International Dentistry Australasian Edition - Vol.11 No.1

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VOL. 1 1 NO. 1 IN THIS ISSUE

Howard Gluckman, Jonathan Du Toit Aesthetic laser therapy correction of physiological gingival hyperpigmentation Nikolaos Papagiannoulis, Marius Steigmann Non-compromised aesthetics with multiple single implants in the anterior maxillae Giuseppe Galvagna, Paolo Brunamonti Binello, Massimo Galli, Mauro Labanca Use of Ă&#x;-tricalcium phosphate for bone regeneration in oral surgery Johan Hartshorne Are short implants acceptable as an alternative to longer implants with sinus floor elevation in the posterior maxilla?

Mohamed Fayad Cone beam computed tomography: a new era in diagnosis and treatment planning Crispian Scully Making sense of mouth ulceration: recurrent aphtous stomatitis

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Henry Schein Cares first ever Back to School Program!

On Thursday, 26 November 2015, Team Schein Members took part in Australia’s first ever Henry Schein Cares Back to School Program! "Back to School" is a flagship initiative of Henry Schein Cares and is supported by the Henry Schein Cares Foundation. The program’s initiative is to help build the confidence of many less fortunate children who would otherwise return to the classroom without essential school supplies or new clothes. Participating children are provided with school essentials, including backpacks filled with classroom supplies, books and hygiene products donated by Henry Schein so that when they start their first day of school they start on the right foot! Henry Schein "Back to School" events are taking place at 29 Henry Schein locations this year. In 2014, the program expanded beyond the United States and Canada to Europe and now Australia! Since the program's inception in 1998, more than 32,000 children have headed back to school equipped for success!

"Our 'Back to School' program has been one of Henry Schein's longestrunning and largest community service events, during which enthusiastic Team Schein Members make a significant difference in the lives of underserved children, boosting their confidence from the first day they walk through the classroom doors," said Gerry Benjamin, Executive Vice President and Chief Administrative Officer of Henry Schein. "Giving back to society is a core value of Team Schein, and we are proud to host 'Back to School' every year, having grown the program from one event at our Company's headquarters in Melville to now 29 events worldwide."

Cabramatta Public School was selected as the pilot for this program in Australia. The school was amazingly well aligned with our own Team Schein Values and they’ve developed their own program for incoming kinder children for the next school year conveniently called the SMILE program. Smile stands for Smooth Movement Into The Learning Environment and allows the 2016 kinder group to spend some time in their future classrooms; so they can easily transition into the school environment the next year. During this time, the parents stay on the school grounds in a different area and are also inducted into the school.

Henry Schein Halas, through the Henry Schein Cares Foundation, was happy to be able to sponsor the school allowing them to give each incoming student a backpack full of goodies for the new school year. We also took the opportunity to speak to the parents about the importance of good oral health for their children with the help of two of our Customer Service Representatives who are trained Oral Health Therapists. With up to 3 interpreters in the room at any given time, the team did an amazing job emphasizing the importance of oral health care in younger children to the attending parents. Other Henry Schein Halas staff assisted teachers in the Kinder Classes by singing songs with the children and helping them with some colouring in and other art projects!

Scott Davidson, the Principal at Cabramatta Public School, stated ‘Thank you and your team for your participation and support of the SMILE program. The backpacks have been an outstanding success and having you and your team in classes was very helpful!’

We consider the day a huge success and are hoping to expand the program at the end of 2016.

2 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 11, NO. 1

Vol. 11 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 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

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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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4

Contents Volume 11 No. 1

18

4

Clinical Aesthetic laser therapy correction of physiological gingival hyperpigmentation Howard Gluckman, Jonathan Du Toit

18

Case Report Non-compromised aesthetics with multiple single implants in the anterior maxillae Nikolaos Papagiannoulis, Marius Steigmann

26 Case Report 24

Use of Ă&#x;-tricalcium phosphate for bone regeneration in oral surgery Giuseppe Galvagna, Paolo Brunamonti Binello, Massimo Galli, Mauro Labanca

38 Clinical Are short implants acceptable as an alternative to longer implants with sinus floor elevation in the posterior maxilla?

Johan Hartshorne

44 Clinical 44

Cone beam computed tomography: a new era in diagnosis and treatment planning Mohamed Fayad

58 Clinical Making sense of mouth ulceration: recurrent aphtous stomatitis Crispian Scully

62 Products

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CLINICAL

Aesthetic laser therapy correction of physiological gingival hyperpigmentation Howard Gluckman1, Jonathan Du Toit2

Keywords: Gingival hyperpigmentation treatment, aesthetic laser therapy Abstract A beautiful smile is dependent on many factors. One of those factors is the gingival scaffold. Symmetry, proportion, as well as colour and appearance of the gingiva are critical to an aesthetically pleasing smile. Physiological gingival hyperpigmentation does not present as clinical pathology requiring intervention, nonetheless it may be of aesthetic concern to the patient. Minimally invasive intervention by means of cryosurgery, electrosurgery, laser therapy or other may produce dramatic change in the appearance of the patient’s smile with a sustainable, long-term aesthetic outcome.

Hereafter a case is presented demonstrating laser therapy removal of gingival hyperpigmentation with stable, pink gingival aesthetics at the 2-year follow-up.

Introduction

1

Howard Gluckman BDS, MChD (OMP) Specialist in periodontics and oral medicine, director of the Implant and Aesthetic Academy

2

Jonathan Du Toit BChD, Dipl. Implantol., Dip Oral Surg, MSc Dent Department of Periodontics and Oral Medicine, School of Dentistry, Faculty of Health Sciences, University of Pretoria Corresponding Author Howard Gluckman BDS, MChD (OMP) Specialist in periodontics and oral medicine Contact email: docg@theimplantclinic.co.za Telephone: +27 21-426-2300 Website URL: www.implantacademy.co.za

Aesthetics are a set of principles concerned with the nature and appreciation of beauty, and as these are applied to dentistry both patient and clinician scrutinize these toward achieving a healthy and aesthetic smile. Gingival hyperpigmentation, especially in cases of vertical maxillary excess, high lip line, high aesthetic demand, may be of significant concern to the patient seeking its correction.1 There may further be a psychological and cultural consequence to hyperpigmentation of the gingiva visible upon smiling that is displeasing to the patient. Normal, healthy gingiva is described in texture, consistency and colour, as firm, stippled, and coral-pink or salmon-pink in nature. 2 Briefly, gingival hyperpigmentation may be considered physiological or pathological in nature.3 Discernment between the two is paramount since physiological hyperpigmentation may be removed for aesthetic concerns while pathological lesions may be sinister in nature and require more scrupulous intervention for the sake of the patient’s health. Physiological variations in differing race groups, particularly of African and Indian descent, may or may not include hyperpigmentation of the gingiva seen as macules varying greatly in terms of size, shape and location.4 Melanocytes are located in the epithelial basal and suprabasal layers and synthesize and store melanin pigments, by converting tyrosine into melanin, stored in these layers in the form of melanosomes.5 The degree of pigmentation depends on melanocyte activity, determined by one’s race, genetic disposition, and hormone production.

Removal of hyperpigmented gingival tissue for aesthetic reasons may be carried out by a variety of methods including cryosurgery, chemical agent cauterization, bur abrasion, scalpel gingivoplasty, electrosurgery, gingival graft, and laser techniques.1 The latter comprises an extensive branch of dentistry by itself, employing a variety of devices (Table 1) including diode lasers, CO2 lasers, Er:YAG laser, Nd:YAG laser, and Er,Cr:YSGG laser.6 Here a case is reported of aesthetic intervention of physiological gingival hyperpigmentation by Er,Cr:YSSG laser with stable and aesthetically pleasing results at the 2-year follow-up.

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CLINICAL

Figure 1: Preoperative view of the patient’s smile

Figure 2: Retracted, preoperative, intraoral view demonstrating the degree of pigmentation and extension of the affected areas

Case report

chlorhexidine gluconate aqueous solution (never use an alcohol solution with medical lasers). An Er,Cr:YSSG laser (Waterlase iPlus 2.0, Biolase) was used for all the periodontal soft tissue surgeries. The crown lengthening by gingivectomy was first carried out as per the DSD guide, with a fine tip (MGG6), applied more parallel to the tooth, with the unit's power settings at 3W 75Hz, with water and air settings 50 and 40 respectively. Thereafter, a broader, chisel tip (MC3) was interchanged for the depigmentation/gross de-epithelialization, with power settings increased to 5W 25Hz. The tip size and power allowed for faster removal of tissue with water and air settings on for cooling.

Broad, gradual strokes de-epithelialized the pigmented areas up to 1 – 2 mm beyond the lesions’ borders. To conclude

A 34-year-old female patient of Indian descent presented by referral to a specialist in periodontics and oral medicine at her request for “pink gums”. The patient was a non-smoker and the medical history was non-contributory. Examination of the face denoted multiple, poorly defined, hyperpigmented macules of the lips, mild in severity and greater in number on the lower lip. The patient’s high smile line was noted with excessive gingival display, the entirety of which involved hyperpigmentation, blue-black/dark brown in colour (Fig. 1). Intraoral examination denoted a healthy, largely restorative-free dentition, with exemplary oral hygiene maintenance. Hyperpigmentation was noted involving the attached gingiva of both the mandible and maxilla, with the latter greater in severity (Fig. 2). The patient scored 4 on the Dummet Oral Pigmentation Index in terms of pigmentation intensity (heavy clinical pigmentation), and scored 2 on the Takashi melanin pigmentation index in terms of its extension (formation of continuous ribbon extending from the neighboring solitary units).4 In both the mandible and the maxilla the hyperpigmentation appeared mostly as singular, posteriorly extending macular lesions with well demarcated borders limited coronal to the mucogingival junctions. A diagnosis of physiological gingival hyperpigmentation was made and intervention for aesthetic correction was indicated (the patient initially sought treatment of the maxilla only). Digital smile design (DSD) and smile analysis of the patient indicated need for correction of the altered passive eruption. De-epithelialization of the affected areas as well as crown lengthening by laser gingivoplasty was opted for. The working field was retracted and isolated (OptraGate, Ivoclar Vivadent), and local anaesthesia achieved by slow infiltration of a 4 % articaine with adrenaline (1:200,000) local anaesthetic solution (Ubistesin™ forte, 3M ESPE). The area, mucosa and teeth surfaces, were cleaned with sterile gauze soaked in

Figure 3: Immediately postoperative, crown lengthening and deepithelialization of pigmented tissue completed

Figure 4: 10-days postoperative, rapid healing with dramatic results in gingival colour

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GLUCKMAN / DU TOIT

Figure 5: The patient’s smile 10 days after the laser deepithelialization and crown lengthening

Figure 6: Patient’s smile at the 2-year recall; dental bleaching, increased clinical crown size, coral-pink gingiva, all contribute to a healthy, aesthetic smile

the procedure, the unit was set to "laser bandage" mode, with lowered power settings at 1-1.5W 75Hz, and water and air off for hemostasis, leaving a layer of coagulum that would aid with the tissue healing. After the entire affected area was de-epithelialized (Fig. 3) postoperative instructions were given (no tooth brushing near the treated area for 1 week, rinse with chlorhexidine mouthwash BID 1 minute (Andolex C, iNova Pharmaceuticals), soft diet avoiding spicy/irritating foods). The patient was recalled at 10 days, reporting having had no pain or discomfort, and demonstrating near complete healing of the entire treated area (Fig. 4). There were no areas of hyperpigmentation noted (Fig. 5). The patient was rescored as zero for both pigmentation indices. Following dental bleaching the patient presented at the 2-year recall with no notable signs of repigmentation. The patient remained a score of zero on both indices. The gingival contour and colour remained stable with aesthetic results pleasing to the patient (Fig. 6).

energy to do work. Wavelength is the distance between two corresponding points on the wave – the unit typically in laser dentistry is nanometer (nm). Waves rise and fall around the zero axis many times a second, referred to as oscillations, and the number of oscillations per second is the frequency, measured in hertz (Hz). The laser utilized in the treatment of this case (Er,Cr:YSSG) functions at a wavelength

Discussion Pigmentation of the gingiva may pose an aesthetic concern to the patient seeking cosmetic correction thereof. Laser depigmentation is an evidence-supported, beneficial treatment modality.1 “Laser” is an acronym for light amplification by stimulated emission of radiation.7 Possibly the first report of laser radiation on oral soft tissues was as early as 1965.8 The first commercial laser for use in dentistry, the dLase 300 Nd:YAG laser, was introduced in 1990.6 At present, a range of laser wavelengths are used in dentistry for a plethora of applications (Table 1). The fundamental mode of action of lasers is that waves consisting of photons (basic unit of radiant energy, light) travel at the speed of light and these waves can be defined by their wavelength and amplitude.11 Amplitude is the vertical height of the wave, and in lasers this corresponds to “brightness”, its potential

7a

7b

Figure 7: (a) Components of a gas or solid active-medium laser, eg. CO2 or Nd:YAG laser, and (b) a diode laser. Adapted from Principles and Practice of Laser Dentistry 2nd ed (p. 14), by Convissar RA, 2015, St. Louis: Mosby Elsevier

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Table 1: Lasers currently used in dentistry Laser type

Active medium

Wavelength (nm) Treatments, applications

Excimer lasers

Argon fluoride (ArF)

488

Hard tissue ablation, phased out of dentistry.

Medical use primarily

Xenon-chloride (XeCl)

308

Dental caries and calculus detection

Carbon dioxide (CO2)

9300;10,600

Sulcular debridement, peri-implantitis, soft tissue surgery

Gas lasers

Diode lasers

Argon (Ar)

488 - 514

Phased out of dentistry. Medical use primarily.

