corresponding author: Prof. JA Morkel Academic Head, Department of Maxillo-Facial and Oral Surgery Faculty of Dentistry, University of the Western Cape Private Bag X1, Tygerberg 7505, South Africa Tel: + 27 21 937 3087 Fax: +27 21 931 2287 E-mail: jamorkel@uwc.ac.za

Introduction Postoperative sore throat (POST) is a frequent complaint following endotracheal intubation with incidence rates varying from 14.4% to 61%.1-3 It ranks along nausea as the most common complaint after endotracheal intubation for general anaesthesia.4 Regardless of the incidence or duration, POST is rated as a patient’s 8th most undesirable outcome in the postoperative period,5 and is certainly an opportunity to improve patient outcomes.6 In order to improve patient satisfaction, avoiding POST is a major priority in patients undergoing endotracheal intubation.5 Drugs such as clonidine, betamethasone gel, benzydamine hydrochloride and chamomile extract spray have been used to reduce POST with varying degrees of success.7-10 Simple, safe, and inexpensive therapies to reduce or eliminate POST would be helpful and could improve patient satisfaction significantly.

Honey has been used as a medication throughout the ages and in more recent times has been ‘rediscovered’ by the medical profession for its medicinal properties. It has antimicrobial, antioxidant, anaesthetic and wound healing properties. Although the actual mechanism responsible for the healing power of honey is not well understood, it has proven to be effective in healing nearly all types of wounds including abrasions, ulcerations, burns and septic wounds.11 Honey and lemon juice in tea are thought to coat the pharyngeal mucosa thus soothing inflammation and reducing irritation.12 Strepsils® (Amyl-m-cresol) have also been successfully used to treat oral inflammation and pain and more recently to reduce the incidence of POST when administered preoperatively.13 However, the efficacy of these two medications in the treatment of POST postoperatively is unknown, especially in patients undergoing third molar surgery.

Therefore, the aim of this study was to evaluate the efficacy of honey and lemon juice with tea and Strepsils® versus no medication in relieving postoperative sore throat.

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SCIENTIFIC

Materials and methods Patients This prospective, randomised, controlled study was approved by the senate research committee of the University of the Western Cape (ref no.11/8/27) and written informed consent was obtained from all patients prior to enrolment in the study. Sixty American Society of Anesthesiologists (ASA) physical status I, nonsmoking patients were randomly selected from patients undergoing surgical removal of third molars under general anaesthesia. Patients with a history of throat problems, associated third molar pathology, and those who were using homeopathic or alternative medication were excluded from the study.

Patients were randomly divided into three groups after completion of the procedure. Group 1 formed the control group and did not receive any palliative medication. Group 2 were administered 200 ml tea with honey and lemon juice (5 ml of honey and 5 ml of lemon juice added to unsweetened English tea). Group 3 were administered honey and lemonflavoured Strepsils® (Boots, Nottingham, UK) containing 2,4-dichlorobenzyl alcohol 1.2 mg, amylmetacresol 0.6 mg, sucrose, glucose syrup, honey, tartaric acid, peppermint oil, terpeneless lemon oil, and quinolone yellow.

Dosages of tea with honey and lemon juice were measured and standardized at 200 ml for all patients. The medications for all patients in groups 2 and 3 were administered at the following time intervals: Interval 1: 30 minutes after surgery before taking analgesics (Ramsay Sedation Score of 2 i.e. patient was cooperative, oriented and tranquil); Interval 2: before going to sleep on the first night before taking any analgesics; and Interval 3: the following morning before taking any analgesics. Patients were instructed to drink the total 200 ml of tea at each interval.

Method of Anaesthesia Surgery was performed under standardised general anaesthesia protocol. Patients had an intravenous catheter inserted. At induction they received Propofol 2 mg/kg and Fentanyl 3-5 mcg/kg. Rocuronium bromide (Esmeron ® ) 0.6 mg/kg was administered as a nondepolarising neuromuscular blocker. This was followed by atraumatic placement of a north facing cuffed nasotracheal tube and placement of moist throat pack with McGill’s forceps using a laryngoscope under direct vision by the anaesthetist. A standard surgical procedure, for the removal of impacted third molars was followed.