Helium-neon (HeNe)

630

Pulp vitality testing, therapeutic photobiomodulation

Indium-gallium-arsenidephosphorus (InGaAsP)

800 – 1064

Dental caries and calculus detection

Galium-aluminum-arsenide (GaAlAs) Galium-arsenide (GaAs)

Solid-state lasers

Erbium group:

Other

Intraoral general and implant soft tissue surgery, sulcular debridement (subgingival curettage in periodontitis and periimplantitis), analgesia, treatment of dentin hypersensitivity, pulpotomy, root canal disinfection, aphthous ulcers, gingival depigmentation

Potassium titanyl phosphate (KTP)

532

Dental bleaching, medical applications

Neodymium:yttriumaluminum-garnet (Nd:YAG)

1064

Soft tissue surgery, sulcular debridement, analgesia, dentin hypersensitivity, pulpotomy, root canal disinfection, enamel caries removal, aphthous ulcers, gingival depigmentation

Erbium-doped yttrium aluminium garnet (Er:YAG)

2940

Erbium: yttrium-scandiumgallium garnet (Er:YSSG)

2790

Erbium, chromium: yttrium-scandium-gallium garnet (Er,Cr:YSSG)

2780

Caries removal, cavity preparation, soft tissue surgery, sulcular debridement (teeth and implants), scaling root surfaces, osseous surgery, dentin hypersensitivity, analgesia, pulpotomy, root canal treatment & disinfection, aphthous ulcers, gingival pigmentation

Low level lasers

600 – 635

Non-surgical, photobiomodulation, caries detection

2780 nm, and at a frequency of 1 – 100 Hz. Hertz also states the number of laser pulses per second of emitted energy. To put these properties into perspective, light from a household bulb is white and diffuse, it is not focused. Laser light differs in that it is monochromic (a beam of single colour), and that its waves are coherent. This means they are identical in size and shape. The amplitude as well as the frequency of all the waves of photons are identical. The production of focused electromagnetic (EM) energy is a direct result of this coherence. Whilst a 100Watt bulb may light a room, a 2Watt laser may perform a surgical excision,

since all the photons in the laser light are focused and “work together”.12 A laser consists of three structural components, namely the active medium, the pumping mechanism, and the optical resonator (Figs. 7a, b). In-depth electromagnetism physics may not be essential knowledge for the clinician, but it may be helpful to know that lasers derive their product nomenclature from these components. The active medium may consist of a container of gas (CO2 lasers), a solid crystal (Er,Cr:YSSG laser), a solid-state semiconductor (diode laser), or as a liquid. The active medium is surrounded by the pumping mechanism which is an excitation source

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Figure 8: Wavelengths of the various laser lights and their position within the EM spectrum. Adapted from Principles and Practice of Laser Dentistry 2nd ed (p. 14), by Convissar RA, 2015, St. Louis: Mosby Elsevier

(source of energy, electric coil, lamp strobe, etc.). The excitation source will excite electrons, and as they return to their resting state they emit energy in the form of photons.

Completing the laser cavity are optical resonators (typically mirrors) that reflect waves back and forth, thereby collimating and amplifying the beam.12 As with normal light, the clinician may note that laser light waves exist on the EM spectrum and can correlate the type of laser to its respective wavelength (Fig. 8 ). All commercially available dental lasers emit light and wavelengths ranging 500 – 10,000 nm.13 As such, a dental laser may fall within the visible or invisible and nonionizing range of the EM spectrum. An erbium laser for example then may have an additional light source in the device for the clinician to visualize the application point.

Furthermore, the point of caution here is that all persons in the laser operating room are to wear laser protective eyewear.

When the laser is activated there may be four possible interactions between the laser light and the target area, depending on the tissues’ optical properties, depending on the light’s wavelength.10 Reflection will occur when the light is deflected off the surface, with no effect. This may be of consequence to neighbouring, absorbing tissues, and may cause injury to a nearby person’s unprotected eyes. The laser light may also be transmitted, again with no effect on the target tissue, but possible unintended or detrimental effect to neighbouring tissue. Absorption may be the most desired effect. The amount of absorption further depends on the tissue’s water content, and pigmentation. The fourth interaction is scattering, whereby the photons penetrating the tissue change directions and leads to absorption in a greater area. As laser energy is absorbed by the tissue the interaction is photothermal (laser energy transformed into thermal

energy). The effects then are either incision/ excision, ablation/vaporization, or hemostatic/ coagulation.14 When the beam’s spot size (diameter) is small and focused, it is suited for an incision/excision procedure. A wider beam size will interact with the tissue more superficially producing surface ablation. And when the beam is out of focus or less focused coagulation can be performed. In the treatment of this gingival hyperpigmentation case, a larger beam diameter allowed for superficial tissue interaction but deep enough to target the basal and suprabasal epithelial layers rich in melanocytes. The ablative action of the laser over a wider area allowed for removal of the superficial gingival layers rather than focused cutting. Oral mucosa is high in water content and the laser’s effect primarily involves the thermal change in the tissue. When water temperature is raised to 100° C vaporization of the water within the mucosa occurs, called ablation. Incision and excision of oral soft tissues occurs at this temperature. Between 60° and 100° C proteins will denature without vaporization of underlying tissue, ideal for the removal of diseased degranulation tissue, for hemostasis and coagulation.15 Charring of the tissues will however occur at temperatures at around 200° C.16 When removing hyperpigmented tissues, lower temperatures are needed, and much less energy is needed since chromophores attract lasers. Conversely, higher energy would be needed to excise fibrotic tissue with less chromophores.17 Lasers used for the aesthetic correction of physiological hyperpigmentation have been extensively described in the literature, and suggested as superior to other treatments due to the fast healing, reduced pain and discomfort, clean and dry operating field, and stable results.1, 19, 20,21 The formation of protein coagulum on the laser treated wound surface

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Table 2: Literature review 1951 – 2013; pigmentation recurrence rates (%) by random-effects Poisson regression1 Treatment

No. of

Repigmentation

studies

rate (%)

Bur abrasion

16

8.99

Scalpel gingivoplasty

23

4.25

Gingival graft

3

1.96

27

1.16

9

0.74

12

0.32

Laser Electrosurgery Cryosurgery

Laser Nd:YAG

4

2.86

CO2

4

2.14

Er:YAG

8

1.41

Diode

12

0.19

reduces postoperative pain. Laser light may also “seal” free nerve endings.18 The patient treated in the case presented here required only 1 ampoule local anaesthetic infiltration per quadrant delivered segmentally across the working area.

The operating field was dry and void of any profuse bleeding. Nearly the entirety of the hyperpigmented lesions had the superficial layers of tissue layers removed. Healing was rapid with no report of pain, infection, nor discomfort.

At as early as 10 days postoperative the area was nearly entirely healed with radical results in tissue colour and contour. The literature reports the expected chronological and degrees of repigmentation following removal by various modes of treatment. Depigmentation by laser ranks low (1.16 %) in terms of percentage repigmentation (Table 2).

Conclusion Er,Cr:YSSG laser therapy for de-epithelialization can successfully alter blue – black/dark brown gingiva to uniform pink colour with numerous benefits for both clinician and patient. The results can be dramatic for patients seeking this treatment, remaining stable over the long-term, contributing greatly to an aesthetically pleasing smile.

References 1. Lin YH, Tu YK, Lu CT, Chung WC, Huang CF, Huang MS, et al.

Systematic review of treatment modalities for gingival depigmentation: a random-effects poisson regression analysis. J Esthet Restor Dent.

2014;26(3):162-78.

2. Fiorellini JP, Kim DM, Uzel NG. Anatomy of the periodontium. In:

Newman MG, Takei HH, Klokkevold PR, Carranza FA, editors.

Carranza’s Clinical Periodontology. St. Louis: Elsevier; 2012. p. 12 – 27.

3. Fiorellini JP, Kim DM, Uzel NG. Clinical features of gingivitis. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, editors.

Carranza’s Clinical Periodontology. St. Louis: Elsevier; 2012. p. 79 - 80.

4. Bakhshi M, Rahmani S, Rahmani A. Lasers in esthetic treatment of gingival melanin hyperpigmentation: a review article. Lasers Med Sci. 2015;30(8):2195-203.

5. Peeran SW, Ramalingam K, Peeran SA, Altaher OB, Alsaid FM, Mugrabi MH. Gingival pigmentation index proposal of a new index with a brief review of current indices. Eur J Dent 2014;8:287-90.

6. Sulewski JG. Einstein’s “Splendid Light”: Origins and Dental Applications. In: Convissar RA. Principles and Practice of Laser Dentistry.

2nd ed. St. Louis: Mosby Elsevier; 2015. p. 7.

7. Coluzzi DJ, Convissar RA, Roshkind DM. Laser Fundamentals. In: Convissar RA. Principles and Practice of Laser Dentistry. 2nd ed. St. Louis: Mosby Elsevier; 2015. p. 12 – 26.

8. Taylor R, Shklar G, Roeber F. The effects of laser radiation on teeth, dental pulp, and oral mucosa of experimental animals. Oral Surg Oral Med Oral Pathol. 1965,;19(6):786–795.

9. Hamblin MR, Huand YY. Handbook of Photomedicine. Boca Raton: CRC Press; 2013.

10. Shanelec DA, Tibbetts LS, Ishikawa I, Butler B, Akira Aoki, McGregor A, et al. Recent Advances in Surgical Technology. In: Newman MG, Takei HH, Klokkevold PR, Carranza FA, editors.

Carranza’s Clinical Periodontology. St. Louis: Elsevier; 2012. p. 606.

11. The photonics dictionary. 43rd ed. Pittsfield: Laurin Publishing; 1997.

12. Myers TD. Lasers in dentistry. J Am Dent Assoc. 1991;122(1): 46-50.

13. Parker S. Surgical lasers and hard dental tissue. Br Dent J. 2007;202(8):445-54.

14. McKenzie AL. Physics of thermal processes in laser-tissue interaction. Phys Med Biol. 1990;35(9):1175-209.

15. Knappe V, Frank F, Rohde E. Principles of lasers and biophotonic effects. Photomed Laser Surg. 2004;22(5):411–417.

16. Bornstein E. Near-infrared dental diode lasers: scientific and photo biologic principles and applications. Dent Today.

2004;23(3):102–104.

17. Miserendino LJ, Pick RM. Lasers in dentistry. Chicago: Quintessence; 1995. p. 145–160.

18. Simsek Kaya G, Yapici Yavuz G, Sümbüllü MA, Dayi E. A comparison of diode laser and Er:YAG lasers in the treatment of gingival melanin pigmentation. Oral Surg Oral Med Oral Pathol Oral Radiol.

2012, 113(3):293–299.

19. Ribeiro FV, Cavaller CP, Casarin RC, Casati MZ, Cirano FR, Dutra-Corrêa M, et al. Esthetic treatment of gingival hyperpigmentation with Nd:YAG laser or scalpel technique: a 6-month RCT of patient and professional assessment. Lasers Med Sci. 2014;29(2):537-44.

20. Basha MI, Hegde RV, Sumanth S, Sayyed S, Tiwari A, Muglikar S. Comparison of Nd:YAG Laser and Surgical Stripping for Treatment of Gingival Hyperpigmentation: A Clinical Trial. Photomed Laser Surg.

2015;33(8):424-36.

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Maximum ergonomics have been achieved with a seamless housing: a layered layout of the internal components as well as a shortened measuring tip. As a result, the VITA Easyshade V naturally fits in the user's hand and has an especially convincing, modern user concept. The brilliant OLED color touchscreen is controlled in the same way as a smartphone, offering a state-of-the-art user experience that is equally convenient and intuitive. The easily understandable user interface is the visible face of a completely new software that is based on an intelligent neural network.

Exciting technology Shade determination takes place via the high-precision VITA vEye optical system. Behind every detected shade is spectral information that has to be evaluated first. The precise interpretation is based on physical principles such as the L*a*b* color space, and the unique neural network VITA vBrain also accesses the wealth of experience of a selected group of experts. By implementing the experience from over 100,000 measurements as well as over 40 scientific studies, the software imitates the neural networking in an intelligent brain. The 32-bit microcontroller with an ARM Cortex M3 core provides high computing power, and the durable and long-lasting battery technology with integrated self-discharge protection ensures particularly stable operation, even when in continuous

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ADVERTORIAL

Figure 2: VITA Easyshade V with a new design.

Figure 3: Brilliant color OLED touchscreen display.

use. The measuring results – the basic tooth shade or the shade gradient from incisal to cervical – are displayed either according to the VITA SYSTEM 3D-MASTER, VITA classical A1-D4, VITABLOCS or the bleached shades according to the American Dental Association (ADA).

selecting material for direct filling therapy – especially in the difficult-to-see posterior area – or when planning esthetic corrections with veneers. The traditional visual comparison with shade scales is certainly out-of-date in the age of CAD/CAM. The application area of the VITA Easyshade V goes far beyond this and offers a true added value to dentists and dental technicians. This not only includes support for the planning process for a professional tooth whitening through digital documentation of the actual and target tooth shade.

Shade gradient displays of the patient tooth shade, for example, especially help in fabricating layered restorations.

In addition, it is possible to check if there are deviations from the desired target shade after the first firing – if this is the case, helpful information for optimization measures is displayed.

The restoration mode always provides a multitude of options for permanently optimizing one's own quality assurance system. As a standard, the shade matching should be checked before delivery to the practice, or after delivery by the laboratory and before application in the patient's mouth.

Further advantages of using the digital shade determination device for dental laboratories include eliminating the need for a daylight lamp and possibly even a treatment chair. The objectification of the shade determination process may also make it possible to eliminate one or two critical customer meetings. For dental practices, it is recommended to carry out the measurement routinely at each patient visit, in order to document any shade changes reliably.

Virtual communication for real shade reproduction Systematic transmission of the shade information along with patient photos, notes etc. from the dental practice to the dental laboratory is made possible by the PC software VITA Assist. Communication is even easier and more flexible with VITA mobileAssist. The practical app is an especially costeffective and reliable solution for tooth shade communication.

The data of the VITA Easyshade V is wirelessly transmitted to the app in a few seconds via an internal Bluetooth interface. This can be done with the app using the predecessor model VITA Easyshade Advance 4.0 as well.

Before the mobile data transmission, the measuring results can be supplemented with a patient photo and then easily sent.

The multi-purpose resource for practice and laboratory The device can be used for selecting CAD/CAM materials, fabricating layered crowns, selecting prosthetic teeth,

Made in Germany

Figure 4: Measuring basic tooth shades or shade gradients.

The VITA Easyshade V is manufactured in Bad Säckingen, Germany, the company headquarters of VITA Zahnfabrik.

In addition to development and assembly being located at the headquarters, now all production processes have been bundled on site as well. This increases the flexibility for optimizing production and allows an even closer

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ADVERTORIAL

Figure 5: Transmitting shade information and patient photos via the smartphone app VITA mobileAssist.

Figure 6: Checking restorations for the desired target shade.

monitoring of supplier components. The manufacturing is done according to strict quality criteria and standardized methods. Each device is not only subject to a visual inspection but also to the examination of its electronic components and further test measurements during factory calibration. In this process, all measurement modes are tested, and different shade scales as well as different test samples of ceramic and a material that simulates the natural tooth substance are used.

Competence in tooth shades with a future The new spectrophotometer VITA Easyshade V from VITA Zahnfabrik is more reliable, more stable and can be used at any time thanks to the newly developed software concept. With VITA Easyshade V, all your shade management questions are answered. The fifth generation of this device offers more performance, more precision, more applications and software and more added value for dentists and dental technicians. You can find further information online at www.vita-zahnfabrik.com.

Taken from ZWP Zahnarzt Wirtschaft Praxis 09/15, OEMUS MEDIA AG, Germany VITA® and the names of the VITA products mentioned are registered trademarks of VITA Zahnfabrik H. Rauter GmbH & Co. KG.

VITA Zahnfabrik H. Rauter GmbH & Co. KG

Figure 7: All development and production processes take place directly at the company headquarters of VITA Zahnfabrik.

Based in Bad Säckingen, Germany, VITA Zahnfabrik H. Rauter GmbH & Co. KG has been developing, manufacturing and selling consistently high-quality innovative solutions for dental prosthetics for over 90 years. Users in over 125 countries benefit from the analog and digital product solutions manufactured by VITA for shade determination, shade communication, shade reproduction and shade verification, which are accompanied by a comprehensive range of service options. In the last 90 years, the interaction between tradition and innovation has transformed dental visions into reality, with VITA Zahnfabrik playing a fundamental role in shaping the future of dentistry.

Figure 8: Comprehensive quality control measures are performed.

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CASE REPORT

Non-compromised aesthetics with multiple single implants in the anterior maxillae Nikolaos Papagiannoulis1, Marius Steigmann2 Tooth mobility is a clinical finding that indicates several difficulties regarding the treatment possibilities of the patients affected. Regardless of the mobility’s cause, periodontal disease, occlusal trauma or a combination, the prosthetic rehabilitation of such patients is challenging. As this case report shows, conventional single-unit prostheses, such as full-ceramic crowns, may solve the aesthetic problems. The aesthetic outcome may be satisfactory at the beginning, but in the medium term the soft tissue will continue to retract. At the same time, the main problem will not have been resolved. Mobility, especially in cases of untreated periodontal disease, will proceed despite the prostheses, which will eventually lose functionality, and a new treatment plan will be needed.

Periodontal treatments have priority over every other treatment. Depending on the attachment loss, tooth mobility can persist, requiring a long-term stability solution. In this case report, the clinical examination found a tooth mobility of Grade II for teeth #12–23 as a result of an attachment loss that persisted even after successful conservative periodontal treatment. As mentioned, fixed prostheses are not an alternative, and fixing the teeth with a bridge would only accelerate further attachment loss, although it would reduce the occlusal load. A removable denture was not an option for the patient. An implant solution was thus deemed the only acceptable treatment. A removable temporary denture was not an option for us and therefore we decided to replace each extracted tooth with an implant with immediate loading.

Figure 1a: Initial situation before extraction.

Figure 1b: Extraction sockets immediately after extraction.

1

Dr Nikolaos Papagiannoulis Dental Esthetics www.fsde.com.gr

2

Dr Marius Steigmann Steigmann Implant Institute www.steigmann-institute.com

Figure 2: Soft-tissue quality and anatomy after extraction.

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CASE REPORT

Figure 3: Flap raising and implant insertion, showing the bone morphology after extraction.

Figure 4: Implant positioning, frontal view.

Figure 5: Guided bone regeneration: filling the gap to the buccal plate and the interproximal space.

In such cases, surgeons have to deal with tooth loss, epithelial proliferation, bone resorption and loss of the periodontal ligament. In this case, we could clearly see in the pretreatment analysis that major bone resorption had occurred both horizontally and vertically. The bony defects affected more than one wall, but the bone resorption around the root was not infiltrated with soft tissue.

Clinical and radiographic findings The clinical examination found severe periodontal defects with a screening index of Grade IV, pocket depths up to 4mm and tooth mobility. The functionality was very limited and the aesthetic situation unsatisfactory. The radiographic findings confirmed that all four maxillary incisors and the left canine needed to be extracted (Figs. 1 & 2). The patient had a low scalloped gingiva with a middle thick gingival biotype, rectangular teeth and a bright smile.

Treatment plan A removable denture was not acceptable, nor was a temporary or definitive denture. Although the major focus of treatment was on functional rehabilitation, aesthetics should not be underestimated in such cases. Once functionality has been obtained, the patient’s attention turns to his or her

Figure 6: Flap closure, coronal view.

appearance. The patient was to receive implants for teeth #12–23 in an immediate implantation with simultaneous guided bone regeneration. The implants were to be loaded immediately with a high-filler resin temporary bridge.

Surgery With a wax-up on the situation model, an optimal form was created to support and manipulate soft tissue during the healing phase. At the same time, the temporary bridge functions as wound coverage if primary closure is not possible (Figs. 3–6).1–4 In the next step, teeth #12–23 were extracted. The flap outline preserved the papillae of the adjacent teeth by an incision at the papilla base. Owing to the interproximal bone defects, papilla raising in this region would have led to severe recession. The vertical bone defects were obvious after raising a full-thickness flap. A releasing incision was made only mesiodistally at tooth #12 and only in attached gingiva to prevent scar formation through vertical cuts at the mucosa. The low vestibule made a split-thickness or periosteal pocket flap the less logical choice. Mobilising soft tissue from the lips too, through other flap designs, would have caused functional limitations, suture tension and a second gingival surgery to reposition the coronally

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Figure 7: Flap closure, frontal view.

Figure 8: Provisorium and temporary bridgework.

transpositioned soft tissue. The wound margins were cut back to remove excess epithelium and the bone defects freed from soft-tissue ingrowth (Figs. 7–10).

The horizontal bone loss was moderate. The implants were placed slightly sub-crestally. Although the gap between the implants and buccal plate was due to the resorption of approximately 1–1.5 mm and the buccal plate thickness of less than 1 mm, we decided on 3.8 mm implants, leaving a 1.5 mm gap from the buccal plate.5–10 The inter-implant space and the buccal plate were augmented with a combination of allograft and xenograft materials. Autologous bone obtained with a bone scraper was placed directly on the implant surface and covered with a mixture of allograft and xenograft materials. A pericardium membrane was used as barrier (Fig. 11).

The anatomy of the maxillae and the low vestibule did not allow primary closure. To protect the augmentation and the membrane from proteolytic resorption, we placed two layers of collagen tissue fleece above the membrane. Through the collagen fleece and the protection of the provisional bridge, free granulation of the extraction socket was expected after two weeks (Figs. 11 & 12).

The patient was recalled weekly for prophylaxis and hygiene instructions. Three weeks post-operatively, the sutures were removed. The tissue was not inflamed and the wound healing and closure ideal (Fig. 13).

mm, enough for the necessary emergence profile. With the help of convex or concave prostheses, soft tissue can be manipulated in the direction desired for aesthetic reasons (Figs. 15 & 16).13–16 The final crowns showed great results. The papillae and pseudo-papillae filled the interproximal space. The interproximal contact had to be deeper and wider than normal in order to compensate for the previous vertical bone loss, especially in regions #11 and 12. Nevertheless, no black triangles could be seen, the patient was satisfied and it was expected that with the proper hygiene the aesthetic outcome would be optimised in the next several months. Therefore, there was no need to use gingival ceramics.

Re-entry and prostheses Three months post-operatively, an impression was taken without removing the abutments using special impression screws. The abutments were not removed (except for photographs) until the zirconia abutments had been fabricated. The healed situation showed optimal soft-tissue quality and an adequate quantity of attached gingiva. Above the implant necks, we measured a soft-tissue height of 2–2.5

Discussion In a periodontally compromised situation, it is important to decide whether a curative periodontal treatment offers satisfactory long-term results. As was the case on this occasion, an extraction at the crucial time helps us to preserve what we have, use it to the maximum for implant surgery and risk no further bone loss or recession. Any other procedure would have led to a two-stage surgical approach and probably to a removable prosthesis.

The patient’s thick biotype, particularly the low lip line, was very favourable. The quantity of soft tissue was evident. Tension on the flap closure was prevented through the surgical protocol and free granulation of the wound. The bone quantity ensured primary stability of the implant. The immediate implantation provided stability for the augmentation and reduced the amount of material required. The positioning of the implant allowed us to create an optimal emergence profile, making complicated soft-tissue procedures unnecessary.17–19 Through the positioning of the implants and the free granulation of the extraction wound, we enhanced the soft tissue, a major advantage for the re-entry and prosthesis.20–22

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Figure 9: Aesthetics with temporary bridgework.

Figure 10: Soft-tissue healing three months post-op.

The implants placed have microgrooves of 1 mm in height on the implant neck. This laser-manufactured design imitates biology and promises improved cell adhesion to this surface.

Such modern designs, combined with the advantages of platform switching, result in high-tech products. Modern crestal bone maintenance works by means of the protection of the crestal bone. When implants are placed sub-crestally or crestally, a soft-tissue ring is built up on the platform to protect the bone below. When implants are placed supra-crestally, the implant neck designs secure the crestal bone below through soft-tissue fibre attachment to their necks, implants can be placed closer to each other, cases like this can be treated successfully with single implants, and fibre attachment to the surface and between the implants secures the crestal bone, building a natural barrier.23, 24 In cases in which primary closure is not possible or mobilisation of adjacent soft tissue through other flap designs is not desired, temporary prostheses are essential. The soft-tissue manipulation begins from the very first moment and is crucial for the aesthetic outcome.25–27 Owing to the implants used and the immediate loading, the soft tissue did not have to be manipulated. The implant system allowed us to take the impressions without having to remove the abutments. The

continuous removal and insertion of implant components may introduce bacteria under the soft tissue. Every aesthetic try-in could also be performed on the initial abutments. In this protocol, we only removed the temporary abutments once the fixed single-unit crowns had been fabricated.

The clinical situation at the point of implant loading with the crowns showed optimal soft-tissue quality and quantity. No individual abutments were needed. The aesthetic achieved was more than satisfactory, especially regarding the soft-tissue outcome.13–15 The combination of these biomaterials forms part of our standard augmentation protocol and is well documented. The results of guided bone regeneration are predictable and can be planned, even in case of major defects. The structure of the combined biomaterials is very important. Rocky and edgy particles help to establish internal stabilisation at the augmentation area. Often, external stabilisation with pins or screws is unnecessary. The porosity of the particles is defined by their biology. This is the reason that we do not prefer alloplastic biomaterials and take advantage of the benefits of allografts and xenografts through their combination. These are the requirements of modern biomaterials, including of course osteoinductivity and osteoconductivity.28–30

Figure 11: Soft-tissue quantity and quality before loading.

Figure 12: Soft-tissue healing, coronal view.

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Figure 13: Zirconia abutments before loading.

Figure 14: Fixed single-unit prosthesis.

Conclusion Periodontal disease is frequently a limiting factor in oral implantology, but there are situations in which periodontal disease presents no contra-indication for implantology.

Prerequisites for similar procedures are an understanding and knowledge of biology, surgery and prosthetics. There are no algorithms for such procedures, rather the treatment outcome depends on proper diagnosis, analysis and planning for every individual patient and the selection of the right implant system and biomaterials. As the presented case has shown, modern implantology provides all of the tools for successful implant treatment.

Reprinted with permission by Implants 01/2015

Figure 15: Radiographic control immediately after loading.

24 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 11, NO. 1

Figure 16: Radiographic control one year after loading.

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CLINICAL

Use of ß-tricalcium phosphate for bone regeneration in oral surgery

Giuseppe Galvagna1, Paolo Brunamonti Binello2, Massimo Galli3, Mauro Labanca4

In prosthetic implant rehabilitation, loss of bone volume in atrophic maxillae is one of the major problems faced by surgeons in their clinical practice. In the presence of horizontal and vertical bone defects, atrophic ridges need to be restored to make them suitable for implant placement and for restoration of masticatory and aesthetical functions.

For this reason, in recent years the term “GBR” has been closely associated with the concept of prosthetically guided implantology.

The purpose of this study is to demonstrate the osteoconductive properties of synthetic biomaterials, particularly ßtricalcium phosphate or R.T.R., and its benefit for a suitable GBR.

Introduction In order to obtain effective bone regeneration using natural or synthetic fillers, a series of favourable conditions must occur that allow the body to perform the bone growth15 as follows: 1

Giuseppe Galvagna, Dental practitioner, Catania, Italy 2

Paolo Brunamonti Binello, Consultant Professor, University of Genoa. Galliera Hospital, Genoa, Italy 3

Massimo Galli, Oral surgeon, dental practitioner, Pistoia, Italy Mauro Labanca, Professor of Oral Surgery and Anatomy, Milan, Italy 4

presence of a blood clot with a high concentration of mesenchymal stem cells (MSC) capable of evolving in the osteoblast line and of endothelial cells forming a rich vascular network

-

presence of vital bone tissue, from which osteogenic and angiogenic cells originate through adequately prepared surrounding bone (cortical perforation)

-

stabilization and maintenance of volume underneath the membrane

-

protection of blood clot with a membrane, with the function of the stabilization of the clot, protecting growing vascular structures and blocking the migration of epithelial cells, which proliferate faster than bone cells.