During the procedure, head movement was kept to a minimum. No local anaesthesia was administered as to allow for postoperative pain assessment.

After the surgery, the throat pack was removed by the

anaesthetist with McGill’s forceps under direct vision and pharyngeal toilet was performed with soft tip sucker (Yankur).

All patients received the same antibiotic and analgesic regime i.e. preoperative, 1.2 g amoxicillin with clavulanic acid IV followed up with 500 mg amoxicillin 8-hours orally for 48 hours, 75 mg of diclofenac IM was administered at the start of surgery, 1 gram paracetamol orally 6-hourly for five days, 400 mg Ibuprofen orally 8-hourly for five days and 15ml, 0.2% chlorhexidine gluconate mouth rinse after meals.

Demographic data, duration of anaesthesia (time from intubation to extubation), complications with surgery, difficulty with intubation and the presence of clinical throat injuries were recorded. The Cormack–Lehane classification14 used to describe laryngeal view during direct laryngoscopy was applied and only Cormack-Lehane grade 1-2 cases were included in the study.

Parameters Measured For all three groups POST was evaluated immediately after surgery (prior to giving any medication); after administering the first dosage of medication for groups 2 and 3 (approximately 30 minutes); and 24 hours after surgery.

POST was evaluated using a four- point grading scale as suggested by Harding and McVey15 for Sore Throat: 0 – no sore throat at any time since your operation; 1 – minimal sore throat, less severe than a cold; 2 – moderate sore throat, similar to that noted with a cold; 3 – severe sore throat, more severe than noted with a cold.

Statistical Analysis The data are presented as means and percentages and was analysed using SPSS package (14.0, SPSS Inc., Chicago, IL, USA). Comparison of the POST score at different time intervals for each group was performed using the student’s ttest. The scores of groups 2 and 3 were compared with the control group using the Fisher exact test. Findings were considered statistically significant when P < 0.05.

Results Each group consisted of 20 patients of similar age range and duration of anaesthesia (Table 1). None of the patients complained of any discomfort after being administered either, honey and lemon in tea, or Strepsils®.

The score of POST immediately after surgery and prior to administering any medication was comparable in all three groups (Figure 1). However, the score of POST after administration of the first dose of medication differed among the three groups. The score of POST for group 1 (control group) was unchanged (P > 0.05). For group 2 the POST score was significantly lower after administration of the first

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dose (P < 0.01). For group 3, the POST score was also significantly lower after administration of the first dosage (P < 0.001) compared to the baseline POST score.

The severity of POST significantly decreased 24 hours after surgery for all three groups (P < 0.05). A comparison of POST scores between the control group and the honey and lemon in tea group showed no statistically significant differences (P > 0.05). However, when the Strepsils® group was compared to the control group, a statistically significant (P < 0.02) difference was found between the POST scores, hence indicating the high efficacy of Strepsils® in relieving postoperative throat symptoms.

Discussion Postoperative sore throat is a minor but common postoperative complaint with an estimated incidence of 14.4% to 61%.1-3 Routine endotracheal intubation for elective surgical procedures, such as third molar surgery, can result in pathological changes to the surrounding tissues, trauma and nerve damage which may also account for postoperative throat symptoms.16 In this study, the overall incidence of POST in the immediate postoperative period was very high at 93.3%.

This complication was shown to be reduced significantly with the administration of honey and lemon in tea and Strepsils® immediately after surgery. Likewise, a 24-hour follow-up of patients confirmed the effectiveness of honey and lemon in tea and Strepsils ® lozenges in relieving POST in patients undergoing third molar surgery.

In this study, patient characteristics and duration of anaesthesia were comparable among the three groups. We excluded patients who underwent anaesthesia of long duration as well as those with difficult intubation and any other surgical complications. A standardized anaesthetic protocol was also followed. Consequently, it is safe to conclude that the observed reduction in the POST scores among the three groups can be attributed to the use of Strepsils® and honey and lemon in tea, respectively.