In 1980 Nyman and Karring first introduced the concept of guided tissue regeneration (GTR) of periodontal tissues, showing that the cells of soft tissue can grow faster than bone tissue.10 Thus, based on the results obtained, the migration of

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CLINICAL

soft tissue cells above the implanted material must be

Graft biomaterials

stopped, thereby blocking migration within the porosity of

The alloplastic biomaterials available on the market

the same material, thus promoting osseointegration rather

represent an excellent alternative to autologous bone graft

than fibrointegration. The main characteristic of a

and are classified into two large groups: bioinert and

membrane should be semi-permeability, i.e. the presence

bioactive, according to their interaction when they come

of porosity approximately 22 microns in diameter.

into contact with the receiving site.

Initially, a thin vascular network and a primary fibrous

The main requirement of a synthetic biomaterial is to have

osteoid tissue -also called primary spongiosa- will begin to

a surface porosity that must promote colonization and

form within the clot. The latter is later mineralized thanks to

development within its structure. These porosities must

osteoblasts that cover its surface, forming a new poorly

measure between 200/400 microns in diameter (Lynch et

calcified cortical bone.

al., 2000; Bauer and Muschler, 2000). Synthetic

The process stops when intertrabecular spaces narrow

biomaterials have been the subject of many studies, though

due to the formation of new bone tissue, until they reach

their long term results have not always been considered.1-3

the characteristic dimensions of Havers channel which,

Today, osteoblastic cells or bone morphogenetic proteins

along with concentric lamellae, originate primary

(BMP obtained with in vitro cultures) can be added to a

osteomas. All this occurs during the first 3-4 months, though

graft material4-5 to enhance its osteoinductive and

actual bone remodelling requires more time, as it creates

osteoconductive abilities and therefore reduce the time

secondary spongiosa.

required for cells colonization.6-7

Research conducted by Hämmerle in 199611 on human

Among alloplastic biomaterials, ß-tricalcium phosphate is

subjects confirmed what had previously been observed in

the one that mostly displays a stable bond with bone

animals, i.e. in the presence of large bone defects,

neoformation; indeed, its characteristics have made it

regeneration can be limited to the more peripheral areas

suitable for use in orthopedics since the early 1900s. In the

of the defect, while less activity is observed in the central

presence of H2O it becomes instable, turning into

area, where granules of biomaterial remain over time,

hydroxyapatite, and this characteristic makes it suitable as

though less frequently when tricalcium phosphate is used.

an osteoconductive material (Coetree, 1980, De Leonardis

The process of ossification always starts from the walls of

and Pecora, 1999; 2000).

the defect toward the center of the clot, along the newly

ß-TCP is characterized by a lower Ca/P ratio, which makes it more soluble than natural apatite.

formed vessels.

A number of studies clearly describe the regenerative

The Beta form is commonly obtained by mixing calcitis

ability of autologous bone compared with synthetic

(CC) and dibasic calcium phosphate anhydrous (DCPA).

biomaterials, but unfortunately not without negative aspects.

The product obtained is rapidly cooled, and Alfa-TCP is

Indeed, collection from the donor site is very often painful

obtained.

for the patient; additionally, this results in longer surgical

Conversely,

extended

800/950°C results in the beta form.

repeat

baking

at

9,12,13

procedures and postoperative pain ; finally, the implanted

Multiple studies conducted on the TC and bone

material has a high degree of resorption (not a negligible

interaction have shown that histological examination at four

factor).

months shows an initial bone neoformation in the

The materials used for bone regeneration are grouped

intergranular spaces and in the surface porosity that helps

into: Autogenous bone, allogenic bone, xenogenic bone,

guided bone formation. Indeed, the granules are

alloplastic bone.

reabsorbed by phagocytosis, releasing Ca/Mg and

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phosphates in the surrounding bone tissue, thereby

• Implant defects

activating alkaline phosphatase, a key ossification process.

• Sinus lift procedure

Between 6 and 18 months, fibroblasts begin invading the

• Reconstruction of peri-implant defects

biomaterial, activating the extracellular dissolution process,

• Filling periodontal pockets with two or more walls

which ends with the calcification phase. If this should occur

• Residual cavities after oral surgery (like cyst)

sooner, graft integration, rather than biodegradation, would

• Filling defects after apicectomy

happen.

• Alveolar filling following extraction of impacted teeth.

5-8

R.T.R.

Materials and Methods

Synthetic, biocompatible and totally resorbable 99% pure

We conducted a multicenter study to evaluate the clinical

tricalcium phosphate bone replacement, available in

application of R.T.R. (ß-tricalcium phosphate).

granules and in a cone shape, for regeneration in

This study examines the regeneration of bone defects with

periodontal defects, implant, post-extraction bone defects

R.T.R. (ß-tricalcium phosphate) in patients eligible for

and bone lesions following endodontic surgery.

prosthetic implant rehabilitation. Patients were randomly

The micro and macro-porous R.T.R. structure, with

selected, according to the following key criteria:

macropores measuring between 100 and 400 µm and

-

aged between 20 and 60 years

micropores measuring less than 10 µm.

-

either male or female

These morphological characteristics allow excellent

-

non-smokers

osteogenic cell in-depth colonization and easy compacting.

-

in good general health

Unlike hydroxyapatite, R.T.R. is progressively and totally

-

having at least one crestal bone defect (no morphology and etiopathogenesis restrictions).

reabsorbed, thereby releasing calcium and phosphate ions that participate actively in the formation of new bone

The cases treated were identified in the following clinical

tissue. Over a period of time between 6 and 9 months,

situations:

which may vary according to the patient’s physiological

-

Post-extraction sites

response, while stimulating bone regeneration, R.T.R. is

-

Bone regeneration around implants placed in areas with bone loss or post-extraction.

progressively reabsorbed, leaving space for bone neoformation.

-

GBR (sinus lift or major bone defects).

In all cases, patients received antibiotic therapy with 1 gr Indications:

every 8 h of Amoxicilline plus Clavulanic Acid (starting 24

• Post-extraction sites

hours before surgery up to day 5 post-surgery), repeated

• Filling post-extraction sites to maintain the dimensions of

daily rinses with chlorhexidine and therapy with FANS

alveolar bone

(ibuprofen 800 mg/day in single dose), as necessary.

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Case Report no.1 Patient: Female Age: 30 History: odontogenic cyst in maxillary bone at 2.1.

Cyst was removed in October 2013. Vertical guided 1

2

3

4

regeneration with resorbable membrane and R.T.R. was performed. Implant placement: bone peak follow-up intraoral X-ray in consecutive months. 2nd surgery ISQ value: 61.

Figure 1-4: Different projections of radiographic C.T images show the large bone defect in site 2.1.

Figure 6: X-ray image before grafting.

Figure 7: X-ray image after 5 months.

Figure 10: The ISQ test confirms a good stability of the implant.

Figure 8: X-ray after insertion of the implant.

Figure 5: Temporary prosthesis to cover the cosmetic defect.

Figure 9: The local objective examination and routine radiographic examination showed a good short-term healing.

Figure 11: To obtain a good aesthetics of the final prosthesis is important to condition the soft tissue with the healing screws that favors the emergence profile.

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Case Report no.2 Patient: Female Age: 60 History: large cyst in upper maxillary bone extending from 2.2 to 1.1.

The cyst was removed and the cavity was filled with R.T.R. enhanced with PRGF (platelet-enriched plasma) and simultaneous placement of five implants was also performed.

12

13

Figure 12, 13: Presence of large cysts of 2.1. The oral cavity examination shows a poor oral hygiene.

14

16

15

17

Figure 14, 15: Removal of the cyst; it is very important to remove all residual epithelial.

19

18

Figure 16-18: Filling the bone cavity with granular R.T.R..

20

Figure 19, 20: During the same surgery were included five implants.

Figure 21: X-ray control after five months.

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Case Report no.3 Patient: Female Age: 50 History: severe atrophy of the alveolar ridge, upper right jaw, affecting the area of 1.3, 1.4, 1.5, 1.6.

22

These teeth were extracted and the alveolar ridge was reconstructed with R.T.R., covering biomaterial with Tabotamp (oxidized cellulose).

23

Figure 22, 23: Resorption of the alveolar process caused by periodontal disease. The local examination shows the class III mobility of the teeth.

24

25

26

Figure 24--26: Resorption of the alveolar process caused by periodontal disease. The local examination shows the class III mobility of the teeth.

27

29

31

28

30

32

Figure 27, 28: Use of Tabotamp to cover the graft.

Figure 29, 30: The local examination after 10 days.

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Figure 31, 32: The radiographic image after 4 months showed an increase in the vertical dimensions.

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Case Report no.4 Patient: Female Age: 30 History: root fracture of 1.6, previously treated with root canal treatment and large crown composite reconstruction. The roots

were carefully extracted, and an implant was placed, using the interadicular septum bone and by performing an elevation of the maxillary sinus with osteotomes. The alveoli were filled with R.T.R. and covered with a collagen membrane.

33

34

Figure 33, 34: Fracture of the first molar with the insertion of implant with post-extraction procedure.

35

36

37

Figure 35-37: Extraction was performed with piezosurgery technique to preserve the alveolar bone.

38

39

40

Figure 38-40: The gap was filled using R.T.R.-size cone.

41

42

Figure 41, 42: The intraoral examination and radiographic examination after 4 months showed good integration of the implant.

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Case Report no.5 Patient: Female Age: 64 History: loss of 2.2 and 2.3 due to trauma.

CT revealed a significant resorption of buccal vestibular alveolar process.

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Two implants were placed (measuring 3.3 mm in diameter and 13 mm long) and the gap was filled with R.T.R. Re-opening was done after 5 months and evaluation of osteointegration with Osstel.

2.2 showed a value of 22-ISQ, and 2.3 –ISQ 64.

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45

Figure 43-45: Severe post-traumatic atrophy of the alveolar process in place 2.2- 2.3.

46

47

48

Figure 46, 47: Insertion of two implants with “split-crest” surgical technique.

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Figure 48, 49: The gap between the two margin bone was filled with phosphate-tricalcium R.T.R.

51

53

54

52

Figure 50: X-ray control after 4 months showed a good bone density.

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Figure 51, 52: The intraoral examination does appreciate a good recovery and an increase in bone volume.

Figure 53, 54: The ISQ value confirms a good osseointegration.

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Case Report no.6 Patient: Female Age: 55 History: residual cyst at 3.6. To proceed to prosthetic molar

rehabilitation with an implant, the cyst was extracted and the cavity was filled with R.T.R.; after a 4-month period for bone regeneration, the implant was placed.

55

56

Figure 55, 56: The C.T. examination before surgery showed a residual cyst.

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58

Figure 57, 58: After having removed the cyst, to speed up the healing time, the cavity has been filled with R.T.R. granules.

Figure 59: Wound at 30 days.

Figure 60: X-ray at 3 months.

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Conclusion Based on the results obtained in the short term, the authors confirm the excellent properties of R.T.R., both in the first weeks of healing and in the following months, and they consider it an excellent alternative to autologous bone grafts. No inflammatory reactions or loss of bone volume evaluated clinically and radiographically occurred in any of the cases examined. The most encouraging data came from the observation of the compactness and density of the bone neo-formation, which easily allowed the placement of implants with high ISQ values both during and after the placement of R.T.R. graft.

References 1. Labanca M., Leonida A., Rodella FL: Natural synthetic biomaterial in Dentistry: Science and ethics as criteria for their use. Implantologia 2008; 1:9-23 2. Ohgushi H, Caplan AI: Stem Cell Technology and Bioceramics: From Cell to Gene Engineering. J Biomed Mater Res 48(6): 913-927, 1999 3. Anselme K: Osteoblast adhesion on biomaterals.

Biomaterials 2000 Apr; 21(7):667-81.

4. Toquet J, Roahanizadeh R, Guicheux J, Couillaud S, Passuti N, Daculsi G, Heymann D: Osteogenic. Potential in vitro of human bone marrow cells cultured on macroporous biphasic 5. Maddox E, Zhan M, Mundy GR, Drohan WN, Burgess WH: Optimizing human demineralized bone matrix for clinical application. Tissue Eng 6(4): 441-448, 2000 calcium phosphate ceramic. J Biomed Mater Res. 1999 Jan; 44(1):98-108.

6. Gauthier O, Bouler JM, Aguado E, Pilet P, Daculsi G: Macroporous biphasic calcium phosphate ceramics: influence of macropore diameter and macroporosity percentage on bone ingrowth. Biomaterials 1998 Jan Feb;19(1-3):133-9.

7. Martinetti R, Belpassi A, Nataloni A, Biasini V,

Martignani G: Idrossiapatite porosa sintetica per sostituzioni ossee: Caratterizzazione Chimico-Fisica. Biomateriali: Atti del Congresso; 51 55, Roma Enea, 1999 8. Martinetti R, Belpassi A et al.: Key Engineering Materials Vols. 192-195 (2001), 507-510 – Proceeding of the 13th Int. Symp. On Ceramics in Medicine, Bologna, Italy, 22-26 Nov. 9. Caplan AI: Mesenchymal stem cells. J Orthop Res 9: 641-650, 199 10. Nyman S, Lindhe J, Karring T et Rylander H: New attachment following surgical treatment of human periodontal disease. Journal of Clinical Periodontology 9: 290-296, 1982; 39 11. Hämmerle CH, Brägger U, Bürgin W, Lang NP: The effect of subcrestal placement of the polished surface of ITI implants on marginal soft and hard tissues. Clin Oral Implants Res. 1996 Jun;7(2):111-9 12. Chin M: Distraction Osteogenesis in Maxillofacial Surgery. In Lynch SE, Genco RJ, Marx RE (eds). Tissue Engineering – Application in Maxillofacial Surgery and Periodontics. Illinois; Quintessence Publishing Co, Inc, 1999; 147 13. Arun K. Garg: Grafting Materials in Repair and Restoration. In Lynch SE, Genco RJ, Marx RE, (eds). Tissue Engineering - Application in Maxillofacial Surgery and Periodontics. Illinois; Quintessence Publishing Co, Inc, 1999; 83 14. Scipioni A, Bruschi GB, Calesini G: The edentulous ridge expansion technique: A five-year study. Int J Periodont Rest Dent 14: 451-459, 1994 Trans Tech Publications, Switzerland 15. Schenk RK and Buser D: Osseointegration: a reality.

Periodontology 2000, Vol 17. 1998, 22.35 16. Bauer TW and Muschler GF: Bone graft materials. An overview of the basic science. Clin Orthop Relar Res, 2000 Feb;(371):10-27.

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Are short implants acceptable as an alternative to longer implants with sinus floor elevation in the posterior maxilla?

Johan Hartshorne1

A critical appraisal of a systematic review: D.S. Thoma, M. Zeltner, J. Hüsler, C.H.F Hämmerle, R.E. Jung. Short implants versus sinus lifting with longer implants to restore the posterior maxilla.

European Association of Osseointegration Supplement Working Group 4 – European Association of Osseointegration Consensus Conference 2015.

Clinical Oral Implants Research 00, 2015, 1-16 doi:10.111/clr.12615 Accepted for publication: 13 April 2015 Origin of research – Clinic for Fixed and Removable Prosthodontics and Dental Material Science, University of Zurich, Switzerland

Summary Systematic review conclusion The outcomes of the systematic review demonstrated high implant and reconstruction survival rates for short implants, and sinus floor elevation (SFE) with simultaneous placement of longer implants. Both treatment options are safe and predictable for implant therapy in the posterior maxilla. Biological complications are frequent, but mainly associated with SFE. The increased biological complications, costs and surgical time associated with SFE with longer implants, favors the use of shorter dental implants in the posterior maxilla.

Critical appraisal conclusion The evidence suggests the use of short implants (5 to 8.5 mm long) as an alternative to SFE with longer implants (≥10 mm) for rehabilitation of the posterior maxilla. The outcomes indicate that there are less intra-operative complications when short implants are used. There is limited evidence that less post-operative complications with short implants and prosthesis will occur after loading compared to longer implants with SFE. The evidence presented should be interpreted and applied with caution because studies are limited, not all the important outcomes were measured and the duration of followup was less than 18 months.

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

Implications for clinical practice: Implant treatment options for rehabilitation of the posterior maxilla are dictated by the available alveolar bone height, type of bone and inter-arch space. The evidence suggests that both short implants or SFE with longer dental implants can be recommended for implant therapy in the posterior maxilla presenting with limited alveolar bone height, provided careful case selection and evidence-based clinical protocols are followed. Where short implants are indicated, the best way to compensate for reduced implant surface and to ensure best possible primary stability

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is to use a wider diameter (4 – 6 mm) implant. Until more evidence is available it would be prudent for clinicians to avoid placing short implants in single free-end cases; follow a 2-stage implant surgery approach; allow for longer periods of osseointegration; avoid immediate loading; and consider splinting of prosthesis. Clinical choice of the most appropriate implant therapy modality should be based on assessment of the residual alveolar bone height, width and sinus morphology with a CBCT scan, current scientific evidence, surgical skills and experience of the surgeon, and the patient’s preferences. Following a good surgical protocol and excellent oral hygiene maintenance program are fundamental elements in achieving a successful and predictable outcome.

Data extraction Two authors independently screened the titles and abstracts derived from the search. Eligible articles were then obtained in full text. Disagreements regarding eligibility of studies and data extraction between authors were resolved by discussion and consensus. Cohen’s Kappa coefficient was calculated to measure agreement between the two readers. The primary outcomes were survival rates of implants and reconstructions.

Secondary outcomes included complication rates for implants and reconstructions, radiographic bone levels, as well as patient related outcome measures, surgical time, costs and the feasibility to perform the two procedures.

Are short implants comparable to longer implants with SFE in terms of i) morbidity and surgically related complications ii) clinical and radiographical outcomes?

Method of analysis and Quality assessment Two reviewers independently evaluated the methodological quality of all included studies using the Cochrane Collaboration’s tool for assessing risk of bias in randomized trials. Any disagreement was discussed until consensus was achieved. Survival rates with corresponding 95% confidence intervals (95%CI) were calculated with implants as unit.

Review methodology

Main results

Search strategy An electronic MEDLINE (PubMed) search was performed for controlled clinical studies, published from January 1990 up to 31 October 2014, comparing short implants (≤8 mm) (Group A) to longer implants (>8 mm) with lateral window sinus floor elevation (SFE) (Group B) for rehabilitating the posterior maxilla. The search was limited to the English, German, Italian and French language. The search was complimented by an additional hand search of the selected papers and reviews published between 2011 and 2014.

Reference list of all included publications were screened for relevant studies.

Eight RCTs comparing short implants with longer implants with SFE met the eligibility criteria. Studies were well conducted with respect to randomization, allocation, data collection and reporting, thus resulting in a low risk for selection, attrition and reporting bias. All of the studies presented with a high risk of performance bias due to a lack of blinding of patients and surgeons. Four studies had a high risk of bias from blinding of outcome assessment (detection bias). Surgeons placed implants in specialized clinical settings.

A total of 406 implants were placed in 217 patients with a mean age of 54 years. 197 implants were placed in the short implant group (Group A) and 209 implants in the longer implant with SFE (Group B). Length of short implants varied between 5 and 6 mm, with either, 4, 5, or 6mm diameter. Length of longer implants ranged between 10 and 15 mm. Lateral window SFE in Group B were performed simultaneously with implant placement.

Based on the pooled analyses of longer follow-ups (5 studies, 16–18 months), the survival rate of longer implants with SFE amounted to 99.5% (95% CI: 97.6–99.98%) and for shorter implants 99.0% (95% CI: 96.4–99.8%). For shorter follow-ups (3 studies, 8–9 months), the survival rates

Clinical question

Inclusion criteria Eligible studies were selected based on the following inclusion criteria (i) human trials with a minimum amount of 20 patients, (ii) randomized controlled trials (RCT) or controlled clinical trials (CCT), (iii) short implants with an intrabony length of ≤8 mm, (iv) SFE in combination with longer implants with an intrabony length of >8 mm, (v) screwtype implants with a moderately rough surface, (vi) implants placed within the alveolar bone and the augmented sinus floor, and (vii) patients needed to be examined clinically.

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of longer implants were 100% (95% CI: 97.1–100%) and for shorter implants 98.2% (95% CI: 93.9–99.7%).

Complications were predominantly sinus floor membrane perforations. Patient reported outcomes, i.e. morbidity, surgical time and costs were generally in favor of shorter dental implants.

suggests that both treatment options are reliable and predictably successful. 1, 2

Commentary

Are the results valid?

The individual studies presented with various methodological limitations that could potentially increase risk of bias and thus affect the validity of the evidence.

Inadequate blinding of participants and investigators; short follow-up time; small samples sizes and calculation of sample sizes based on secondary outcomes contributed towards a high risk for bias. Heterogeneity or group imbalances such as using different study designs, assessment tools, differing implant diameters; splinting of reconstructions within and between groups may also potentially affect the estimate of the outcome. The authors did not report whether tests for heterogeneity were conducted.

Overall, the limited number of studies, variation in study design, heterogeneity and limitations in research methodology amongst individual studies could potentially result in increased risk of bias that may affect the estimates of effect and thus affect the validity of the evidence.

Background and importance Alveolar bone height will often fall short of the optimum 10mm in the posterior maxilla due to alveolar bone loss and sinus pneumatization. Clinicians are consequently faced with the challenge of optimizing success and limiting complications when placing implants where there is reduced alveolar ridge height and poor bone quality (type IV) in the rehabilitation of the posterior maxilla.

In cases presenting with reduced alveolar bone height in the posterior maxilla, SFE procedures using either a lateral or crestal approach have traditionally been the treatment of choice to increase bone height to allow the placement of dental implants of optimal length (≥10mm). SFE procedures are however associated with increased risk of complications, higher patient morbidity, longer treatment time and costs, and require advanced skills. To avoid the complications and disadvantages associated with SFE’s, the use of shorter dental implants (<10 mm in length) has been advocated as an alternative treatment option. Simultaneously, implant texture and design have been improved to compensate for situations with compromised bone quality and quantity.

The survival rates, complications and patient related outcomes of short implants in the posterior maxilla have never been compared to those of longer implants in combination with SFE for the same indications. The literature comparing the two treatment options in well-designed controlled clinical trials was scarce for many years, but more recent evidence

What are the key findings?

The pooled survival rates for shorter implants were similar to that of longer implants with SFE. Due to heterogeneity in observation periods, no meta-analysis was conducted for the eight studies combined. The meta-analysis of the pooled data for short-term (8-9 months) (3 studies) and longer term (1618 months) (5 studies) showed high implant and reconstruction survival rates for both the short implant group as well as with longer implants with SFE. The high survival rates should be interpreted with caution due to the relatively short follow-up observation period (maximum 18 months).

Although the survival results were consistent throughout individual studies, the confidence intervals were wide indicating that the estimate of survival of implants was lacking precision. This could be ascribed to the limitations in the research methodology.

In all of the studies, except one, the differences between the two groups with respect to complication rates were statistically insignificant. More intra-operative biological complications were observed in the longer implant group, the most frequent complication being sinus floor membrane perforation. The data in this review suggest that the risk of complications increased by threefold with sinus floor elevation procedures. There were no statistically significant differences in marginal bone level changes between short implants and longer implants with SFE.

Conclusion The analysis demonstrated predictably high implant and reconstruction survival rates for both groups. Given the higher number of biological complications, increased morbidity, costs and surgical time of longer dental implants with SFE, shorter dental implants may represent the preferred treatment alternative.

The authors declared that no funding was provided for the elaboration of this study nor was there potential conflict of interest with respect to the authorship and/or publication of this review.

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Available data indicate less morbidity and greater patient acceptance associated with the use of shorter implants.

Comparison between the two groups is difficult because only four studies reported patient-related outcome data. To complicate matter further, different assessment tools were used.

Qualitative analysis of descriptive statistics were further hampered due to small sample sizes, different study designs and variations in intervention within same populations (i.e. number of implants placed) The single study that assessed surgical time and costs.3 showed that surgical time increased by 50% when a SFE procedure was performed compared to just using a short dental implant. It can be inferred that increased surgical time may be associated with the increase in morbidity, complication rate and negative patient-related outcomes. Shorter implants accounted for only half the costs compared to longer implants with SFE. Although the availability of data was limited, patient-reported outcomes, morbidity, costs and surgical time were all in favor of shorter dental implants.

Most of the studies included in the review did not report on all the secondary outcomes. Only three studies reported on changes in marginal bone levels, and four provided data on patient-related outcome measures. The four studies reporting on patient-related outcome lacked standardization in methods and criteria thus ruling out an appropriate comparative analysis.

Important patient-related outcomes such as post-operative pain or discomfort, morbidity, impact on quality of life, surgical time and costs were largely not reported on.

Secondary outcomes were only reported on descriptively and not subjected to meta-analysis. No data was provided on initial alveolar bone height, alveolar ridge width, type of bone, systemic conditions, smoking habits, periodontal health, para-functional habits, sinus morphology and interarch relations. These variables may be critical to clinical decision-making.

The evidence reported in this review supports that of a previous systematic review, namely that there is not enough evidence to show whether SFE techniques are more or less successful in reducing the implant and prosthetic failures when compared to simply using short implants, up to one year after loading and that there were fewer complications when short implants were used without SFE.4 How are the results of this review applicable in clinical practice?

Increasing implant and prosthesis success rates, minimizing complications and morbidity, and improving patient acceptance and satisfaction with implant therapy are key

factors in clinical decision-making. For the patient, costs and limiting surgical interventions and associated discomfort also play an important role when making choices between treatment options.

Considering that SFE requires more treatment time, greater costs, have more complications and more advanced surgical skills, the use of shorter dental implants may open dental implant therapy to a broader spectrum of clinicians and subsequently a broader patient population may benefit from this treatment option. Clinicians may elect to use short implants in cases where SFE are contra-indicated (i.e. chronic sinusitis, abnormal sinus morphology, smoking), provided there is adequate alveolar bone volume (â&#x2030;Ľ 5 mm).

Implant surface roughness and increasing the diameter of the implant for achievement of sufficient primary stability at time of implant placement may contribute to the long-term survival of the implant and prosthesis.5 Proper case selection is essential to achieve a predictable and successful outcome, irrespective of which choice of treatment is selected. Cone beam computed tomography (CBCT) is critical tool for proper case selection and treatment planning. Important factors that must be considered include: patient related factors (systemic conditions, smoking habits, periodontal health, para-function); biological factors (residual alveolar bone height, alveolar bone width, bone quality and sinus morphology); surgical considerations (one or two stages, skills of the surgeon; and prosthetic considerations (splinted or not).

Clinical resolution Today, both patients and practitioners demand simplified, minimally invasive, affordable and predictable approaches to increase acceptance and success of implant therapy.

Restoring the edentulous maxilla with dental implants is challenging due to reduced residual alveolar bone and proximity of the maxillary sinus. Short implant can be a successful minimally invasive treatment alternative to placing longer implants with SFE in cases where the alveolar bone height in the posterior maxilla is â&#x2030;Ľ 5mm. Using short implants in the posterior maxilla with reduced alveolar ridge height has several advantages for the patient including less surgical intervention and intra-operative complications, reduced waiting period for treatment completion and less costs. It may also render implant treatment accessible to a larger pool of patients. The evidence presented in this systematic review offers modest evidence for placement and restoration of short implants so long as clinicians understands the limitations, indications and risk factors thereof. The results from this

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review should however be interpreted with caution due to lack of good quality studies and longer follow-up. SFE may still be the procedure of choice for surgeons that do not elect to use short implants or when short implants are contraindicated. The use of short implants is promising but there are still many unanswered questions that require more research. Firstly, we do not know what the long-term success rates of short implants are from a biological and prosthetic perspective. Secondly, what is the optimum bone-to-implant contact surface (implant geometry, length and width) that will ensure the best primary and secondary stability, and a predictable and successful osseointegration. Further controversies include whether short implants should be used single or two-stage, should longer time for healing and bone maturation be allowed before loading, and should prosthesis on short implants be splinted?

Disclosure and Disclaimer 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.