There has recently been a revival in the use of honey as a medicine. Zumla and Lulat17 referred to honey as 'a remedy rediscovered’, and stated the view that the therapeutic

potential of honey is largely underexploited. It is readily available in most communities and although the exact healing mechanism of honey is not well understood, its medicinal properties need to be further explored. To the best of our knowledge, this is one of the first studies to report on the use of honey to treat postoperative throat complications after endotracheal intubation.

A major cause of discomfort and pain in wounds is the inflammation of surrounding tissue due to tissue damage. The mechanical irritation of the pharyngeal and tracheal mucosa occurs during laryngoscopy, throat pack placement, the endotracheal tube cuff and during the process of intubation and extubation.18-20 Other factors contributing to POST include large tracheal tube size, cuff design, increased intra-cuff pressure, use of succinylcholine and prolonged laryngoscopy.16, 21-23 Conway et al.3 and Hartsell and Stephen24 found that the incidence of sore throat doubled when a nasogastric tube was used.

The placement of protective throat packs following endotracheal intubation is commonly used in oral surgery and otolaryngology. Their function is to prevent aspiration, pharyngeal and tracheal contamination and the passage of blood into the stomach.

Various materials have been used as a throat pack including ribbon gauze, tampons, bandage roll, Raytex® swabs, tapered sponge and pharyngeal foam packs made from polyurethane. Throat packs inadvertently induce POST due to mechanical irritation of tracheal and pharyngeal tissues.18-20 A study by Parker25 compared dry tampons to ribbon gauze soaked in sterile saline in relation to the severity and incidence of POST. The study showed that there was no significant difference in pain experienced in the immediate postoperative interval, but at the 24 hour postoperative interval, symptoms of POST decreased by 50% in patients in which dry tampons were used instead of saline soaked ribbon gauze.

It is hypothesised that POST is mediated by an aseptic inflammatory process caused by the removal of protective mucous from the pharyngeal and tracheal mucosal surface.18 In addition, low pressure, high volume cuffs produce grooving in the mucosa because of wrinkling of the cuff as it is inflated which is markedly reduced when inflating with a high pressure, low volume cuff. 26

Table 1: Characteristics of patients in the three groups Control

Honey and lemon in tea

Strepsils®

Mean age (years)

22.70

22.65

24.45

Male: female

10:10

5:15

8:12

Mean duration of anaesthesia (minutes)

39.75

39.50

44.00

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3 2.5

POST score

2 Control

1.5

Honey and lemon in tea

1

Strepsils®

0.5 0

Pre-medication

After 30 mins

After 24 hrs

Figure 1: POST scores prior to administering any medication, 30 minutes after surgery and 24 hours after surgery for all three groups.

Histologically, the inflammatory process involves leukocyte migration to the site of irritation and the release of cytokines by inflammatory cells. It is possible that fibroblast proliferation may also be induced.27 The formation of arachidonic acid produces leukotriene-B4 leading to increased levels of interleukin-2 and therefore contributing to the inflammatory process.

In a study by Peppard and Dickens 28 , indirect laryngoscopic examination of 475 patients who had been intubated for elective operations showed that only a small proportion (6%) has traumatic lesions of the larynx and hypopharynx. The injury resulted in haematoma formation on the glottis in most of the cases.28 Honey has been reported to reduce inflammation, oedema and exudation.29,30 This would account for the soothing effect observed when honey is applied to wounds and the associated reduction of pain.31 Honey and lemon juice in tea are thought to coat the pharyngeal mucosa, reducing inflammation and irritation.12 Strepsils® have previously been used for the treatment of oral inflammatory conditions by Gaspar et al.32 It was reported in this study that Strepsils® may be effective in the prophylaxis and treatment of oral inflammation. In another study by Gaspar et al. 33 , Strepsils ® were administered to patients with oral inflammatory diseases and it was found that the healing time was shortened by 30% while pain levels were reduced by 30% in patients treated with Strepsils® compared with controls. More recently Ebneshahidi and Mohseni 13 evaluated the efficacy of Strepsils® in reducing the incidence of POST. They were able to show that the use of Strepsils® perioperatively reduced the incidence of POST and hoarseness of voice. Along with the findings of this study,