References 1. Esposito M, Cannizzaro G, Soardi E, Pistilli R, Piattelli M, Corvino V, Felice P. Posterior atrophic jaws rehabilitated with prostheses supported by 6 mm-long, 4 mm-wide implants or by longer implants in augmented bone.

Preliminary results from a pilot randomized controlled trial.

European J Oral Implantol 2012; 5: 19â&#x20AC;&#x201C;33.

2. Gulje FL, Raghoebar GM, Vissink A, Meijer HJ. Single crowns in the resorbed posterior maxilla supported by either 6-mm implants or by 11-mm implants combined with sinus floor elevation surgery: a 1-year randomized controlled trial.

European J Oral Implantol 2014; 7: 247â&#x20AC;&#x201C;255.

3. Thoma DS, Haas R, Tutak M, Garcia A, Schincaglia GP, Hammerle CHF. Randomized controlled multicenter study comparing short dental implants (6mm) versus longer dental implants (11-15 mm) in combination with sinus floor elevation procedures . Part I: demographics and patient-reported outcomes at 1 year of loading. J Clin Periodontol 2015; 42: 72-80.

4. Esposito M, Felice R, Worthington HV. Interventions for replacing missing teeth: augmentation procedures of the maxillary sinus. Cochrane Database of Systematic Reviews.

2014, Issue 5.

Art.No: CD008397.

DOI: 10.1002/14651858. CD008397.pub2.

5. Javea F, Romanos GE. Role of implant diameter on longterm survival of dental implants placed in the posterior maxilla: a systematic review. Clin Oral Investigations 2015; 19(1): 1-10

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Cone beam computed tomography: a new era in diagnosis and treatment planning Mohamed Fayad1

1

Mohamed Fayad DDS MS PhD Director of endodontic research and a clinical assistant professor at the UIC College of Dentistry.

Private Practice, Chicago, USA

Clinical examination and diagnostic imaging are both essential components of endodontic preoperative diagnosis and treatment planning. Clinical examination must be carried out before considering any radiographic examination. Accurate diagnostic imaging supports the clinical diagnosis and allows the clinician to better visualise the area in question. Preoperative imaging is an essential part of endodontic practice, from diagnosis and treatment planning to outcome assessment.

Conventional two-dimensional radiographs continue to be the most popular method of imaging today. However, the diagnostic potential of periapical radiographs is limited. Information may be difficult to interpret, especially when the anatomy and background pattern is complex. Intraoral radiographs have inherent limitations due to the compressed three-dimensional structures in a two-dimensional image. Interpreting the film-based radiograph or digital image continues to be a somewhat subjective process. Goldman and colleagues showed that the agreement between six examiners was only 47% when evaluating healing of periapical lesions using two-dimensional periapical radiographs (1972). In a follow-up study, Goldman and colleagues also reported that when examiners evaluated the same films at two different times, they only had 19%-80% agreement with their previous interpretations (1974). In a recent study, interobserver and intraobserver reliability in detecting periradicular radiolucency by using a digital radiograph system was evaluated. Agreement among all six observers for all radiographs was less than 25%, and agreement for five of six observers was approximately 50% (Tewary, Luzzo and Hartwell, 2011).

New radiographic imaging systems have recently become available for use in dentistry. Among these new imaging technologies is cone beam volumetric tomography (CBVT). In 2000, the US Food and Drug Administration approved the first cone beam computed tomography (CBCT) unit for dental use in the USA. CBCT systems are available in different field of views (FOV): CBCT limited (dental) ranges in diameter from 40-100mm or full (ortho or facial) CBCT ranges from 100-200mm. The voxel size is generally smaller for the limited version (0.1-0.2mm vs 0.3-0.4mm), thus offering higher resolution and greater utility for endodontic applications. For endodontic application, the limited field of view is the most acceptable as it is capable of providing images at a low radiation dose and with sufficient spatial resolution for applications in endodontic diagnosis and treatment planning.

The advent of CBCT can overcome these issues by visualising the dentition and the relationship of anatomic structures in three dimensions. CBCT units reconstruct the projection data to provide interrelational images in three orthogonal planes (axial, sagittal and coronal). For most endodontic applications, limited or focused FOV CBCT is preferred over large volume CBCT. This article will review the utilisation of CBCT in endodontic diagnosis and management of periapical pathology, diagnosis of pain, cracked teeth and vertical root fractures, internal and external resorptive defects.

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Figure 1: Patient presented for diagnosis of a non-localised pain in the left quadrant. Periapical radiographs of the upper and lower quadrants were inconclusive (A and B). All vitality, periodontal and palpation tests were WNL. Tooth #14 was slightly tender to percussion. Anaesthetic test was performed by administering 2% lidocaine 1:100:1000. Pain was not relieved. CBCT was taken for both quadrants; C is a sagittal view of tooth #18 demonstrating an internal resorptive defect in the distal root. Line in C represents the axial section in E; D is a three-dimensional reconstruction of the cropped distal root showing the extent of the resorptive defect; F is a clinical image of a distal crack that extends into the distal canal

Figure 2: This represents the complex anatomy of tooth #18 that was referred for root canal therapy. A – axial view of the mesial and distal roots of tooth #18. Note the mid-mesial canal in the mesial root (black arrow); B is a three-dimesional rendering of tooth #18 demonsttrating the mid-mesial canal (blue arrow); C – coronal view of tooth #18 demonstarting the complexity of the three mesial canals (red arrow); D is a working length measurement of the three mesial canals; E is postoperative axial view demonstrating the root canal fillings in three mesial canals; F – three-dimensional rendering and coronal view demonstrating the root canal filling in the mesial canals. Note the similarity from the preoperative coronal view in C; G – three-dimensional rendering

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Imaging application While there are presently no definitive patient selection criteria for the use of CBCT in endodontics, the use of CBCT in endodontic diagnosis and treatment should not be avoided or ignored. In May 2015, an updated joint position statement of the American Association of Endodontists and the American Academy of Oral and Maxillofacial Radiology was published, with the intention of providing scientifically based guidance to clinicians regarding the use of cone beam computed tomography in endodontic treatment and reflect new developments since the 2010 statement. The updated statement addressed the potential applications of cone beam computed tomography in different phases of treatment.

Potential applications of cone beam computed tomography in endodontic practice are as follows.

Utilisation of cone beam computed tomography in endodontic diagnosis of pain and detection of periapical lesions Endodontic diagnosis is dependent upon evaluation of the patientâ&#x20AC;&#x2122;s chief complaint, medical and dental history, clinical and radiographic examination. Preoperative imaging is an essential part of endodontic practice, from diagnosis and treatment planning to outcome assessment.

CBCT imaging has the ability to detect periapical pathology prior to being apparent on two-dimensional radiographs (De Paula-Silva et al, 2009). This was validated in clinical studies in which periapical periodontitis detected in intraoral radiographs and CBCT was 20% and 48% respectively (Patel et al, 2012). Ex vivo studies in which simulated periapical lesions were created showed similar findings (Sogur et al, 2012; Patel et al, 2009a).

Diagnosis of pain is a challenging process for the clinician prior to and after treatment. In challenging diagnostic pain cases, the clinical and radiographic evaluation of the patient is inconclusive. Inability to determine the aetiology of the pain can be attributed to the limitations in both clinical vitality testing and intraoral radiographs to detect the aetiology of the source of the pain.

Persistent pain following root canal therapy presents with a diagnostic challenge to the clinician. Atypical odontalgia (AO) is an example of persistent dentoalveolar pain (Nixdorf and Moana-Filho, 2011). The diagnostic yield of intraoral radiographs and CBCT was evaluated in the differentiation between patients presenting with apical periodontitis and suspected AO without the evidence of periapical bone

destruction. CBCT imaging detected 17% more teeth with apical bone loss (apical periodontitis) than intraoral radiographs (Pigg et al, 2011). Figure 1 is an example of a case that presented with non-localised pain. CBCT imaging information was able to aid in the determination of the aetiology of the odontogenic pain.

Utilisation of cone beam computed tomography in preoperative anatomy assessment The success of endodontic treatment depends on the identification of all root canal systems so that they can be treated. The efficacy of CBCT as a modality to accurately explore tooth anatomy and identify the prevalence of a second mesiobuccal canal (MB2) in maxillary molars when compared to the gold standard (clinical and histologic sectioning) has been well documented (Blattner et al, 2010; Michetti et al, 2010). CBCT showed higher mean values of specificity and sensitivity when compared to intraoral radiographic assessments in the detection of the MB2 canal (Vizzotto et al, 2013). Figure 2 is an example of using the three-dimensional rendering in determining the presence and location of canals in lower mandibular molar (UR8) prior to root canal therapy.

Utilisation of cone beam computed tomography in endodontic diagnosis and detection of cracked teeth and vertical root fracture Two-dimensional radiographs are of limited value for the diagnosis of VRFs and usually only provide indirect evidence of the presence of a VRF. Several studies have demonstrated the validity of utilising CBCT to detect VRFs. In a comparative study evaluating the sensitivity and specificity of CBCT and periapical radiographs (PR) in detecting VRFs, sensitivity and specificity for VRF detection of CBCT were 79.4% and 92.5% and for PR were 37.1% and 95%, respectively. The same study reported that the specificity of CBCT was reduced in the presence of root canal filling material (Hassan et al, 2009). Higher sensitivity and specificity were observed in a clinical study where the definitive diagnosis of vertical root fracture was confirmed at the time of surgery to validate CBCT findings, with sensitivity being 88% and specificity 75% (Edlund, Nair and Nair, 2011).

Several case series studies have concluded that CBCT is a useful tool for the diagnosis of vertical root fractures. In vivo and laboratory studies (Metska et al, 2012; Brady et al, 2014) evaluating CBCT in the detection of vertical root fractures agreed that sensitivity, specificity, and accuracy of

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CBCT were generally higher and reproducible. The detection of fractures was significantly higher for all CBCT systems when compared to intraoral radiographs. However, these results should be interpreted with caution because detection of vertical root fracture is dependent on the size of the fracture, presence of artifacts caused by obturation materials and posts, and the spatial resolution of the CBCT. In a recent study, the diagnostic ability of a CBCT scan to assess longitudinal root fractures in prosthetically treated teeth was evaluated (Melo et al, 2010). The presence of guttapercha or cast-gold posts reduced the overall sensitivity and specificity. This was attributed to star-shaped streak artifacts that mimics fracture lines in axial spatial views.

One significant problem, which can affect the image diagnostic quality and accuracy of CBCT images, is the scatter and beam hardening caused by high density neighboring structures, such as enamel, metal posts and restorations. If this scattering and beam hardening is associated close to or with the tooth being assessed, the overall sensitivity and specificity is dramatically reduced.

Clinically, a thorough dental history, classic clinical and radiographic signs and symptoms such as pain, swelling,

presence of a sinus tract and/or presence of an isolated deep periodontal pocket can be helpful hints to suggest the presence of a VRF. Radiographically, a combination of periapical and lateral root radiolucency ‘halo’ appearance is valuable information, indicating the possible presence of VRF. Several of the previously mentioned clinical and radiographic elements have to align to establish a presumptive diagnosis of VFR (Tsesis et al, 2010); however, dye examination, usually requiring surgical exposure, is still the gold standard for diagnosis of VRF. In a case series, the following five findings on CBVT exam were consistent with confirmed VRF (Fayad, Ashkenaz and Johnson, 2012): 1) loss of bone in the mid-root area with intact bone coronal and apical to the defect; 2) absence of the entire buccal plate of bone in axial, coronal and/or three-dimensional reconstruction; 3) radiolucency around a root where a post terminates; 4) space existing between the buccal/or lingual plate of bone and fractured root surface; 5) visualisation of the VRF on the CBCT spatial projection views. Figures 3, 4 and 5 are different examples of the sensitivity of CBCT imaging in the diagnosis of cracked teeth and VRF. Figure 3: A – periapical radiograph of tooth #30. B – coronal view of the distal root demonstrating the space between the distal root and the buccal cortical plate (black arrow); C – axial view of the distal root demonstrating the space between the distal root and the buccal cortical plate (white arrow); D – three-dimensional reconstruction of the distal root demonstrating the space between the distal root and the buccal cortical plate; E – clinical digital image after surgical sectioning and extraction and confirmation of distal root VRF

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Figure 4: A – periapical radiograph of tooth #30. B – three-dimensional reconstructed view demonstrating the mid-root buccal defect (blue arrow). Lines correspond to the axial section views (C–E). Note axial view demonstrating the mid-root buccal bone loss (white arrow) in D

Utilisation of cone beam computed tomography in nonsurgical and surgical treatment planning Diagnostic information directly influences treatment planning and clinical decisions. Accurate data leads to better treatment decisions and potentially more predictable outcomes (Liang et al, 2011). Ee and colleagues compared endodontic treatment planning with CBCT and periapical radiography (2014). Thirty endodontic cases completed in a private endodontic practice were randomly selected to be included in this study. Each case was required to have a preoperative digital periapical radiograph and a CBCT scan. Three board certified endodontists reviewed the 30 preoperative periapical radiographs. Two weeks later, the CBCT volumes were reviewed in random order by the same evaluators. The evaluators were asked to select a preliminary diagnosis and treatment plan based solely on interpretation

of the periapical and CBCT images. Diagnosis and treatment planning choices were then compared to determine if there was a change from the periapical radiograph to the CBCT scan.

Under the conditions of the previous study, CBCT was a more accurate imaging modality for diagnosis of endodontic pathology when compared to diagnosis using only periapical radiographs. An accurate diagnosis was reached in 36.6% to 40% of the cases when using periapical radiographs compared to an accurate diagnosis in 76.6% to 83.3% of the cases when using CBCT. This high level of misdiagnosis is potentially clinically relevant, especially in cases of invasive cervical root resorption and vertical root fracture where a lack of early detection could lead to unsuccessful treatment and tooth loss. The previous study also demonstrated that the treatment plan may be directly

Figure 5: A – coronal view demonstrating the mid-root buccal bone loss (white arrow); B – surgical exploration and confirmation of VRF. Note the granulation tissue at mid-root level (black arrow) coinciding with CBVT images in Figure 9; C – surgical degranulation of the defect demonstrating the VRF in the mesial root (arrow)

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Figure 6: A – a periapical radiograph of teeth #7 and 8. Treatment was initiated on both teeth before referral to an endodontist.

Treatment was initiated on both teeth (initial treatment #7 and retreatment attempt on #8); B – a clinical picture showing normal soft tissue color and architecture; C and D are sagittal CBVT images showing buccal perforations on teeth #7 and 8, respectively

influenced by information gained from a CBCT scan as the examiners altered their treatment plan after viewing the CBCT scan in 62.2% of the cases overall (range from 56.6% to 66.7%). This high number indicates that CBCT had a significant influence on the examiners’ treatment plan (Figures 6 and 7).

The use of CBCT has been recommended for treatment planning of endodontic surgery (Venskutonis et al, 2015; Bornstein et al, 2011; Low et al, 2008). CBCT visualisation of the true extent of periapical lesions and their proximity to important vital structures and anatomical landmarks is

superior to that of periapical radiographs.

The use of CBCT has enabled the clinician to evaluate the true extent of the periapical lesion and their spatial relationship to important anatomical landmarks and vital structures (Figures 8-10).

Utilisation of cone beam computed tomography in endodontic diagnosis and detection of inflammatory restorative defects Diagnosis and detection of root resorption is often challenging due to the quiescent onset nature and varying

Figure 7: Continued: A and B are three-dimensional reconstructions showing the buccal perforations on teeth #7 and 8 (black and blue arrows); C – reflection of a full-thickness mucoperiosteal flap confirmed the presence of perforations on both teeth. The perforations were repaired with Geristore (Denmat). Both teeth were then treated via an orthograde approach with subsequent surgical root end resection and filling of tooth #8; D and E – one-year recall radiograph demonstrating soft and hard tissue healing

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Figure 8: A – periapical radiograph of tooth #3 that was referred for periapical surgery. A non-surgical retreatment attempt was performed prior to periapical microsurgery. Mesiopalatal canal was blocked. The black line corresponds to the level of the axial view in E; B – sagittal view demonstrating the extent of the periapical defect; C – three-dimensional rendering of the periapical defect; D – clinical picture demonstrating the endodontic/periodontal communication; E – axial view of the mesial, distal and palatal roots. Note the fused distal and palatal roots; F and G are the coronal view of the mesial root and the fused distal-palatal roots respectively

Figure 9: Continued: A – three-dimensional rendering demonstrating the periodontal defect at the marginal bone (black arrow); B – after flap reflection demonstrating the periodontal defect communicating with the periapical defect (blue arrow); C – root resection of the fused distal and palatal roots prior to ultrasonic preparation; D – MTA root end filling of the ultrasonically prepared distal and palatal preparation; E – periodontal and periapical defects grafted with Puros allograft (Zimmer Dental) material; F – grafted defect covered with Copios membrane (Zimmer Dental)

clinical presentation. Definitive diagnosis and treatment planning is ultimately dependent on the radiographic representation of the disease. Two-dimensional imaging

offers a limited diagnostic potential when compared to threedimensional imaging (Estrela et al, 2009; Durack et al, 2011) (Figures 11-13).

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Figure 10: Continued: A1, 2 3 and 4 – immediate surgical CBCT scan. Note buccal defect (red and yellow arrows); B1, 2, 3, and 4 – six months recall CBCT scan. Note the initial regeneration of the defect including the buccal cortical plate; C1, 2, 3, and 4 – oneyear recall CBCT scan demonstrating complete remodeling of the defect and the buccal plates (red and yellow arrows)

Figure 11: A is a periapical radiograph of tooth #14 that was referred for experiencing spontaneous pain as well as temperature sensitivity. Clinical testing revealed an irreversible pulpitis and symptomatic apical periodontitis; B – CBCT sagittal view of tooth #14 showing an invasive cervical resorptive defect (ICR) class IV that cannot be detected on the periapical radiograph; C – axial view demonstrating the palatal and mesial location of the defect; D is a coronal view demonstrating the internal aspect of the (ICR) rendering tooth #14 non-restorable. Change in treatment plan was made and patient was referred for extraction

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Figure 12: Patient was referred for evaluation and treatment of an internal resorptive defect on tooth #9. A is a periapical radiograph of tooth #9. The three lines correspond to the axial section views in D, E and F. Note mid-root radiolucency; B is a three-dimensional reconstruction of maxillary anterior teeth demonstrating the internal resorptive defect (black arrow); C is a sagittal view of tooth #9 with the 3.3x4.8mm dimension measurement of the defect; D, E, and F are axial views of tooth #9. Note the normal canal anatomy coronal and apical sections to the defect (D and F). The maximum width of the defect is demonstrated in axial view (E)

Conclusion Several studies have evaluated the use of CBCT in endodontics (Patel et al, 2015; Cotton et al, 2007; Patel et al, 2009b; Patel, 2009; Scarfe, Farman and Sukovic, 2006; Nair and Nair, 2007). Cone beam computed tomography overcomes many of the limitations of periapical radiography. The increased diagnostic information provided by a CBCT image should result in more accurate diagnosis and improved decision-making for the management of complex endodontic problems. It is a desirable addition to the endodontistâ&#x20AC;&#x2122;s armamentarium.

The effective radiation dose to patients when using CBCT

is higher than conventional two-dimensional radiography and the benefit to the patient must therefore outweigh any potential risks of the additional radiation exposure. Radiation dose should be kept as low as reasonably achievable (ALARA) (Farman and Farman, 2005a; Farman, 2005b).

The value of CBCT for endodontic diagnosis and treatment planning should be determined on an individual basis to assure that the benefit/risk assessment supports the use of CBCT. Reprinted with permission by Endodontic Practice December 2015

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4 Year Recall Figure 13: Continued: A is a coronal view for a four-year recall of tooth #9 and healing of a apicoectomy on tooth #8 that was performed earlier; B, E and F are three-dimensional reconstruction of tooth #9; E and F are three-dimensional templates constructed to determine the interface and adaptability of the root canal filling to the resorptive defect canal walls; C is a sagittal view of the final root canal filling

References Goldman M, Pearson AH, Darzenta N (1972) Endodontic success: who’s reading the radiograph? Oral Surg Oral Med Oral Pathol. 33:432–7. 2 Goldman M, Pearson AH, Darzenta N (1974) Reliability of radiographic interpretation. Oral Surg Oral Med Oral Pathol. 38:287–93. 3 Tewary S, Luzzo J, Hartwell G (2011) Endodontic radiography: Who is reading the digital radiograph? J Endod. 37:919-21 American Association of Endodontics, American Academy of Oral and Maxillofacial Radiology (2015) Joint Position Statement: Use of cone beam computed tomography in endodontics 2015 update. J Endod. 41(9):1393-6 De Paula-Silva FW, Wu MK, Leonardo MR, da Silva LA, Wesselink PR (2009) Accuracy of periapical radiography and cone-beam computed tomography scans in diagnosing apical periodontitis using histopathological findings as a gold standard. J Endod. 35(7):1009-12 Patel S, Wilson R, Dawood A, Mannocci F (2012) The Detection of periapical pathosis using periapical radiography and cone beam computed tomography – part 1: preoperative status. Int Endod J. 8:702-10 Sogur E, Grondahl H, Bakst G, Mert A (2012) Does a combination of two radiographs increase accuracy in detecting acid-induced periapical lesions and does it

approach the accuracy of cone-beam computed tomography scanning. J Endod. 38(2):131-6 Patel S, Dawood A, Mannocci F, Wilson R, Pitt Ford T (2009a) Detection of periapical bone defects in human jaws using cone beam computed tomography and intraoral radiography. Int Endod J. 42(6):507-15 Nixdorf D, Moana-Filho E (2011) Persistent dento-alveolar pain disorder (PDAP): Working towards a better understanding. Rev Pain. 5(4):18-27 Pigg M, List T, Petersson K, Lindh C, Petersson A (2011) Diagnostic yield of conventional radiographic and conebeam computed tomographic images in pa-tients with atypical odontalgia. Int Endod J. 44(12):1365-2591 Blattner TC, Goerge N, Lee CC, Kumar V, Yelton CGJ (2010) Efficacy of CBCT as a modality to accurately identify the presence of second mesiobuccal canals in maxillary first and second molars: a pilot study. J Endod. 36(5):867-70 Michetti J, Maret D, Mallet J-P, Diemer F (2010) Validation of cone beam computed tomography as a tool to explore root canal anatomy. J Endod. 36(7):1187-90 Vizzotto MB, Silveira PF, Arús NA, Montagner F, Gomes BP, Da Silveira HE (2013) CBCT for the assessment of second mesiobuccal (MB2) canals in maxillary molar teeth: effect of voxel size and presence of root filling. Int Endod J. 46(9):870-6 Hassan B, Metska ME, Ozok AR, van der Stelt P,

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Wesselink PR (2009) Detection of vertical root fractures in endodontically treated teeth by a cone beam computed tomography scan. J Endod. 35:719–22 Edlund M, Nair MK, Nair UP (2011) Detection of vertical root fractures by using cone-beam computed tomography: a clinical study. J Endod. 37(6):768–72 Metska ME, Aartman IH, Wesselink PR, Özok AR (2012) Detection of vertical root fracture in vivo in endodontically treated teeth by cone-beam computed tomography scans. J Endod. 38(10):1344-7 Brady E, Mannocci F, Wilson R, Brown J, Patel S (2014) A comparison of CBCT and periapical radiography for the detection of vertical root fractures in non-endodontically treated teeth. Int Endod J. 47(8):735-46 Melo SLS, Bortoluzzi EA, Abreu M, Correa LR, Correa M (2010) Diagnostic ability of a cone-beam computed tomography scan to assess longitudinal root fractures in prosthetically treated teeth. J Endod. 36:1879-82 Tsesis I, Rosen E, Tamse A, Taschieri S, Kfir A (2010) Diagnosis of Vertical Root Fractures in Endodontically Treated Teeth Based on Clinical and Radiographic Indices: A Systematic Review. J Endod. 36:1455-58 Fayad MI, Ashkenaz PJ, Johnson BR (2012) Different Representations of Verti-cal Root Fractures Detected by ConeBeam Volumetric Tomography: A Case Series Report. J Endod. 10:1435–1442 Liang YH, Li G, Wesselink PR, Wu MK (2011) Endodontic outcome predictors identified with periapical radiographs and cone-beam computed tomography scans. J Endod.

37:326-331 Ee J, Fayad MI, Johnson BR (2014) Comparison of endodontic diagnosis and treatment planning decisions using cone-beam volumetric tomography versus periapical radiography. J Endod. 40:910-6 Venskutonis T, Plotino G, Tocci L, Gambarini G, Maminskas J, Juodzbalys G (2015) Periapical and Endodontic status scale based on periapical bone lesions and endodontic treatment quality evaluation using conebeam computed tomography. J Endod. 41(2):190-6 Bornstein MM, Lauber R, Pedram Sendi P, Arx T (2011)

Comparison of Periapical Radiography and Limited ConeBeam Computed Tomography in Mandibular Molars for Analysis of Anatomical Landmarks before Apical Surgery. J Endod. 37(2):151-7 Low KM, Dula K, Bürgin W, Arx T (2008) Comparison of periapical radiography and limited cone-beam tomography in posterior maxillary teeth referred for apical surgery. J Endod. 34(5):557-62 Estrela C, Bueno MR, De Alencar AH, Mattar R, Valladares Neto J, Azevedo BC, De Araújo Estrela CR (2009) Method to evaluate Inflammatory Root Resorption by using Cone Beam computed tomography. J Endod.

35(11):1491-7 Durack C, Patel S, Davies J, Wilson R, Mannocci F (2011) Diagnostic accuracy of small volume cone beam computed tomography and intraoral periapical radiography for the detection of simulated external inflammatory root resorption.

Int Endod J. 44(2):136-47 Patel S, Durack C, Abella F, Shemesh H, Roig M, Lemberg K (2015) Cone beam computed tomography in Endodontics: a review. Int Endod J. 48:3-15 Cotton TP, Geisler TM, Holden DT, Schwartz SA, Schindler WG (2007) Endodontic applications of cone-beam volumetric tomography. J Endod. 33:1121-32 Patel S, Dawood A, Whaites E, Pitt Ford T (2009b) New dimensions in endodontic imaging: part 1. Conventional and alternative radiographic systems. Int Endod J. 42:447-62 Patel S (2009) New dimensions in endodontic imaging: part 2. Cone beam computed tomography. Int Endod J. 42:463-75 Scarfe WC, Farman AG, Sukovic P (2006) Clinical applications of cone-beam computed tomography in dental practice. J Can Dent Assoc. 72:75-80 Nair MK, Nair UP (2007) Digital and advanced imaging in endodontics: a review. J Endod. 33:1-6 Farman AG, Farman TT (2005a) A comparison of 18 different x-ray detectors currently used in dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 99: 66-71 Farman AG (2005b) ALARA still applies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 100:395-7

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Making sense of mouth ulceration: recurrent aphtous stomatitis Crispian Scully1

Recurrent aphthous stomatitis Recurrent mouth ulcers are often aphthae (recurrent aphthous stomatitis), but there are other causes. Recurrent aphthous stomatitis (RAS) is: • Round or ovoid • Often familial • Usually present from youth • Likely to ameliorate with age • Seen in otherwise healthy people.

Patients with RAS are otherwise healthy but a minority of patients have ulcers in association with: • Menstruation • Stress • Lack of smoking.

A minority of people that suffer recurrent oral ulceration prove to have systemic disease – this is then termed aphthous-like ulceration (ALU), not RAS. There are three clinical patterns of RAS, which suggests the condition is heterogeneous in aetiology. The three main types are: minor aphthae (MiRAS); major aphthae (MaRAS), and herpetiform aphthae (HeRAS).

1. Minor aphthae (MiRAS) Features of minor aphthae (such as Mikulicz’s aphthae – Figure 1) include: • Round or ovoid in shape • 2-4mm diameter • Up to six ulcers • Affect mobile mucosae • Duration of seven to 10 days • No scars.