Strepsils ® is an effective anti-inflammatory agent for treating mucosal damage and relieving POST. A possible limitation of this study may be the responsiveness of patients in the immediate postoperative period. Only patients with Ramsey sedation score of 2 i.e. patient was cooperative, oriented and tranquil were included to ensure that accurate POST scores were recorded. Another possible limitation is that patient satisfaction was not evaluated, which could be a significant indicator of the efficacy of our intervention.

Studies have shown various ways to decrease the incidence of POST. The use of a smaller endotracheal tube (ETT)4,6,16,34 without causing a compromise in the ventilation of a patient has been indicated to decrease POST.16 Studies support the use of 7 mm ETT for women and 7.5 mm ETT for men. 4,6,16,35,36 Smaller ETT (6.5 mm for women and 7 mm for men) have also been successfully used in adults.16 In addition to the size of ETT, by limiting ETT cuff pressure the incidence of POST decreases.6,7,16,34,37-39 Determination and maintenance of the minimum pressure for an effective cuff seal during positive pressure ventilation is an effective way to decrease POST.16 The use of pharmacological agents has been used in various ways to decrease POST. Filling ETT cuffs with 2 or 4% lidocaine, 90 minutes prior to tracheal intubation, allows for the continuous diffusion of lidocaine to the tracheal mucosa. This has been shown to safely reduce POST.40-42 Bagchi et al.43 showed that by administering a bolus of dexamethasone 0.2 mg/kg IV (diluted to total volume of 4 ml with normal saline) just before induction, decreased the incidence and severity of POST by around 30%.43 Benzydamine hydrochloride is a topical, non-steroidal,

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anti-inflammatory agent with analgesic, antipyretic, and antimicrobial properties. When sprayed onto the ETT cuff, a significant reduction in the incidence and severity of POST for up to 24 hours occurred.19 Rashwan et al.44 deduced that preoperative gargling with Tramadol (2mg/kg in 30ml apple juice for 1min) reduced the incidence and severity of POST compared to placebo group (30ml apple juice only for 1min).44 In a study by Elkahim et al.45, patients were randomly assigned to have either a 0.2% tenoxicam or a 0.9% saline-impregnated gauze pack in the oropharynx after the endotracheal tube was placed.45 The study concluded that the incidence and severity of POST was reduced by the use of a gauze pack moisturised in a 0.2% tenoxicam solution compared to salineimpregnated gauze packs in patients during general anaesthesia with endotracheal intubation.45

Conclusions We demonstrated in this study that the postoperative use of honey and lemon in tea and Strepsils® lozenges may aid in eliminating sore throat after third molar surgery. Strepsils® reduced sore throat scores significantly more when compared to the control group. Based on the findings of this study, it is recommended that patients undergoing third molar surgery be administered Strepsils® or honey and lemon in tea immediately postoperatively and for a period of up to 24 hours postoperatively to relieve postoperative throat complications and improve patient satisfaction.

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41. Tanaka Y, Nakayama T, Nishimori M, et al. Lidocaine for preventing postoperative sore throat (Review). The Cochrane Collaboration. 2009; 1-40 42. Hung NK, Wu CT, Chan SM, et al. Effect on postoperative sore throat of spraying the endotracheal tube cuff with benzydamine hydochloride, 10% lidocaine, and 2% lidocaine.

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43. Bagchi D, Mandal MC, Das S, Sahoo T, Basu SR, and Sarka S. Efficacy of intravenous dexamethasone to reduce incidence of postoperative sore throat: A prospective randomized controlled trial. J Anaesthesiol Clin Pharmacol 2012 Oct-Dec; 28(4): 477–480.

44. Rashwan S, Abdelmawgoud A, Badawy A. Effect of tramadol gargle on postoperative sorethroat: A double blinded randomized placebo controlled study. Egyptian J Anaes. 2014.

Article in Press. http://dx.doi.org/10.1016/j.egja.2014.01.010 45. Elhakim M, Siam A, Rashed I, Hamdy MH. Topical tenoxicam from pharyngeal pack reduces postoperative sore throat. Acta Anaesthesiol Scand 2000; 44: 733–736.

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For more information, visit softwareofexcellence.com or contact Software of Excellence on 1300 889 668 (AU) or 0800 930 171 (NZ).

Vita Physiodens denture teeth are crafted in Germany, using a multi-dimensional layering technique and nature-identical surface morphology. The range of impressive corporeal moulds ensures a true-to-nature restoration for partial dentures– particularly in the case of implant restorations. Anatomically moulded palatal ridges and the convex labial facet design enhance the restoration of the chewing function, the phonetics and the natural lip contour. The specifically designed interdental ridges provide a lifelike, age-specific design of the papillae. Esthetic aspects as well as optimum function have been given exemplary consideration.

In addition to the existing 3D shades, this range of premium denture teeth is now available in the Vita Classical shades in Australia.

VITA

UVENEER

V60 I-LINE CERAMIC FURNACE

UVENEER is an exciting NEW Template System that creates gorgeous direct composite veneers using the composite of your choice.

Uveneer is dentist designed and engineered so it delivers correct anatomy & contour from central, lateral, canine and first and second pre-molars. It is based on the Golden Proportion of tooth size, shape and smile design.

Uveneer also makes it fast and easy to produce a predictable outcome every time from a single tooth restoration and up to 10 teeth per arch using the ‘press & cure’ technique. Another wonderful benefit is that you will cut back on finishing and polishing time since Uveneer leaves a glossy surface. Uveneer is autoclavable & reusable.

Clinical videos are available at www.uveneer.com. Information and sales through your Henry Schein Halas Representative.

VITA continues its successful tradition of building excellent furnaces customers can rely on with the V60 i-Line. Representing a new level of VITA quality, the V60 meets the demands of international customers for a robust, heavy-duty furnace perfectly.

A state-of-the-art touch interface and the tried-and-tested VITA quartz firing muffle guarantee optimal firing results.

The clean, no-frills design make the VITA V60 a real workhorse, functioning 24/7 under the most extreme conditions with amazing reliability.

Easy to maintain, easy to handle and made in Germany, the V60 i-line sets new standards around the world.

QUINTESSENCE BOOKS A Concept Of "En Bloc" Movement Of Teeth Using Gummetal Wire - Shin Hasegawa This book outlines a system of orthodontic therapy based on the use of Gummetal arch wire that can improve patient comfort and shorten treatment time. Although many alloys have been used for orthodontic wire, none offer the benefits of Gummetal, which combines a super-low Young modulus with extreme strength. The use of Gummetal in en bloc protocols allows clinicians to construct simple orthodontic appliances that not only distribute a gentle, near-optimum force but can also achieve an ideal occlusion in less time than traditional treatment.

Q-5120783 $ 229.45

KURARAY NORITAKE

CLEARFIL MAJESTY ES-2 CLEARFIL MAJESTY™ ES-2 is a nano-hybrid universal composite, ideal for anterior and posterior applications.

CLEARFIL MAJESTY™ ES-2 has the world’s first shade concept for direct composites, made possible by only three components: one-layer classic shades multi-layer premium shades with enamel, dentine & translucent shades and an intuitive shade guide, all approved by VITA™. During the last seven years, we’ve re-engineered every detail of our universal composite technology. By introducing CLEARFIL MAJESTY™ ES-2, we have created a new gold standard in direct composite resins. CLEARFIL MAJESTY™ ES-2 Premium and Classic are available in Kits, in both Syringe and PLT (preloaded tip) & Refills.

All products available from: HENRY SCHEIN HALAS • Tel: 1300 65 88 22 • www.henryschein.com.au 64 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 10, NO. 1

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