2. Major aphthae (MaRAS) Features of major aphthae (periadenitis mucosa necrotica recurrens or Sutton’s aphthae – Figure 2) include: • Up to six ulcers • Affect any mucosae • Duration of up to months • Deeper • More persistent • Scarring.

1

Professor Crispian Scully CBE FMedSci DSc FDS MD is professor emeritus at UCL, London, King James IV professor at the Royal College of Surgeons, Edinburgh, Harley Street Diagnostic Centre, 16 Devonshire Street and 19 Wimpole Street, London.

3. Herpetiform aphthae Features of herpetiform aphthae (Figure 3) include: • Up to 100 ulcers • Pinpoint ulcers fuse, giving ragged ulcers • Affect any mucosae • Duration of seven to 10 days.

Aetiology, diagnosis and therapy The aetiology of RAS is unclear but there is altered immune response induced by genetic causes. A Toll-like receptor (TLR2) involved in control of epithelial barrier integrity may be involved. T regulatory lymphocytes CD4 (+) CD25 (high) are both functionally and quantitatively compromised and indoleamine 2,3-dioxygenase (IDO) expression in oral mucosa decreased, reducing local immune tolerance.

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Figure 1: Recurrent aphthous stomatitis

Figure 2: Major aphthae

There is also enhanced expression of several helper T lymphocyte genes, such as IFNγ, TNF, and IL-15 (interleukin) and an abnormal cytokine cascade, leading to enhanced cellular and innate immune responses with T-cells and neutrophils invading the epithelium, leading to ulceration.

RAS diagnosis is clinical but it is important to exclude systemic disease clinically and with investigations. Blood tests should include: • Full blood picture (FBP) • Erythrocyte sedimentation rate (ESR)/CRP • Haematinics (iron, folate, vitamin B12) • Transglutaminase.

Microbial studies and biopsy should also be considered. There is no curative treatment for RAS, and treatment aims are to minimise pain, reduce ulcer number and size and increase disease-free periods.

RAS therapy is usually use of topical agents, especially corticosteroids. In severe ulceration, systemic drugs that may help include: • Corticosteroids • Colchicine • Calcineurin inhibitors • Dapsone • Thalidomide • Anti-TNF biologics.

Innovative measures include use of: • Aloe vera • Bee propolis • Clofazamine • Fumaric acid esters • Lavender oil • Montelukast • Raw egg white • Vitamin B12.

• • • •

Aphthous-like ulceration Aphthous-like ulceration (ALU) can result from:

Auto-inflammatory (periodic) syndromes Behçet syndrome (and complex aphthosis) Crohn/orofacial granulomatosis (OFG) Deficiencies – Haematinic – Immune – any immune defect, including HIV.

Auto-inflammatory syndromes Auto-inflammatory (periodic) syndromes are characterised by raised acute phase proteins (ESR and CRP), may lead to amyloidosis but may respond to colchicine. Some also regard Behçet syndrome and Crohn’s disease as ‘auto-inflammatory’.

Behçet syndrome Behçet syndrome (BS), also known as Behçet disease and Adamantiades syndrome, is a triple symptom complex of (AGE): • Aphthous-like ulcers • Genital ulceration • Eye disease (especially iridocyclitis).

BS is potentially life-threatening because of: • Venous thrombosis in: – Venae cavae – Dural sinuses • Neurologic • Intestinal perforation.

Behçet syndrome is an immune-related vasculitis with various T lymphocyte abnormalities and increased polymorphonuclear leukocyte motility.

Although it has not been proved to be infectious, contagious, or sexually shared, high levels of Streptococcus mutans are associated with oral ulcers and low levels of mannose-binding lectin (MBL).

The relationship between increased Streptococcus mutans and MBL deficiency may indicate streptococcal hypersensitivity and an impaired innate immune response.

Triggering factors produce a delayed-type hypersensitivity reaction against oral streptococci mediated by IL-12 cytokines.

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– – – –

Azathioprine Pentoxifylline Colchicine Anti-TNF biologics.

Crohn’s disease/orofacial granulomatosis Part five of this series, published in May’s issue of Private Dentistry, explains more about Crohn’s disease and orofacial granulomatosis.

Figure 3: Herpetiform aphthae

HLA-B51 and its restricted CD8+ T-cell response correlates with target tissues. There is increased T-cell (Th-1) activity, expressing interferon-gamma (IFN-gamma) and pro-inflammatory cytokines (eg, TNF-alpha) and interleukins (such as IL-12, IL-18).

Behçet syndrome is rare and affects mainly peoples from around the Mediterranean, central Asia, Korea, China, Japan (the silk road of Marco Polo).

Non-specific features include: • Malaise • Anorexia • Weight loss • Generalised weakness • Headache • Sweating • Decreased or elevated temperature • Lymphadenopathy.

More specific features include: • ALU is most common onset manifestation (88.7%) • Genital ulcers • Eye disease (retinal vasculitis and uveitis) • Skin (pustules, erythema nodosum and pustules on venepuncture – pathergy) • CNS lesions • Arthralgia: large joints • Intestinal: IBD • Lungs: pneumonitis • Renal: haematuria • Thrombosis: large veins.

Behçet syndrome is diagnosed by exclusion since there are no specific diagnosis tests (possibly pathergy). Finding HLA-B5101 and raised serum IgD and cardiolipin antibodies are supportive of a BS diagnosis.

Behçet syndrome management is with: • Topical tetracyclines or corticosteroids • Systemic immunomodulators: – Prednisolone (enteric-coated) – Thalidomide – Lenalidomide

Deficiencies Deficiency states: • Haematinics • Iron • Folate • Vitamin B • Immune.

References Gandolfo S, Scully C, Carrozzo M (2006) Oral medicine. Elsevier Churchill Livingstone (Edinburgh and London). ISBN 13: 29780443100376 Scully C, Almeida ODP, Bagan J, Diz PD, Mosqueda A (2010) Oral medicine and pathology at a glance. Wiley-Blackwell (Oxford) ISBN 978-1-4051-9985-8 Scully C, Flint S, Bagan JV, Porter SR, Moos K (2010) Oral and maxillofacial diseases. Informa Healthcare (London and New York).

ISBN-13: 9780415414944 Scully C, Bagan JV, Carrozzo M, Flaitz C, Gandolfo S (2012) Pocketbook of oral disease. Elsevier, London. ISBN 978-0-702-046490 Scully C (2013) Oral and maxillofacial medicine. 3rd edition.

Churchill Livingstone (Edinburgh). ISBN 9780702049484 Scully C (2012) Aide memoires in oral diagnosis: mnemonics and acronyms (the Scully system). Journal of Investigative and Clinical Dentistry 3(4): 262-3 Scully C (2013) RULE for cancer diagnosis. British Dental Journal 215: 265-6

Disclosure This series offers a brief synopsis of the diagnosis and management of mouth ulceration – a complex topic that includes common disorders, and less common but life-threatening conditions. It does not purport to be comprehensive, and the series may include some illustrations from books written or coauthored by the author and colleagues from UK and overseas, published by Elsevier-Churchill Livingstone, Wiley-Blackwell, or Informa/Taylor & Francis – all of whose cooperation is acknowledged and appreciated.

Published with permission by Private Dentistry November 2014

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GC

COMPOSI-TIGHT® 3D FUSION™ ULTRA ADAPTIVE WEDGE

ESSENTIA

Garrison Dental Solutions is pleased to introduce a new interproximal wedge: the 3D Fusion Ultra Adaptive Wedge.

It has a patent pending design that combines a Soft Face™ overmold with a firm inner core and advanced mechanical features to produce a wedge with improved adaptation to interproximal irregularities. Further, while insertion and separation are significantly improved with the new design, soft retentive fins help to prevent back-out, even when wet. Providing enhanced adaptation and separation, it works in concert with a sectional matrix system. The wedges are available in a range of sizes (extra-small, small, medium, and large).

For more information visit www.garrisondental.com

GC introduces Essentia™, a paradigm shift in simplified composite layering, created in a forward thinking design collaboration between GC experts and leading aesthetic specialists drawing from their extensive shading expertise.

The result is a unique and intuitive seven shade system which simplifies yet delivers exceptional aesthetic outcomes. The bi-layer shade range presents four anterior options based on the patient’s age, each perfectly finished with the new Essentia™ Enamel shades which guarantee an exceptional surface gloss and long lasting polish.

Posterior restorations effortlessly blend with the remarkable Essentia™ Universal shade, with the option still open to use a duo-layering technique.

Essentia™; aesthetic, simple and with a guaranteed finish that impresses

KOMET

B&L BIOTECH

DENTINPOST X COATED

ALPHA HEAT CARRIER

This glass fiber post offers an unprecedented combination of minimal invasiveness and maximum aesthetics: •Aesthetic restoration even of severely damaged teeth •Minimum weakening of the root •Excellent retention •Quick and easy application

Cordless obturation device for optimal warm Gutta Percha techniques.

•Precision control of heat with 4 precise temperature settings.

•Variable positions for easy access into any canal •Quickly reaches desired temperature setting •Very long battery life ALPHA Heat Carrier is available in Black or White and comes with 3 Pluggers 55/06 55/08 and 55/10.

All products available from: HENRY SCHEIN HALAS • Tel: 1300 65 88 22 • www.henryschein.com.au 62 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 11, NO. 1

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The South African Society of Endodontics & Aesthetic Dentistry

SPONSORS DIAMOND

Endodontic & Restorative Excellence at the Apex of Africa

SILVER

BRONZE

SPEAKERS Christine Berthold (Canada) Elio Berutti (Italy) Guiseppe Cantatore (Italy) Arnaldo Castellucci (Italy) Antonis Chaniotis (Greece) Bernard Friedland (USA) Gianluca Gambarini (Italy) James L Guttman (USA)

Markus Haapasalo (Canada) Sergio Kuttler (USA) Martin Levin (USA) Tara Mc Mahon (Belgium) Francesco Mangani (Italy) John Meechan (UK) Yoshitsugu Terauchi (Japan) Martin Trope (USA) Peet van der Vyver (South Africa)

3-6 June 2016, Cape Town, South Africa â&#x20AC;¢ www.ifea2016.com

OTHER SPONSORS

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PRODUCTS

MORITA

KURARAY NORITAKE

TRI AUTO MINI

PANAVIA SA CEMENT PLUS

Morita’s cordless Tri Auto Mini endodontic handpiece opens up new realms of freedom in the preparation of the root canal. This is thanks to its minimal weight, ultra compact head and innovative safety features, such as the “Auto Torque Reverse” which helps reduce file breakage.

Optionally, when the Tri Auto mini is connected to Morita’s Root ZX mini apex locator, via a transmission cable and file electrode, the “Auto Apical Reverse” will help prevent over-preparation.

•Cordless, ultra compact endodontic handpiece •11 rotation speeds can be set from 50 to 1,000 rpm.

•9 torque reverse levels from 0.2 to 3.0 Ncm •6 programmable memory combinations of speed, torque etc.

•Optional: Link to an apex locator (Root ZX mini) for added features (*Feature when connected to Root ZX mini) •Safety features include; Torque Reverse, Torque Slow Down, Auto Start/Stop*, Auto Apical Reverse or Stop*, Apical Slow Down* & Apical Torque Reduction* •Operates in forward or reverse direction •290 degree rotation of the contra angle head for optimal access •Left or right-handed operational LCD setting options •Bright LCD screen displays all settings during operation •Highly durable rechargeable battery system

PANAVIA™ SA Cement Plus Automix is a dual-cure (light-cure and/or self-cure), fluoride releasing, radiopaque self-adhesive resin cement for ceramic (porcelain, lithium disilicate, zirconia, etc.), composite resin, and metal restorations. It is supplied in an convenient automix delivery system. The next generation of the original PANAVIA SA Cement delivers stronger shear bond strengths, faster light-curing time and room temperature storage.

Your Everyday PANAVIA™ NOW with Special Features • NEW Translucent shade • NEW Chemistry • Even Stronger Bond • NO Refrigeration required, with a stable 3 year shelf-life • Exceptional handling, EASY, Clean Up of excess cement • Easy – to use Automix

GC

B&L BIOTECH

EXPERIA CEMENT

BETA OBTURATION GUN

GC EXPERIA CEMENT is an aesthetic resin cement featuring proven, no compromise resin technologies that deliver maximum strength and optimum adhesion to ensure the best outcome for your indirect tooth coloured restorations. GC EXPERIA CEMENT cementation system contains 3 separate components:

Cordless obturation device is designed for optimal backfil •4 temperature settings

GC EXPERIA CEMENT, a strong, dual-cure, hand-mixed resin cement that has a low 6µm film thickness and easy clean-up of excess.

Available in 3 radiopaque shades; Universal, Clear and Opaque

•Ergonomic, lightweight and practical.

SELF-ETCHING PRIMER A&B, a dual-cure self-etching dentine and enamel adhesive CERAMIC PRIMER II, a specialised primer for all indirect aesthetic restorations

•360 degree swivel needle for easy access in the canal •Cordless and compact •Thermal protector cap that prevents accidental burns from a hot needle or gutta percha •Complements B&L’s Alpha heat carrier BETA Cordless Obturation Gun is available in Black or White

HALYARD

LAVENDER* NITRILE GLOVES Finally, A Glove Dental Professionals Will Love!

As a dental practitioner you wear gloves sometimes over 40 hours a week. It can increase your risk of developing certain health conditions such as contact dermatitis and latex allergy from latex gloves.

Halyard* Lavender Nitrile Exam Gloves are thinner, lighter, and more economical than standard nitrile, yet they retain the protective

properties required for excellent performance across a wide range of healthcare tasks. They’re the ideal replacement for latex gloves, providing the durability of nitrile and outstanding tactile sensitivity, while avoiding the problem of latex allergy.

All products available from: HENRY SCHEIN HALAS • Tel: 1300 65 88 22 • www.henryschein.com.au 64 INTERNATIONAL DENTISTRY – AUSTRALASIAN EDITION VOL. 11, NO. 1

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